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Women’s perceptions of their illness experience with myocardial infarction Dunn, Penelope Claire 1985

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WOMEN'S PERCEPTIONS OF THEIR I L L N E S S EXPERIENCE WITH MYOCARDIAL INFARCTION By P e n e l o p e C l a i r e Dunn B.Sc.N., The U n i v e r s i t y o f W e s t e r n O n t a r i o , 1976 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES The S c h o o l o f N u r s i n g We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o ijhe r e q u i r e d . s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA O c t o b e r , 1985 © P e n e l o p e C l a i r e Dunn, 1985 In p r e s e n t i n g this thesis in partial fu l f i lment of the r e q u i r e m e n t s for an a d v a n c e d d e g r e e at the Univers i ty of Brit ish C o l u m b i a , I agree that the Library shall m a k e it freely avai lable for re fe rence a n d s tudy . 1 further agree that p e r m i s s i o n for ex tens ive c o p y i n g of this thesis for scho lar ly p u r p o s e s may be g ranted by the h e a d of m y d e p a r t m e n t or by his o r her representat ives . It is u n d e r s t o o d that c o p y i n g o r p u b l i c a t i o n of this thesis for f inanc ia l gain shall not b e a l l o w e d w i t h o u t m y wr i t ten p e r m i s s i o n . T h e Un ivers i ty of Brit ish C o l u m b i a 1 9 5 6 M a i n M a l l V a n c o u v e r , C a n a d a D e p a r t m e n t of V 6 T 1Y3 DE-6(3/81) ABSTRACT T h i s s t u d y was d e s i g n e d t o e l i c i t women 's p e r c e p t i o n s o f t h e i r i l l n e s s e x p e r i e n c e w i t h m y o c a r d i a l i n f a r c t i o n f o r t h e p u r p o s e o f e x p l o r i n g a n d d e s c r i b i n g t h e n a t u r e a n d m e a n i n g o f t h i s i l l n e s s e x p e r i e n c e a n d i t s i m p a c t on e v e r y d a y l i f e . The p h e n o m e n o l o g i c a l m e t h o d , a t y p e o f q u a l i t a t i v e r e s e a r c h , was u s e d t o d i r e c t t h e s t u d y . The d a t a were c o m p i l e d t h r o u g h a s e r i e s o f s e m i - s t r u c t u r e d i n t e n s i v e i n t e r v i e w s w i t h e i g h t women. The women were 36 t o 71 y e a r s o f a g e . S i x o f t h e women were m a r r i e d a n d l i v i n g w i t h t h e i r h u s b a n d s . The women h a d b e e n a t home f o l l o w i n g d i s c h a r g e f r o m h o s p i t a l f o r 2 t o 14 w e e k s . D a t a c o l l e c t i o n a n d d a t a a n a l y s i s p r o c e e d e d s i m u l t a n e o u s l y a n d d a t a c o l l e c t i o n c e a s e d o n c e c o n s i s t e n t t h e m e s were i d e n t i f i e d a n d v a l i d a t e d a n d t h e d a t a c o l l e c t e d were s u f f i c i e n t l y r i c h a n d i n - d e p t h . Women e x p l a i n t h e i r i l l n e s s e x p e r i e n c e w i t h m y o c a r d i a l i n f a r c t i o n a s a l o s s phenomenon a n d t h e c e n t r a l a n d d o m i n a n t l o s s w i t h i n t h e h e a r t a t t a c k e x p e r i e n c e f o r women i s l o s s o f p r e d i c t a b i l i t y . Women's n e e d f o r i n f o r m a t i o n f o l l o w i n g m y o c a r d i a l i n f a r c t i o n i s n o t met a n d l a c k o f e n e r g y i s a p r o m i n e n t f e a t u r e i n e v e r y d a y l i f e a f t e r a h e a r t a t t a c k . T r a d i t i o n a l s e x r o l e s o c i a l i z a t i o n s e t s t h e s t a g e f o r p o t e n t i a l p r o b l e m s i n women 's c a r d i a c r e h a b i l i t a t i o n , e s p e c i a l l y i n r e l a t i o n t o s u p p o r t a n d r o l e e n a c t m e n t . P h y s i c a l r e h a b i l i t a t i o n i s n o t a s e l e c t e d s t r a t e g y t o g a i n c o n t r o l o v e r t h e i r l o s s e x p e r i e n c e f o r women w i t h m y o c a r d i a l i n f a r c t i o n . The f i n d i n g s a n d c o n c l u s i o n s o f t h i s s t u d y s u g g e s t a number o f i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e . T h e r e i s c l e a r d i r e c t i o n f o r f a m i l y - c e n t e r e d n u r s i n g c a r e i n t h e r e h a b i l i t a t i o n o f women w i t h m y o c a r d i a l i n f a r c t i o n t o a d d r e s s p o t e n t i a l p r o b l e m s i n r e l a t i o n t o s u p p o r t a n d r o l e e n a c t m e n t . T h i s s t u d y r e i n f o r c e s t h e v a l u e o f u s i n g t h e c o n c e p t s o f l o s s a n d g r i e f t o c a r e f o r p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . A l s o , t h i s s t u d y i n d i c a t e s t h a t , i n p l a n n i n g n u r s i n g c a r e f o r women w i t h m y o c a r d i a l i n f a r c t i o n , n u r s e s s h o u l d f o c u s on I n t e r v e n t i o n s t o i n c r e a s e s u p p o r t , t o meet p a t i e n t a n d f a m i l y e d u c a t i o n a l n e e d s , a n d t o h e l p women t o a n t i c i p a t e n o r m a l p h y s i c a l a n d p s y c h o l o g i c a l r e s p o n s e s t o m y o c a r d i a l i n f a r c t i o n . T h i s s t u d y a l s o h a s s p e c i f i c i m p l i c a t i o n s f o r t h e d e v e l o p m e n t o f s t r u c t u r e d c a r d i a c r e h a b i l i t a t i o n p r o g r a m m e s a d d r e s s i n g t h e s p e c i a l n e e d s o f women. In r e l a t i o n t o n u r s i n g e d u c a t i o n , n u r s e s must be p r e p a r e d t o a s s e s s , t e a c h , a n d c o u n s e l p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n a n d t h e i r f a m i l i e s . M o s t i m p o r t a n t l y , t h i s s t u d y d i r e c t s n u r s i n g e d u c a t o r s t o p r o v i d e c o u r s e work i n women 's h e a l t h i s s u e s t o s e n s i t i z e n u r s e s t o t h i s f i e l d o f s t u d y a n d t o e q u i p n u r s e s w i t h t h e u n d e r s t a n d i n g n e c e s s a r y t o f a c i l i t a t e c h a n g e s i n women 's h e a l t h c a r e . I m p l i c a t i o n s f o r f u t u r e r e s e a r c h i n c l u d e f u r t h e r e x p l o r a t i o n o f i n f o r m a t i o n n e e d s , s u p p o r t , a n d s t r a t e g i e s f o r c o n t r o l i n r e l a t i o n t o women w i t h m y o c a r d i a l i n f a r c t i o n . _ i v TABLE OF CONTENTS ABSTRACT i i TABLE OF CONTENTS i v LIST OF FIGURES v i ACKNOWLEDGEMENTS v i i CHAPTER 1 INTRODUCTION Background to the Study 1 Co n c e p t u a l Framework ...6 Problem Statement 7 Purpose of the Study 8 I n t r o d u c t i o n t o t h i s S t u d y ' s Methodology 8 D e f i n i t i o n of Terms 10 Assumptions and L i m i t a t i o n 10 Summary 11 CHAPTER 2 REVIEW OF SELECTED LITERATURE I n t r o d u c t 1 on 13 Women With MI: Res e a r c h D i r e c t l y S t u d y i n g Women 14 Women w i t h MI: S t u d i e s I n c l u d i n g Women 18 MI and P a t i e n t P e r c e p t i o n s 21 Summary 23 CHAPTER 3 METHODOLOGY I n t r o d u c t i on 24 S e l e c t i o n of P a r t i c i p a n t s 24 C r i t e r i a f o r S e l e c t i o n 25 S e l e c t i o n P r o c e d u r e .....25 Data C o l l e c t i o n 26 C o n s t r u c t i o n of Accounts 28 Data A n a l y s i s 29 E t h i c a l C o n s i d e r a t i o n s 30 Summary 31 CHAPTER 4 PRESENTATION OF THE STUDY'S FINDINGS I n t r o d u c t i on 32 The Study's A n a l y t i c Framework 32 C h a r a c t e r i s t i c s of the P a r t i c i p a n t s 35 The Women's P e r c e p t i o n s of T h e i r I l l n e s s E x p e r i e n c e 36 Loss of H e a l t h y S t a t e 36 Loss of P r e d i c t a b i l i t y 40 Lack of Energy 47 Lack of A n t i c i p a t e d Support 51 Change i n Usu a l Role Enactment 61 S t r a t e g i e s f o r C o n t r o l 67 Summary 73 CHAPTER 5 DISCUSSION OF THE FINDINGS I n t r o d u c t i on 75 MI a s a L o s s Phenomenon 76 L o s s o f H e a l t h y S t a t e 77 L o s s o f P r e d i c t a b i l i t y 79 L a c k o f E n e r g y 84 L a c k o f A n t i c i p a t e d S u p p o r t 86 Change i n U s u a l R o l e E n a c t m e n t 94 S t r a t e g i e s f o r C o n t r o l 95 Summary 97 CHAPTER 6 SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR NURSING I n t r o d u c t i on 98 Summary o f t h e S t u d y 98 C o n c l us i ons 102 I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e 103 I m p l i c a t i o n s f o r N u r s i n g E d u c a t i o n 105 I m p l i c a t i o n s f o r N u r s i n g R e s e a r c h 106 Summary 106 REFERENCE L I S T 108 APPENDICES A p p e n d i x A P a t i e n t I n f o r m a t i o n L e t t e r 114 A p p e n d i x B C o n s e n t Form 115 A p p e n d i x C Sample I n t e r v i e w Q u e s t i o n s 116 A p p e n d i x D Key t o B l o c k Q u o t a t i o n s 117 L I S T OF FIGURES F i g u r e 1 The S t u d y ' s A n a l y t i c Framework ACKNOWLEDGEMENTS I w o u l d l i k e t o e x t e n d my s i n c e r e g r a t i t u d e to the e i g h t women who so w i l l i n g l y a n d o p e n l y s h a r e d t h e i r i l l n e s s e x p e r i e n c e w i t h m y o c a r d i a l i n f a r c t i o n t o h e l p o t h e r women. F o r t h e i r k i n d s u p p o r t a n d s c h o l a r l y c o u n s e l , I w o u l d l i k e t o t h a n k my t h e s i s c o m m i t t e e members, C l a r i s s a P. G r e e n ( c h a i r ) a n d D r . M a r g a r e t C a m p b e l l . I w o u l d a l s o l i k e t o e x p r e s s my l o v e a n d a p p r e c i a t i o n t o my f a m i l y , B r u c e Dunn, S t e p h a n i e Dunn, a n d W i l l i a n Dunn f o r t h e i r c o n t r i b u t i o n s t o t h i s e n d e a v o u r . F i n a l l y , I w o u l d l i k e t o s a y a s p e c i a l t h a n k you t o H a l l n a S t r e u s e r f o r h e r f r i e n d s h i p i n t h e w r i t i n g o f t h i s t h e s i s a n d t o A n g e l a B o v e y f o r e f f o r t a n d commitment b e y o n d r e q u e s t i n t h e t y p i n g o f t h i s m a n u s c r i p t . CHAPTER 1 I n t r o d u c t i on B a c k g r o u n d t o t h e S t u d y S t a t i s t i c a l e v i d e n c e r e f u t e s t h e commonly b e l i e v e d myth t h a t m y o c a r d i a l i n f a r c t i o n ( M I ) i s a p o t e n t h e a l t h p r o b l e m f o r men o n l y , t h a t women a r e i n v u l n e r a b l e t o MI. T h i s myth o b s c u r e s t h e r e a l i t y a n d s i g n i f i c a n c e o f t h i s h e a l t h p r o b l e m f o r women. A l t h o u g h MI i s much more common i n men t h a n i n women, an e x a m i n a t i o n o f t h e m o r t a l i t y r a t e s e s t a b l i s h e s MI a s a m a j o r h e a l t h p r o b l e m f o r men a n d f o r women. D e s p i t e r e c e n t d e c l i n e s i n d e a t h r a t e s , i s c h e m i c h e a r t d i s e a s e r e m a i n s t h e l e a d i n g c a u s e o f d e a t h i n Canada f o r b o t h s e x e s a n d MI, i n p a r t i c u l a r , a c c o u n t s f o r t h e g r e a t e s t number o f t h e s e m o r t a l i t i e s ( S z k l o , 1981; P a t r i c k , P a l e s c h , F e i n l e i b , & B r o d y , 1 9 8 2 ; ' S t a t i s t i c s C a n ada 8 4 - 2 0 6 , 1 9 8 2 ) . The t o t a l number o f d e a t h s f o r 1982 due t o MI was 19,552 male d e a t h s a n d 10,858 f e m a l e d e a t h s ( S t a t i s t i c s C a n a d a 8 4 - 2 0 3 , 1982, p . 6 8 ) . These numbers c o n f i r m t h e e n o r m i t y o f t h i s h e a l t h p r o b l e m . F o r o l d e r women, t h e m a g n i t u d e o f t h e p r o b l e m i s s i m i l a r t o t h a t o f o l d e r men. The number o f d e a t h s due t o MI i n women i n c r e a s e s d r a m a t i c a l l y i n t h e 65-69 y e a r age g r o u p a n d c o n t i n u e s t o r i s e s o t h a t f o r t h e 7 5 - 7 9 , 8 0 - 8 4 , a n d 85+ age g r o u p s , t h e s e x d i f f e r e n c e s a r e m i n i m a l ( S t a t i s t i c s C a n ada 8 4 - 2 0 3 , 1982, p . 6 9 ) . The s e x r a t i o s d e c r e a s e w i t h age b e c a u s e o f a d e c r e a s e i n t h e s l o p e o f t h e age i n c r e m e n t In men, r a t h e r t h a n an a c c e l e r a t e d i n c r e a s e i n m o r t a l i t y r a t e w i t h age i n women ( S z k l o , 1981). G e n e r a l l y , t h e s e m o r t a l i t y s t a t i s t i c s s u p p o r t t h e s i g n i f i c a n c e o f t h i s h e a l t h p r o b l e m o f MI i n women by d o c u m e n t i n g t h e m a g n i t u d e o f t h e number o f l i v e s l o s t a n d e m p h a s i z i n g t h a t r i s k o f d e a t h i s a p r o m i n e n t f e a t u r e o f t h i s i l l n e s s e x p e r i e n c e . H o w e v e r , what i s t h e r e l a t i o n s h i p o f t h i s h e a l t h p r o b l e m o f MI i n women t o women's o t h e r h e a l t h p r o b l e m s ? An e x a m i n a t i o n o f m o r b i d i t y s t a t i s t i c s f o r common h e a l t h p r o b l e m s o f women a s s i s t s l n p u t t i n g MI i n women i n t o p e r s p e c t i v e among women's r e c o g n i z e d h e a l t h p r o b l e m s . The r e a s o n t o e x a m i n e m o r b i d i t y s t a t i s t i c s i s t h e p a r a d o x i c a l r e l a t i o n s h i p b e t w e e n m o r b i d i t y a n d m o r t a l i t y r a t e s f o r men a n d women ( F o g e l & Woods, 1 9 8 1 ) . F o r women, m o r t a l i t y r a t e s a r e l o w e r , w h i l e men e x h i b i t t h e r e v e r s e . T h e r e f o r e , m o r b i d i t y s t a t i s t i c s g i v e a more c o m p l e t e p i c t u r e when d i s c u s s i n g women's h e a l t h . H o s p i t a l m o r b i d i t y s t a t i s t i c s f o r h e a l t h p r o b l e m s u s u a l l y a s s o c i a t e d w i t h women ( F o g e l & Woods, 1981) were r e v i e w e d . The i m p r e s s i v e f i n d i n g i s t h a t t h e numbers a r e c l o s e l y p a r a l l e l ( S t a t i s t i c s C anada 8 2 - 2 0 6 , 1 9 7 8 ) . F o r e x a m p l e , t h e r e were 16,811 women h o s p i t a l i z e d w i t h b r e a s t c a n c e r a n d 14,379 women h o s p i t a l i z e d w i t h MI i n 1978, t h e most r e c e n t a v a i l a b l e s t a t i s t i c s . T h i s f u r t h e r I m p l i e s t h a t MI i s an I m p o r t a n t women's h e a l t h p r o b l e m . T h e r e a r e a s u b s t a n t i a l number ; o f women who must c o p e w i t h t h e p r o c e s s o f r e h a b i l i t a t i n g f r o m t h i s c a r d i a c e v e n t . I n a d d i t i o n t o t h e m o r t a l i t y a n d m o r b i d i t y s t a t i s t i c s , t h e n a t u r e o f t h e i l l n e s s e x p e r i e n c e i t s e l f i m p a r t s an i m p o r t a n t s i g n i f i c a n c e . The d r a m a t i c way MI p r e s e n t s , the p e r i o d of extreme u n c e r t a i n t y tha t f o l l o w s , and t h e n , the l i v i n g wi th the consequences of t h i s l i f e - t h r e a t e n i n g p a t h o p h y s i o l o g i c a l event c o n t r i b u t e to t h i s s i g n i f i c a n c e . T y p i c a l l y , MI occur s s u d d e n l y , wi th l i t t l e or no w a r n i n g . The predominant symptom i s one of e x c r u c i a t i n g and u n r e l e n t i n g ches t p a i n . A f e e l i n g of impending doom, tha t something Is very wrong, c h a r a c t e r i s t i c a l l y accompanies the c h e s t p a i n . How the p a t i e n t d e s c r i b e s the MI p a i n ep i sode i s so c h a r a c t e r i s t i c of and i n t e g r a l to MI t h a t i t i s a nece s s a ry component of the d i f f e r e n t i a l d i a g n o s i s ( H u r s t , K i n g I I I , W a l t e r , F r i e s i n g e r & Edwards, 1982). I f an i n d i v i d u a l s u r v i v e s t h i s i n i t i a l phase of the i l l n e s s e x p e r i e n c e , a p e r i o d of i n t e n s i v e ca re f o l l o w s . The r a t i o n a l e f o r t h i s type of care i s to moni tor p a t i e n t s c l o s e l y d u r i n g t h i s h i g h l y p r e c a r i o u s time p o s t - i n f a r c t ion when e x t e n s i o n of the i n f a r c t i o n , another i n f a r c t i o n , a n d / o r c o m p l i c a t i o n s , e s p e c i a l l y f a t a l a r r h y t h m i a s , t h r e a t e n . F o l l o w i n g t h i s p e r i o d of i n t e n s i v e c a r e , the i n d i v i d u a l then i s f aced w i t h the consequences of the h e a r t a t t a c k : the p h y s i c a l and p s y c h o s o c i a l impact of MI . The a f t e rmath of MI i s w i d e l y viewed i n the l i t e r a t u r e as a complex and d i f f i c u l t e x p e r i e n c e (Croog , L e v i n e , & L u r i e , 1968; Doehrman, 1977; W i l s o n - B a r n e t t , 1979), encompassing profound p h y s i c a l and p s y c h o s o c i a l e f f e c t s . One reason f o r the p s y c h o s o c i a l re sponses i s the s y m b o l i c meaning a t t a c h e d to the h e a r t . Because the h e a r t i s commonly symbo l i zed as the " seat of our emot ions " and as the " f o u n t a i n of l i f e , " when an MI, a l i f e - t h r e a t e n i n g e v e n t , o c c u r s , a c o m p e l l i n g p s y c h o l o g i c a l d imens ion i s added to the e x p e r i e n c e (Cassem & H a c k e t t , 1977). T h i s s y m b o l i z a t i o n , c o u p l e d w i t h the r e a l t h r e a t of sudden d e a t h , c o n t r i b u t e s to the p s y c h o s o c i a l responses to a h e a r t a t t a c k . The nature of t h i s response has been d e s c r i b e d i n the l i t e r a t u r e as one in which f e e l i n g s of a n x i e t y and d e p r e s s i o n predominate (Cay , V e t t n e r , & P h i l i p , 1972; Cassem & H a c k e t t , 1977).- I t i s suggested tha t the t h r e a t of dea th p l u s the day-to-day l i v i n g w i t h t h i s fearsome r e a l i t y p r e c i p i t a t e the f e e l i n g s of a n x i e t y . A h e a r t a t t a c k f r e q u e n t l y means l i f e s t y l e adjustment and t h i s impact on l i f e s t y l e i s l i n k e d to the f e e l i n g s of d e p r e s s i o n . The i l l n e s s e x p e r i e n c e f o l l o w i n g MI p r e s e n t s a c h a l l e n g e f o r h e a l t h care p r o f e s s i o n a l s . There i s e x t e n s i v e r e s e a r c h and w r i t i n g on MI as i t r e l a t e s to men in the h e a l t h s c i e n c e s l i t e r a t u r e . To d a t e , however, there has been l i m i t e d work d i r e c t l y s t u d y i n g MI as i t r e l a t e s to women. I n s t e a d , g e n e r a l l y , women are subsumed under r e s e a r c h on men; there i s a d e a r t h of s t u d i e s tha t e x p l o r e women's i l l n e s s e x p e r i e n c e . Because the needs and concerns of women cannot be assumed to be r e p r e s e n t e d , u s i n g s t u d i e s on men to d i r e c t the care of women may r e s u l t i n care t h a t i s not a p p r o p r i a t e . There e x i s t s an i d e n t i f i a b l e need to s tudy women's i l l n e s s e x p e r i e n c e w i t h MI. The s i t u a t i o n in the h e a l t h s c i e n c e s l i t e r a t u r e d e s c r i b e d above i s an i l l u s t r a t i o n of one of the reasons f o r d i s s a t i s f a c t i o n w i t h women's h e a l t h care v o i c e d by women's h e a l t h a c t i v i s t s . The predominance of the male p e r s p e c t i v e to the apparent e x c l u s i o n of the p e r s p e c t i v e o f women demonstrates a r e s e a r c h b i a s . M a r i e s k i n d (1980) remarks on the p a u c i t y o f a c c u r a t e d a t a and the l i m i t e d v a l i d i t y of what does e x i s t c o n c e r n i n g the h e a l t h s t a t u s of women i n g e n e r a l . I n the n u r s i n g l i t e r a t u r e , S t evenson (1979) p o i n t s out t h a t n u r s i n g r e s e a r c h has p a i d l i t t l e a t t e n t i o n t o women's h e a l t h c a r e needs as a s e p a r a t e e n t i t y . G i v e n the s t a t u s of the l i t e r a t u r e s t u d y i n g MI i n women, an a p p r o p r i a t e way to b e g i n t o s t u d y t h i s a r e a i s by e x p l o r i n g and d e s c r i b i n g the p a t i e n t s ' views of t h e i r i l l n e s s e x p e r i e n c e as p e r c e i v e d and e x p r e s s e d by the women t h e m s e l v e s . T h i s approach i s c ongruent w i t h a major t h r u s t of the Women's H e a l t h Movement, w i t h e g a l i t a r i a n r a t h e r than h i e r a r c h i c a l h e a l t h c a r e ( M a r i e s k i n d , 1980; Ruzek, 1978). F o c u s i n g on the p a t i e n t ' s u n d e r s t a n d i n g of the i l l n e s s e x p e r i e n c e r educes the power d i f f e r e n t i a l between the p a t i e n t and the p r o f e s s i o n a l and communicates to the p a t i e n t a genuine r e s p e c t f o r her views and a s u p p o r t f o r h e r i n v o l v e m e n t . F o r n u r s e s , u n d e r s t a n d i n g women's e x p e r i e n c e w i t h a h e a r t a t t a c k i s im p o r t a n t f o r the d i r e c t i o n p r o v i d e d i n p a t i e n t assessment and i n the p l a n n i n g and p r o v i s i o n of me a n i n g f u l and e f f e c t i v e r e h a b i l i t a t i v e c a r e . S t u d y i n g the p a t i e n t ' s p o i n t of view i s a l s o h i g h l y c o m p a t i b l e w i t h the n u r s i n g p r o f e s s i o n ' s g o a l of p a t i e n t - c e n t e r e d and h o l i s t i c c a r e (Swanson & C h e n i t z , 1982). F u r t h e r , the n u r s i n g p r o f e s s i o n v a l u e s the c o l l a b o r a t i v e p r o c e s s i n the p l a n n i n g and p r o v i s i o n of n u r s i n g c a r e . 6 Conceptual Framework The c o n c e p t u a l framework t h a t was s e l e c t e d to d i r e c t t h i s s t u d y i s Kleinman , E i s e n b e r g , and Good's E x p l a n a t o r y Model (1 9 7 8 ) . These t h e o r i s t s i d e n t i f y t h r e e domains of h e a l t h c a r e i n s o c i e t y , each h a v i n g an e x p l a n a t o r y model. Kleinman e t a l . emphasize the importance of e l i c i t i n g the p a t i e n t ' s e x p l a n a t o r y model, so t h a t n e g o t i a t i o n of d i s c r e p a n c i e s between p r o f e s s i o n a l and p a t i e n t models may o c c u r and me a n i n g f u l and e f f e c t i v e c a r e can be p r o v i d e d . In t h i s model, a sha r p c o n c e p t u a l d i s t i n c t i o n Is made betweed d i s e a s e and i l l n e s s . K leinman e t a l . (1978) contend t h a t " d i s e a s e i n the Western m e d i c a l paradigm i s m a l f u n c t i o n i n g or m a l a d a p t a t i o n of b i o l o g i c and p s y c h o l o g i c p r o c e s s e s ; whereas i l l n e s s r e p r e s e n t s p e r s o n a l , i n t e r p e r s o n a l , and c u l t u r a l r e a c t i o n s to d i s e a s e o r discomfort"" ( p . 2 5 2 ) . S i m p l y p u t , d i s e a s e s are t r e a t e d and i l l n e s s e s a r e e x p e r i e n c e d . I l l n e s s r e p r e s e n t s the human e x p e r i e n c e of s i c k n e s s . I l l n e s s , t h e r e f o r e , i s s o c i a l l y and/or c u l t u r a l l y c o n s t r u c t e d . T h i s s o c i a l and/or c u l t u r a l c o n s t r u c t i o n of the i l l n e s s e x p e r i e n c e c o n s t i t u t e s the p a t i e n t ' s e x p l a n a t o r y model of s i c k n e s s . I t f o l l o w s , t h e n , t h a t v a r i a t i o n i n d e s c r i b i n g and c o p i n g w i t h an i l l n e s s e x p e r i e n c e may o c c u r a c r o s s c u l t u r a l , s o c i a l , and f a m i l y b o u n d a r i e s . The t h r e e s t r u c t u r a l domains of h e a l t h c a r e i n s o c i e t y d e s c r i b e d by Kleinman e t a l . (1978) are as f o l l o w s : 1) p r o f e s s i o n a l , 2) p o p u l a r ( f a m i l y , s o c i a l network, community), and 3) f o l k ( n o n p r o f e s s i o n a l h e a l e r s ) . How an i l l n e s s e x p e r i e n c e i s p e r c e i v e d i s dependent upon one's domain. Kleinman e t a l . s t a t e t h a t , f o r the p a t i e n t and h e a l t h c a r e p r o f e s s i o n a l , " i n t e r a c t i o n s are t r a n s a c t i o n s between e x p l a n a t o r y models..." ( p . 2 5 4 ) , between the p o p u l a r and the p r o f e s s i o n a l e x p l a n a t o r y model. I t i s not s u r p r i s i n g t h a t d i s c r e p a n c i e s i n i n f o r m a t i o n as w e l l as i n v a l u e s , e x p e c t a t i o n s , and o b j e c t i v e s of c a r e o f t e n o c c u r between these two e x p l a n a t o r y models. D i f f e r e n t p e r c e p t i o n s and e x p l a n a t i o n s a f f e c t p a t i e n t c a r e outcomes; n e g o t i a t i o n between models i s a p r e r e q u i s i t e t o r e l e v a n t and competent c a r e . H e a l t h c a r e p r o f e s s i o n a l s are d i r e c t e d by t h i s model to e l i c i t t h e i r p a t i e n t s ' e x p l a n a t o r y models so t h a t they may t r u l y s t r i v e t o u n d e r s t a n d t h e i r p a t i e n t s and p r o v i d e c a r e a p p r o p r i a t e t o the meaning of the i l l n e s s e x p e r i e n c e f o r those i n d i v i d u a l s . Problem Statement The g e n e r a l problem t h i s s t u d y a d d r e s s e d i s the l a c k of e m p i r i c a l knowledge about women's i l l n e s s e x p e r i e n c e w i t h MI as p e r c e i v e d and e x p r e s s e d by women. The s t a t i s t i c s t o g e t h e r w i t h the n a t u r e of the i l l n e s s e x p e r i e n c e a c c e n t u a t e the s i g n i f i c a n c e of t h i s h e a l t h problem f o r women. The l i m i t e d a t t e n t i o n to t h i s h e a l t h problem f o r women i n the h e a l t h s c i e n c e s l i t e r a t u r e i s r e l a t e d to the p o p u l a r view t h a t h e a r t a t t a c k s a re f o r men o n l y and t o the more g e n e r a l problem of male-dominated h e a l t h s c i e n c e s r e s e a r c h . I t Is c o n s i s t e n t w i t h b o t h the g o a l s of women's h e a l t h a c t i v i s m and the g o a l s of the n u r s i n g p r o f e s s i o n to f o c u s on the p e r c e p t i o n s of i n d i v i d u a l s ; t h i s focus a c k n o w l e d g e s t h e i r w o r t h a s i n d i v i d u a l s a n d a l s o t h e v a l u e o f t h e i r e x p e r i e n c e . K l e i n m a n e t a l . ( 1 9 7 8 ) p r o v i d e a u s e f u l f r a m e w o r k f o r c o n c e p t u a l i z i n g t h i s r e s e a r c h p r o b l e m . They e m p h a s i z e t h e i m p o r t a n c e o f e l i c i t i n g t h e p a t i e n t ' s v i e w , t h e p e r s o n a l a n d s o c i a l m e a n i n g s o f t h e i l l n e s s e x p e r i e n c e . T h e s e d a t a w i l l e q u i p n u r s e s w i t h a more v a l i d b a s i s f o r t h e i r p r a c t i c e . N u r s e s must d e v e l o p t h e i r u n d e r s t a n d i n g o f women 's i l l n e s s e x p e r i e n c e w i t h MI i n o r d e r t o p l a n a n d p r o v i d e a p p r o p r i a t e , e f f e c t i v e n u r s i n g c a r e , n u r s i n g c a r e w h i c h r e f l e c t s t h e n a t u r e a n d m e a n i n g o f t h e h e a r t a t t a c k e x p e r i e n c e f o r women. P u r p o s e o f t h e S t u d y The o v e r a l l p u r p o s e o f t h i s s t u d y was t o e x p l o r e a n d d e s c r i b e women 's p e r c e p t i o n s o f t h e i r i l l n e s s e x p e r i e n c e w i t h M I . The f o l l o w i n g s p e c i f i c q u e s t i o n s were d e r i v e d f r o m t h i s p u r p o s e : 1. What i s t h e n a t u r e o f t h e i l l n e s s e x p e r i e n c e f o r women w i t h MI? 2. What i s t h e m e a n i n g o f t h e i l l n e s s e x p e r i e n c e t o women f o l l o w i n g MI? What i s t h e i m p a c t o f t h i s i l l n e s s e x p e r i e n c e on e v e r y d a y l i f e ? ( a c t i v i t i e s o f d a i l y l i v i n g , i n t e r p e r s o n a l r e l a t i o n s h i p s , w o r k , l e i s u r e a c t i v i t i e s , f e e l i n g s , e m o t i o n s , a n d o u t l o o k on l i f e ) . I n t r o d u c t i o n t o T h i s S t u d y ' s M e t h o d o l o g y The p h e n o m e n o l o g i c a l m e t h o d , a t y p e o f q u a l i t a t i v e m e t h o d o l o g y , was s e l e c t e d f o r t h i s s t u d y . T h i s m e t h o d o l o g y i s c o n s i s t e n t w i t h the c o n c e p t u a l framework and the r e s e a r c h q u e s t i o n s of t h i s s t u d y . Kleinman (1977) argues f o r the use of the p h e nomenological method to e l u c i d a t e how s i c k n e s s i s s o c i a l l y c o n s t r u c t e d i n everyday l i f e . F u r t h e r , Kleinman a s s e r t s t h a t such s t u d i e s would p r o v i d e c o n c r e t e c o n t r i b u t i o n s t o p a t i e n t c a r e . Anderson (1981) i d e n t i f i e s the s o c i a l c o n s t r u c t i o n of i l l n e s s as a t o p i c " p r o f i t a b l y s t u d i e d w i t h i n the p h e n omenological framework" (p . 1 3 0 ) . The n a t u r e and purpose of the phenomenological method a l s o s u p p o r t i t s use i n t h i s s t u d y . The phe n o m e n o l o g i c a l method r e q u i r e s the r e s e a r c h e r t o see the s i t u a t i o n under s t u d y from the s u b j e c t ' s p e r s p e c t i v e ( R i s t , 1979). T h i s methodology c o n s i d e r s a l l phenomena to be s o c i a l l y c o n s t r u c t e d and s t r e s s e s " i n n e r o r s u b j e c t i v e u n d e r s t a n d i n g s of e v e n t s , b e h a v i o u r s , and s u r r o u n d i n g s " o r "how the w o r l d i s e x p e r i e n c e d " ( R i s t , 1979, p.19). Ornery ( 1983) d e f i n e s the g o a l of t h i s methodology as "an a c c u r a t e d e s c r i p t i o n of the e x p e r i e n c e o r phenomena under s t u d y " ( p . 6 1 ) . O i l e r (1981) s t a t e s t h a t the purpose of phenomenological I n q u i r y i s to " d e s c r i b e e x p e r i e n c e as i t i s l i v e d " ( p . 1 7 8 ) . Because the fo c u s of t h i s s t u d y was an e x p l a n a t i o n of women's i l l n e s s e x p e r i e n c e w i t h MI from the p e r s o n a l p e r s p e c t i v e of these women, i t was a p p r o p r i a t e t o s e l e c t t h i s methodology. F u r t h e r , i n c o n t r a s t t o t r a d i t i o n a l q u a n t i t a t i v e methods, a d i s t i n c t i v e f e a t u r e of t h i s methodology i s the sheer depth of st u d y a f f o r d e d . As R i s t (1979) s t a t e s , t h i s r e s e a r c h method "en a b l e s a comprehension of human b e h a v i o u r i n g r e a t e r depth t h a n i s p o s s i b l e f r o m t h e s t u d y o f s u r f a c e b e h a v i o u r , f r o m p a p e r and p e n c i l t e s t s , a n d f r o m s t a n d a r d i z e d i n t e r v i e w s " ( p . 2 0 ) . G i o r g i ( 1 9 7 5 a ) i d e n t i f i e s t h e v a l u e o f t h e p h e n o m e n o l o g i c a l method t o be " t h e d i r e c t a c c e s s i t p r o v i d e s t o m e a n i n g by i n t e r r o g a t i n g i t s q u a l i t a t i v e a s p e c t s " ( p . 1 0 1 ) . The p h e n o m e n o l o g i c a l method f i t s w e l l w i t h t h e n u r s i n g p r o f e s s i o n ' s v a l u e s a n d g o a l s ( D a v i s , 1978; A n d e r s o n , 1981; O i l e r , 1982; Ornery, 1 9 8 4 ) . The n u r s i n g p r o f e s s i o n ' s v a l u i n g o f t h e i n d i v i d u a l a n d n u r t u r a n t f u n c t i o n p a r a l l e l t h e r e v e r e n c e f o r t h e human e x p e r i e n c e c e n t r a l t o t h i s m e t h o d o l o g y . D e f i n i t i o n o f Terms I n t h i s s t u d y , t h e f o l l o w i n g d e f i n i t i o n s a p p l y : women: a d u l t f e m a l e s i n t h e Lower M a i n l a n d u n d e r t h e c a r e o f a p h y s i c i a n , r e f e r r e d t o t h i s s t u d y by t h a t p h y s i c i a n , a n d who have b e e n d i a g n o s e d w i t h MI. p e r c e p t i o n s : t h e p a t i e n t ' s v i e w , t h e p a t i e n t ' s u n d e r s t a n d i n g , t h e p a t i e n t ' s p e r s p e c t i v e , t h e p a t i e n t ' s e x p l a n a t i o n , i l l n e s s e x p e r i e n c e : a s d e f i n e d by K l e i n m a n e t a l . ( 1 9 7 8 , p .252) " . . . p e r s o n a l , i n t e r p e r s o n a l , a n d c u l t u r a l r e a c t i o n s t o d i s e a s e o r d i s c o m f o r t . " The r e a c t i o n s o f women t o MI and t o i t s i m p a c t on e v e r y d a y l i f e . A s s u m p t i o n s and L i m i t a t i o n The a s s u m p t i o n s t h a t g u i d e d t h i s s t u d y w e r e : 1. An u n d e r s t a n d i n g o f t h e i l l n e s s e x p e r i e n c e o f women w i t h MI c a n be d e t e r m i n e d by u s i n g t h e p h e n o m e n o l o g i c a l method. 2. Women's p e r c e p t i o n s of t h e i r i l l n e s s e x p e r i e n c e wi th MI d i f f e r from those of men. 3. The i l l n e s s e x p e r i e n c e w i t h MI has meaning f o r women. MI a f f e c t s everyday l i f e . The f o l l o w i n g s tudy l i m i t a t i o n was i d e n t i f i e d : The r i c h n e s s of the da t a i s l i m i t e d by the time c o n s t r a i n t s of the r e s e a r c h e r . These time c o n s t r a i n t s account f o r the number of women s e l e c t e d as p a r t i c i p a n t s and the number of i n t e r v i e w s c o n d u c t e d . summary MI i s a s i g n i f i c a n t h e a l t h problem f o r women as e v i d e n c e d by the m o r t a l i t y and m o r b i d i t y s t a t i s t i c s rev iewed i n t h i s c h a p t e r and the o v e r a l l d e v a s t a t i n g nature of a hear t a t t a c k . I t Is i n c r e a s i n g l y r e c o g n i z e d t h a t the t r a d i t i o n a l r e s e a r c h t reatment of women's h e a l t h problems i s f raught wi th many d i f f i c u l t i e s , i n c l u d i n g the e x c l u s i v e use of the male p e r s p e c t i v e , subsuming women under men, and not s t u d y i n g women. These d i f f i c u l t i e s a p p l y here f o r women w i t h MI. T h i s s tudy proposed to e x p l o r e and d e s c r i b e women's p e r c e p t i o n s of t h e i r i l l n e s s e x p e r i e n c e w i t h MI and thus to address the l ack of e m p i r i c a l knowledge c o n c e r n i n g t h i s h e a l t h problem f o r women. U n d e r s t a n d i n g h e a l t h problems from the p a t i e n t ' s p e r s p e c t i v e l a y s a sound f o u n d a t i o n f o r nurses to unders tand the t o t a l phenomenon of the I l l n e s s e x p e r i e n c e . From t h i s b a s i s , nurses are d i r e c t e d to p l a n and p r o v i d e empathic and r e l e v a n t n u r s i n g c a r e . T h i s means n u r s i n g care w h i c h r e f l e c t s t h e n a t u r e a n d m e a n i n g to women o f t h e i r i l l n e s s e x p e r i e n c e w i t h M I . I t i s a l s o n u r s i n g c a r e w h i c h r e i n f o r c e s n u r s i n g ' s b e l i e f s i n t h e w o r t h o f i n d i v i d u a l s a n d n u r s i n g ' s u n i q u e n u r t u r a n t f u n c t i o n . CHAPTER 2 Review of S e l e c t e d L i t e r a t u r e I n t r o d u c t i o n T h i s c h a p t e r p r e s e n t s a rev iew of the l i t e r a t u r e p e r t i n e n t to t h i s s t u d y ' s r a t i o n a l e and purpose . The i n t e n t of t h i s rev iew i s to f u r t h e r s u b s t a n t i a t e the need to s tudy women's e x p e r i e n c e wi th MI and to l o c a t e t h i s s tudy w i t h i n the c o n t e x t of r e l a t e d p r o f e s s i o n a l l i t e r a t u r e . The r e s e a r c h e r r e c o g n i z e s t h a t a l i t e r a t u r e rev iew i s u s u a l l y woven i n t o the d e s c r i p t i o n of the r e s u l t s when u s i n g the phenomenolog ica l method, so as to " b r a c k e t " e x p l a n a t i o n s about the phenomenon under s tudy ( O i l e r , 1981). However, women's e x p e r i e n c e w i t h MI i s not a phenomenon about which there i s a body of knowledge. The l i t e r a t u r e rev iew emphasizes t h i s l a c k of a t t e n t i o n by p r e s e n t i n g the t o t a l works to date found by the r e s e a r c h e r on women's e x p e r i e n c e w i t h MI. The f i n d i n g s of these s t u d i e s h i g h l i g h t the need f o r f u r t h e r i n v e s t i g a t i o n s because of s tudy l i m i t a t i o n s . These s t u d i e s do not generate a mind se t or p r e s u p p o s i t i o n s about the nature and meaning of the MI i l l n e s s e x p e r i e n c e f o r women. I t must be noted t h a t there i s a sma l l body of e p i d e m i o l o g i c a l l i t e r a t u r e c o n c e r n i n g women and c o r o n a r y or i s chemic h e a r t d i s e a s e (see f o r example: Bengt s son , H a l l s t r o m , & T i b b l i n , 1973; S z k l o , T o n a s c l a , & G o r d i s , 1976; Waldron , 1978; Haynes & F e l n l e i b , 1980; S a l o n e n , 1982; and Rosenberg e t a l . , 1983). The r e s e a r c h focus of t h i s l i t e r a t u r e i s an e x p l a n a t i o n of the sex d i f f e r e n t i a l in i n c i d e n c e r a t e s f o r hear t d i s e a s e . These works s t u d y the r e l a t i v e e f f e c t s of r i s k f a c t o r s i n the development of h e a r t d i s e a s e i n men and women. A d d i t i o n a l l y , the r e l a t i o n s h i p of p s y c h o s o c i a l v a r i a b l e s to h e a r t d i s e a s e i n women i s i n v e s t i g a t e d i n an e f f o r t t o deter m i n e the re a s o n s f o r the marked d i f f e r e n c e s between the se x e s . The f i n d i n g s t o date from these works a re i n c o n c l u s i v e . The d i f f e r e n c e s between men and women are not thought t o be a s s o c i a t e d w i t h sex d i f f e r e n c e s i n r i s k f a c t o r s ( S z k l o , 1980) and a r e , a t p r e s e n t , not u n d e r s t o o d . Because the s t u d i e s w i t h i n t h i s a r e a are not d e s i g n e d t o a d d r e s s any f a c e t s of women's i l l n e s s e x p e r i e n c e w i t h MI, but o n l y p r e - i n f a r c t i o n e v e n t s , these s t u d i e s a r e not i n c l u d e d i n t h i s l i t e r a t u r e r e v i e w . The r e v i e w of the l i t e r a t u r e i s o r g a n i z e d i n t o t h r e e s e c t i o n s . The f i r s t s e c t i o n i s a summary of the s t u d i e s t h a t t h i s w r i t e r found i n the l i t e r a t u r e d i r e c t l y and s p e c i f i c a l l y a d d r e s s i n g women's e x p e r i e n c e w i t h MI. The second s e c t i o n i s a p r e s e n t a t i o n of MI s t u d i e s t h a t i n c l u d e d women i n the samples and d i f f e r e n t i a t e d the a n a l y s i s by sex. The f i n a l s e c t i o n i s a d i s c u s s i o n of the l i t e r a t u r e on p a t i e n t p e r c e p t i o n and MI. T h i s s e c t i o n speaks t o the need t o s t u d y the p a t i e n t ' s p o i n t of view and p r o v i d e s a b a s i s from which t o view t h i s r e s e a r c h problem. Women With MI: Rese a r c h D i r e c t l y S t u d y i n g Women P e t e r , L u x t o n , and Harper (1974) r e s e a r c h e d m o r t a l i t y i n women w i t h acute MI d u r i n g a f o u r year p e r i o d i n A u s t r a l i a . The r e s e a r c h e r s were p r o m p t e d to t h i s i n v e s t i g a t i o n by f i g u r e s w h i c h s u g g e s t e d t h a t t h e p r o g n o s i s o f a c u t e MI was d i f f e r e n t f o r women t h a n f o r men. In t h i s s t u d y , women were shown t o h a v e a s i g n i f i c a n t l y h i g h e r m o r t a l i t y r a t e one y e a r p o s t - i n f a r c t i o n c o m p a r e d to t h e t o t a l one y e a r p o s t - i n f a r c t i o n m o r t a l i t y r a t e . I t i s i m p o r t a n t t o n o t e t h a t women c o m p r i s e d 17% o f t h e t o t a l s a m p l e o f 903 p a t i e n t s , o r 154 women. T h i s i s a r e l a t i v e l y s m a l l s a m p l e s i z e . The s t r e n g t h s o f t h i s s t u d y a r e t h e i n v e s t i g a t i o n t i m e p e r i o d ( f o u r y e a r s ) a n d t h e t o t a l s a m p l e s i z e . P a p a d o p o u l o s , B e a u m o n t , S h e l l e y , a n d L a r r i m o r e ( 1 9 8 3 ) , i n a more r e c e n t w o r k , s t u d i e d MI a n d t h e s e x u a l a c t i v i t y o f women p a t i e n t s . T h e s e r e s e a r c h e r s c i t e d t h e p a u c i t y o f d a t a on t h i s s u b j e c t a s t h e i m p e t u s f o r t h e i r i n v e s t i g a t i o n . B e c a u s e a c o n s i d e r a t i o n o f s e x u a l i t y i s w e l l e s t a b l i s h e d a s a c r i t i c a l c o m p o n e n t o f t h e p r o c e s s o f c a r d i a c r e h a b i l i t a t i o n ( M c L a n e , K r o p , & M e h t a , 1 9 8 0 ) , t h i s l a c k o f r e s e a r c h c o n c e r n i n g women 's s e x u a l i t y a f t e r a h e a r t a t t a c k i s h i g h l y s i g n i f i c a n t t o n o t e w i t h i n t h e c o n t e x t o f t h e r e s e a r c h p r o b l e m o f t h i s s t u d y . P a p a d o p o u l o s e t a l . i n t e r v i e w e d 130 women p a t i e n t s a n d f o u n d t h a t a n MI h a d a n e g a t i v e i m p a c t on women 's s e x u a l i t y , a n d , f u r t h e r , t h a t c o u n s e l l i n g on s e x u a l i t y was n o t a d e q u a t e l y p r o v i d e d . D a t a c o l l e c t i o n f o c u s e d on r e s u m p t i o n a n d f r e q u e n c y o f s e x u a l a c t i v i t y a n d r e p o r t s o f symptoms d u r i n g s e x u a l a c t i v i t y . The s t u d y d i d n o t e x p l o r e how women p o s t - i n f a r c t i o n v i e w e d t h e i r s e x u a l i t y , t h e i r f e e l i n g s a n d t h o u g h t s . J o h a n s s o n e t a l . ( 1 9 8 4 ) r e s e a r c h e d s e x d i f f e r e n c e s i n p r e -i n f a r c t i o n c h a r a c t e r i s t i c s a n d l o n g t e r m s u r v i v a l . The s t u d y spanned e l e v e n y ears and the sample c o n s i s t e d of 262 women and 1,259 men. T h e i r s i g n i f i c a n t f i n d i n g was t h a t once a woman has had an MI, the r i s k of de a t h i s a t l e a s t as h i g h as t h a t f o r men. G r i f f o e t a l . (1983) conducted a c o m p a r a t i v e s t u d y of the e f f e c t s of a p h y s i c a l r e h a b i l i t a t i o n programme i n 179 men and 49 women po s t - M I . The stu d y demonstrated t h a t c o n t r o l l e d p h y s i c a l t r a i n i n g In women c o n v a l e s c i n g from an MI r e s u l t e d i n an improvement i n work c a p a c i t y s i m i l a r t o t h a t a c h i e v e d i n men. However, t h i s improvement was not m a i n t a i n e d because of the women's poor c o m p l i a n c e t o the programme a t home. The i n v e s t i g a t o r s c o n c l u d e t h a t these r e s u l t s do not s u p p o r t a u t o m a t i c a l l y e x c l u d i n g women from such p h y s i c a l r e h a b i l i t a t i o n programmes. T h i s s t atement i s an example of the i n c l i n a t i o n w i t h i n the MI l i t e r a t u r e t o f i t women i n t o the male p e r s p e c t i v e r a t h e r than to c o n s i d e r women's unique problems and needs. In the most r e c e n t work t h a t t h i s w r i t e r found, C h i r i k o s and N i c k e l (1984) r e s e a r c h e d work d i s a b i l i t y from c o r o n a r y h e a r t d i s e a s e i n women. These a u t h o r s c o n c l u d e from r e c e n t U n i t e d S t a t e s s t a t i s t i c s t h a t , d e s p i t e the q u i t e d i f f e r e n t i n c i d e n c e r a t e s , work d i s a b i l i t y due to h e a r t d i s e a s e i s the same i n men and women. They i n f e r t h a t t h i s i s due to an i n c r e a s e d l i k e l i h o o d of women r e s p o n d i n g t o h e a r t d i s e a s e by c h a n g i n g work b e h a v i o u r o r d r o p p i n g out of the l a b o u r f o r c e . C h i r i k o s e t a l . a s s e r t t h a t work d i s a b i l i t y i s i m p o r t a n t t o examine because r e t u r n t o work i s f r e q u e n t l y u t i l i z e d as a measure of s u c c e s s f u l c a r d i a c r e h a b i l i t a t i o n and because changes i n work a c t i v i t y have s o c i a l and economic e f f e c t s . These a u t h o r s speak e m p h a t i c a l l y t o the d e a r t h of r e s e a r c h on women and h e a r t d i s e a s e i n the face of an expanse of l i t e r a t u r e on b e h a v i o u r a l a d j u s t m e n t s t o h e a r t d i s e a s e f o r men. To i l l u s t r a t e t h i s p o i n t , C h i r i k o s e t a l . (1984) r e p o r t the r e s u l t s of t h e i r b i b l i o g r a p h i c s e a r c h conducted on the t o p i c of post-MI and p o s t - c o r o n a r y a r t e r y bypass work r e s u m p t i o n from 1964-1982. Of the 33 s t u d i e s found, o n l y seven i n c l u d e d women s u b j e c t s and a n a l y z e d r e s u l t s by sex. They f u r t h e r noted the s m a l l sample s i z e s i n these works t o be a major l i m i t a t i o n . The g o a l of C h i r i k o s e t a l . ' s (1984) r e s e a r c h was to determine the presence of sex d i f f e r e n c e s i n l a b o u r f o r c e w i t h d r a w a l a f t e r a d i s c r e t e and s i m i l a r e p i s o d e of h e a r t d i s e a s e ; a c u t e MI was s e l e c t e d . A secondary g o a l was t o s t u d y f a c t o r s a f f e c t i n g women's h i g h e r r a t e s of work w i t h d r a w a l . C h i r i k o s e t a l . (1984) d i d indeed f i n d t h a t a s i g n i f i c a n t l y l a r g e r p e r c e n t a g e of p r e v i o u s l y employed w o r k i n g women were w o r k - d i s a b l e d subsequent t o a h e a r t a t t a c k compared w i t h w o r k i n g men (work d e f i n e d i n t h i s s t u d y as market work). Another i m p o r t a n t f i n d i n g was t h a t those p e r s o n s who r e p o r t e d a c t i v i t y l i m i t a t i o n s i n the e a r l y p o s t - h o s p i t a l p e r i o d were found t o be l e s s l i k e l y t o r e t u r n t o work. I n t e r e s t i n g l y , e x p e c t e d market e a r n i n g s were not shown to i n f l u e n c e the r e t u r n t o work b e h a v i o u r of women as was the s i t u a t i o n f o r the male c o u n t e r p a r t s i n t h i s s t u d y and f o r men i n o t h e r s t u d i e s as c i t e d by C h i r i k o s e t a l . These a u t h o r s c o n c l u d e t h a t s i g n i f i c a n t l y h i g h e r r a t e s of work d i s a b i l i t y i n women are not due to d i s e a s e s e v e r i t y , but to the b e h a v i o u r a l response to the co u r s e of the i l l n e s s e x p e r i e n c e . The r e s u l t s of t h i s r e s e a r c h h i g h l i g h t the need t o e x p l o r e the i l l n e s s e x p e r i e n c e of women w i t h MI. An u n d e r s t a n d i n g of the meaning t o women of t h e i r h e a r t a t t a c k e x p e r i e n c e may a s s i s t i n p u t t i n g these f i n d i n g s i n t o p e r s p e c t i v e . T h i s s t u d y was r e v i e w e d i n d e t a i l because i t i s c u r r e n t and m e t h o d o l o g i c a l l y sound (sample s i z e and e m p i r i c a l model d e s i g n ) . T h i s s t u d y p o w e r f u l l y s u p p o r t s the c o n t e n t i o n of t h i s problem statement t h a t MI i s a h i g h l y s i g n i f i c a n t h e a l t h problem f o r women. The r e s e a r c h d i r e c t l y and s p e c i f i c a l l y s t u d y i n g women's e x p e r i e n c e w i t h MI i s a s t o n i s h i n g l y l i m i t e d — the f i v e s t u d i e s r e v i e w e d above comprise the t o t a l works t h i s w r i t e r was a b l e t o l o c a t e i n a h e a l t h s c i e n c e s l i t e r a t u r e s e a r c h . These s t u d i e s r e p r e s e n t v e r y d i v e r s e f a c e t s of women's e x p e r i e n c e w i t h MI: 1) m o r t a l i t y , 2) s e x u a l a c t i v i t y , 3) l o n g term s u r v i v a l , 4) p h y s i c a l r e h a b i l i t a t i o n , and 5) work d i s a b i l i t y . I t i s impo r t a n t to note t h a t a l l f i v e s t u d i e s y i e l d e d s i g n i f i c a n t f i n d i n g s i n r e l a t i o n t o women's e x p e r i e n c e w i t h MI. These r e s u l t s p o i n t t o a p o s t - i n f a r c t i o n p e r i o d t h a t i s d i f f i c u l t and d i f f e r e n t f o r women and emphasize the need t o s t u d y women's exper i e n c e . Women With MI: S t u d i e s I n c l u d i n g Women There are a few r e p o r t e d s t u d i e s on the a f t e r m a t h of a h e a r t a t t a c k which i n c l u d e women s u b j e c t s i n the samples and d i f f e r e n t i a t e the r e s e a r c h a n a l y s i s by sex. These s t u d i e s are now b r i e f l y r e v i e w e d . A Japanese s t u d y i n 1970 ( H i n o h a r a , 1970) r e s e a r c h e d p s y c h o l o g i c a l a s p e c t s of c a r d i a c r e h a b i l i t a t i o n . Women who had s u f f e r e d a h e a r t a t t a c k were found t o be more type "A" ( h a r d d r i v i n g , c o m p e t i t i v e ) than the c o n t r o l group of h e a l t h y women. T h i s f i n d i n g s u p p o r t e d the e a r l i e r work of Friedman and Rosenman (19 6 1 ) , the o r i g i n a t o r s of the type "A" and type "B" p e r s o n a l i t y t y p o l o g i e s . They had noted women w i t h c o r o n a r y h e a r t d i s e a s e (not MI s p e c i f i c a l l y ) t o be more type "A" than t h e i r matched sample of h e a l t h y women. In an e x t e n s i v e l o n g i t u d i n a l s t u d y c o n ducted i n Sweden (Bengtsson e t a l . , 1973), women w i t h MI were noted t o d i f f e r from h e a l t h y women i n t h e i r h i g h e r l e v e l s of s t r e s s , a g g r e s s i v e and n e u r o t i c s e l f - a s s e r t i o n ( t y p e "A" b e h a v i o u r ) . Moss, De C a m i l l a , and D a v i s (1976) r e s e a r c h e d p r o g n o s t i c f a c t o r s i n the e a r l y p o s t - h o s p i t a l phase f o l l o w i n g an MI. In t h e i r s t u d y , female sex was a s s o c i a t e d w i t h a s i g n i f i c a n t l y i n c r e a s e d m o r t a l i t y r a t e . T h i s marks the second s t u d y r e p o r t e d i n t h i s l i t e r a t u r e r e v i e w w i t h t h i s f i n d i n g . I t must be n o t e d , however, t h a t i n both s t u d i e s , t h e r e a re r e l a t i v e l y s m a l l sample s i z e s of women. The women i n t h i s s t u d y r e p r e s e n t e d 18% of the t o t a l p o p u l a t i o n of 518 p a t i e n t s , a l i m i t a t i o n i n g e n e r a l i z i n g the r e s u l t s . S t e r n , P a s c a l e , and Ackerman ( 1 9 7 7 ) , i n t h e i r e x t e n s i v e s t u d y o v e r a one year p e r i o d of l i f e a d j u s t ment p o s t - i n f a r c t i o n , a l s o r e p o r t e d a s i g n i f i c a n t l y h i g h e r m o r t a l i t y f o r the women i n t h e i r s t u d y . A g a i n , t h e i r s m a l l sample s i z e of women i s p r o b l e m a t i c . The o c c u r r e n c e of t h i s f i n d i n g i n yet a n o t h e r 20 s t u d y , however, i s im p o r t a n t to n o t e . S t e r n e t a l . ' s (1977) s t u d y r e p o r t e d as a "new and c h a l l e n g i n g f i n d i n g " (p.1684) the c o m p a r a t i v e l y more d i f f i c u l t r e h a b i l i t a t i o n c o u r s e e x p e r i e n c e d by the p o s t - i n f a r c t i o n women. They noted the women to be s i g n i f i c a n t l y d e p r e s s e d and a n x i o u s both i n h o s p i t a l and a t the one year f o l l o w - u p . A l s o , the women sampled took l o n g e r to r e t u r n to work and to r e g a i n s e x u a l f u n c t i o n i n g . C h i r i k o s e t a l . ( 1 9 8 4 ) , as r e v i e w e d p r e v i o u s l y , s u b s t a n t i a t e d the r e t u r n to work f i n d i n g and Papadopoulos e t a l . ' s ( 1983) s t u d y of women's s e x u a l a c t i v i t y p o s t - i n f a r c t i o n s u p p o r t s d i f f i c u l t i e s i n r e s u m p t i o n of s e x u a l a c t i v i t y . To account f o r t h e i r r e s u l t s , S t e r n e t a l . (1977) p o s t u l a t e t h a t the p o o r e r r e h a b i l i t a t i o n c o u r s e f o r the women i n t h e i r s t u d y i s r e l a t e d t o p s y c h o s o c i a l a s p e c t s . The r a t i o n a l e f o r t h i s a s s e r t i o n stems from the h i g h degree of type "A" b e h a v i o u r measured i n the women, h i g h e r even than the men i n the s t u d y . These r e s u l t s a r e more a l a r m i n g than those d i s c u s s e d above. P r e v i o u s s t u d i e s found p o s t - i n f a r c t i o n women to be more type "A" i n a comparison w i t h o t h e r women. T h i s s t u d y s u g g e s t s t h a t p o s t - i n f a r c t i o n women are more type "A" tha n a c o r r e s p o n d i n g group of p o s t - i n f a r c t i o n men. These r e s e a r c h e r s acknowledge t h a t f u r t h e r r e s e a r c h i s w a r r a n t e d t o t e s t these f i n d i n g s , b oth the type "A" f i n d i n g s and the s e e m i n g l y p o o r e r r e h a b i l i t a t i o n outcome f o r women. T h i s w r i t e r assumes t h a t t h i s c a l l f o r f u r t h e r r e s e a r c h i s s t i m u l a t e d b oth by the s m a l l sample s i z e of women s u b j e c t s and these i m p o r t a n t f i n d i n g s i n r e l a t i o n to women. In a st u d y of c o n v a l e s c e n t d i s c o m f o r t f o l l o w i n g acute c o r o n a r y e v e n t s , S p e e g l e , Bayer, and Greene (1979) q u a n t i f i e d p a t i e n t s ' e x p r e s s i o n s of d i s c o m f o r t . There was found t o be a s i g n i f i c a n t a s s o c i a t i o n between b e i n g female and h i g h e r d i s c o m f o r t s c o r e s . The r e s e a r c h e r s a t t r i b u t e d t h i s to women's g r e a t e r a cceptance i n v e r b a l i z i n g d i s c o m f o r t compared w i t h men i n our s o c i e t y . T h i s s t u d y i s im p o r t a n t as i t i s the o n l y s t u d y of women w i t h MI t h a t r e s e a r c h e d some a s p e c t of women's view of the i l l n e s s e x p e r i e n c e . T h i s l i t e r a t u r e r e v i e w of s t u d i e s i n c l u d i n g women i n samples and a n a l y s e s s u g g e s t s t h a t women may be an a t - r i s k group i n terms of the c o u r s e of r e h a b i l i t a t i o n p o s t - i n f a r c t i o n . S m a l l sample s i z e s c l e a r l y l i m i t g e n e r a l i z a t i o n , but the f i n d i n g s r e p o r t e d here g i v e d e f i n i t e e v i d e n c e of the need t o st u d y women's e x p e r i e n c e w i t h a h e a r t a t t a c k . MI and P a t i e n t P e r c e p t i o n s There i s a body of l i t e r a t u r e c o n c e r n e d w i t h the v a r i a b l e s a f f e c t i n g the co u r s e and outcome of MI. Croog e t a l . ( 1 9 6 8 ) , i n a c l a s s i c r e v i e w of the l i t e r a t u r e on s o c i a l and p s y c h o l o g i c a l f a c t o r s i n the r e c o v e r y p r o c e s s of the h e a r t p a t i e n t , o u t l i n e d d i r e c t i o n s f o r f u t u r e r e s e a r c h . These r e s e a r c h e r s noted the p a u c i t y of work on p a t i e n t p e r c e p t i o n and p o s s i b l e r e l a t i o n s h i p s between p e r c e p t i o n and outcome of r e h a b i l i t a t i o n . These a u t h o r s emphasized the need f o r e m p i r i c a l work f o c u s i n g on how the p a t i e n t views the i l l n e s s e x p e r i e n c e . T h e i r o b s e r v a t i o n s s t i m u l a t e d a number of s t u d i e s on p a t i e n t p e r c e p t i o n and outcome. G a r r i t y (1973) c o n c l u d e d t h a t " h e a l t h p e r c e p t i o n s h o u l d perhaps be c o n s i d e r e d t h e o r e t i c a l l y as a major i n t e r v e n i n g v a r i a b l e . . . " ( p . 7 1 5 ) . G a r r i t y found the p a t i e n t ' s p e r c e p t i o n of h e a l t h s t a t u s to be more i m p o r t a n t than even c l i n i c a l h e a l t h s t a t u s i n r e l a t i o n to r e t u r n to work p o s t - i n f a r c t i o n . Cay e t a l . (1973) i d e n t i f i e d t h a t p a t i e n t s ' own o p i n i o n s of t h e i r p h y s i c a l s t a t u s and e x t e n t of d i s a b i l i t y d e t e r m i n e d t h e i r r e t u r n t o work p a t t e r n . In a subsequent s t u d y , G a r r i t y and o t h e r s ( G a r r i t y , Somes, & Marx, 1978) r e p l i c a t e d many e a r l i e r works i n f i n d i n g s e v e r a l c o r r e l a t e s of t h i s v a r i a b l e of p a t i e n t p e r c e p t i o n . They proposed the development of a c o n c e p t u a l model of p a t i e n t h e a l t h p e r c e p t i o n . In a more r e c e n t s t u d y , Byrne (1982) found a s t r o n g r e l a t i o n s h i p between i l l n e s s b e h a v i o u r and outcome a t e i g h t months p o s t - i n f a r c t i o n . In t h i s s t u d y , the d e f i n i t i o n of i l l n e s s b e h a v i o u r i s s i m i l a r to p a t i e n t p e r c e p t i o n . C h i r i k o s e t a l . ' s (1984) r e s e a r c h , as r e p o r t e d i n t h i s l i t e r a t u r e r e v i e w e a r l i e r , n o t e d t h a t r e t u r n to work b e h a v i o u r was a s s o c i a t e d w i t h the p a r t i c i p a n t s ' view of t h e i r p h y s i c a l l i m i t a t i o n s . These l i t e r a t u r e f i n d i n g s s u p p o r t a r e l a t i o n s h i p between p a t i e n t p e r c e p t i o n and the c o u r s e of the i l l n e s s e x p e r i e n c e w i t h MI. I f p e r c e p t i o n i s s t r o n g l y l i n k e d w i t h subsequent b e h a v i o u r , i t i s c l e a r l y a p r i o r i t y to r e s e a r c h the p a t i e n t ' s p o i n t of view. Because a major component of c a r d i a c r e h a b i l i t a t i o n i s l i f e s t y l e a d j u s t m e n t , knowledge of how the p a t i e n t sees the i l l n e s s e x p e r i e n c e would a s s i s t n u r s e s to p r o v i d e m e a n i n g f u l h e l p . Summary The importance of MI i n r e l a t i o n to women cannot be u n d e r r a t e d . MI i s a s i g n i f i c a n t h e a l t h problem f o r women. However, women w i t h MI have r e c e i v e d l i m i t e d a t t e n t i o n i n the p r o f e s s i o n a l l i t e r a t u r e . The f i n d i n g s of the few s t u d i e s c o n d u c t e d of women's e x p e r i e n c e w i t h MI i n t i m a t e t h a t women may w e l l p r e s e n t a p a r t i c u l a r c h a l l e n g e i n c a r d i a c r e h a b i l i t a t i o n . K l einman e t a l . ' s (1978) model a s s e r t s t h a t s o c i a l i z a t i o n a f f e c t s how i n d i v i d u a l s p e r c e i v e t h e i r i l l n e s s e x p e r i e n c e s . T h i s model d i r e c t s h e a l t h p r o f e s s i o n a l s t o e l i c i t the p a t i e n t ' s view so t h a t s o c i a l f a c t o r s a re c o n s i d e r e d i n the p l a n n i n g and p r o v i s i o n of c a r e . C u r r e n t c o n c e p t s In c a r d i a c r e h a b i l i t a t i o n are based upon an u n d e r s t a n d i n g of t h i s p r o c e s s i n men. An u n d e r s t a n d i n g of women's p e r c e p t i o n s of t h e i r i l l n e s s e x p e r i e n c e w i t h MI would p r o v i d e a more v a l i d b a s i s f o r n u r s i n g p r a c t i c e . As d e s c r i b e d i n Ch a p t e r 1, the ph e n o m e n o l o g i c a l method of i n q u i r y i s the a p p r o p r i a t e methodology f o r the c o n c e p t u a l framework and purpose of t h i s s t u d y . Chapter 3 o u t l i n e s the im p l e m e n t a t i o n of the s e l e c t e d methodology i n t h i s s t u d y . CHAPTER 3 Methodology lRtr°dMCt;iqn, T h i s c h a p t e r d e s c r i b e s the a p p l i c a t i o n of the phenomenolog ica l method of i n q u i r y in t h i s s t u d y . The r e s e a r c h e r ' s i n t e r p r e t a t i o n and implementa t ion of the s t u d y ' s methodology are p r e s e n t e d in r e l a t i o n to s e l e c t i o n of p a r t i c i p a n t s , da t a c o l l e c t i o n , da ta a n a l y s i s , and e t h i c a l cons i d e r a t i o n s . S e l e c t i o n of P a r t i c i p a n t s The phenomenolog ica l method d i r e c t s the r e s e a r c h e r to c o l l e c t da t a from s u b j e c t s who l i v e the e x p e r i e n c e t h a t i s under i n v e s t i g a t i o n . F u r t h e r , t h i s r e s e a r c h methodology c o n s i d e r s the i n f o r m a n t ' s n a t u r a l s e t t i n g or the home environment to be most conduc ive to the s h a r i n g of p e r c e p t i o n s of l i f e event s ( O i l e r , 1982). Women who had r e t u r n e d home f o l l o w i n g h o s p i t a l i z a t i o n f o r MI were de termined to be the a p p r o p r i a t e da t a s o u r c e . C o n s i s t e n t w i t h t h i s methodology, a p u r p o s i v e or t h e o r e t i c a l s ampl ing t echnique was u t i l i z e d to s e l e c t the s t u d y ' s p a r t i c i p a n t s (Swartz & J a c o b s , 1979). The p a r t i c i p a n t s were s e l e c t e d a c c o r d i n g to t h e i r a b i l i t y to addres s the s t u d y ' s r e s e a r c h q u e s t i o n s . In t h i s s t u d y , p a r t i c i p a n t competency was de termined by the meeting of f i v e c r i t e r i a . C r i t e r i a f o r S e l e c t i o n The s e l e c t i o n of p a r t i c i p a n t s f o r t h i s s t u d y was g u i d e d by the f o l l o w i n g f i v e c r i t e r i a : 1. Over 18 ye a r s of age, 2. Able to speak and r e a d E n g l i s h , 3. A l e r t and o r i e n t e d t o t i m e , p e r s o n , and p l a c e , 4. Diagnosed w i t h an MI, and 5. Home f o l l o w i n g h o s p i t a l d i s c h a r g e f o r a p p r o x i m a t e l y 2 to 16 weeks. S e l e c t i o n Procedure I n i t i a l l y , the r e s e a r c h e r sought p o t e n t i a l s u b j e c t s through r e f e r r a l from the community p r a c t i c e s of p a r t i c i p a t i n g c a r d i o l o g i s t s i n the G r e a t e r Vancouver a r e a . Because s u b j e c t s were not f o r t h c o m i n g , the s o u r c e s f o r s u b j e c t s were expanded to e x p e d i t e the r e s e a r c h p r o c e s s . C o n s e q u e n t l y , women were s e l e c t e d from one Homecare f a c i l i t y and from the census r e c o r d s i n two acu t e c a r e h o s p i t a l s , a l l l o c a t e d w i t h i n the G r e a t e r Vancouver a r e a . When the r e s e a r c h e r r e c e i v e d the name of a p o t e n t i a l s u b j e c t , s u i t a b i l i t y was de t e r m i n e d as p e r the s e l e c t i o n c r i t e r i a and the p r o f e s s i o n a l o p i n i o n of the p h y s i c i a n and/or nurse i n v o l v e d . F o l l o w i n g t h i s s t e p , the r e s e a r c h e r m a i l e d out the P a t i e n t I n f o r m a t i o n L e t t e r < Appendix A ) . F o r some of the p o t e n t i a l s u b j e c t s , t h i s l e t t e r was the i n i t i a l c o n t a c t . For o t h e r s , t h e i r c a r d i o l o g i s t and/or nurse p r o v i d e d an i n t r o d u c t o r y e x p l a n a t i o n of the s t u d y and d e t e r m i n e d a g e n e r a l w i l l i n g n e s s to p a r t i c i p a t e . A p p r o x i m a t e l y one t o two weeks l a t e r , the r e s e a r c h e r t e l e p h o n e d the p o t e n t i a l s u b j e c t t o answer q u e s t i o n s , a s s e s s a w i l l i n g n e s s t o p a r t i c i p a t e , and to s e t up a m u t u a l l y c o n v e n i e n t appointment time f o r the home i n t e r v i e w . There was one d e p a r t u r e from t h i s p r o c e d u r e , the s u b j e c t r e f e r r e d by Homecare. In t h i s i n s t a n c e , the Homecare nurse h a n d - d e l i v e r e d the P a t i e n t I n f o r m a t i o n L e t t e r . Only two women were not r e c r u i t e d through p a r t i c i p a t i n g c a r d i o l o g i s t s , the woman r e f e r r e d by Homecare and a n o t h e r woman from the census r e c o r d s i n one of the acu t e c a r e h o s p i t a l s . In the case of these s u b j e c t s , the r e s e a r c h e r informed t h e i r c a r d i o l o g i s t s of t h e i r i nvolvement i n the s t u d y . In t o t a l , e i g h t women were approached f o r p a r t i c i p a t i o n . A l l e i g h t women r e a d i l y a greed t o be i n v o l v e d . The r e s e a r c h e r ' s f i r s t c o n t a c t by t e l e p h o n e was a p o s i t i v e e n c o u n t e r i n a l l i n s t a n c e s . The women seemed to ask q u e s t i o n s e a s i l y about the s t u d y and what was e x p e c t e d of them. The Consent Form (Appendix B> was s i g n e d a t the f i r s t i n t e r v i e w . P r i o r to the s i g n i n g , s u b j e c t s were g i v e n an o p p o r t u n i t y t o a g a i n ask q u e s t i o n s . The s u b j e c t ' s r o l e i n the s t u d y was r e i t e r a t e d and e t h i c a l s a f e g u a r d s were o u t l i n e d . The r e s e a r c h e r r e a d the consent a l o u d . The s u b j e c t then r e r e a d the consen t and s i g n e d i t . The i n t e r v i e w then commenced. Data C o l l e c t i o n The d a t a were c o m p i l e d t h r o u g h a s e r i e s of 11 i n t e n s i v e i n t e r v i e w s o ver a t h r e e month time frame. There were e i g h t f i r s t i n t e r v i e w s and t h r e e second i n t e r v i e w s . The l e n g t h of the i n t e r v i e w s ranged from 45 to 90 minute s . The i n t e r v i e w s were s e m i - s t r u c t u r e d . The r e s e a r c h e r was gu ided by q u e s t i o n s adapted from Kle inman e t a l . ' s (1978) s i x q u e s t i o n s (Appendix C ) . The adapted q u e s t i o n s se rved o n l y as a b a s i s f o r b e g i n n i n g da ta c o l l e c t i o n . Quest ions were added or d e l e t e d as de termined by the r e s e a r c h e r d u r i n g a n d / o r f o l l o w i n g the f i r s t i n t e r v i e w . T h i s procedure i s c o n s i s t e n t w i t h phenomenolog ica l methodology, where the r e s e a r c h e r ' s r o l e i s one of a c t i v e involvement in s t r i v i n g to see the s u b j e c t ' s p e r s p e c t i v e as i t u n f o l d s . The r e s e a r c h e r p a r t i c i p a t e s " i n the c o n s t i t u t i o n of the a c t u a l d a t a " ( G i o r g i , 1975a, p . 1 0 1 ) . As O i l e r (1983) p o i n t s o u t , the r e s e a r c h e r ' s involvement i s " e x p l o i t e d " and "empathic and i n t u i t i v e awareness" are i n t e g r a l to the r e s e a r c h p roce s s in t h i s methodology ( p . 1 7 9 ) . The women seemed c o m f o r t a b l e and u n i n h i b i t e d w i t h the a u d i o t a p i n g . Once the i n t e r v i e w commenced, the t a p i n g seemed to be f o r g o t t e n and the women o f t e n seemed s u r p r i s e d when the tape r e c o r d e r c l i c k e d o f f to i n d i c a t e a completed s i d e . A l t h o u g h the o p t i o n of r e f u s i n g to answer any q u e s t i o n s or to t e rminate the i n t e r v i e w a t any time was c l e a r l y communicated to the women, not one of the women made such a r e q u e s t . There were no apparent d i f f i c u l t i e s in e s t a b l i s h i n g and m a i n t a i n i n g r a p p o r t w i t h the women. Before and f o l l o w i n g the taped p o r t i o n of the i n t e r v i e w , there was a time f o r s o c i a l c o n v e r s a t i o n . Most of the women expre s sed f e e l i n g p l e a s e d to be c o n t r i b u t i n g to an u n d e r s t a n d i n g of women's e x p e r i e n c e w i t h MI. Many a l s o thanked the r e s e a r c h e r f o r her time and i n d i c a t e d tha t the e x p e r i e n c e was in some way b e n e f i c i a l to them. A f t e r l e a v i n g the p a r t i c i p a n t ' s home, the r e s e a r c h e r r e c o r d e d f i e l d n o tes as an addendum t o the taped i n t e r v i e w . These f i e l d n o t e s c o n s i s t e d of s p e c i f i c d a t a r e l a t e d to the c h a r a c t e r i s t i c s of the p a r t i c i p a n t s and g e n e r a l o b s e r v a t i o n s and i m p r e s s i o n s about the p a r t i c i p a n t and the i n t e r v i e w p r o c e s s . A l s o , any s i g n i f i c a n t d a t a i n t e r j e c t e d i n the non-taped s o c i a l c o n v e r s a t i o n were n o t e d . The f i e l d n o t e s and the v e r b a t i m t r a n s c r i p t s of the taped i n t e r v i e w s c o m p r i s e d the d a t a f o r t h i s s t u d y . c o n s t r y c t i o n of Accounts The r e s e a r c h e r i s i n t i m a t e l y and a c t i v e l y i n v o l v e d i n the r e s e a r c h p r o c e s s i n p h e n o m e n o l o g i c a l r e s e a r c h . Because the s o c i a l l y c o n s t r u c t e d n a t u r e of a l l phenomena i s a b a s i c t e n e t of the p h e n o m e n o l o g i c a l method, t h i s methodology acknowledges and a c c e p t s the i n t e r s u b j e c t i v i t y of r e s e a r c h e r and s u b j e c t . Meanings are not a t t a c h e d to phenomena i n a vacuum. Both the r e s e a r c h e r and the s u b j e c t b r i n g t h e i r own unique frame of r e f e r e n c e to the r e s e a r c h s i t u a t i o n t h r ough which the s i t u a t i o n i s i n t e r p r e t e d . The r e s e a r c h e r e x p l o r e s "the meaning of t h a t e x p e r i e n c e as i t u n f o l d s f o r the p a r t i c i p a n t " (Ornery, 1983, p. 5 4 ) . R i s t ( 1979) r e g a r d s the t a s k of the r e s e a r c h e r as "always one of l e a r n i n g how those i n v o l v e d i n t e r p r e t e d and gave meaning t o the e x p e r i e n c e " ( p . 2 0 ) . In t h i s s t u d y , the r e s e a r c h e r used the i n t e r v i e w q u e s t i o n s as a l o o s e i n t e r v i e w s t r u c t u r e . Q u e s t i o n s were posed i n an open-ended way. The r e s e a r c h e r responded to the p a r t i c i p a n t s u s i n g r e f l e c t i o n and c l a r i f i c a t i o n and f r e q u e n t s u g g e s t i o n s to " t e l l me more." Through t h i s i n t e r v i e w s t y l e , the p a r t i c i p a n t s g u i d e d the c o n s t r u c t i o n of the a c c o u n t s . The r e s e a r c h e r ' s major r o l e was to a s s i s t the p a r t i c i p a n t s t o e x p l o r e the meaning to them of t h e i r i l l n e s s e x p e r i e n c e . As d a t a c o l l e c t i o n p r o c e e d e d , the r e s e a r c h e r was a b l e t o become submerged w i t h i n the e x p e r i e n c e . The q u a l i t y of the d a t a i n c r e a s e d w i t h the r e s e a r c h e r ' s enhanced u n d e r s t a n d i n g of the i l l n e s s e x p e r i e n c e . Data A n a l y s i s To a n a l y z e the c o l l e c t e d d a t a , the r e s e a r c h e r d e v e l o p e d a proced u r e by s y n t h e s i z i n g the w r i t i n g s of s e l e c t e d p h e n o m e n o l o g i c a l r e s e a r c h e r s ( G i o r g i , 1975a, 1975b; Ornery, 1983; L o f l u n d & L o f l u n d , 1984). F o l l o w i n g each i n t e r v i e w , the r e s e a r c h e r l i s t e n e d t o the tape t o g e t a "sense of the whole" ( G i o r g i , 1975b). The tape was t r a n s c r i b e d v e r b a t i m . The r e s e a r c h e r then l i s t e n e d t o the tape and r e a d the t r a n s c r i p t t o immerse h e r s e l f i n the d a t a . The next s t e p was to c o n s i d e r each p i e c e of d a t a and t o a s s i g n n a t u r a l t h i n k i n g u n i t s o r meaning u n i t s o r c o n t e n t c a t e g o r i e s . T h i s s t e p was c a r r i e d out assuming an a t t i t u d e of "maximum openness" ( G i o r g i , 1975b). F o l l o w i n g t h i s s t e p , the r e s e a r c h e r s t a t e d the theme t h a t dominated each u n i t o r c a t e g o r y , u s i n g the same "maximum openness." At t h i s p o i n t , the themes were c o n s i d e r e d i n r e l a t i o n t o the s t u d y ' s purposes and r e s e a r c h q u e s t i o n s . From t h i s a n a l y s i s , the r e s e a r c h e r p l a n n e d q u e s t i o n s and t o p i c s f o r the second i n t e r v i e w w i t h the p a r t i c u l a r p a r t i c i p a n t and a l s o f o r m u l a t e d g u i d e l i n e s f o r o t h e r subsequent i n t e r v i e w s . The r e s e a r c h e r d e c i d e d t o s t o p i n t e r v i e w i n g when i t became e v i d e n t t h a t c o n s i s t e n t themes were b e i n g i d e n t i f i e d and v a l i d a t e d and the da t a c o l l e c t e d were s u f f i c i e n t l y i n - d e p t h and r i c h . The s t u d y ' s a n a l y t i c framework i s the f i n a l p roduct d e r i v e d from t h i s p roce s s of a n a l y z i n g the s t u d y ' s da ta and r e f i n i n g that a n a l y s i s over t i m e . E t h i c a l C o n s i d e r a t i o n s The r i g h t s of the s u b j e c t s were p r o t e c t e d as f o l l o w s : 1. W r i t t e n consent of the s u b j e c t was o b t a i n e d p r i o r to i n t e r v i e w i n g . 2. The r e s e a r c h e r made h e r s e l f r e a d i l y a v a i l a b l e f o r q u e s t i o n s about the s t u d y . 3. The r e s e a r c h e r c l e a r l y o u t l i n e d what p a r t i c i p a t i o n in the s tudy i n v o l v e d . 4. The r e s e a r c h e r r e i t e r a t e d to the s u b j e c t s p r i o r to each In terv iew t h e i r r i g h t to choose not to answer any q u e s t i o n s or to t e rmina te the i n t e r v i e w . 5. S u b j e c t s were informed tha t t h e i r d e c i s i o n at any time not to p a r t i c i p a t e would not p r e j u d i c e t h e i r h e a l t h care . 6. The s u b j e c t s were t o l d t h a t the s tudy i n v o l v e d no a n t i c i p a t e d r i s k s to them. The p o t e n t i a l b e n e f i t of u n d e r s t a n d i n g women's i l l n e s s e x p e r i e n c e w i t h MI to the n u r s i n g care of women h e a r t a t t a c k v i c t i m s in the fu ture was a r t i c u l a t e d by the r e s e a r c h e r . 7. The r e s e a r c h e r informed s u b j e c t s that s a f e -guards would be u t i l i z e d to ensure anonymity and c o n f i d e n t i a l i t y of the i n t e r v i e w d a t a . The tapes would be coded and then e ra sed upon c o m p l e t i o n of the s t u d y . W r i t t e n m a t e r i a l s would be shredded and d i s c a r d e d . The o n l y i n d i v i d u a l s who would have acces s to these da ta would be the r e s e a r c h e r and the r e s e a r c h e r ' s t h e s i s committee . 8. The r e s e a r c h e r a d v i s e d s u b j e c t s t h a t s h o u l d the r e s e a r c h e r a s ses s the need fo r i n t e r v e n t i o n by a h e a l t h care p r o f e s s i o n a l , the s u b j e c t would be r e f e r r e d back to the p a r t i c i p a t i n g p h y s i c i a n . The r e s e a r c h e r and s u b j e c t would d i s c u s s the s i t u a t i o n p r i o r to the r e f e r r a l s t e p . Summary T h i s c h a p t e r d i s c u s s e d the implementa t ion of the s e l e c t e d methodology, the phenomenolog ica l method, to e l i c i t women's p e r c e p t i o n s of t h e i r i l l n e s s e x p e r i e n c e wi th MI. E i g h t women p a r t i c i p a t e d i n the s tudy and 11 i n - d e p t h i n t e r v i e w s were conducted over a three month time p e r i o d . The d a t a , the t r a n s c r i b e d tapes and f i e l d n o t e s , were a n a l y s e d to determine t h i n k i n g u n i t s and themes. Data c o l l e c t i o n and da t a a n a l y s i s were i n t e r t w i n e d . The a n a l y s i s from the b e g i n n i n g i n t e r v i e w s shaped the da ta c o l l e c t e d in the subsequent i n t e r v i e w s . The r e s e a r c h e r assumed the r o l e of f a c i l i t a t o r in the e x p l o r a t i o n of the meaning of t h i s i l l n e s s e x p e r i e n c e . The r e s e a r c h e r and the p a r t i c i p a n t s c o n t r i b u t e d to the c o n s t r u c t i o n of the a c c o u n t s . Chapter 4 d e s c r i b e s the r e s e a r c h e r ' s i n t e r p r e t a t i o n of these a c c o u n t s . CHAPTER 4 P r e s e n t a t i o n o f t h e S t u d y ' s F i n d i n g s I n t r o d u c t i o n T h i s c h a p t e r p r e s e n t s t h e f i n d i n g s o f t h i s s t u d y , t h e c h a r a c t e r i s t i c s o f t h e p a r t i c i p a n t s a n d t h e women 's a c c o u n t s o f t h e i r i l l n e s s e x p e r i e n c e w i t h M I . B e f o r e d i s c u s s i n g t h e d a t a , t h e s t u d y ' s a n a l y t i c f r a m e w o r k i s i n t r o d u c e d a n d d e l i n e a t e d . T h i s a n a l y t i c f r a m e w o r k r e p r e s e n t s t h e r e s e a r c h e r ' s i n t e r p r e t a t i o n a n d c o n c e p t u a l i z a t i o n o f t h e d a t a . E x p l i c a t i n g t h e r e s e a r c h e r ' s f r a m e w o r k i s a c r i t i c a l c r i t e r i o n i n t h e i m p l e m e n t a t i o n o f t h e p h e n o m e n o l o g i c a l m e t h o d . G i o r g i ( 1 9 7 5 a , 1975b) a s s e r t s t h a t t h e c o n t r o l i n q u a l i t a t i v e r e s e a r c h comes f r o m t h i s c o m m u n i c a t i o n o f t h e r e s e a r c h e r ' s p e r s p e c t i v e o f t h e d a t a . A d o p t i n g t h i s same f r a m e w o r k , a n o t h e r i n v e s t i g a t o r s h o u l d be a b l e t o a l s o s e e what t h e r e s e a r c h e r saw i n t h e d a t a . The S t u d y ' s A n a l y t i c F ramework The women 's a c c o u n t s d e s c r i b e t h e n a t u r e a n d m e a n i n g o f t h e i r h e a r t a t t a c k e x p e r i e n c e a n d t h e i m p a c t o f t h i s i l l n e s s e x p e r i e n c e on t h e i r e v e r y d a y l i v e s . W h i l e t h e a c c o u n t s o f t h e p a r t i c i p a t i n g women r e f l e c t u n i q u e i l l n e s s e x p e r i e n c e s w i t h M I , d i s t i n c t t h e m e s r u n t h r o u g h t h e d a t a t h a t p o i n t t o t h e i r common e x p e r i e n c e . T h e s e t h e m e s a r e t h e b a s i s f o r t h e s t u d y ' s a n a l y t i c f r a m e w o r k ( F i g u r e 1 "The S t u d y ' s A n a l y t i c F r a m e w o r k " ) . F i g u r e 1 The S tudy's A n a l y t i c Framework  A Loss Framework Loss of H e a l t h y S t a t e ( l e a d s t o ) l a c k of energy Loss of P r e d i c t a b i 1 i t # L _ l a c k of ant i c i p a t e d s u p p o r t ( l e a d s t o ) ;hange i n u s u a l r o l e enactment I S t r a t e g i e s f o r C o n t r o l The c o r e theme t h a t emerged from an a n a l y s i s of the d a t a was l o s s . There was a d e f i n i t e communication by the women of b e i n g w i t h o u t t h a t which had meaning f o r them (a u s u a l d e f i n i t i o n of l o s s ) . The women p e r c e i v e d t h e i r l i v e s to be f r a u g h t w i t h many s i g n i f i c a n t changes s i n c e t h e i r MI and they c o n s t r u c t e d t h e i r a c c o u n t s around these changes. I t was t h i s f o c u s on change t h a t d i r e c t e d the r e s e a r c h e r t o see the d a t a from the p e r s p e c t i v e of the concept of l o s s . In s h a r i n g t h e i r p e r c e p t i o n s t h r o u g h the c o n t e x t of change, the women were g r i e v i n g the l o s s e s i n h e r e n t i n these changes. G i v e n t h i s , the s t u d y ' s a n a l y t i c framework i s b a s i c a l l y a l o s s framework. The framework c o n s i s t s of s i x component p a r t s : 1) l o s s of h e a l t h y s t a t e , 2) l o s s of p r e d i c t a b i l i t y , 3) l a c k of energy, 4) l a c k of a n t i c i p a t e d s u p p o r t , 5) change i n u s u a l r o l e enactment, and 6) s t r a t e g i e s f o r c o n t r o l . W i t h i n t h i s a n a l y t i c framework, l o s s of h e a l t h y s t a t e i s o p e r a t i o n a l l y d e f i n e d as a r e l i n q u i s h i n g of a former concept of one's s e l f as a h e a l t h y p e r s o n . T h i s p a r t i c u l a r l o s s i s a r e s u l t of the r e a l event of c a r d i a c damage, the s t a r t i n g p o i n t , b a s i s f o r , and/or impetus f o r the subsequent l o s s of p r e d i c t a b i l i t y . I t i s the l o s s of t h e i r former h e a l t h y s t a t e t h a t grounds the women's i l l n e s s e x p e r i e n c e w i t h MI. The l o s s of h e a l t h y s t a t e t h a t o c c u r s w i t h an MI e x p e r i e n c e l e a d s t o a l o s s of p r e d i c t a b i l i t y . L o ss of p r e d i c t a b i l i t y r e f e r s t o the women's p e r c e p t i o n of the p r e c a r i o u s n e s s of t h e i r i l l n e s s e x p e r i e n c e . The women f e l t suspended, u n c e r t a i n , and p e r p l e x e d . I t was as i f they were a d r i f t and f l o u n d e r i n g i n an u n f a m i l i a r r e a l i t y , t h i s new and u n p r e d i c t a b l e r e a l i t y of f a c i n g the impact of t h e i r MI i n t h e i r e v eryday l i v e s . S i n c e p e r c e p t i o n s r e f l e c t i n g a l o s s of p r e d i c t a b i l i t y permeated and dominated the d a t a , t h i s l o s s c h a r a c t e r i z e s and c a p t u r e s the essence of the women's i l l n e s s e x p e r i e n c e w i t h MI. Loss of p r e d i c t a b i l i t y was f e l t p a r t i c u l a r l y i n r e l a t i o n to energy, a n t i c i p a t e d s u p p o r t , and r o l e enactment. The s u b j e c t s e x p e r i e n c e d a l a c k of energy, p h y s i c a l and p s y c h o l o g i c a l . They d i d not have the s t r e n g t h o r endurance they used t o have and they f e l t t h a t t h e i r z e s t f o r l i v i n g was m i s s i n g from t h e i r l i v e s . The women a l s o f e l t a l a c k of a n t i c i p a t e d s u p p o r t from t h e i r f a m i l i e s , e s p e c i a l l y t h e i r husbands. They f e l t t h a t they d e s e r v e d f u l l s u p p o r t because of the c o m p e l l i n g n a t u r e of t h e i r i l l n e s s e x p e r i e n c e and were d i s a p p o i n t e d t h a t t h i s s u p p o r t was not e n t i r e l y r e a l i z e d . There were a l s o changes i n p e r f o r m i n g u s u a l r o l e s t h a t c o n t r i b u t e d to t h e i r sense of u n p r e d i c t a b i l i t y . T h i s i l l n e s s e x p e r i e n c e i n f l u e n c e d the enactment of the women's u s u a l s o c i a l and homemaker r o l e s . S t r a t e g i e s f o r c o n t r o l are d e f i n e d as b e h a v i o u r s used by the women to g a i n c o n t r o l over e x p e r i e n c e d l o s s e s . Because of the p r o f o u n d sense of not knowing what to e x p e c t d a y - t o - d a y , the women used a wide v a r i e t y of s t r a t e g i e s t o engender f e e l i n g s of c o n t r o l w i t h i n t h e i r d a i l y l i v e s . The women's a c c o u n t s d e s c r i b e d b o t h t h e i r l o s s e s and t h e i r s t r a t e g i e s f o r c o n t r o l . The s t u d y ' s a n a l y t i c framework, t h e n , i s the r e s e a r c h e r ' s c o n c e p t u a l i z a t i o n of the women's e x p l a n a t o r y model of t h e i r i l l n e s s e x p e r i e n c e w i t h MI. C h a r a c t e r i s t i c s of the P a r t i c i p a n t s A l l e i g h t p a r t i c i p a n t s were E n g l i s h s p e a k i n g Canadians. T h e i r ages a t the time of the f i r s t i n t e r v i e w ranged from 36 t o 71 y e a r s . S i x of the women were m a r r i e d and l i v i n g w i t h t h e i r husbands d u r i n g the i l l n e s s e x p e r i e n c e . Of the two r e m a i n i n g women, one was widowed and one d i v o r c e d . Two of the women had c h i l d r e n s t i l l l i v i n g a t home w i t h them. F i v e of the women had grown c h i l d r e n l i v i n g away from them, some w i t h f a m i l i e s of t h e i r own. One women d i d not have c h i l d r e n . One woman had her mother l i v i n g w i t h h e r i n a basement apartment. Only two of the women were employed o u t s i d e the home a t the time of t h e i r h e a r t a t t a c k s . The o t h e r s i x women had been homemakers f o r most of t h e i r l i v e s . Of the spouses, t h r e e were wo r k i n g and t h r e e were r e t i r e d . A l l p a r t i c i p a n t s l i v e d i n the G r e a t e r Vancouver Ar e a . F i v e women l i v e d i n s i n g l e f a m i l y d w e l l i n g s , t h r e e women l i v e d i n a p a r t m e n t s . From the r e s e a r c h e r ' s very g e n e r a l o b s e r v a t i o n s of the p h y s i c a l s e t t i n g , the women seemed to be homogeneously middle c l a s s i n r e l a t i o n to s o c i o e c o n o m i c s t a t u s . The t i m i n g of the f i r s t i n t e r v i e w was from one to f o u r months p o s t - i n f a r c t i o n , w i t h t h r e e months b e i n g the u s u a l c a s e . T h i s means t h a t the women had been a t home f o l l o w i n g d i s c h a r g e from h o s p i t a l f o r 2 to 14 weeks. Only one woman was s c h e d u l e d f o r bypass s u r g e r y ; the rem a i n d e r were b e i n g t r e a t e d m e d i c a l l y . None of the women was i n v o l v e d i n a s t r u c t u r e d r e h a b i l i t a t i o n programme ( e . g . The Y.M.C.A. C a r d i a c E x e r c i s e Programme). F o r f i v e of the women, t h i s was t h e i r f i r s t MI. The r e m a i n i n g women had e x p e r i e n c e d one to t h r e e Mi's p r e v i o u s l y . Most of the women had a d d i t i o n a l i l l n e s s e s . Two women r e p o r t e d b e i n g h y p e r t e n s i v e ; one women was d i a b e t i c ; and one had s u r g e r y f o r ca n c e r of the bowel i n the p r e v i o u s year ( 1 9 8 4 ) . One woman d i s c l o s e d an e x t e n s i v e h i s t o r y of p a s t i l l n e s s e s , i n c l u d i n g 29 s u r g e r i e s . Two of the women were r e a d m i t t e d f o r a n g i n a d u r i n g the i n t e r v i e w p e r i o d . The Women's P e r c e p t i o n s of T h e i r I l l n e s s E x p e r i e n c e Loss of H e a l t h y S t a t e The f i r s t a s p e c t of the MI e x p e r i e n c e f o r the s e women was t h e i r p e r c e i v e d l o s s of h e a l t h y s t a t e . The women made sense of t h e i r h e a r t a t t a c k e x p e r i e n c e by d e s c r i b i n g the s h i f t i n t h e i r l i v e s from h e a l t h to i l l n e s s . T h i s s h i f t was marked by the 37 h e a r t a t t a c k i t s e l f , the event t h a t c a t a l y s e d a s e r i e s o f subsequent changes. A l t h o u g h d a t a c o n c e r n i n g the h e a r t a t t a c k per se were not s p e c i f i c a l l y sought, the women chose to t e l l about t h e i r h e a r t a t t a c k p a i n e x p e r i e n c e s w i t h i n t h e i r a c c o u n t s . These d e s c r i p t i o n s were d i v e r s e . Each woman v i v i d l y remembered her p a i n e x p e r i e n c e and d e s c r i b e d the event i n a t r u l y unique way. They s t r i v e d to a c c u r a t e l y r e c o u n t what had happened, and used v a r i o u s d e s c r i p t i o n s t o i s o l a t e and i d e n t i f y what p r o f e s s i o n a l s tend t o c a l l " p a i n . " The h e a r t a t t a c k p a i n e p i s o d e was d i s t i n c t l y i n d i v i d u a l i n the way I t was p e r c e i v e d and e x p e r i e n c e d , but i t always marked the b e g i n n i n g of l o s s . The women's subsequent i n t e r f a c e w i t h the p r o f e s s i o n a l s e c t o r s e r v e d to even more e m p h a t i c a l l y b r i n g home t h e i r l o s s of h e a l t h y s t a t e . F o r two of the women, t h e i r h e a r t a t t a c k p r e s e n t e d i n i t i a l l y as " h e a r t b u r n " o r " i n d i g e s t i o n . " A l t h o u g h these women d i d not i n i t i a l l y p e r c e i v e t h e i r d i s c o m f o r t as h e a r t r e l a t e d , they d i d p e r c e i v e a need f o r m e d i c a l a s s i s t a n c e . And i t was j u s t l i k e a bad case of h e a r t b u r n . That's a l l i t was. (See Appendix D f o r key t o the p r e s e n t a t i o n of the b l o c k q u o t a t i ons.) You know, I thought n o t h i n g of i t . I d i d n ' t know what i t was, t o t e l l you the t r u t h . I thought i t was i n d i g e s t i o n and I was t a k i n g t h a t a n t i - a c i d t h i n g , you know. And I d i d l e t out a b e l c h o r so. Then i t went away. Then i t came back and i t d i d n ' t go away and I s a i d t o my husband, w e l l , t h i s i s an a w f u l , you know, b u r n i n g s e n s a t i o n . Maybe I'd b e t t e r go. I s t a r t e d to p e r s p i r e , you know, the back of my neck and t h a t and I knew t h a t i t wasn't j u s t a n y t h i n g , you know. So, I s t a r t e d g e t t i n g ready to go to the h o s p i t a l . Two o t h e r women put f o r t h g r a p h i c d e s c r i p t i o n s of t h e i r p a i n e x p e r i e n c e s t h a t a re a sharp c o n t r a s t t o the p r i o r d e s c r i p t i o n s of g a s t r o i n t e s t i n a l d i s c o m f o r t . Both of these women r e l a t e d s c e n a r i o s t h a t s t a n d out f o r t h e i r c o l o u r f u l e x p r e s s i o n and u n u s u a l n e s s . I got t h i s , s o r t of t h i s t i g h t n e s s — w e l l , i t was i n the s i d e here and a l s o w e l l , I'd had even when I was i n the h o s p i t a l , i t was j u s t l i k e a p i e c e of wet l e a t h e r , l i k e s o r t of a t i g h t n e s s r i g h t i n h e r e . I was s i t t i n g i n a c h a i r and the whole room s t a r t e d s p i n n i n g around. T h i s i s my e x p e r i e n c e . The whole f r o n t room s p i n n i n g around and I c a l l e d my husband and then I became n a u s e a t e d . The r e m a i n i n g women d e s c r i b e d symptoms t h a t are most f a m i l i a r t o the p r o f e s s i o n a l domain. They d e s c r i b e d t h e i r p a i n u s i n g t e r m i n o l o g y such as c r u s h i n g , c h o k i n g , p r e s s u r e , h e a v i n e s s , r a d i a t i n g , and/or e x c r u c i a t i n g . The e x p e r i e n c e i n c l u d e d symptoms such as nausea, p e r s p i r a t i o n , and s h o r t n e s s of b r e a t h . The f o l l o w i n g two women se r v e as examples of such d e s c r i p t i o n s . Yeah, w e l l , i t happened about 2:00 o ' c l o c k i n the morning and I was I broke out i n p e r s p i r a t i o n a l l o v e r . I got r e a l wet on my c h e s t , on my neck and my head and a l i t t l e l a t e r on I got t h a t heavy f e e l i n g and k i n d of a l i t t l e p a i n w i t h i t , you know. I t i s n ' t r e a l l y , you know, a p a i n . I t ' s a — i t ' s a c h o k i n g f e e l i n g not a c h o k i n g . I t ' s as though somebody i s p u s h i n g . I t ' s p r e s s u r e , you know. I had such a p a i n i n my h e a r t t h a t I was i n t e a r s a l l the way [ t o the h o s p i t a l ] and i t j u s t f e l t l i k e my h e a r t was t e a r i n g i n two. W e l l , the p a i n was r i g h t i n t o my arm, r i g h t down t o my w r i s t and I j u s t f e l t l i k e someone was s i t t i n g on my c h e s t and the p a i n i n s i d e was r e a l l y -- i t was r e a l l y t e a r i n g . You know, i t j u s t f e l t t e r r i b l e . T e r r i b l e p a i n . These e a r l y e x p e r i e n c e s , i t seems, r e p r e s e n t t h e e n d o f h e a l t h y s t a t e a n d t h e b e g i n n i n g o f t h e i l l n e s s e x p e r i e n c e . The women d i d n o t r e l a t e p r i o r e x p e r i e n c e s t h a t w a r n e d them o r h e l p e d them a n t i c i p a t e t h i s e v e n t . I t was t h e a c t u a l h e a r t a t t a c k e p i s o d e p l u s t h e s u b s e q u e n t i n t e r a c t i o n w i t h t h e p r o f e s s i o n a l s e c t o r t h a t marked t h e t r a n s i t i o n f r o m h e a l t h t o i l l n e s s . T h a t t h e i r h e a l t h y s t a t e h a d u n d e r g o n e r e d e f i n i t i o n was f u r t h e r e n t r e n c h e d by t h e a d v i c e g i v e n t o t h e women by t h e p r o f e s s i o n a l s e c t o r . W e l l , t h e y j u s t s a i d do n o t h i n g , you know. D o n ' t do a n y t h i n g b u t maybe w a l k h a l f a b l o c k a n d t h e n come b a c k . W e l l , a s t h e y warn y o u , d o n ' t o v e r d o a n y t h i n g . Don't o v e r w o r k . D o n ' t o v e r e a t . Don't o v e r w a l k , I s u p p o s e a n d a l l t h a t . The n a t u r e o f t h i s a d v i c e , t h i s p r e s c r i p t i o n f o r r e g a i n i n g w e l l n e s s , a c c e n t u a t e s a s p e c i a l f e a t u r e o f t h i s i l l n e s s e x p e r i e n c e . The women were t o l d t o c a r e f u l l y m o n i t o r t h e i r a c t i v i t y d u r i n g t h e e a r l y p h a s e s o f c a r d i a c r e h a b i l i t a t i o n . T h i s i s d i s t i n c t l y d i f f e r e n t f r o m many o t h e r i l l n e s s e x p e r i e n c e s . I n many i l l n e s s e x p e r i e n c e s , " d o i n g t o o much" may r e s u l t i n f e e l i n g s o f e x h a u s t i o n , b u t , f o r t h e MI p a t i e n t , " d o i n g t o 6 much" c o u l d w e l l mean p a i n , r e - i n f a r c t i o n o r p o s s i b l e d e a t h . The p r e s c r i p t i o n f o r w e l l n e s s c l e a r l y r e i n f o r c e d t h e l o s s o f h e a l t h y s t a t e . F o r t h e women, t h e n , t h e i r I l l n e s s e x p e r i e n c e w i t h MI was c h a r a c t e r i z e d by a b r u p t a n d i m p o r t a n t c h a n g e s i n t h e way t h e y l i v e d t h e i r l i v e s . L o s s o f P r e d i c t a b i l i t y T h i s s e c t i o n d e s c r i b e s t h e c e n t r a l l o s s i n t h e s t u d y ' s a n a l y t i c f r a m e w o r k l o s s o f p r e d i c t a b i l i t y . L o s s o f p r e d i c t a b i l i t y s t e m s f r o m t h e s h i f t f r o m h e a l t h t o i l l n e s s i d e n t i f i e d i n t h i s f r a m e w o r k a s l o s s o f h e a l t h y s t a t e . The women r e l a t e d f e e l i n g a n o v e r w h e l m i n g s e n s e o f n o t k n o w i n g , n o t k n o w i n g what t o t h i n k , f e e l , o r d o . I t was a s i f t h e i r h e a r t a t t a c k h a d c a t a p u l t e d them i n t o a d i f f e r e n t a n d u n f a m i l i a r r e a l i t y . B e c a u s e t h e s h i f t f r o m h e a l t h t o i l l n e s s was s u d d e n a n d u n e x p e c t e d , t h e women f e l t s u s p e n d e d a n d b e w i l d e r e d a s t h e y t r i e d t o c a r r y on i n t h e i r e v e r y d a y l i v e s . Y e s , i t Is q u i t e u p s e t t i n g e m o t i o n a l l y . You know, you j u s t wonder what s o r t o f l i f e am I g o i n g t o h a v e , you know, f r o m h e r e on i n , you know. ° I t k i n d o f l e a v e s you h a n g i n g In m i d - a i r , s o r t o f . You know, i f you f e e l l i k e - - I ' d l i k e t o f e e l I s t i l l h a v e a f u t u r e a n d t h i s way you d o n ' t know t h a t . Y o u ' r e j u s t s o r t o f l i v i n g e v e r y d a y f o r i t s e l f . P e r h a p s t h a t ' s t h e way t o do i t , you know. I d o n ' t r e a l l y know. Y o u ' r e j u s t s o r t o f i n l i m b o f o r a w h i l e u n t i l you c a n p i c k up where you l e f t o f f , w h i c h w o u l d be s o r t o f a g r a d u a l p r o c e s s I i m a g i n e . You s o r t o f w o n d e r t o a d e g r e e , where t o go f r o m h e r e . B u t I d o n ' t know. Y o u ' r e j u s t i n l i m b o w a i t i n g t o c a r r y o n . " H a n g i n g i n m i d - a i r " a n d " i n l i m b o w a i t i n g t o c a r r y o n " c o n j u r e v i v i d images o f b e i n g i n a f o r e i g n a n d u n p r e d i c t a b l e r e a l i t y . L o s s o f p r e d i c t a b i l i t y e x t e n d e d e v e n t o t h e c u e s t h e women h a d p r e v i o u s l y r e l i e d on a s b a r o m e t e r s a b o u t t h e i r s t a t e o f h e a l t h . A f t e r t h e M I , t h e s e c h a n g e d i n m e a n i n g , y i e l d i n g a new c o n f u s i o n . Now, t h e women f e l t t h a t t h e y d i d n ' t e v e n know what t h e y ' r e b o d i e s were s a y i n g t o t h e m . I t h i n k y o u ' v e had a h e a r t a t t a c k a n d you come home a n d you know, you c a n c o n v a l e s c e f o r f o u r months a n d you d o n ' t know - - y o u ' r e a l i t t l e a p p r e h e n s i v e b e c a u s e - - s a y you g e t a p a i n i n t h e c h e s t o r a p a i n s o m e w h e r e , an a c h e o r w h a t e v e r i t i s , now, c o n c e i v a b l y , I h a d t h o s e p a i n s o r t h o s e a c h e s a l w a y s b e f o r e a n d you r e a l l y t h o u g h t n o t h i n g a b o u t them b e c a u s e we a l w a y s h a v e a c h e s a n d p a i n s i n o u r b o d y . B u t I t h i n k a f t e r a h e a r t a t t a c k , you s o r t o f t h i n k , i s t h a t r e l a t e d t o a h e a r t a t t a c k ? I s t h a t a n g i n a ? What i s t h a t ? And w h a t e v e r i t i s , you d o n ' t e v e r g e t t h e a n s w e r s r e a l l y , you know. I s a y you d o n ' t g e t the a n s w e r s p r o b a b l y b e c a u s e l i k e t h e n e t r e s u l t o f i t i s n ' t s e r i o u s e n o u g h . I mean , I g u e s s i f you h a d a n o t h e r h e a r t a t t a c k , t h e n y o u ' d know. S o , - - t h e n t h e o t h e r t h i n g t h a t I 'm s t r u g g l i n g w i t h p e r h a p s i n my m i n d p e r h a p s i s I h a v e t o b e l i e v e t h a t I 'm e i t h e r e n t e r i n g o r g o i n g t h r o u g h , w h a t e v e r , t h e menopause a n d k n o w i n g a s l i t t l e — i t ' s my own f a u l t b e c a u s e I h a v e n ' t g o t a book a n d r e a d a n y t h i n g a b o u t i t - - I t h i n k t h e r e ' s p r o b a b l y a s p e c t s o f t h e menopause I 'm g o i n g t h r o u g h t h a t I 'm a l s o c o n f u s i n g m y s e l f a s t o w h e t h e r t h a t h a s g o t s o m e t h i n g t o do w i t h my h e a r t . Q . Can you g i v e me a n e x a m p l e o f s o m e t h i n g ? A . Y e a h , b e c a u s e I g e t q u i t e warm, f o r e x a m p l e , now, I d o n ' t know w h e t h e r t h a t i s a h o t f l u s h o r f l a s h o r i f i t h a s s o m e t h i n g - - i t ' s a l s o a symptom o f t h e h e a r t , t h a t I ' v e come t o f i n d o u t . I g e t q u i t e l i g h t - h e a d e d a t t i m e s . T h a t a g a i n i s a symptom o f h e a r t . I t c a n be a symptom o f many o t h e r t h i n g s . S o , I d o n ' t know what i t i s . B u t I do know t h a t I w a s , you know, g e t t i n g my m e n s t r u a l p e r i o d s e s s e n t i a l l y up u n t i l S e p t e m b e r , O c t o b e r - - O c t o b e r , I t h i n k , b e f o r e my h e a r t a t t a c k a n d I h a v e n o t h a d one s i n c e . So - - a n d I 'm f i f t y . S o , I t h i n k t h a t s o m e t h i n g i n my p h y s i c a l a n d m e n t a l m a k e - u p i s t h e menopause b u t I 'm a l s o n o t f o o l i n g m y s e l f t h a t t h e r e i s a p o s t h e a r t a t t a c k t h a t I 'm c o p i n g w i t h a s w e l l . T h i s l o s s o f p r e d i c t a b i l i t y p r o f o u n d l y a f f e c t e d t h e women i n t h e i r d e c i s i o n m a k i n g a n d i n t h e i r p e r c e p t i o n s o f r e a l i t y i n t h e i r e v e r y d a y l i v e s . T h i s f o l l o w i n g a c c o u n t d r a m a t i c a l l y r e l a t e s t h e f e e l i n g o f b e i n g t o t a l l y " u n h i n g e d " by t h i s i l l n e s s e x p e r i e n c e . T h i s woman e x p r e s s e d t h e n e e d f o r h e r h u s b a n d t o be a t h e r s i d e a t h e r d o c t o r ' s a p p o i n t m e n t t o h e l p h e r t o s o r t o u t t h e i n t e r a c t i o n w i t h t h e p h y s i c i a n . N o t e t h i s woman's d e s c r i p t i o n of her mind as "a l i t t l e b i t mushed." The l o s s of f a m i l i a r i t y has r e s u l t e d i n a l o s s of c o n f i d e n c e in her a b i l i t y to p roce s s i n f o r m a t i o n , to t h i n k ! Now, when I went to my g e n e r a l p r a c t i t i o n e r each week or every two weeks or however o f t e n I went, f o r the most p a r t , I asked my husband to go wi th me. And I - - ye s , and he d i d go and I wanted that s p e c i f i c a l l y because y o u ' r e g o i n g to go i n ; y o u ' r e g o i n g to ask the d o c t o r q u e s t i o n s or he can v o l u n t e e r i n f o r m a t i o n or whatever and you come out and your mind i s a l i t t l e b i t mushed. Y o u ' r e not sure whether t h e y ' v e answered your q u e s t i o n . In many cases they h a v e n ' t but you a l s o may get an impre s s ion of what t h e y ' v e s a i d and i t may not n e c e s s a r i l y be what t h e y ' v e s a i d or what they meant. So , t h a t ' s why I wanted my husband to go because I thought i f I got o f f base or t r a c k on what i t was, he c o u l d say no , B . , t h a t i s n ' t what the d o c t o r was t e l 1 i n g . Because of the l o s s of p r e d i c t a b i l i t y , the women needed s p e c i f i c , c o n c r e t e i n f o r m a t i o n about t h e i r c o n d i t i o n . They wanted s t r a i g h t , d e f i n i t e answers about t h e i r home management of t h e i r MI. To not get these answers r e i n f o r c e d the u n c e r t a i n t y and dilemma in t h e i r everyday l i v e s . You know, another t h i n g , I — tha t has confused me, perhaps , or I ' ve been apprehens ive about , i s I d o n ' t r e a l l y unders tand or know what I can do p h y s i c a l l y and nobody has answered t h a t . L i k e I ' ve asked i t r e a l l y o f , not so much the c a r d i o l o g i s t as I have of my g e n e r a l p r a c t i t i o n e r , and he has s a i d w e l l , j u s t do t h i n g s s l o w l y l i k e j u s t do them, j u s t do them s l o w l y . W e l l , what i s d o i n g them s l o w l y . L i k e , do you know what I'm s ay ing? L i k e i f you vacuum, what i s vacuuming s l o w l y . E i t h e r you vacuum or you d o n ' t vacuum. C l e a n i n g windows, r e a c h i n g say to c l e a n windows or be i t c u t t i n g a lawn or whatever , you know, l i k e I j u s t d o n ' t know and I t h i n k to m y s e l f , I d o n ' t want to do something t h a t , you know, i s wrong and y o u ' r e go ing to j e o p a r d i z e y o u r s e l f f o r d o i n g i t and yet on the o t h e r hand, you d o n ' t want t o , you know, codd le y o u r s e l f to the p o i n t you t h i n k , w e l l , I c a n ' t do . And you d o n ' t r e a l l y get the answers f o r t h a t . You know, so , as a r e s u l t , you know, i t can get a l i t t l e b i t d e p r e s s i n g . And I walk but I d o n ' t do any o t h e r e x e r c i s e s because I h a v e n ' t yet been t o l d by my d o c t o r or the c a r d i o l o g i s t tha t I can e x e r c i s e beyond w a l k i n g . They say , w e l l , take i t easy . W e l l , I d o n ' t know what easy i s . A l t h o u g h there was a need f o r s p e c i f i c i n f o r m a t i o n about t h e i r i l l n e s s e x p e r i e n c e , i t was not met to t h e i r s a t i s f a c t i o n . The consequences of l i v i n g w i t h unanswered q u e s t i o n s were an even deeper f e e l i n g of l o s s of p r e d i c t a b i l i t y which a f f e c t e d t h e i r p e r c e i v e d a b i l i t y to cope . And I'm f e e l i n g very uneducated about i t . And a t y p i c a l example was I take a medic ine — o n l y one medic ine f o r t u n a t e l y . And i t ' s c o r g a r d © and i t ' s a be ta b l o c k e r . Okay, when I was t o l d t h i s was a be ta b l o c k e r , I s a i d to my d o c t o r , what i s a be ta b l o c k e r and he s a i d , B. - - w e l l , he s a i d , w e l l , i t ' s a d r u g , of c o u r s e , t h a t ' s taken f o r a h e a r t c o n d i t i o n and he s a i d i t does a l o t of t h i n g s . W e l l , I l ooked at him and I t h o u g h t , now, I d e c l a r e . Now, tha t wasn ' t any k i n d of an answer to the q u e s t i o n I was a s k i n g , to me. P o s s i b l y i t was to h i m . And I never d i d get an answer. L i k e I d i d n ' t f e e l equ ipped at a l l , to come home from the h o s p i t a l and cope w i t h hav ing had a h e a r t a t t a c k . Accompanying the pro found and p e r v a s i v e emotions tha t c h a r a c t e r i z e d l o s s of p r e d i c t a b i l i t y were p a r t i c u l a r c o n c e r n s f e l t by the women. These i n c l u d e d the p o s s i b i l i t y of a r epea t MI, the p o s s i b i l i t y of sudden d e a t h , and the p o t e n t i a l f o r r e t u r n i n g to n o r m a l . These c o n c e r n s c l e a r l y r e f l e c t the women's p e r c e i v e d l o s s of p r e d i c t a b i l i t y . Even minor d i s c o m f o r t s s t i m u l a t e d f e a r s of an impending a t t a c k . At t imes you g e t , you know, not r e a l l y a p a i n but you j u s t s o r t of get t h a t — l i k e a funny f e e l i n g and a lmost l i k e a s t i t c h or something l i k e t h a t , you know, and I t h i n k - - i t k i n d of makes me s top now and t h i n k , you know, o h , i s i t g o i n g to happen aga in? D e s p i t e a r e c o g n i t i o n t h a t t h i n g s were p r o c e e d i n g wi thout i n c i d e n t , the nagging dread of another a t t a c k p e r s i s t e d . But I ' ve had no problems so I j u s t keep my f i n g e r s c r o s s e d hop ing t h a t ' s the way i t ' l l s t a y . But then I went two months and never had any p a i n and then a l l of a sudden I 've got i t a g a i n , you know, so I never know when I'm g o i n g to 44 ge t i t . The p o i g n a n t m e m o r i e s of t h e h e a r t a t t a c k i t s e l f c o n t r i b u t e d to t h e f e a r of a n o t h e r a t t a c k . F o r t h e women who h a d e x p e r i e n c e d more t h a n one c a r d i a c e v e n t , t h e s e f e a r s were p a r t i c u l a r l y h e i g h t e n e d . My c o n c e r n s a r e t h a t I ' d be v e r y f r i g h t e n e d t o h a v e a n o t h e r o n e . T h a t ' s one t h i n g I 'm c o n c e r n e d a b o u t . I ' v e h a d two v e r y b a d o n e s , one a y e a r ago l a s t O c t o b e r a n d t h e n O c t o b e r a n d t h e n when my h e a r t l o s t i t ' s r h y t h m , t h a t was q u i t e an e x p e r i e n c e i n i t s e l f . I ' d do a n y t h i n g t o s t a y away f r o m i t . I t ' s so d r e a d f u l . I t ' s r e a l l y a d r e a d f u l e x p e r i e n c e . Nobody knows u n t i l t h e y e x p e r i e n c e j u s t how d r e a d f u l i t i s . You j u s t f e e l l i k e y o u r h e a r t i s s h r e d d i n g . The f e a r o f d y i n g s u d d e n l y was s h a r e d . The f o l l o w i n g woman r e a l i z e d t h a t h e r r e l u c t a n c e t o go o u t was l i n k e d to t h i s f e a r a n d t o a f r i e n d ' s s u d d e n d e a t h . The u n c e r t a i n t y t h a t c h a r a c t e r i z e s t h e l o s s o f p r e d i c t a b i l i t y i s s t r i k i n g l y c l e a r i n t h i s e x c e r p t . A . I t h a s c u t down on my a c t i v i t i e s t h a t I w o u l d l i k e t o d o , you know, a n d I c a n ' t d o . T h a t ' s a p r o b l e m . And t h e o t h e r i s t h a t i t l e a v e s you w i t h a — a t l e a s t i t d o e s me, i t l e a v e s me w i t h a c e r t a i n f e a r . J u s t a f e a r . Q. T e l l me more a b o u t t h a t . A . W e l l , I g u e s s you f e e l l i k e y o u ' r e g o i n g t o s l i p away a n d y o u ' r e n o t r e a d y t o g o , you know a n d b u t on t h e o t h e r h a n d , I f e e l t h a t I s h o u l d n ' t f e e l t h a t way b e c a u s e the Good L o r d knows what h e ' s d o i n g . You know, I s h o u l d t a k e t h a t i n t o c o n s i d e r a t i o n b u t i t s t i l l d o e s n ' t s t o p t h a t f e a r o f t h a t h a p p e n i n g t o y o u . You go t o b e d a t n i g h t a n d you t h i n k w e l l , am I g o i n g t o be h e r e i n t h e m o r n i n g a n d I t h i n k t h a t ' s one o f t h e r e a s o n s I f e a r g o i n g o u t . I ' d h a t e t o j u s t d r o p somewhere b e c a u s e a g o o d f r i e n d o f mine j u s t h a d gone down t o t h e s t o r e a n d she was d o i n g f i n e a n d she made i t i n h e r d r i v e w a y a n d p r a c t i c a l l y t o h e r f r o n t d o o r a n d t h e n e i g h b o u r s saw h e r l y i n g o u t on t h e p a v e m e n t a n d she was g o n e . M r s . L . S o , you know, i t was a t e r r i b l e t h i n g t o h a p p e n t o a n o l d b u d d y , i f s h e knew. I hope I d o n ' t know when i t comes b u t i t l e a v e s you w i t h t h a t f e e l i n g . So - - i t ' s k i n d o f a s c a r y b u s i n e s s b u t t h a t ' s a b o u t a l l I c a n t e l l you a b o u t i t . I t ' s j u s t t h a t you t h i n k , you h a d o n e ; now you r e a l l y d o n ' t know how s t r i c t you have to do t h e s e t h i n g s o r how l o n g i t t a k e s . I t h i n k i n t h e b a c k o f a p e r s o n ' s m i n d , t h e y t h i n k t h e y ' v e h a d o n e ; now, j u s t how l o n g i s i t b e f o r e t h e y have a n o t h e r one a n d how many do you h a v e . b e f o r e t h a t ' s s o r t o f t h e e n d o f w h a t e v e r l i f e be i t . C o n c e r n a b o u t t h e p o t e n t i a l f o r r e t u r n i n g t o n o r m a l was v o i c e d by s e v e r a l o f t h e women. In e s s e n c e , t h e y seemed t o be g r i e v i n g f o r t h e i r o l d h e a l t h y s e l f a n d t h e i r f o r m e r f a m i l i a r r e a l i t y . I r e a l l y wonder a b o u t t h a t , w h e t h e r I ' l l e v e r g e t b a c k t o where I c a n do j u s t a n y t h i n g . Or want t o do i t . Or be a b l e t o do i t . You know. T h e r e ' s a d i f f e r e n c e r i g h t now o f w a n t i n g t o do i t a n d b e i n g a b l e t o do i t . I w o u l d j u s t l i k e t o be t h e way t h a t I was b e f o r e b u t I 'm n o t . I know t h a t . I 'm n o t t o t h e p o i n t t h a t I h a v e n ' t g o t t h e s t r e n g t h t o do t h i n g s . I s t i l l want t o do e v e r y t h i n g . I s t i l l w o u l d l i k e t o do e v e r y t h i n g . W e l l , t h e r e ' s a l w a y s t h e u n a n s w e r e d q u e s t i o n s , how l o n g u n t i l I ' l l be n o r m a l a g a i n . My c o n c e r n i s t h a t i t d o e s n ' t h a p p e n a g a i n . W e l l , I t h i n k o f , you know, g e t t i n g t h i s a l l h e a l e d a n d g e t t i n g b a c k t o , you know, n o r m a l . I d o n ' t know when - -i f I ' l l have t o t a k e m e d i c a t i o n s a l l t h e t i m e o r w h a t . I d o n ' t know. B u t I 'm j u s t t h i n k i n g a b o u t g e t t i n g b a c k t o n o r m a l a c t i v i t i e s . You know, I l o v e t o go t o t h e - - to t h e h o r s e r a c e s . I l o v e g a m b l i n g . I l o v e t o go t o R e n o . I p r o b a b l y c o u l d n ' t p u l l t h a t s l o t m a c h i n e t o o many t i m e s y e t b u t n o , I — I j u s t t h i n k o f g e t t i n g m y s e l f a l l b e t t e r a g a i n . P a r t o f t h i s c o n c e r n a b o u t t h e p o t e n t i a l f o r r e t u r n i n g t o n o r m a l was a c o m p a r i s o n o f s e l f w i t h o t h e r s . The women seemed t o use d a t a a b o u t o t h e r s i n s i m i l a r s i t u a t i o n s a s a means t o m e a s u r e t h e i r own p r o g r e s s . T h i s a p p e a r e d seemed to g i v e them 46 a r e f e r e n c e p o i n t i n t h e i r w o r l d o f unknowns f r o m w h i c h to e v a l u a t e t h e i r own c a r d i a c r e h a b i l i t a t i o n . I t was a v e r y s c a r y e x p e r i e n c e a n d i t ' s s o m e t h i n g t h a t you hope w i l l n e v e r h a p p e n t o you a g a i n a n d s t i l l you we have h a d d i f f e r e n t f r i e n d s a n d you t h i n k , w e l l , gee w h i z , t h e y t h e y seemed t o be on t h e mend a n d a l l a t o n c e , t h e y were gone l i k e t h a t a n d I ' v e h a d q u i t e a number o f t h e m . T h e y seem t o — a n d s t i l l , you s h o u l d n ' t f e e l t h a t way . S o , b u t a s I s a y , b e y o n d t h a t , I d o n ' t know how l o n g a n d I s u p p o s e t h e t i m e w i l l c o m e , i t ' s k i n d o f l i k e a d e a t h p e r h a p s , t h e t i m e w i l l come when you f o r g e t t h a t you h a d o n e , p r o v i d i n g t h i n g s go a l o n g r e a s o n a b l y w e l l . I m e a n , I h a v e f r i e n d s — I h a v e a v e r y g o o d f r i e n d — he was o u r b e s t man a t o u r w e d d i n g . He h a d a m a s s i v e h e a r t a t t a c k t e n y e a r s ago a n d l i k e , h e ' s n e v e r h a d a n y t h i n g s i n c e a n d h e , you know. You k n o w , a s I s a y i t ' s k i n d o f l i k e a d e a t h . I t h i n k f o r some t i m e you do t h i n k a b o u t i t w h e t h e r you want t o o r n o t a n d h o p e f u l l y a s t i m e g o e s o n , y o u ' l l t h i n k l e s s a n d l e s s a b o u t i t , a n d g e t b a c k t o d o i n g t h i n g s a s you d i d them b e f o r e . B u t now, I d o n ' t know, y o u ' r e n o t y o u ' r e a l i t t l e a l i t t l e b i t w e a k e r a n d a l i t t l e b i t — b u t I hope I c a n g e t b a c k t o my n o r m a l . I t h i n k h e a r t p a t i e n t s d o . I 'm n o t so s u r e , b u t I 'm t r y i n g t o t h i n k o f a p e r s o n t h a t h a d h e a r t p r o b l e m s i n my t i m e . I know my a u n t d i d . She h a d a n g i n a p r o b l e m s b u t she — she c o n t i n u e d p r e t t y g o o d . She was s t r o n g a n d she d i d t h i n g s t h e way she n o r m a l l y d i d , you know. In s u m m a r y , l o s s o f h e a l t h y s t a t e , t h e MI e v e n t i t s e l f , i s t h e b a s i s f o r t h e s u b s e q u e n t p e r v a s i v e a n d c o m p e l l i n g l o s s o f p r e d i c t a b i l i t y . L o s s o f p r e d i c t a b i l i t y c o n s t i t u t e s t h e e s s e n c e o f t h e w o m e n ' s l o s s e x p e r i e n c e f o l l o w i n g M I . In a d d i t i o n t o i n v o l v i n g a c o m p l e x p a t t e r n o f e m o t i o n s a n d s p e c i f i c c o n c e r n s , l o s s o f p r e c l t a b i l I t y was f e l t i n r e l a t i o n t o e n e r g y , s u p p o r t , a n d r o l e e n a c t m e n t . The women 's a c c o u n t s i d e n t i f i e d c h a n g e s i n b o t h t h e i r p h y s i c a l a n d p s y c h o l o g i c a l e n e r g y a s a p r o m i n e n t f e a t u r e i n t h e i r e v e r y d a y l i v e s a f t e r d i s c h a r g e f r o m h o s p i t a l . T h e s e e n e r g y c h a n g e s were t a n g i b l e a n d p o t e n t i n d i c a t o r s o f t h e p r e c a r i o u s n e s s o f t h e i r s t a t e o f h e a l t h . L a c k o f e n e r g y was m a n i f e s t e d i n v e r y d r a m a t i c w a y s . As t h e women e x p l o r e d t h e i r e n e r g y c h a n g e s w i t h i n t h e i r e v e r y d a y l i v e s , t h e y d e s c r i b e d t h e i r l a c k o f e n e r g y i n t e r m s o f t h e i r b o d y ' s r e s p o n s e t o e x e r t i o n . L a c k o f e n e r g y , f o r e x a m p l e , a l t e r e d t h e i r a p p r o a c h t o a n d t h e p a c e a n d s c o p e o f t h e i r a c t i v i t i e s a s w e l l a s p a t t e r n s o f s l e e p i n g . F u r t h e r , l a c k o f e n e r g y i n f l u e n c e d t h e i r a t t i t u d e t o w a r d s d a i l y l i f e . F o r t h e women, t h e s e c h a n g e s i n t h e i r e n e r g y were u n e x p e c t e d l y t r o u b l e s o m e . The women d e s c r i b e d t h e i r l a c k o f e n e r g y a s a r e a c t i o n a n d o u t l i n e d i t a s a s e q u e n c e o f p h y s i c a l man i f e s t a t i o n s . Yeah a n d I s t i l l g e t t i r e d . I s t i l l g e t t i r e d . My l e g s , t h e l o w e r p a r t o f my l e g s , b e l o w my k n e e s , g e t s q u i t e weak a t t i m e s a n d I ' v e t o l d my d o c t o r s a b o u t t h a t . I h a v e no i d e a what t h a t i s . S o m e t i m e s , you know, you j u s t f e e l l i k e y o u r l e g s a r e n ' t g o i n g t o h o l d y o u . And t h e n i t p a s s e s a n d t h e n w e ' r e o k a y . I f i n d t h a t I want t o do some t h i n g s a n d I c a n ' t . B e c a u s e i t ' s a m a z i n g how w e a k e n i n g i t i s r e a l l y b e c a u s e t h e o t h e r d a y , I was d o i n g some i r o n i n g a n d I - - r e a l l y I s t a y e d a t i t a l i t t l e l o n g e r a n d I n o t i c e d I was s t a r t i n g t o g e t t i r e d . I h a d n ' t done a n a w f u l l o t , j u s t one o r two t h i n g s I w a n t e d t o d o . B u t you k n o w , my l e g s were a c t u a l l y r u b b e r y . I c o u l d h a r d l y g e t f r o m t h e r e t o t h e r e , i n the h o u s e h e r e . I t was a n odd f e e l i n g , you know, l i k e , you f e e l l i k e y o u r l e g s a r e g o i n g t o go o u t f r o m u n d e r y o u . The women r e a l i z e d t h a t t h e y c o u l d no l o n g e r p u s h 48 themselves to get t h i n g s done once they sensed they were t i r i n g . T h i s r e p r e s e n t e d a new l i m i t a t i o n f o r them to face in d a i l y 1 i v i n g . Q. What happens - - how do you know when - - to gauge your a c t i v i t y ? T e l l me how you determine when you have to s top and when you c a n ' t do something . A . I j u s t get f e e l i n g a l i t t l e washed o u t . Maybe an hour and a h a l f , an hour and whereas b e f o r e , I would keep on go ing r e g a r d l e s s , u n t i l what I wanted to do was done. Now, I t h i n k I ' d b e t t e r n o t . I f e e l I'm g e t t i n g t i r e d . I ' d b e t t e r s i t down. Or I b e t t e r l i e down now. For a few minutes before I can go on . But you j u s t s o r t of get a r e a l drawn t i r e d f e e l i n g . I'm g o i n g to have to s i t down. I f i n d I get t i r e d very e a s i l y , tha t I j u s t run out of energy and I run out of i t to an e x t e n t where I j u s t c a n ' t do another t h i n g . I'm j u s t a b s o l u t e l y f l a t u n t i l I go and l i e down f o r about a h a l f an hour or so . You know, I never f e l t I r a n out of e n e r g y . I might get t i r e d but I c o u l d push mysel f and now I c a n ' t even push myse l f to do a t h i n g . The women's l a ck of energy a f f e c t e d the q u i c k n e s s of t h e i r a c t i v i t i e s . There was a d e f i n i t e f e e l i n g of b e i n g s lower s i n c e the h e a r t a t t a c k . The women were unable to keep pace and slowed down as a way of c o p i n g w i t h the r i s k of o v e r e x t e n d i n g t h e m s e l v e s . I go g r o c e r y shopping now, p r o v i d i n g he d r i v e s me. I f the c a r t ge t s too f u l l , n a t u r a l l y he has to take over the c a r t . I used to be a very f a s t w a l k e r . Now, I'm n o t . And I'm always t r a i l i n g way beh ind him somewhere. T h i s i s what ' s i r r i t a t i n g . A l l of a sudden he r e a l i z e s I'm not bes ide him and h e ' s walked away too f a s t . I d i d t h i n g s a l o t q u i c k e r . You know, when I went to do something , i t was j u s t now and now, I j u s t I t h i n k about i t and I'm s lower now, you know. I f I t u r n around f a s t , I t h i n k I ' d get d i z z y . But I was very q u i c k b e f o r e . I was q u i c k at e v e r y t h i n g . I d i d n ' t walk , I r a n . I know t h a t I o p e r a t e s l o w e r , b u t I t h i n k t h a t t h e r e a s o n a g a i n t h a t I do i t , a s I s a i d t o y o u , a t w o r k , f o r e x a m p l e , w h i c h i s where i t comes maybe m o r e , you g e t t h e a d r e n a l i n f l o w i n g a n d r e a l l y , you know, g e t i n t o i t a n d do w h a t e v e r i t i s t h a t y o u ' r e d o i n g . Now, i t ' s t h e same a s a t home, i f I do t h a t I c a n f e e l i t p h y s i c a l l y . I f I r e a l l y , you know, g e t i n t o d o i n g s o m e t h i n g , I c a n f e e l i t p h y s i c a l l y . So I you know, I d i s c i p l i n e m y s e l f n o t t o l e t t h a t h a p p e n . In a d d i t i o n t o s p e e d , t h e i r w h o l e a p p r o a c h t o a c t i v i t i e s was a f f e c t e d . Now, a t h i n k i n g t h r o u g h p r o c e s s p r e c e d e d e v e r y d a y a c t i v i t i e s . The women p r e - e v a l u a t e d w h e t h e r o r n o t t h e a c t i v i t y w o u l d a f f e c t t h e i r h e a r t a n d t h e i r r e h a b i l i t a t i o n . You a l m o s t g e t t o t h e p o i n t b e f o r e you do s o m e t h i n g , you t h i n k , o h , b o y , i s t h i s g o i n g t o s e t s o m e t h i n g o f f a g a i n o r i s i t o k a y t o go a h e a d a n d do t h i n g s , you k n o w , l i k e do some i r o n i n g o r do a b i t o f c l e a n i n g . Y e s , i t i s d i f f e r e n t b e c a u s e I w e l l , [ b e f o r e ] you d o n ' t t h i n k a b o u t i t . You j u s t g e t down a n d do i t . ' L o s s o f e n e r g y a l s o meant l o s s o f o n e ' s z e s t f o r l i v i n g . The women r e p o r t e d f e e l i n g " l e s s e n t h u s e d a b o u t e v e r y t h i n g " a n d no l o n g e r " g u n g h o " t o do t h i n g s . A . And t h e n ' j u s t g u n g ho a n d go a h e a d a n d do i t a l l . 0.. U h - h u m . A . I j u s t I c a n ' t do t h a t a n y m o r e . Q. U h - h u m . A . B u t now I f i n d - - e v e n j u s t i f I do t h i s a r e a a n d g e t i t c l e a n e d up t h e n u s u a l l y I h a v e t o s i t down a n d h a v e a r e s t f o r h a l f a n h o u r o r so a n d t h e n I ' l l g e t up a n d go do s o m e t h i n g e l s e . - - a n d a n o t h e r t h i n g , you know, s o m e t i m e s you f e e l l e s s e n t h u s e d a b o u t e v e r y t h i n g . Y o u r e n t h u s i a s m , l i k e b e f o r e , I h a d more e n t h u s i a s m . L i k e , I 'm g o i n g t o do t h i s , I 'm g o i n g t o do t h a t . And I went a h e a d a n d d i d i t a n d now, you d o n ' t h a v e t h a t . You know, you j u s t g o t t o t h i n k , w e l l , g e e , t a k e one t h i n g a t a t i m e ; do t h i s , do t h a t . O v e r a l l , t h e women d e s c r i b e d a g e n e r a l s t a t e o f f e e l i n g f a t i g u e d , e x h a u s t e d , a n d z a p p e d o f e n e r g y . The c h a n g e s i n s l e e p i n g p a t t e r n s were c l e a r s i g n a l s t o t h e women o f t h e e x t e n t o f t h e i r e n e r g y l o s s e s . I ' v e b e e n t h i n k i n g a b o u t t h a t a n d I 'm n o t t o o s u r e what i t m e a n s . I t ' s v e r y f r u s t r a t i n g b e c a u s e I l i k e t o I ' v e b e e n i n h o s p i t a l . I f e e l I s h o u l d be w e l l a n d I want t o c a r r y on w i t h my l i v i n g a n d I c a n ' t . You t r y a n d do a l i t t l e b i t a n d you f e e l you h a v e t o s i t down b e c a u s e you h a v e t o g e t more e n e r g y b e f o r e you c a n go on a g a i n . You know you g e t t i r e d q u i c k e r t h o u g h . You know, l i k e some n i g h t s , i f you t h i n k y o u ' d l i k e t o go o u t a n d you t h i n k , w e l l , I ' d b e t t e r n o t b e c a u s e you j u s t f e e l a l i t t l e b i t t i r e d , you know. I ' l l go t o b e d a t 8 : 0 0 o ' c l o c k o r 8 : 3 0 o r w h a t e v e r . Q. T e l l me m o r e . More a b o u t y o u r d i e t a n d y o u r s l e e p i n g . A . W e l l , I u s e d t o go t o b e d a t m i d n i g h t , 1 : 0 0 a . m . I 'm i n b e d a t 7 : 3 0 , 7 : 0 0 . Q. Why i s t h a t ? A . J u s t t o o e x h a u s t e d . I t s e e m s , t h e n , t h a t t h i s i l l n e s s e x p e r i e n c e meant a l a c k o f b o t h p h y s i c a l a n d p s y c h o l o g i c a l e n e r g y . The u n d e r l y i n g l o s s o f p r e d i c t a b i l i t y was c l e a r l y a p p a r e n t i n t h e women 's a c c o u n t s . The women were f a c e d w i t h g e t t i n g t o know a n d u n d e r s t a n d a new p h y s i c a l s e l f . T h e r e was a c o n s t a n t c o m p a r i s o n w i t h t h e o l d p h y s i c a l s e l f a s t h i s p r o c e s s e n s u e d . The women s h a r e d t h e i r s t r u g g l e t o come t o t e r m s w i t h t h e s e e n e r g y c h a n g e s , a s t r u g g l e b e c a u s e o f t h e unknowns o f t h e i r s i t u a t i o n . T h i s woman 's r e a l q u a n d a r y a b o u t h e r a b i l i t i e s s p e a k s t o t h i s s t r u g g l e . j You know, i f I 'm s t r o n g e n o u g h t o do i t t h e n - - I d o n ' t know. How s t r o n g a r e t h e y a f t e r a h e a r t a t t a c k ? They s a y , you know, [ y o u ] g e t b a c k t o n o r m a l . L o s s o f e n e r g y c h a r a c t e r i z e s t h e p e r v a s i v e l o s s o f p r e d i c t a b i 1 i t y . L a c k o f A n t i c i p a t e d S u p p o r t L a c k o f a n t i c i p a t e d s u p p o r t r e p r e s e n t s a s e c o n d a s p e c t o f t h e c e n t r a l l o s s o f p r e d i c t a b i l i t y . The women h a d t h o u g h t t h a t t h e y c o u l d c o u n t on t h e i r h u s b a n d s t o w h o l l y s u p p o r t them a t t h i s c r i t i c a l t i m e i n t h e i r l i v e s . I n s t e a d , t h e women e x p e r i e n c e d v a r y i n g d e g r e e s o f d i s a p p o i n t m e n t f o r w h i c h t h e y w e r e , u n p r e p a r e d b e c a u s e t h i s e x p e c t e d q u a l i t y o f s u p p o r t d i d n o t m a t e r i a l i z e . T h i s l a c k became a r e a l i t y when t h e women r e t u r n e d home f r o m h o s p i t a l . A c o n f l i c t s i t u a t i o n d e v e l o p e d b e t w e e n t h e c o m p e t i n g demands o f t h e i r home a n d f a m i l y l i v e s a n d t h e i r own h e a l t h s t a t u s . F u e l i n g t h i s s t r u g g l e w i t h i n t h e women was t h e r e c o g n i t i o n t h a t t h e s u p p o r t t h e y e x p e c t e d was n o t f o r t h c o m i n g . The women a l s o s e n s e d t h a t t h e s i t u a t i o n w o u l d be d i f f e r e n t i f t h e r o l e s were r e v e r s e d , i f t h e i r h u s b a n d s h a d h a d t h e h e a r t a t t a c k . F u r t h e r , u n d e r l y i n g t h i s d i f f i c u l t y was t h e p e r c e p t i o n t h a t t h e MI i l l n e s s e x p e r i e n c e was a l e s s v a l i d a n d s i g n i f i c a n t one f o r a woman. L a s t l y , t h e l a c k o f a n t i c i p a t e d s u p p o r t i n f l u e n c e d t h e women 's c a r d i a c r e h a b i l i t a t i o n a t home i n a number o f w a y s . The t i m e a t home f o l l o w i n g h o s p i t a l d i s c h a r g e was a s i g n i f i c a n t p e r i o d i n t h e women 's i l l n e s s e x p e r i e n c e . The women' r e c a l l e d t h e i r i l l n e s s e x p e r i e n c e i n h o s p i t a l a s a t i m e when t h e y a c c e p t e d what was h a p p e n i n g t o t h e m . T h e y d e s c r i b e d t h e i r f e e l i n g s t a t e a s r e l a t i v e l y f r e e o f e m o t i o n s . I t h i n k p r o b a b l y i t ' s t h e f a c t s o m e t i m e s how s h o u l d I p u t t h i s . W h i l e I was i n t h e h o s p i t a l , I d i d n ' t r e a l l y h ave t h a t many f e e l i n g s a b o u t i t . I j u s t f e l t s o m e t h i n g had h a p p e n e d , you know, t o t h e r e b e i n g a h e a r t a t t a c k . I a c c e p t e d t h e f a c t t h a t i t was a h e a r t a t t a c k . I t d i d n ' t u p s e t me. I t d i d n ' t -- I w a s n ' t d e p r e s s e d . I d i d n ' t r e a l l y have t h a t many e m o t i o n s a b o u t i t . The i m p a c t o f t h e i r h e a r t a t t a c k became much more f u l l y r e a l i z e d when t h e women were d i s c h a r g e d home f r o m h o s p i t a l . R e - e n t e r i n g t h e i r home a n d f a m i l y l i v e s b r o u g h t i n t o f o c u s how t h i s p a t h o p h y s i o l o g i c a l e v e n t w o u l d a f f e c t them. Coming home was a p u s h i n t o t h e i r new r e a l i t y . F o r t h e s e women, b e i n g a t home meant i n t e r f a c i n g w i t h t h e i r work e n v i r o n m e n t . The p r o b l e m s i n h e r e n t i n r e h a b i l i t a t i n g f r o m an MI i n o n e ' s p l a c e o f work were i m m e d i a t e l y e v i d e n t . A v e r y a c u t e d i l e m m a d e v e l o p e d . As one woman e x p l a i n e d : I s u p p o s e t h e f i r s t t h i n g you n o t i c e i s h a l f a n i n c h o f d u s t on e v e r y t h i n g . The b a t h r o o m s no one h a s t o u c h e d . You know. N e w s p a p e r s s t a c k e d h i g h . And you know t h a t you won't e v e n go a h e a d a n d do i t [ u n l e s s ] you want t o k i l l y o u r s e l f a n d i t ' s k i l l i n g you t o go l o o k a t i t a l l t h e t i m e . My h u s b a n d r e a l i z e s t h e r e ' s s o m e t h i n g w r o n g . C a n ' t you a t l e a s t g e t a l l t h e s e n e w s p a p e r s o u t ? M u s t t h e y l i e t h e r e i n a s t a c k l i k e t h a t ? You know, t h e d i s h w a s h e r , e v e r y t h i n g , t h e r e ' s no r e a s o n why men c a n ' t t h i n k a l i t t l e . I d o n ' t know what most women's a t t i t u d e i s . N o t so much t o h a v i n g a h e a r t a t t a c k . I t ' s what h a p p e n s a f t e r you come home. I t ' s w o r s e , I i m a g i n e , f o r t h o s e women who have s m a l l c h i l d r e n a t home a n d t h e r e a r e s e v e r a l women t h a t I know o f who s t i l l h a v e c h i l d r e n a t home. E v e n t h o u g h t h e d e s c r i p t i o n s o f t h e i m p a c t were n o t a s s t r i k i n g a n d f r u s t r a t i n g t h r o u g h o u t t h e a c c o u n t s , t h e r e was a d e f i n i t e s e n s e t h a t r e c u p e r a t i n g a t home was n o t a smoot h p r o c e s s . F o r t h e f o l l o w i n g woman, t h e r e was t h e a w a r e n e s s t h a t , a l t h o u g h she was n o t d o i n g h e r u s u a l w o r k , she was s t i l l r e s p o n s i b l e f o r o r g a n i z i n g t o g e t i t d o n e . F u r t h e r m o r e , t h e r e was t h e r e a l i z a t i o n t h a t t h e s u p p o r t she had h o p e d f o r was w a n i n g a n d 53 t r y i n g to keep i t g o i n g was not always worth the e f f o r t . Yes . And then you t r y to o r g a n i z e everybody to s o r t of take over and t h a t ' s very d i f f i c u l t because t h e y ' r e in and o u t . In f a c t , I t h i n k i t ' s one of the more d i f f i c u l t p a r t s of r a i s i n g c h i l d r e n . I t ' s j u s t when they reach t h a t age to get them to r e a l i z e tha t i t ' s s o r t of communal l i v i n g and they a l l have to c h i p i n . And they were w e l l o r g a n i z e d when I was away but when you come home, they s o r t of s l a c k o f f a l i t t l e b i t . Q. How do you f e e l about I guess what I want to say i s do you f e e l your f a m i l y unders tands the k i n d of d i f f i c u l t y y o u ' r e fee 1ing? A. No. No. They d o n ' t . Q. T e l l me about t h a t . A . W e l l , I ' ve never spoken to them about i t f o r one t h i n g . And l i k e most young people when they see Mother s t a r t i n g to get w e l l , they s l a c k o f f a b i t . No, t h e y ' r e normal k i d s . They d o n ' t r e a l l y want to get up and s t a r t supper i f t h e i r f a v o u r i t e T . V . programme i s on . And I ' d r a t h e r do i t myseLf than h a s s l e them to do i t . And I t h i n k t h a t ' s normal t o o . In a d d i t i o n to the sharp c o n t r a s t to the p r e s c r i b e d t h e r a p e u t i c environment of r e s t and r e l a x a t i o n , there was the p e r c e p t i o n t h a t t h i n g s would be d i f f e r e n t f o r a man. The e s s e n t i a l d i f f e r e n c e i d e n t i f i e d was the l e v e l of suppor t and u n d e r s t a n d i n g . There was a b e l i e f t h a t , i f the r o l e s were r e v e r s e d , t h e i r husbands would have b e n e f i t e d from t h e i r w i v e s ' utmost e f f o r t s to f a c i l i t a t e the p roce s s of c a r d i a c rehab i 1 i t a t i o n . One woman sugges ted t h a t t h i s d i f f e r e n c e was due to her t r a d i t i o n a l r o l e w i t h i n the home, but then q u i c k l y d i s m i s s e d t h i s as a p o s s i b l e e x p l a n a t i o n . Another woman i m p l i e d tha t the support she had expec ted was more c l o s e l y a l i g n e d w i t h usual women's r o l e s . She f e l t tha t i t d i d not f i t w i t h the male p e r s p e c t i v e where market work s u p e r c e d e s . Not o n l y was i t d i f f i c u l t f o r these husbands to p r o v i d e the expected u n d e r s t a n d i n g and s u p p o r t , b u t , i t seems, they c o n t i n u e d w i t h i n t h e i r l i v e s a s i f n o t h i n g h a d h a p p e n e d , w i t h o u t o v e r t l y a c k n o w l e d g i n g t h e i r w i v e s ' i l l n e s s e x p e r i e n c e . C l e a r l y , t h e s e women w a n t e d more a n d e x p e r i e n c e d a b i t t e r d i s i l l u s i o n m e n t . My f e e l i n g w a s , God f o r b i d , b u t h a d i t b e e n my h u s b a n d , I f e l t I w o u l d have c o p e d w i t h i t d i f f e r e n t l y . L i k e I w o u l d h a v e b e e n i n a p o s i t i o n , i f you w i s h , o r a c o n d i t i o n t o h a v e r e a l l y gone a n d e d u c a t e d m y s e l f a s t o how t o h a n d l e t h i s , f o r my h u s b a n d , o k a y , t o c o o k f o r h i m , t o e n c o u r a g e h i m , t o do w h a t e v e r , b u t you come home a s a w i f e who d o e s t h e c o o k i n g a n d d o e s t h e h o u s e w o r k , e t c e t e r a a n d e t c e t e r a a n d y o u ' r e n o t f e e l i n g t h a t g o o d t o s t a r t w i t h a n d y o u ' r e n o t e q u i p p e d a t a l l a s t o h a n d l e i t a n d you d o n ' t f e e l , you know, j u s t g u n g ho a n d f u l l o f w h a t e v e r t o do t h i s . A g a i n , i t m i g h t be j u s t t h e i n d i v i d u a l b u t I mean a l l I 'm s p e a k i n g f o r i s my own h u s b a n d , o k a y . To my k n o w l e d g e he h a s done — l i k e he h a s done n o t h i n g t o f i n d o u t a n y t h i n g a b o u t a h e a r t a t t a c k , o k a y . I t h i n k he t h i n k s to h i m s e l f , w e l l , she h a s done i t . B ' s done i t . You know, B ' s f o u n d o u t o r s h e ' s t a l k e d t o t h e d o c t o r o r she p h o n e d t h e H e a r t F o u n d a t i o n o r she d i d t h i s . B u t you k n o w , he h a s t o go t o work a n d I 'm s u r e , l i k e i f I s a i d s o m e t h i n g to h i m , h e ' d s a y , w e l l — l i k e he g o e s t o work a t t w e n t y a f t e r s e v e n a n d he g e t s home a t 5 : 3 0 a t n i g h t . L i k e what i s i t I want h i m t o d o . You know. S o , i f I was a c a r e e r woman, a n d my h u s b a n d h a d o n e , i t m i g h t be d i f f e r e n t b u t n o , I d o n ' t t h i n k s o . B e c a u s e , I 'm j u s t i n t h a t e r a where t h a t i s t h e w i f e ' s r o l e , o k a y . S o , some h u s b a n d s may b u t I t h i n k f o r t h e most p a r t [ n o t ] I d o n ' t know. I t ' s d i f f e r e n t f o r a man. T h e y w o r r y a b o u t , w h a t , you know, g o e s on a t t h e o f f i c e o r w h a t e v e r j o b t h e y h a p p e n t o be a t . T h e y ' r e t o t a l l y d e p e n d e n t on t h e i r w i f e f o r m o r a l s u p p o r t , p h y s i c a l c o m f o r t , e v e r y t h i n g . I d o n ' t know. F o r some r e a s o n , men j u s t d o n ' t u n d e r s t a n d . When I come home f r o m t h e h o s p i t a l , he a u t o m a t i c a l l y s i t s a n d w a i t s f o r d i n n e r t o be s e r v e d . F i n a l l y i t dawns on h i m , h e y , w a i t a m i n u t e . B u t s t i l l , i t n e v e r r e a l l y , r e a l l y r e a c h e s down d e e p i n s i d e , I d o n ' t t h i n k . L o o k , s h e ' s r e s t r i c t e d i n what she c a n do o r a t l e a s t what s h e ' s t o l d she c a n d o . T h e y n e v e r t h i n k t h a t way . S o , you a s k a few t i m e s a n d t h e n you f i n a l l y j u s t g i v e up a n d f o r g e t a b o u t i t . And e v e r y now a n d t h e n t h e y do t h i n k , w e l l , you know - - t h e y g e t t h e vacuum c l e a n e r a n d vacuum o r some s u c h t h i n g . I c o u l d h a v e someone come i n b u t by t h e t i m e you g e t t h r o u g h s h o w i n g t h e m , t e l l i n g t h e m , e x p l a i n i n g t o t h e m , why t h a t ' s e q u a l l y a s b a d on you a s i t i s t o do i t y o u r s e l f , I t h i n k . I t h i n k when a woman h a s a h e a r t a t t a c k , t h e man, t h e h u s b a n d , a n d i f t h e r e a r e a n y c h i l d r e n , t h e r e s h o u l d be some c l a s s , some s o m e t h i n g t h a t c a n r e a l l y make them aware what has h a p p e n e d , what is e x p e c t e d o f t h e m . How i t a c t u a l l y h a s t o g o . C o n t r i b u t i n g to t h e women 's p e r c e p t i o n s o f l a c k o f a n t i c i p a t e d s u p p o r t was t h e s t a t e d o r u n s t a t e d p r e m i s e t h a t a h e a r t a t t a c k was a l e s s s i g n i f i c a n t e v e n t f o r a woman. As t h i s woman s h a r e d : L i k e t h e one t h i n g my h u s b a n d s a i d , f o r e x a m p l e , he s a i d , w e l l , y o u ' r e l u c k y - - i f I 'm u s i n g t h e words c o r r e c t l y , he s a i d , w e l l , y o u ' r e l u c k y i n c o m p a r i s o n , he s a i d . T h e r e ' s b e e n men down a t t h e m i l l f o r e x a m p l e , who h a d a h e a r t a t t a c k . T h e r e was two t h a t h a d them a n d t h e y were o f f work f o r s o m e t h i n g l i k e s i x m o n t h s . S o , he s a i d , c a n you i m a g i n e , he s a i d , t h e s t r e s s a n d t h e a n x i e t y a n d e t c e t e r a , t h a t t h e y were u n d e r b e c a u s e t h e y were t h e p r o v i d e r s a n d t h e y h a d t o w o r r y a b o u t t h e i r j o b a n d t h i n k a b o u t , l i k e when am I g o i n g t o g e t b a c k t o my j o b w h e r e a s , he s a i d , you d i d n ' t h a v e t o w o r r y a b o u t t h a t . A n y w a y , when he s a i d t h a t , I d i d n ' t s a y a word t o h i m b u t I t o o k r a t h e r o f f e n c e o f t h a t . B e c a u s e I d i d n ' t n e e d t o h e a r t h a t . You k n o w , i t was s o r t o f l i k e , I g o t t h e f e e l i n g t h a t , l i k e y o u ' v e h a d one b u t you r e a l l y d o n ' t h a v e a n y t h i n g t o w o r r y a b o u t s o , l i k e j u s t g e t on w i t h i t a n d g e t b e t t e r . Do you know what I 'm s a y i n g ? B e c a u s e I d i d n ' t h a v e t o t h e r e d i d n ' t h a v e t o be s t r e s s o r w h a t e v e r a b o u t me g o i n g b a c k t o w o r k . I d i d n ' t e v e r h a v e t o go b a c k t o w o r k , i f my h e a l t h w o u l d n ' t a l l o w me t o , o k a y . B u t i t h a p p e n s t o be t h e work t h a t I — b e c a u s e I w o r k , i t ' s s o m e t h i n g t h a t I do b e c a u s e I want t o do i t . I f i t ' s a s e l f i s h t h i n g , t h a t ' s what i t i s . I c e r t a i n l y d o n ' t h a v e t o do i t . J u s t f o r t h e m o n e t a r y a s p e c t o f i t . B u t t h a t was j u s t a t y p i c a l r e m a r k a n d he d i d n ' t mean i t u n k i n d l y . I know he d i d n ' t , b u t I g u e s s when he s a i d i t , I w i s h e d t h a t he h a d n ' t a n d I j u s t t a l k e d t o a g i r l f r i e n d o f mine a b o u t i t a n d I t h i n k , you know - - a n d I 'm n o t b e i n g c h a u v i n i s t i c t h e o t h e r way a r o u n d b u t I t h i n k i t ' s r a t h e r — i n my f e e l i n g r a t h e r , t y p i c a l l y male t h a t - - a n d y e t the t a b l e s w o u l d be q u i t e t u r n e d i f i t was t h e y who h a d t h e h e a r t a t t a c k . B e c a u s e he s a i d t o me l i k e t h e s e p e o p l e t h a t he s u p p o s e d l y knows t h a t h a d a h e a r t a t t a c k , t h e y were o f f work a n d he s a i d t o me, you know, a man t h a t h a s a h e a r t a t t a c k , some o f them d o n ' t know i f t h e y ' r e j o b w i l l be t h e r e when t h e y go b a c k ; o t h e r s d o . L i k e what he was s a y i n g , I g u e s s i s s a y t h e y ' r e a p l u m b e r o r a c a r p e n t e r o r t h a t s o r t o f t h i n g t h a t , you know, t h e y d o n ' t n e c e s s a r i l y h a v e b e n e f i t s . I t w o u l d j u s t be t h e s t r e s s t h e y ' d be u n d e r by b e i n g o f f w o r k . I u n d e r s t a n d a l l t h a t . B u t i t was j u s t t h e way I f e l t , I j u s t f e l t I d i d n ' t n e e d t o h e a r t h a t . I g u e s s I d o n ' t want s y m p a t h y so to s p e a k b e c a u s e I 'm n o t t h a t t y p e o f a p e r s o n . P e r h a p s j u s t a l i t t l e b i t more u n d e r s t a n d i n g o r a n a t t e m p t o f u n d e r s t a n d i n g what h a s h a p p e n e d . B u t he j u s t h a d my h u s b a n d h a p p e n s to be t h e t y p e o f p e r s o n t h a t - - l i k e n a t u r a l l y he w i s h e s i t d i d n ' t h a p p e n b u t he r e a l l y d o e s n ' t want to t a l k a b o u t i t . He d o e s n ' t r e a l l y want to y e a h , d i s c u s s i t . He j u s t w a n t s me t o g e t b e t t e r a n d l e t ' s g e t on w i t h t h e way t h i n g s w e r e . L i k e you s h o u l d be a b l e to be o k a y . W i t h i n t h e a b o v e e x c e r p t , w o m e n ' s i l l n e s s e x p e r i e n c e w i t h MI was p o i g n a n t l y m i n i m i z e d a n d d i s m i s s e d . T h i s i n c o m p l e t e v a l i d a t i o n o f women 's h e a r t a t t a c k e x p e r i e n c e was a n i n h e r e n t c o m p o n e n t o f l a c k o f a n t i c i p a t e d s u p p o r t . C o n s e q u e n t l y the women 's r e h a b i l i t a t i o n p r o c e s s was n e g a t i v e l y I n f l u e n c e d . In a d d i t i o n t o t h e c o n s i d e r a b l e e m o t i o n a l wear a n d t e a r a n d p o s s i b l e p h y s i c a l o v e r - e x e r t i o n b e c a u s e o f t h e l a c k o f a n t i c i p a t e d s u p p o r t , t h e r e was d i f f i c u l t y a c t u a l i z i n g t h e l i f e s t y l e c h a n g e s t o e f f e c t a s u c c e s s f u l c a r d i a c r e h a b i l i t a t i o n . And s e e , my h u s b a n d was a l s o a s m o k e r . Now, I 'm n o t s m o k i n g a n d I hope t h a t I 'm n o t a b o u t t o a n d he was g o o d when I f i r s t come home f r o m t h e h o s p i t a l . L i k e he d i d n o t smoke i n t h e home. And I t h o u g h t , l i k e he was c u t t i n g down a n d h o p e f u l l y he w o u l d s t o p b u t w e ' l l be s i t t i n g i n t h e d e n a n d he d o e s smoke i n t h e d e n a n d I d o n ' t r e a l l y l i k e i t , b u t I t h i n k t o m y s e l f — l i k e , I g e t up a n d wa lk o u t o f t h e d e n b e c a u s e o n c e a g a i n , I j u s t t h i n k t o m y s e l f , l i k e he knows a n d I ' v e t o l d h i m , you know, t h a t i t b o t h e r s me a n d I g u e s s , e x - s m o k e r s a r e t h e w o r s t . B u t i t d o e s b o t h e r me, p l u s I know t h a t i f I 'm g o i n g t o s i t i n t h a t d e n a t n i g h t a n d i n h a l e t h e smoke o f t e n c i g a r e t t e s , I m i g h t a s w e l l h a v e f i v e o f my own. I m e a n , t h a t ' s how much damage i s b e i n g d o n e . So - - b u t you know, I 'm n o t g o i n g t o s a y t o h i m , you c a n ' t s m o k e . T h i s i s h i s home t o o . I g u e s s i f he w a n t s t o s m o k e , you know, I 'm t h e one t h a t h a s t o make t h e c h o i c e . Now, I t h i n k i n my m i n d , i f t h e t a b l e s were t u r n e d a g a i n , I w o u l d n ' t smoke i n t h e home. I f he w a s n ' t s m o k i n g , I w o u l d n ' t do t h a t t o h i m . B u t I o n l y t h i n k t h a t . I mean , I d o n ' t know. I w o u l d hope I w o u l d n ' t . B e c a u s e s m o k i n g i s o b v i o u s l y s u c h a b i g p a r t o f i t . T h u s , n o t v a l i d a t i n g t h e e x p e r i e n c e seemed to e x t e n d a s w e l l i n t o a l a c k o f s u p p o r t f o r t h o s e f a c e t s o f d a i l y l i v i n g d i r e c t l y r e l a t e d t o a p o s i t i v e r e c o v e r y ( l i f e s t y l e m o d i f i c a t i o n s ) . In a d d i t i o n t o c e s s a t i o n o f s m o k i n g , d i e t a r y c h a n g e s were a l s o p r o b l e m a t i c when t h e h u s b a n d ' s s u p p o r t was n o t f e l t . As t h i s woman r e l a t e d , i t was d i f f i c u l t b e c a u s e h e r h u s b a n d was n o t f o l l o w i n g t h e d i e t p r e s c r i b e d f o r h e r . P l a n n i n g a n d c o o k i n g two m e a l s meant a n i n c r e a s e d e n e r g y o u t p u t f r o m h e r t h a t she was u n w i l l i n g t o e x p e n d . I t s e e m e d t h a t i t was n o t e a s y t o p u t h e r s e l f f i r s t when h e r i l l n e s s e x p e r i e n c e h a d b e e n n u l l i f i e d . B u t t h e c o o k i n g , I f i n d t h e c o o k i n g v e r y d i f f i c u l t . And I t h i n k i t ' s b e c a u s e i t ' s f o r m y s e l f . B e c a u s e I 'm c o o k i n g f o r m y s e l f a n d I w o u l d be c o o k i n g one way f o r m y s e l f a n d one way f o r my h u s b a n d , i f I r e a l l y d i d what I was s u p p o s e d t o d o . And I f i n d t h a t d i f f i c u l t . S o , a l l I 'm d o i n g i s - - a s o p p o s e d t o c o o k i n g f o r m y s e l f , I 'm j u s t c u t t i n g some t h i n g s o u t t h a t I c o o k f o r h i m . B e c a u s e I d o n ' t l i k e c o o k i n g t h a t much t o s t a r t w i t h . I 'm a r e a s o n a b l y g o o d c o o k b u t I d o n ' t r e a l l y l i k e i t a n d i t ' s j u s t n o t i n me. I h a v e n ' t g o t t h e i n t e r e s t t o c o o k two d i n n e r s . Q . Do you t h i n k t h a t i f i t was r e v e r s e d , you w o u l d c h a n g e y o u r e a t i n g h a b i t s . A . Y e a h . No q u e s t i o n . Now, t h e — y e a h , b e c a u s e I w o u l d c o o k f o r h i m a n d I w o u l d e a t w h a t ' s t h e r e b e c a u s e I know t h a t what I ' d be c o o k i n g f o r h i m i s f o o d t h a t I s h o u l d be e a t i n g m y s e l f a n y w a y . B u t , you know, when I came home f r o m t h e h o s p i t a l , I s a i d t o h i m , you k n o w , c o u l d we s i t down a n d p l a n a menu , you k n o w , s o m e t h i n g t h a t w o u l d a p p e a l t o h i m , you k n o w , t h a t w o u l d be w i t h i n t h i s . O h , y e a h , he t h o u g h t t h a t was a g o o d i d e a , b u t l i k e i t ' s n e v e r h a p p e n e d . S o , l i k e I 'm n o t g o i n g t o p u s h . I j u s t t h i n k i t ' s w rong t o p u s h somebody e l s e i n t o s o m e t h i n g t h a t e v e n t h o u g h i t w o u l d be t h e b e s t t h i n g f o r t h e m , i f t h a t i s n ' t what t h e y w a n t . The women c o u n t e r e d t h e i r f e l t d i s a p p o i n t m e n t i n t h e l a c k o f a n t i c i p a t e d s u p p o r t by t r y i n g t o u n d e r s t a n d t h e i r h u s b a n d s ' r e s p o n s e s t o t h e i r i l l n e s s e x p e r i e n c e . T h e r e was a n a l m o s t u n i v e r s a l o p i n i o n among t h e women t h a t t h e i r h u s b a n d s were i m p a i r e d i n t h e i r a b i l i t i e s t o h e l p . B o t h t h e i r h u s b a n d s ' d i f f i c u l t i e s i n c o m i n g t o t e r m s w i t h t h e i r MI a n d t h e i r s i m p l y n o t k n o w i n g how t o e f f e c t i v e l y h e l p o u t , were t h o u g h t t o l i m i t the q u a l i t y o f t h e i r h u s b a n d s ' s u p p o r t . H e ' s , you know — a n d a s I s a y , he h a s n ' t - - t h e r e was a programme o n , P . , l a s t W e d n e s d a y . I t came on a t 9 : 0 0 o ' c l o c k . I t h i n k i t was on C h a n n e l 9 a n d i t was t h i s c h a p w h o ' d h a d a h e a r t a t t a c k . I t was on f o r a n h o u r . O k a y , i t was — w e l l , i t was o n l y t h a t h o u r a n d o f c o u r s e , I - -my Mom h a d t o l d me a b o u t i t a n d I j u s t made a p o i n t o f w a t c h i n g i t . A c t u a l l y i t was q u i t e g o o d . I mean I w a t c h w h a t e v e r I c a n a n d r e a d w h a t e v e r c e r t a i n l y I c a n a n d I t o l d my h u s b a n d i t was c o m i n g on a n d t h i s w i l l j u s t g i v e you a n e x a m p l e , when i t f i r s t f l a s h e d on a t 9 : 0 0 o ' c l o c k , he g o t up a n d I d i d n ' t know where he was g o i n g o r what he was d o i n g b u t he went a n d r a n the b a t h t u b a n d h a d a b a t h . I t was l i k e he d i d n ' t want t o s e e ; he d i d n ' t want t o know. S o , you know, when a p e r s o n - - when you g e t t h a t f e e l i n g t h a t a p e r s o n i s t h a t way , i t ' s d i f f i c u l t b e c a u s e you d o n ' t want l i k e I d o n ' t want t o p u t s o m e t h i n g o n t o h i m t h a t ' s g o i n g t o d i s t r e s s h i m . I mean , you k n o w , I t h i n k you h a v e t o h a v e I t w i t h i n y o u r s e l f a n d we you know, w e ' l l have b e e n m a r r i e d t w e n t y - n i n e y e a r s t h i s y e a r . S o , i t ' s n o t l i k e we s o r t o f d o n ' t know e a c h o t h e r o r know e a c h o t h e r ' s moods a n d what h a v e y o u , you know. W i l l i n g n e s s t o h e l p a n d r e a s o n a b l e e f f o r t were c o m f o r t i n g , on some l e v e l , f o r t h e women. T h e r e was s t i l l a s e n s e o f n o t b e i n g w h o l l y s u p p o r t e d , b e c a u s e t h e r e was n o t a c o m p l e t e t a k e o v e r o f t h e r e s p o n s i b i l i t i e s p e r c e i v e d t o be t h e i r s . T h i s l a c k was a l m o s t a l w a y s l i n k e d t o t h e i r h u s b a n d s ' g e n d e r - r e l a t e d e x p e c t a t i o n s . As t h e s e women e x p l a i n e d : And he d o e s t h e c o o k i n g a n d i n f a c t , he was b r a g g i n g , w e l l , I w o n ' t g e t k i c k e d o u t o f t h e k i t c h e n a n y more now, he s a y s . He l o v e s t o c o o k . And he d o e s t h e v a c u u m i n g a n d he d o e s t h e l a u n d r y b u t he d r a w s t h e l i n e a t i r o n i n g . o f c o u r s e [ u n d e r l i n i n g a d d e d ] . H e ' s n o t one o f t h o s e men t h a t w i l l jump i n t o t h e l a d y ' s work a n d a l l t h a t , you know, b u t he t r i e s v e r y h a r d t o — t o o b l i g e . L i k e he c e r t a i n l y d o e s n ' t vacuum w e e k l y . He d i d i t o n c e a n d t h e n he d i d i t a g a i n t h e o t h e r d a y . A c h , I d o n ' t t h i n k he was v e r y t h o r o u g h b u t i t d o e s n ' t m a t t e r . H e ' s d o i n g i t . S o , t h e r e i t i s . You know, what c a n vou  a s k o f h im [ u n d e r l i n i n g a d d e d ] . 59 T h e r e ' s t h i n g s t h a t I s h o u l d n ' t be d o i n g l i k e maybe v a c u u m i n g o f f t h e c h e s t e r f i e l d o r d o i n g e x t r a v a c u u m i n g , t h a t a woman d o e s [ u n d e r l i n i n g a d d e d ] you k n o w , he d o e s n ' t - - I j u s t f e e l l i k e I 'm i m p o s i n g on h i m a n a w f u l l o t a n d — I t ' s j u s t t h a t I f e e l t h a t I 'm e x p e c t i n g t o o much o f h i m . You know, o f b e i n g a man a n d n o t u s e d t o t h a t s o r t o f t h i n g [ u n d e r l i n i n g a d d e d ] . And I c a n ' t do i t . I h a v e f o u n d t h a t o u t . I n e a r l y k n o c k e d m y s e l f o u t . One d a y I t h o u g h t w e l l , I c a n a t l e a s t vacuum t h e c h e s t e r f i e l d . W e l l , I g o t t h e c h a i r done b u t I f o l d e d up b e f o r e I g o t to t h e c h e s t e r f i e l d . C l e a r l y , t h e n , i t i s e v i d e n t t h a t t h e l e s s t h a n t o t a l s u p p o r t h a d d e l e t e r i o u s c o n s e q u e n c e s , b o t h p h y s i c a l a n d e m o t i o n a l . The women e x p e n d e d e i t h e r e m o t i o n a l o r p h y s i c a l e n e r g y t o g e t t h i n g s done t o t h e i r s a t i s f a c t i o n . T h e y were n o t f r e e d o f t h e i r r e s p o n s i b i l i t i e s so t h e y c o u l d f o c u s on r e h a b i l i t a t i n g f r o m t h e i r M I . L a c k o f a n t i c i p a t e d s u p p o r t v a r i e d i n t e r m s o f how s t r o n g l y i t was f e l t among t h e women. The v a r i a t i o n s e e m e d t o be r e l a t e d t o t h e women 's f a m i l y c i r c u m s t a n c e s . F o r e x a m p l e , t h e two women n o t i n p a r t n e r r e l a t i o n s h i p s d i d n o t p e r c e i v e t h e a r e a o f s u p p o r t t o be a n i s s u e f o r t h e m . The women w i t h r e t i r e d h u s b a n d s f e l t some d e g r e e o f d i s a p p o i n t m e n t w i t h t h e i r h u s b a n d s ' i n p u t . L a c k o f a n t i c i p a t e d s u p p o r t was most v i s i b l e a n d p r o f o u n d i n t h e a c c o u n t s o f t h e women w i t h e m p l o y e d h u s b a n d s . F o r t h e s e women, l a c k o f s u p p o r t was d e v e l o p e d e x t e n s i v e l y w i t h i n t h e i r a c c o u n t s a n d r e p r e s e n t e d a f u n d a m e n t a l a n d c r i t i c a l d i m e n s i o n o f t h e i r MI i l l n e s s e x p e r i e n c e . The f o l l o w i n g two e x c e r p t s i l l u s t r a t e t h e m a g n i t u d e o f t h e i m p a c t o f t h i s l a c k o f a n t i c i p a t e d s u p p o r t . He f i n d s t h a t s u p p o r t d i f f i c u l t t o g i v e . W e l l , i f he d o e s , t h a t ' s s o m e t h i n g t h a t I e i t h e r h a v e t o l i v e w i t h o r make a d e c i s i o n . You know. But t h i s h e a r t a t t a c k , I j u s t g e t t h e f e e l i n g t h a t he d o e s n ' t know how t o c o p e w i t h i t a n d maybe d o e s n ' t know how t o c o p e w i t h i t b u t d o e s n ' t want t o . He j u s t s o r t o f wants t o he w a n t s t o a v o i d i t a s much a s he c a n . I t h i n k , h e ' s j u s t a s g l a d t o g e t o u t o f h e r e a t t w e n t y a f t e r s e v e n a n d go t o work a n d come home a n d I make d i n n e r . L i k e he i s n ' t one t o h e l p a r o u n d . L i k e he n e v e r s a i d , l i k e , c a n I vacuum f o r you o r c a n I do s o m e t h i n g f o r y o u , when he knows t h a t t h e s e t h i n g s a r e i m p o r t a n t t o me b e c a u s e I ' v e a l w a y s b e e n a f u s s y h o u s e k e e p e r . He c a n ' t u n d e r s t a n d o r a c c e p t t h a t j e e p e r s , a f t e r two m o n t h s , she s h o u l d be a b l e t o do s o m e t h i n g . You know. W e l l a n y t h i n g . You s h o u l d be a b l e t o wash w i n d o w s . You s h o u l d be a b l e t o do j u s t a b o u t a n y t h i n g you e v e r d i d d o . And he d o e s n ' t seem t o u n d e r s t a n d why. W e l l , D r . L . t r i e d t o e x p l a i n p a r t o f i t t h e o t h e r d a y . W e l l , we u s e d t o be f r i e n d s . Not o n l y h u s b a n d a n d w i f e , b u t f r i e n d s . I t ' s a l i t t l e d i f f e r e n t . I t ' s much d i f f e r e n t now. We u s e d t o make a b i g t h i n g o u t o f g o i n g g r o c e r y s h o p p i n g . B u t up u n t i l — I d o n ' t know how i t a f f e c t s o t h e r c o u p l e s . E v e r y b o d y ' s d i f f e r e n t , o f c o u r s e . H e ' s s o u s e d t o c o m i n g home t o a v e r y t i d y h o u s e . And h e ' s so u s e d t o h a v i n g h i s l a u n d r y a n d h i s m e a l s m e a l s a r e a l w a y s d i n n e r t o us was a c e r e m o n y . Now h e ' s d o i n g most o f t h e c o o k i n g . I t ' s - - I c a n s e e where t h i s s o r t o f s i t u a t i o n , d e p e n d i n g on t h e p e o p l e o f c o u r s e [ c o u l d ] a c t u a l l y t o t a l l y d e s t r o y a m a r r i a g e . The t i m e p e r i o d a t home f o l l o w i n g h o s p i t a l d i s c h a r g e i s c h a r a c t e r i z e d by l a c k o f a n t i c i p a t e d s u p p o r t . The women r e c a l l e d t h e i r i l l n e s s e x p e r i e n c e i n h o s p i t a l a s a n i n t e r l u d e i n t e r m s o f d e a l i n g w i t h t h e i m p a c t o f t h e i r h e a r t a t t a c k on t h e i r d a y - t o - d a y l i v e s . C o m i n g home m a r k e d a t r a n s i t i o n t o a d i f f e r e n t r e a l i t y . Home meant i m m e d i a t e i m m e r s i o n i n a work s e t t i n g . T h i s c o n t a c t meant e x p e r i e n c i n g t h e c o n f l i c t i n g demands o f t h e s i t u a t i o n . C o n c o m i t a n t l y , i t s e e m s , t h e women s e n s e d t h a t t h e s i t u a t i o n w o u l d h a v e b e e n d i f f e r e n t i f i t h a d b e e n t h e h u s b a n d who h a d s u f f e r e d t h e h e a r t a t t a c k . A d d i t i o n a l l y , n o t v a l i d a t i n g t h e w o m e n ' s i l l n e s s e x p e r i e n c e was a n i n h e r e n t c o m p o n e n t o f t h i s l a c k o f a n t i c i p a t e d s u p p o r t . O v e r a l l , t h e women's c a r d i a c r e h a b i l i t a t i o n was n e g a t i v e l y a f f e c t e d . The women e x p l a i n e d t h e i r h u s b a n d s ' b e h a v i o u r i n t e r m s o f t h e i r d i f f i c u l t y f a c i n g t h e i r w i v e s ' i l l n e s s e x p e r i e n c e and t h e i r n o t k n o w i n g how t o e f f e c t i v e l y h e l p . The l a c k o f a n t i c i p a t e d s u p p o r t was f e l t i n v a r y i n g i n t e n s i t y a c r o s s t h e p a r t i c i p a n t s . F o r some o f t h e women, t h i s a s p e c t o f l o s s o f p r e d i c t a b i l i t y f o r m e d a m a j o r p o r t i o n o f t h e i r e x p l a n a t o r y m o d e l s o f t h e i r i l l n e s s e x p e r i e n c e . Change i n U s u a l R o l e E n a c t m e n t L o s s o f p r e d i c t a b i l i t y was a l s o f e l t i n r e l a t i o n t o a ch a n g e i n u s u a l r o l e e n a c t m e n t . T h i s s e c t i o n s p e a k s t o t h e chan g e i n p e r f o r m i n g u s u a l s o c i a l a n d homemaker r o l e s . W i t h i n t h e i r a c c o u n t s , t h e women f o c u s e d on t h e s e two p a r t i c u l a r r o l e s . The i m p a c t on t h e homemaker was d e v e l o p e d most f u l l y by t h e women a s w o u l d be e x p e c t e d c o n s i d e r i n g t h a t a l l e i g h t women were p r i m a r i l y homemakers. The c h a n g e i n a c t i v i t y l e v e l b e c a u s e o f t h e p r e s c r i p t i o n f o r r e g a i n i n g w e l l n e s s f r o m t h e p r o f e s s i o n a l s e c t o r a n d t h e p h y s i c a l e f f e c t s o f t h e MI was v e r y t r o u b l e s o m e . The s u d d e n c h a n g e f r o m a b u s y , a c t i v i t y - f i l l e d d a y was a d i f f i c u l t a d j u s t m e n t . B e c a u s e o f t h e p r e s c r i b e d a c t i v i t y r e s t r i c t i o n s , s o c i a l r o l e s were p e r c e i v e d t o be a d v e r s e l y a f f e c t e d . The women e x p e r i e n c e d u n c o m f o r t a b l e boredom. The w o r s t p a r t I t h i n k i s s i t t i n g a r o u n d . Y o u ' r e n o t a l l o w e d t o do t h i s ; y o u ' r e n o t a l l o w e d t o do t h a t ; you c a n ' t go a n y w h e r e . You nee d t o be a b l e t o g e t i n t o y o u r own c a r and d r i v e t o t h e g r o c e r y s t o r e . Do you have any i d e a what a p r i v i l e g e t h a t i s . I t ' s one o f t h o s e t h i n g s you t a k e a s -- b e f o r e t h i s , i t was s o m e t h i n g t h a t h a d t o be done t h a t you d i d n ' t r e a l l y c a r e a b o u t , b u t you had t o do i t because you had to have food in the house , e t c e t e r a . Now I c o n s i d e r i t a p r i v i l e g e . But the boredom. T h a t ' s what - - t h a t ' s r e a l l y what get s me i s j u s t b e i n g b o r e d , not b e i n g ab le to do a n y t h i n g . D e p r e s s i o n was a l s o t i e d to a change in s o c i a l r o l e s . W e l l , I get down a l i t t l e , you know, because I c a n ' t go out and do the same as I used t o . You know, you f e e l a l i t t l e down but o t h e r than t h a t , i t d o e s n ' t bo ther me. The tremendous o v e r r i d i n g sense of not knowing which t y p i f i e s l o s s of p r e d i c t a b i l i t y genera ted f e e l i n g s of f ea r in r e l a t i o n to usua l s o c i a l r o l e s . Going out meant c o n f r o n t i n g t h e i r p r e c a r i o u s h e a l t h s t a t u s . No, I h a v e n ' t been r u n n i n g around shopping l i k e I u s u a l l y do because I was r e a l l y g o i n g s t r o n g b e f o r e , you know. W e l l , I t h i n k t h a t , you know, you k i n d of f e e l i f you want to go a long ways, you k i n d of h e s i t a t e . You e i t h e r ask your husband or go w i t h a f r i e n d or someth ing . Because I w o u l d n ' t l i k e to have i t [ another h e a r t a t t a c k ] happen in the c a r . I c o u l d n ' t go i n t o a s t o r e by m y s e l f . I a lways had to be sure my husband was i n the s t o r e . I might k i n d of take o f f and go and shop f o r something f o r m y s e l f , but tha t d i d n ' t - - I c o u l d n ' t even do my Chr i s tmas shopping because I c o u l d n ' t go i n t o a s t o r e and t h a t was a f t e r we got home. The women's l a c k of energy i n f l u e n c e d how they performed t h e i r usua l s o c i a l r o l e s . There was a d e f i n i t e c u r t a i l m e n t of even c a s u a l e n t e r t a i n m e n t but i t seems t h a t t h i s was not p e r c e i v e d as a nega t ive outcome of t h e i r MI. T h i s change was i d e n t i f i e d i n a m a t t e r - o f - f a c t way, wi thout emot iona l o v e r t o n e s . But I j u s t d o n ' t - - l i k e I d o n ' t f e e l , you know, that I have i t in me enough, to p a r t i c u l a r l y want to do a n y t h i n g [ e n t e r t a i n i n g ] e i t h e r . A b o u t the s a m e , y e a h , b u t you d o n ' t r e a l l y y o u ' r e n o t t h e s a m e . S a y , i f you want t o c a l l somebody f o r d i n n e r a n d t h a t , a t l e a s t , I h a v e n ' t b e e n a b l e t o s a y , w e l l , g e e , come on o v e r f o r d i n n e r , b e c a u s e I d o n ' t r e a l l y f e e l l i k e c o o k i n g , you know, a l l t h a t m u c h . The women 's r e s p o n s e t o a c h a n g e i n t h e u s u a l e n a c t m e n t o f t h e i r homemaker r o l e was e m o t i o n a l l y l a d e n . The women f e l t g u i l t y a b o u t t h e i r h u s b a n d s s t e p p i n g i n t o t h e i r l o n g - e s t a b l i s h e d r o l e w i t h i n t h e home. I d i d a t f i r s t , when I f i r s t came home I f e l t v e r y g u i l t y a b o u t l e t t i n g h i m do t h a t [ h o u s e w o r k ] , you know. I j u s t - -I r e a l l y f e l t t h a t I s h o u l d be d o i n g t h a t . You h a v e a f e e l i n g you s h o u l d be d o i n g t h a t b e c a u s e y o u ' v e done i t a l l t h o s e many y e a r s . I m i n d e d more n o t b e i n g a b l e t o do t h e t h i n g s , you know, a n d I s t i l l d o . I s t i l l m i n d i t v e r y m u c h , you know, t h a t t h i n g s t h a t I ' d l i k e t o do a n d s t i l l I h a v e t o l e t i t p a s s . The g u i l t was a l s o r e l a t e d t o t h e p e r c e p t i o n o f b e i n g a b u r d e n t o t h e i r p a r t n e r s , a n I m p o s i t i o n on t h e i r h u s b a n d s ' t i m e a n d e n e r g i e s . I f e l t v e r y down b e c a u s e I j u s t — you know, you c a n f e e l t h a t y o u ' r e g o i n g t o be a b u r d e n t o someone a n d I t h o u g h t , w e l l , p o o r S . , h e ' s g o t so much t o do a n d now, who knows w h e t h e r I 'm g o i n g t o r e a l l y be a b l e to p u l l o u t o f i t o r n o t , b u t I t h i n k I am now. I j u s t g e t d o w n . I f e e l I o u g h t t o be d o i n g m o r e . You f e e l y o u ' r e a b u r d e n . H e ' s l e a r n i n g t o c o o k . So t h a t he c a n s h a r e m o r e , a l t h o u g h h e ' s v e r y b u s y h i m s e l f . And i t ' s n o t t o o f a i r to work a l l d a y a n d h a v e t o come home a n d h a v e t o work a t y o u r m e a l s , i s i t ? In t h i s l a s t e x c e r p t , a n u n d e r l y i n g s e n s e o f a m b i v a l e n c e i s c o m m u n i c a t e d . A m b i v a l e n c e a b o u t a c c e p t i n g o r r e j e c t i n g s u p p o r t i s a n o t h e r d i m e n s i o n o f t h e c o n f l i c t s i t u a t i o n b e t w e e n t h e c o m p e t i n g demands o f t h e h o u s e h o l d a n d t h e i r own c a r d i a c r e h a b i l i t a t i o n d e s c r i b e d i n t h e p r e v i o u s s e c t i o n . A l t h o u g h t h e hear t a t t a c k e x p e r i e n c e c l e a r l y and d e c i s i v e l y e s t a b l i s h e d the p r i o r i t y need to take care of themse lve s , f e e l i n g s of g u i l t and even s e l f i s h n e s s s u r f a c e d . T h i s woman shared f e e l i n g g u i l t y about c o m p a r a t i v e l y minor t h r e a t s to her s o n s ' h e a l t h , because of a change in her usual s t andards of h o u s e c l e a n i n g . The dust i s p i l i n g up. The boys are a l l e r g i c to d u s t . You can keep the sur f ace c l e a n but you c a n ' t get i n t o the c o r n e r s . P u t t i n g themselves f i r s t was not an easy change to e f f e c t , d e s p i t e the powerful reasons f o r t h i s need. And you r e a l i z e y o u ' r e g o i n g to have to take time fo r y o u r s e l f , which I h a v e n ' t done . And then you f e e l s e l f i s h . Because I have an e i g h t y - f o u r year o l d mother 1 i v i n g w i t h me. In a d d i t i o n to f e e l i n g g u i l t y , the women f e l t a l o s s of power and a u t h o r i t y , because of the change in t h e i r homemaker r o l e . Even though t h i s change was a p o t e n t i a l l y p o s i t i v e one i n the women's l i v e s , l e t t i n g go engendered a sense of l o s s and r e q u i r e d a d e f i n i t e e f f o r t from the women. You have mixed f e e l i n g s because I tended to do too much f o r them. And I ' ve done too much f o r them. And i t ' s hard to s i t back and r e a l l y c o n t i n u e encourage them to c o n t i n u e what they s t a r t e d when I was i n the h o s p i t a l . You tend to s o r t of want to take o v e r . Whereas i t ' s not good f o r them and i t ' s not good f o r me. So, we're g o i n g to have to - - I'm g o i n g to have to back o f f and l e t them c o n t i n u e d o i n g more of the chore s and so on . T h e r e ' s s i x people so t h e r e ' s a f a i r amount. R e l i n q u i s h i n g t h e i r r o l e meant power s t r u g g l e s about the bes t way to do r o u t i n e househo ld c h o r e s . We run head on too sometimes. You know, I ' l l s ay , w e l l , t h i s i s the way I do i t ; t h a t ' s the way I want i t done but h e ' l l s ay , o h , y o u ' r e g e t t i n g b e t t e r . Y o u ' r e s t a r t i n g to compla i n . The women d e s c r i b e d a new dependency a r i s i n g from t h e i r r e l y i n g on t h e i r husbands to do the housework. The i n c i d e n t a l d e t a i l s o f d a y - t o - d a y l i f e r e p e a t e d l y e s t a b l i s h e d how much c o n t r o l t h e y h a d l o s t b e c a u s e o f t h i s c h a n g e . W e l l , I f i n d t h a t h e ' s t a k e n q u i t e a l o t o f my r e s p o n s i b i l i t y i n t h e home. F o r one t h i n g , h e ' s r e t i r e d a n d he h a s no h o b b i e s so i t k e e p s h i m b u s y a n d he r e a l l y e n j o y s i t a n d l o v e s t o do i t . He h a s done t h e s h o p p i n g p r e t t y w e l l s i n c e he r e t i r e d . I u s e d t o l i k e to do i t b u t you know, you do h a v e t o make c h a n g e s when t h a t t i m e c o m e s , a s y o u ' l l f i n d o u t . B u t I f i n d I g e t q u i t e r e s e n t f u l a b o u t t h a t , you know. I j u s t f e e l w e l l , I d o n ' t t h i n k t h e r e ' s a n y t h i n g wrong w i t h me m e n t a l l y t h a t I s h o u l d n ' t h a v e - - be a b l e t o make my d e c i s i o n s i n t h e h o u s e , you know. The o t h e r d a y he was t e l l i n g me a b o u t s o m e t h i n g t h a t s h o u l d be done a c e r t a i n way a n d I s a i d , w e l l , l i s t e n h e r e , I d i d i t f o r f o r t y - e i g h t y e a r s a n d e v e r y t h i n g was o k a y so why i s n ' t i t now? O h , I d o n ' t mean t h a t . I d o n ' t mean t h a t . B u t o f t e n o u r ways o f t h i n k i n g a r e d i f f e r e n t , o f c o u r s e ; w e ' r e two d i f f e r e n t p e o p l e a f t e r a l l . B u t n o t h i n g v e r y e a r t h s h a k i n g . I t ' s j u s t m o s t l y a b o u t t h e way t h i n g s a r e c o o k e d a n d what we want t o h a v e . And you know, t h a t k i t c h e n p a r t h a s b e e n t a k e n o v e r by h i m . W e l l , I 'm g e t t i n g u s e d t o i t a n d a t f i r s t , I d i d n ' t t h i n k v e r y much o f i t , you know. I j u s t f e l t l i k e , I was b e i n g p u s h e d o u t o f t h e o n l y t h i n g I h a d a n y a u t h o r i t y i n a n d you k i n d o f f e e l you l o s e y o u r a u t h o r i t y . You r e a l l y d o . I c a n ' t e v e n go i n t o t h e g a r a g e a n d l i f t t h e d o o r o r g e t a n y t h i n g o u t o f t h e f r e e z e r . I h a v e t o h a v e my h u s b a n d do t h a t . P a r t o f t h e l o s s o f power a n d a u t h o r i t y was t h e a d j u s t m e n t t o new s t a n d a r d o f h o u s e k e e p i n g . A . You know, you h a v e y o u r — you h a v e y o u r s y s t e m d a i l y a n d you t h i n k , w e l l , you g o t t o do t h i s a n d you do i t . Q . Y e s . A . B u t now, you d o n ' t . You k n o w . I t b o t h e r s you a l i t t l e b i t b e c a u s e you f e e l u n c o m f o r t a b l e , t h a t y o u r f l o o r i s n ' t v a c u u m e d on t i m e o r s o m e t h i n g l i k e t h a t , you know. And I p i l e d up a w h o l e b u n c h o f i r o n i n g . I a c c e p t e d i t b e c a u s e I t h o u g h t i t ' s t h e o n l y t h i n g I c a n d o . S o , I j u s t l e t h i m do h i s own t h i n g . He d i d t h i n g s d i f f e r e n t l y , m i n d , a n d t h a t , maybe I d i d n ' t c a r e a b o u t b u t t h e n , t h a t d o e s n ' t m a t t e r , a s l o n g a s i t g e t s d o n e . You know. 66 I d o n ' t do t h a t m u c h . M a i n l y b e c a u s e I t h i n k t o m y s e l f , w e l l , I c a n ' t wash w a l l s a n d I c a n ' t c l e a n w i n d o w s , a t l e a s t I t h i n k I c a n ' t . I c a n ' t v a c u u m . S o , you know, I do my p l a n t s a n d I k e e p t h i n g s t i d y a n d do d r a w e r s a n d t h i n g s b e c a u s e I ' v e a l w a y s l i k e I ' v e a l w a y s b e e n a g o o d h o u s e k e e p e r a n d I l i k e h o u s e k e e p i n g b u t i f I c a n ' t do i t a l l o r do i t t h e way I want t o do i t t h e n I j u s t d o n ' t b o t h e r d o i n g i t . S o , I ' v e h a d somebody e l s e come i n . L i k e I h a d t h e [ h o m e m a k i n g ] s e r v i c e when I f i r s t g o t home f r o m t h e h o s p i t a l . I h a d them come i n . W e l l , t h e y were o k a y t o a p o i n t , b u t d i d n ' t do t h i n g s p a r t i c u l a r l y t h e way I w a n t e d . S o , I d o n ' t h a v e them b u t I h a v e a y o u n g l a d y t h a t comes i n now e v e r y s e c o n d week a n d I j u s t o v e r l o o k t h i n g s t h a t were t h a t i m p o r t a n t b e f o r e . I j u s t t h i n k , w e l l , I g u e s s t h e y ' r e n o t so i m p o r t a n t , you know. F e e l i n g g u i l t y a n d a s e n s e o f l o s s o f power a n d a u t h o r i t y o v e r t h e r e l i n q u i s h i n g o f t h e i r homemaker r o l e o v e r t l y c o n t r a d i c t s t h e f i n d i n g s p r e v i o u s l y p r e s e n t e d a b o u t l a c k o f a n t i c i p a t e d s u p p o r t . The women f e l t d i s a p p o i n t e d b e c a u s e t h e i r h u s b a n d s w e r e n ' t s u p p o r t i n g t h e i r c a r d i a c r e h a b i l i t a t i o n by d o i n g h o u s e w o r k a n d y e t , when t h e i r h u s b a n d s d i d p a r t i c i p a t e i n t h e h o u s e w o r k , t h e women f e l t u n c o m f o r t a b l e a n d w o n d e r e d t h e m s e l v e s a b o u t t h e v a l i d i t y o f t h e i r c o n d i t i o n a n d w h e t h e r i t j u s t i f i e d s u c h a s s i s t a n c e i n t h e i r w o r k . A d d e d to t h i s q u a n d a r y was a l o s s o f t h e one a r e n a o f power a n d a u t h o r i t y t h a t t h e s e women a s homemakers owned a n d c o n t r o l l e d . T h e r e f o r e , a l t h o u g h t h e women were d i s a p p o i n t e d b e c a u s e t h e y d i d n o t g e t t h e s u p p o r t t h e y e x p e c t e d , a c c e p t i n g s u p p o r t i n t e r m s o f t h e i r h u s b a n d s d o i n g h o u s e w o r k was a l s o a d i f f i c u l t y . H o w e v e r , l a c k o f a n t i c i p a t e d s u p p o r t e x t e n d e d b e y o n d d o i n g h o u s e w o r k . T h e s e f i n d i n g s t h e n r e p r e s e n t o n l y one a r e a o f a p p a r e n t c o n t r a d i c t i o n . The women a l s o g r i e v e d a b o u t t h e i r h u s b a n d s ' l a c k o f u n d e r s t a n d i n g a b o u t t h e i r i l l n e s s e x p e r i e n c e . P e r h a p s e m o t i o n a l s u p p o r t i n t e r m s o f t r y i n g t o a p p r e c i a t e what t h i s h e a r t a t t a c k meant d a y - t o - d a y w o u l d have b e e n more r e a d i l y a c c e p t e d by t h e women. The women e x p e r i e n c e d a ch a n g e i n t h e i r u s u a l e n a c t m e n t o f t h e i r s o c i a l a n d homemaker r o l e s . F e e l i n g s o f boredom and d e p r e s s i o n were i d e n t i f i e d i n r e l a t i o n t o c h a n g e s i n s o c i a l r o l e s . W h i l e t h e r e were d e f i n i t e d i f f e r e n c e s i n s o c i a l r o l e e n a c t m e n t i n t e r m s o f e n t e r t a i n i n g , t h e s e d i f f e r e n c e s seemed n o t t o be p r o b l e m a t i c f o r t h e women. The c h a n g e i n u s u a l homemaker r o l e e n a c t m e n t was c h a r a c t e r i z e d by g u i l t f e e l i n g s a n d a s e n s e o f l o s s o f power a n d a u t h o r i t y . These c h a n g e s r e f l e c t t h e s t u d y ' s c e n t r a l l o s s o f p r e d i c t a b i l i t y . Women's MI i l l n e s s e x p e r i e n c e meant u n f o r e s e e a b l e a l t e r a t i o n s i n t h e women's d a i l y l i v i n g . S t r a t e g i e s f o r C o n t r o l The women e m p l o y e d a w i d e r a n g e o f s t r a t e g i e s t o g a i n c o n t r o l o v e r t h e i r l o s s e x p e r i e n c e . These s t r a t e g i e s f o r c o n t r o l were e v i d e n t i n t h e women's d i s c u s s i o n s o f t h e c a u s e a nd t h e i r p r o j e c t i o n s o f t h e outcome o f t h e i r h e a r t a t t a c k . P e r s o n a l p h i l o s o p h i e s a n d l i f e e x p e r i e n c e s were a l s o s o u r c e s f o r s t r a t e g i e s f o r c o n t r o l . A d d i t i o n a l l y , t h e r e a c t i o n s o f f a m i l i e s s e r v e d t o d e f l e c t t h e i m p a c t o f t h e h e a r t a t t a c k e x p e r i e n c e away f r o m t h e women a n d p r o v i d e t h e women w i t h f e e l i n g s o f c o n t r o l . The women made s e n s e o f t h e i r i l l n e s s e x p e r i e n c e by i d e n t i f y i n g what t h e y t h o u g h t c a u s e d t h e i r h e a r t a t t a c k . I t seemed t h a t t h i s c a u s a l a t t r i b u t i o n p r o v i d e d a d e g r e e o f o r d e r i n t h i s u n p r e d i c t a b l e i l l n e s s e x p e r i e n c e . And I s t i l l t h i n k t o t h i s d a y t h a t h a d I b e e n t r e a t e d p r o p e r l y f o r h i g h b l o o d p r e s s u r e , t h i s w o u l d n ' t have h a p p e n e d . Q. I 'm w o n d e r i n g what you - - what you f e e l c a u s e d y o u r h e a r t a t t a c k ? A . My f a m i l y . I t ' s m o s t l y h e r e d i t a r y . My s i s t e r d i e d i n h e r s l e e p . She was a b o u t f o r t y - f i v e . A n o t h e r one n o t l o n g a g o , j u s t a c o u p l e o f y e a r s o l d e r t h a n I. My d a d . My b r o t h e r . I have r e a d a l l t h e m a t e r i a l . T h e y g a v e me a l i t t l e b i t a t t h e h o s p i t a l a n d I g o t a b i t more f r o m t h e H e a r t A s s o c i a t i o n on B r o a d w a y . The b o o k s s a y s m o k i n g , w h i c h I d o n ' t d o . D i a b e t e s . W e l l , t h e r e ' s l a t e n t d i a b e t e s i n my m o t h e r ' s f a m i l y , b u t I have b e e n c a r e f u l . We s w i t c h e d t o v e g e t a b l e m a r g a r i n e s a n d so o n . T r i e d t o be c a r e f u l . The o n l y t h i n g t h a t I c a n t h i n k o f i s t h a t p e r h a p s I was r a i s e d on a f a r m a n d t h a t was t h e c a u s e , b u t a l s o my f a t h e r d i e d a t s i x t y - f i v e . H e r e d i t y i s a b i g i t e m , I u n d e r s t a n d . He d i e d a t s i x t y - f i v e o f c o r o n a r y t h r o m b o s i s . A s e c o n d s t r a t e g y f o r c o n t r o l was a p p a r e n t i n t h e women 's p e r c e p t i o n s o f t h e o u t c o m e o f t h e i r h e a r t a t t a c k . The women v o i c e d f e e l i n g s o f hope i n t h e f a c e o f t h e many unknowns w i t h i n t h e i r i l l n e s s e x p e r i e n c e . When a s k e d b y t h e r e s e a r c h e r t o p r o j e c t t h e f u t u r e i m p l i c a t i o n s o f t h e i r M I , t h e w o m e n ' s r e s p o n s e s were g e n e r a l l y p o s i t i v e a n d o p t i m i s t i c . The h o p e f u l t o n e o f t h e r e p l i e s w a s , h o w e v e r , t e m p e r e d w i t h f e e l i n g s o f u n c e r t a i n t y . Q. How do you t h i n k t h e n — how do you t h i n k y o u ' l l be f e e l i n g s a y two months down t h e r o a d ? A . G r e a t . I t h i n k I ' l l f e e l b e t t e r . I t h i n k i f maybe I d o n ' t have t h e h i g h b l o o d p r e s s u r e l i k e I h a d , t h e n I ' l l be f e e l i n g much b e t t e r t h a n I w a s . I 'm h o p i n g t h a t I ' l l g e t s t r o n g e r a n d be what I w a s . I d o n ' t know w h e t h e r i t ' l l come t o t h a t , b u t I 'm h o p i n g i t d o e s . I c a n f e e l t h a t i t ' s t a k e n a l o t o u t o f me, b u t I'm h o p i n g t h a t my s t r e n g t h w i l l come b a c k . Q. I'm w o n d e r i n g now how you t h i n k y o u ' l l be d o i n g o r f e e l i n g s a y two months f r o m now. How do you s e e y o u r s e l f ? A. Oh, s t r o n g e r a n d h e a l t h i e r . Two months f r o m now. T h a t ' s t h r e e m o n t h s . I s h o u l d b e . B u t t o a n s w e r y o u r q u e s t i o n , I j u s t hope t h a t two months f r o m now t h a t -- you know, t h a t I g e t on my l i t t l e pony and g e t on w i t h l i f e t h e way i t was b e f o r e a n d t h a t you know, i t s o r t o f i s n ' t , you know, I ' v e had a h e a r t a t t a c k o r I 've g o t t o be c a r e f u l i n c a s e I hope by t h a t t i m e t h a t I know e n o u g h w i t h t h e h e l p o f my d o c t o r s , r e a d i n g a n d w h a t e v e r , t o f e e l c o m f o r t a b l e a b o u t i t a n d know i n m y s e l f what I c a n do and what t h e c o n s e q u e n c e s o f s o m e t h i n g may o r may n o t be i f I do t h a t . P e r s o n a l p h i l o s o p h i e s a n d l i f e e x p e r i e n c e s a l s o s e r v e d a s s t r a t e g i e s f o r g a i n i n g c o n t r o l . I n o r d e r t o d e a l w i t h t h e a l l -e n c o m p a s s i n g unknowns o f t h e i r i l l n e s s e x p e r i e n c e , t h e women u s e d t h e i r b a s i c a t t i t u d e s t o w a r d s l i f e a n d p a s t e x p e r i e n c e s a s s t r a t e g i e s f o r c o n t r o l . Two o f t h e women d i r e c t l y a s s o c i a t e d t h e i r p a s t i l l n e s s e x p e r i e n c e s w i t h t h e i r a b i l i t y t o cope w i t h t h i s i l l n e s s e x p e r i e n c e . They c l e a r l y v i e w e d t h e i r p a s t i l l n e s s e x p e r i e n c e s a s h e l p f u l i n p u t t i n g t h e i r h e a r t a t t a c k e x p e r i e n c e i n t o a ma n a g e a b l e p e r s p e c t i v e . I t was j u s t , o h , w e l l you know, when you grow up k n o w i n g t h a t you have a h e a r t p r o b l e m . I t h i n k y o u r a t t i t u d e i s a l o t d i f f e r e n t t h a n i f i t ' s a l l o f a s u d d e n , b a n g , you've g o t a h e a r t p r o b l e m . I d o n ' t t h i n k i t s c a r e s you a s much. I w a s n ' t s c a r e d a t a l l . I t d i d n ' t b o t h e r me. S o , t o me, I d i d n ' t t h i n k n o t h i n g o f i t . You know, I ' v e had a l o t o f t h i n g s wrong w i t h me b e f o r e , you know a n d I've had p a i n b e f o r e . S o , i t j u s t seemed t o come a s a n o t h e r s o r t o f a t h i n g w i t h me. When I was a k i d , I had o s t e o m y e l i t i s a n d you know, I was i n t h e h o s p i t a l f o r a y e a r w i t h t h a t , a b o u t . And t h e n I had a c y s t i c mass i n my, you know, f e m a l e o r g a n s and had an o p e r a t i o n on t h a t a n d i t j u s t , you know, a l l t h r o u g h my y e a r s , I had s o m e t h i n g w r o n g . B u t I have come o u t o f i t a l l r i g h t . And o f f I ' d go a g a i n . B u t t h a t ' s a b o u t i t . The women's p e r c e p t i o n t h a t t h e y were s t r i v i n g t o do t h e i r u t m o s t t o p r o m o t e t h e i r r e h a b i l i t a t i o n o p e r a t e d a s an e n c o u r a g e m e n t . T h i s f e e l i n g o f c o m f o r t i n t h e i r e f f o r t s seemed t o e n g e n d e r f e e l i n g s o f c o n t r o l . B u t t h e n i t j u s t g o e s w h s s s a n d I g u e s s I -- I'm t r y i n g my -- I know t h a t I'm t r y i n g m y s e l f t o do e v e r y t h i n g t h a t I c a n t o p r e v e n t i t . T h a t — a n d a s l o n g a s I f e e l t h a t I'm d o i n g t h e b e s t t h a t I c a n , i f i t h a p p e n s , i t ' s g o i n g t o h a p p e n . So, i t ' s — i t ' s a p r e t t y h a r d t h i n g t o t a l k a b o u t . I t h i n k t h a t what I f e e l t h a t I h ave t o do i s j u s t l i v e w i t h i t , n o t t a l k a b o u t i t . J u s t l i v e w i t h i t and do t h e b e s t I c a n . T h a t ' s t h e way I f e e l a b o u t i t . R e l i g i o n p l a y e d an i m p o r t a n t r o l e f o r a few o f t h e women i n t e r m s o f how t h e y c o p e d . These women s h a r e d how t h e i r s p i r i t u a l b e l i e f s h e l p e d them t o make s e n s e o f t h e i r i l l n e s s e x p e r i e n c e . I am b a s i c a l l y a v e r y r e l i g i o u s p e r s o n and I f o u n d t h a t t h a t was one t h i n g t h a t p r a y e r g o t me t h r o u g h q u i t e a b i t i n t h e h o s p i t a l . When y o u ' r e j u s t l y i n g t h e r e w i t h y o u r e y e s c l o s e d , you do a l o t o f p r a y i n g and w h i c h I d i d . I j u s t f i g u r e d , w e l l , you know, you s a y a p r a y e r a n d l e t God t a k e c a r e o f t h e r e s t . S p e c i f i c s t r a t e g i e s were e m p l o y e d t o d e a l w i t h t h e i r h e a r t a t t a c k on a d a y - t o - d a y b a s i s . T h e r e was c o n s i d e r a b l e e f f o r t e x p e n d e d t o e n s u r e t h a t t h i s h e a r t a t t a c k e x p e r i e n c e d i d n o t " g e t t h e b e s t " o f them. I t h i n k i t — I t h i n k i t ' s me. I t ' s j u s t — i t ' s n o t g o i n g t o g e t t h e b e s t o f me. I'm g o i n g t o f i g h t . I t ' s 71 I'm not g o i n g to l i v e the r e s t of my l i f e j u s t l a y i n g around d o i n g n o t h i n g . And I t h i n k y o u ' r e a l o t b e t t e r o f f , i f y o u ' r e n o t s i t t i n g w o r r y i n g a b o u t y o u r h e a r t a t t a c k . You know, i f y o u ' r e s i t t i n g s t e w i n g o r w o r r y i n g a b o u t w h e t h e r y o u ' r e g o i n g t o t a k e o n e , t h e n I t h i n k t h a t ' s a l o t h a r d e r on you a n d m e n t a l l y a s w e l l a s p h y s i c a l l y . You know, I j u s t d o n ' t t h i n k a b o u t i t . L i k e I ' v e s a i d , I ' v e b e e n b o u n d a n d d e t e r m i n e d n o t t o g e t on. t h e s o a p b o x a n d you know, go on a b o u t i t . W e l l , I - - I j u s t t r i e d t o l i v e a s c l o s e — a s n a t u r a l l y a s I p o s s i b l y c o u l d , you know a n d n o t - - n o t t o l e t m y s e l f p i t y m y s e l f . I d i d n ' t want you know, I t h i n k t h a t you c a n p i t y y o u r s e l f a n d make a w r e c k o f y o u r s e l f t o o . You know, you c a n be r e a l l y s i c k i f you l e t i t g e t t o you t o o m u c h . The women d i s c l o s e d f e e l i n g f o r t u n a t e i n t h e i r i l l n e s s e x p e r i e n c e w i t h M I . The a w a r e n e s s t h a t w o r s e t h i n g s c o u l d have b e f a l l e n them seemed t o s e r v e a s a n a d d i t i o n a l s t r a t e g y f o r g a i n i n g c o n t r o l . F u r t h e r , t h e women w e i g h e d t h e a d v a n t a g e s o f a h e a r t a t t a c k o v e r o t h e r i l l n e s s e s . You know, a p a r t f r o m a l l t h a t I ' v e s a i d , I g u e s s - - my f e e l i n g i s t h a t s o m e t h i n g h a s h a p p e n e d t o me t h a t h a s h a p p e n e d t o a l o t o f p e o p l e . F o r w h a t e v e r r e a s o n , i t h a p p e n e d , I d o n ' t know. I j u s t g o t f i n i s h e d s a y i n g t o you what I t h i n k a n d I f e e l v e r y f o r t u n a t e f r o m t h e p o i n t o f v i e w t h a t I o b v i o u s l y d i d n ' t h a v e a m a s s i v e h e a r t a t t a c k . I f e e l f o r t u n a t e t h a t I g o t i n t h r o u g h t h e e m e r g e n c y d o o r o f t h e h o s p i t a l a n d I came o u t t h e f r o n t d o o r o f t h e h o s p i t a l a n d I 'm home. F o r w h a t e v e r r e a s o n d i f f e r e n t t h i n g s a f f e c t d i f f e r e n t p e o p l e , o r c a u s e s them t o have a h e a r t a t t a c k l i k e I ' v e made t h e s t a t e m e n t , f o r e x a m p l e , i f you know, s o m e t h i n g h a s t o h a p p e n t o you — s o m e t h i n g e l s e c o u l d h a p p e n t o me, n o t t o s a y t h a t i t w o n ' t , b u t t h i s h e a r t a t t a c k , I s a i d , you know I f e l t so g r a t e f u l t h a t t h a t ' s a l l t h a t i t w a s . I made t h a t s t a t e m e n t a n d when I went t o t h e h o s p i t a l , t h e t h o u g h t o c c u r r e d to me, what i f t h e y d i a g n o s e d I h a d c a n c e r a n d I c a n t r u t h f u l l y s a y t h a t went t h r o u g h my m i n d a n d s o , when I was t o l d i t was a h e a r t a t t a c k and c e r t a i n l y a n d t h e r e s u l t o f t h e h e a r t a t t a c k a n d where i t was, e t c e t e r a , I j u s t f e l t v e r y f o r t u n a t e and I t h o u g h t , t h o u g h I'm n o t a r e l i g i o u s p e r s o n , I t h o u g h t , you know t h e Good L o r d h a s done s o m e t h i n g h e r e t h a t h a s g i v e n me an o p p o r t u n i t y t o ch a n g e my l i f e s t y l e a l i t t l e b i t t h a t c o u l d c o n c e i v a b l y g i v e me q u i t e a few y e a r s o f a v e r y h e a l t h y l i f e t h a t I w o u l d n ' t n e c e s s a r i l y have h ad o t h e r w i s e . Anyway, so f a r you know, what c a n you s a y . I d o n ' t r e a l l y know f r o m h e r e o n o u t , what l i f e h o l d s . B u t t h e n --and on t h e o t h e r h a n d , you f e e l , w e l l , i t c o u l d have b e e n so much worse what h a p p e n e d . You know you c o u l d have had s o m e t h i n g t h a t ' s g o i n g t o g i v e you a l o t o f p a i n a n d no r e l i e f f r o m i t , you know, b u t t h i s way you f e e l -- . I f y o u ' r e g o i n g t o be w i p e d o u t , i t ' l l a t l e a s t be f a s t . I f e e l I was f o r t u n a t e . B u t I s o r t o f have a c c e p t e d i t a l l i n my s t r i d e a n d I I d o n ' t f e e l -- you know, I d o n ' t -- you know, I f e e l f o r t u n a t e . The women d e s c r i b e d t h e i r f a m i l i e s ' and f r i e n d s ' r e a c t i o n s t o t h e i r h e a r t a t t a c k a s more p r o f o u n d t h a n t h e i r own. I t seemed t h a t t h e women u s e d t h e i r f a m i l i e s a n d f r i e n d s a s d e f l e c t o r s , d i r e c t i n g t h e i m p a c t o f t h e i r h e a r t a t t a c k away f r o m t h e m s e l v e s . T h i s d e f l e c t i o n a c t e d a s y e t a n o t h e r s t r a t e g y f o r c o n t r o l . Oh, t h e y [ f a m i l y ] were q u i t e u p s e t , you know. And were w o r r i e d a n d one t h i n g a n d a n o t h e r . I n f a c t , t h e y w o r r i e d more t h a n I d i d . You know. T h i s i s t h e t i m e o f l i f e where i t ' s p r e t t y h a r d t o l o s e a p a r t n e r . You know, i t ' s n o t e a s y t o make a n o t h e r l i f e a ny more. S o , we've a l w a y s h a d a g o o d m a r r i a g e s o , i t ' s — you know, you d o n ' t f e e l t h a t i t d o e s n ' t m a t t e r i f one o r t h e o t h e r g o e s , b e c a u s e i t m a t t e r s a l o t . S o , i t ' s q u i t e u p s e t t i n g a n d I g u e s s i t was v e r y u p s e t t i n g f o r h i m f o r h i m , f r o m what I h e a r f r o m my f a m i l y . S o , f o r h i s s a k e t o o , I have t o k e e p t h i s t h i n g on an e v e n k e e l , you know. Not j u s t f o r my own. So — b e c a u s e h e ' s a p r e t t y g o o d g u y . So , I hope t o see my g r a n d c h i l d grow up. Yes , t h e y ' v e [ f a m i l y , f r i e n d s ] been q u i t e concerned about me. You know, you can t e l l by the phoning and t h a t . F r i e n d s , the same way. Some of them were r e a l l y shocked . L i k e I say , I t h i n k everybody was more shocked than I was. S t r a t e g i e s f o r c o n t r o l were used by the women to g a i n c o n t r o l in t h i s "out of c o n t r o l " i l l n e s s e x p e r i e n c e . The s t r a t e g i e s f o r c o n t r o l o u t l i n e d here seemed to g ive the women something to h o l d o n t o , something to h e l p them make sense of t h i s i l l n e s s e x p e r i e n c e . C l a r i f y i n g the i l l n e s s e x p e r i e n c e c o n f e r r e d the p e r c e p t i o n of c o n t r o l . The s p e c i f i c s t r a t e g i e s f o r c o n t r o l apparent in the women's account s arose from the a s s i g n i n g of cause and the p r o j e c t i o n of i l l n e s s outcome. P e r s o n a l p h i l o s o p h i e s , l i f e e x p e r i e n c e s , and the r e a c t i o n s of f a m i l i e s and f r i e n d s were a l s o i d e n t i f i e d as s p e c i f i c s t r a t e g i e s used by the women. Summary T h i s c h a p t e r p r e s e n t e d the s t u d y ' s a n a l y t i c framework, a l o s s framework. The framework r e p r e s e n t s the r e s e a r c h e r ' s i n t e r p r e t a t i o n and c o n c e p t u a l i z a t i o n of the women's a c c o u n t s . The c h a r a c t e r i s t i c s of the p a r t i c i p a n t s were then d e s c r i b e d . The women's a c c o u n t s , t h e i r e x p e r i e n c e w i t h MI, were d i s c u s s e d in r e l a t i o n to the s t u d y ' s a n a l y t i c framework. For the women, t h e i r i l l n e s s e x p e r i e n c e w i t h MI meant fundamental and e x t e n s i v e a l t e r a t i o n s in t h e i r everyday l i v e s . By e x p l o r i n g the meaning of t h e i r i l l n e s s through the c o n t e x t of change , the women were g r i e v i n g the l o s s e s i n h e r e n t i n these changes . As these women e x p l a i n e d : Yes , i t s - - i t s — you have — a c t u a l l y you a lmost have to l i v e a d i f f e r e n t way o f l i f e f o r a w h i l e . W e l l , when you s t a r t t o r e c u p e r a t e , you j u s t w o n d e r , you know, how y o u ' r e g o i n g t o - - w e l l , I ' v e a l w a y s b e e n a p e r s o n t h a t l i k e s t o work a n d I t h o u g h t , w e l l , am I g o i n g t o be a v e g e t a b l e f r o m now on t h a t t h e l e a s t l i t t l e t h i n g I do i s g o i n g t o u p s e t t h e a p p l e c a r t . B u t b e c a u s e you r e a l l y d o n ' t know what y o u ' r e g o i n g t o be a b l e t o do a n d what y o u ' r e n o t g o i n g t o be a b l e t o d o . L o s s o f p r e d i c t a b i l i t y r e p r e s e n t s t h e e s s e n c e o f t h e women 's l o s s e x p e r i e n c e w i t h M I , i n v o l v i n g a p e r v a s i v e and p o w e r f u l s e t o f e m o t i o n s a n d s p e c i f i c c o n c e r n s . L o s s o f p r e d i c t a b i l i t y was f e l t p a r t i c u l a r l y i n r e l a t i o n t o e n e r g y , s u p p o r t , a n d u s u a l r o l e e n a c t m e n t . To g a i n c o n t r o l , t h e women u s e d a w ide v a r i e t y o f c o p i n g s t r a t e g i e s . C h a p t e r 5 d i s c u s s e s t h e s e f i n d i n g s i n r e l a t i o n t o c u r r e n t r e l a t e d l i t e r a t u r e . CHAPTER 5 D i s c u s s i o n of the F i n d i n g s Chapter 5 d i s c u s s e s the f i n d i n g s of t h i s s tudy w i t h i n the c o n t e x t of the c u r r e n t p r o f e s s i o n a l l i t e r a t u r e . The purpose of t h i s d i s c u s s i o n i s to compare the f i n d i n g s of t h i s s tudy wi th the p re sen t u n d e r s t a n d i n g of the MI i l l n e s s e x p e r i e n c e as r e c o r d e d in the p r o f e s s i o n a l l i t e r a t u r e r e l a t e d to c a r d i a c c a r e . As c o n c l u d e d in Chapter 2, t h i s p r e s e n t u n d e r s t a n d i n g i s based upon an u n d e r s t a n d i n g of men's e x p e r i e n c e w i t h MI because of the p a u c i t y of work a d d r e s s i n g t h i s h e a l t h problem in r e l a t i o n to women. T h e r e f o r e , i n t h i s d i s c u s s i o n , a compar i son of the f i n d i n g s of t h i s s tudy w i t h the p r o f e s s i o n a l c a r d i a c l i t e r a t u r e i s r e a l l y a compar i son of women's e x p e r i e n c e w i t h MI w i t h men's e x p e r i e n c e w i t h MI. In Chapter 2, l i t e r a t u r e p e r t i n e n t to the s t u d y ' s r a t i o n a l e and purpose was r e v i e w e d . The rev iew l o c a t e d t h i s s tudy w i t h i n the r e l a t e d p r o f e s s i o n a l l i t e r a t u r e and s u b s t a n t i a t e d the need to s tudy women's e x p e r i e n c e w i t h MI. Some of t h i s same l i t e r a t u r e i s used i n the d i s c u s s i o n of the s t u d y ' s f i n d i n g s . A d d i t i o n a l l i t e r a t u r e , both r e s e a r c h and t h e o r e t i c a l works , are a l s o used i n t h i s d i s c u s s i o n . A l t h o u g h some l i t e r a t u r e s p e c i f i c to women's e x p e r i e n c e s i s a l s o c o n s i d e r e d , the rev iewed l i t e r a t u r e i s l i m i t e d p r i m a r i l y to c a r d i a c l i t e r a t u r e , e s p e c i a l l y c a r d i a c r e h a b i l i t a t i o n l i t e r a t u r e . The purpose of t h i s s tudy was to e x p l o r e and d e s c r i b e women's p e r c e p t i o n s o f t h e i r i l l n e s s e x p e r i e n c e w i t h MI. The s t u d y ' s a n a l y t i c f r a m e w o r k r e p r e s e n t s t h e r e s e a r c h e r ' s i n t e r p r e t a t i o n a n d c o n c e p t u a l i z a t i o n o f t h e women 's a c c o u n t s o f t h e i r MI e x p e r i e n c e . In t h i s c h a p t e r , t h e s t u d y ' s a n a l y t i c f r a m e w o r k i s u s e d a s a n o r g a n i z i n g s t r u c t u r e f o r d i s c u s s i n g the f i n d i n g s . MI As A L o s s Phenomenon The d a t a f r o m t h i s s t u d y i n d i c a t e d t h a t t h e women were g r i e v i n g t h e l o s s e s i n h e r e n t i n t h e many s i g n i f i c a n t c h a n g e s i n t h e i r e v e r y d a y l i v e s s i n c e t h e i r M I . T h i s f i n d i n g i s r e f l e c t i v e o f e x i s t i n g l i t e r a t u r e on MI where c o n c e p t s o f l o s s a n d g r i e f a r e u s e d r e p e a t e d l y t o u n d e r s t a n d t h e MI i l l n e s s e x p e r i e n c e . C a s s e m a n d H a c k e t t ( 1 9 7 7 , 1 9 8 2 , 1 9 8 4 ) , f o r e x a m p l e , m a j o r t h e o r i s t s a n d r e s e a r c h e r s on t h e t o p i c o f t h e p s y c h o l o g i c a l a s p e c t s o f c a r d i a c r e h a b i l i t a t i o n , h a v e r e p e a t e d l y i d e n t i f i e d a n x i e t y a n d d e p r e s s i o n a s common p s y c h o l o g i c a l r e s p o n s e s t o M I . Mos t r e c e n t l y , t h e s e w r i t e r s ( 1 9 8 4 ) d e f i n e d e p r e s s i o n a s " a s t a t e o f s a d n e s s due t o a l o s s " ( p . 4 3 7 ) , t h e l o s s o f a v a l u e d p a r t o f o n e s e l f . R e g a r d i n g d e p r e s s i o n a s a n o r m a l r e s p o n s e t o M I , t h e y a d v o c a t e u s i n g t h e c o n c e p t o f g r i e f a s a model to i d e n t i f y p a t h o l o g i c a l d e p r e s s i o n . The same i n t e n s i t y a n d t i m e f rame o f m o u r n i n g a l o v e d one a r e a p p l i e d t o m o u r n i n g t h e l o s s e s a s s o c i a t e d w i t h t h e MI e x p e r i e n c e . In t h e n u r s i n g l i t e r a t u r e , S c a l z i a n d B u r k e ( 1 9 8 2 ) o u t l i n e a p r o c e s s o f a d a p t a t i o n t o MI b a s e d upon t h e c o n c e p t s o f l o s s a n d g r i e f . T h e y i d e n t i f y b e h a v i o u r a l a d a p t a t i o n r e s p o n s e s t h a t c h a r a c t e r i z e e a c h p h a s e o f l o s s . D e l a n e y - N a u m o f f ( 1 9 8 1 ) s t a t e s t h a t g r i e f i s " t h e d o m i n a n t u n d e r l y i n g e m o t i o n " ( p . 8 7 ) f o l l o w i n g M I . She c o n c e p t u a l i z e s t h e p a t i e n t ' s l o s s e x p e r i e n c e w i t h MI a s " l o s s o f h e a r t " a n d d e s c r i b e s t h e g r i e f r e s p o n s e t o MI u s i n g t h e p h a s e s o f c r i s i s a s a f r a m e w o r k . T h u s , v i e w i n g women 's e x p e r i e n c e w i t h MI a s a l o s s phenomenon i s c o n s i s t e n t w i t h c u r r e n t t h e o r e t i c a l p e r s p e c t i v e s w i t h i n t h e p r o f e s s i o n a l l i t e r a t u r e . A l t h o u g h t h e c o n c e p t s o f l o s s a n d g r i e f a r e o p e r a t i o n a l i z e d somewhat d i f f e r e n t l y i n t h i s s t u d y a n d i n a l l t h r e e w o r k s d e s c r i b e d h e r e , t h e s e c o n c e p t s a r e the b a s i c i n g r e d i e n t s i n e a c h w r i t e r ' s u n d e r s t a n d i n g o f t h e MI e x p e r i e n c e . T h i s f i n d i n g t h e n r e p r e s e n t s a common a n d f u n d a m e n t a l p e r s p e c t i v e t o w a r d s t h e i l l n e s s e x p e r i e n c e f o r b o t h men a n d women. L o s s o f H e a l t h y S t a t e In t h i s s t u d y , t h e MI e v e n t i t s e l f , e x p e r i e n c e d a s a p a i n e p i s o d e , m a r k e d t h e t r a n s i t i o n f r o m h e a l t h t o i l l n e s s a n d was t h e i m p e t u s f o r t h e l o s s e s t h a t f o l l o w e d . The p a i n e p i s o d e was f o u n d t o be d i v e r s e l y a n d u n i q u e l y p e r c e i v e d a n d e x p e r i e n c e d . A l s o , t h e women 's s u b s e q u e n t i n t e r a c t i o n w i t h t h e p r o f e s s i o n a l s e c t o r , e s p e c i a l l y t h e n a t u r e o f t h e a d v i c e g i v e n p r i o r t o d i s c h a r g e , m a r k e d t h i s t r a n s i t i o n by r e i n f o r c i n g t h e women 's new p e r c e p t i o n o f t h e m s e l v e s a s i l l i n d i v i d u a l s . T h i s f i n d i n g i n r e l a t i o n t o t h e MI p a i n e p i s o d e was n o t s u r p r i s i n g a n d i s c o n s i s t e n t w i t h t h e l i t e r a t u r e . H u r s t e t a l . ( 1 9 8 2 ) c l e a r l y e s t a b l i s h t h a t i n d i v i d u a l i t y c h a r a c t e r i z e s t h e MI p a i n e x p e r i e n c e . To i l l u s t r a t e t h i s p o i n t , t h e y q u o t e one p a t i e n t ' s d e s c r i p t i o n o f h i s h e a r t a t t a c k p a i n a s a " f a i n t f u z z y f e e l i n g - - a s o f t l y s p o k e n s t e r n a l w o r d . " F u r t h e r , H u r s t e t a l . u r g e c l i n i c i a n s t o e n c o u r a g e p a t i e n t s t o use t h e i r own words t o d e s c r i b e t h e i r p a i n e x p e r i e n c e , s t r e s s i n g t h a t p a t i e n t s w i t h MI may p r e s e n t i n many w a y s . I t d o e s , h o w e v e r , a d d s u p p o r t t o t h e d i r e c t i v e t h a t p r o f e s s i o n a l s , In a s s e s s i n g MI p a i n , must a t t u n e t h e m s e l v e s to how t h e p a t i e n t d e s c r i b e s h e r p a i n e x p e r i e n c e . In t h i s s t u d y , t h e a d v i c e g i v e n t o t h e women by the p r o f e s s i o n a l s e c t o r c o n t r i b u t e d t o t h e w o m e n ' s s e n s e o f l o s s o f h e a l t h y s t a t e t h a t h a d b e e n t r i g g e r e d by t h e h e a r t a t t a c k i t s e l f . The vague a n d p r o s c r i p t i v e n a t u r e o f t h i s a d v i c e , w h i c h i s d i s c u s s e d more f u l l y i n t h e n e x t s e c t i o n , d o e s n o t r e f l e c t t h e p r e c i s e , d e t a i l e d i n s t r u c t i o n s a d v o c a t e d i n t h e l i t e r a t u r e t o p r o m o t e c a r d i a c r e h a b i l i t a t i o n ( s e e , f o r e x a m p l e , W e n g e r , 1 9 8 2 ) . T h i s f i n d i n g d o e s , h o w e v e r , c o n c u r w i t h M u l l e n ' s ( 1 9 7 8 ) f i n d i n g s t h a t , a f t e r a h e a r t a t t a c k , t h e p a t i e n t ' s s i t u a t i o n i s m a r k e d by p r o s c r i p t i o n s a n d t h a t t h i s e m p h a s i s s e p a r a t e s MI f r o m o t h e r i l l n e s s e x p e r i e n c e s . M u l l e n c o i n e d t h e t e r m " t h e h a r d e r d i m e n s i o n " ( p . 2 9 8 ) t o d e s c r i b e t h e t h r e a t t h a t e x i s t s b e c a u s e o v e r e x t e n d i n g a c t i v i t y l i m i t s f o r t h e MI p a t i e n t c o u l d mean d e a t h . In t h i s s t u d y , t h e women were s i m i l a r l y c a u t i o n e d t o c a r e f u l l y m o n i t o r t h e i r a c t i v i t y a n d e x p e r i e n c e d t h e o m i n o u s t h r e a t o f " o v e r d o i n g i t . " T h u s , b o t h w o m e n ' s p e r c e p t i o n s o f t h e i r p a i n e x p e r i e n c e w i t h MI a n d t h e i m p a c t o f vague a d v i c e f o c u s e d on " d o n ' t s " r a t h e r t h a n " d o ' s " mark t h e l o s s o f h e a l t h y s t a t e . B o t h t h e s e e v e n t s c o n c u r w i t h t h e l i t e r a t u r e . U n l i k e t h e p r e c i s e , d e t a i l e d i n s t r u c t i o n s so w i d e l y recommended i n t h e c a r d i a c r e h a b i l i t a t i o n l i t e r a t u r e , t h e s e women r e p o r t e d e n c o u n t e r i n g vague a n d g e n e r a l admon i t i o n s . L o s s o f P r e d i c t a b i l i t y I t was f o u n d i n t h i s s t u d y t h a t t h e women e x p e r i e n c e d a p e r v a s i v e a n d p o w e r f u l l o s s o f p r e d i c t a b i l i t y i n t h e i r e v e r y d a y l i v e s a f t e r t h e i r M I . T h i s l o s s was f e l t , i n p a r t i c u l a r , i n r e l a t i o n t o e n e r g y , a n t i c i p a t e d s u p p o r t , a n d r o l e e n a c t m e n t . A l t h o u g h t h e r e a r e s l i g h t v a r i a t i o n s i n t h e d e s c r i p t o r s u s e d , t h e e s s e n c e o f t h i s l o s s a s s e t o u t i n t h e w o m e n ' s a c c o u n t s a n d d e f i n e d i n t h e s t u d y ' s f r a m e w o r k i s p r e s e n t i n t h e l i t e r a t u r e . In a f r e q u e n t l y q u o t e d s t u d y , W i s h n i e , H a c k e t t , a n d C a s s e m ( 1 9 7 1 ) f o u n d t h a t t h e i r s u b j e c t s f e l t " a l t o g e t h e r u n p r e p a r e d f o r t h e s e n s e o f f o u n d e r i n g ( s i c ) w h i c h r e s u l t e d " ( p . 1 2 9 3 ) a t home p o s t - M I . M u l l e n ( 1 9 7 8 ) n o t e d t h a t h e r s u b j e c t s e x p e r i e n c e d " t h e d i f f i c u l t t a s k o f r e s u m i n g l i f e i n a new a n d a m b i g u o u s s t a t e u n d e r c o n d i t i o n s o f u n c e r t a i n t y " ( p . 2 9 8 ) . D e l a n e y -N a u m o f f ( 1 9 8 1 ) i d e n t i f i e s l o s s o f c o n t r o l a n d l o s s o f d i r e c t i o n a s p a r t o f t h e l o s s e x p e r i e n c e p o s t - M I . C a s s e m a n d H a c k e t t ( 1 9 7 7 ) f o u n d t h a t f e e l i n g s o f a n x i e t y a n d d e p r e s s i o n p r e d o m i n a t e d a s a s c e r t a i n e d by d o c u m e n t i n g p s y c h i a t r i c r e f e r r a l s f o l l o w i n g M I . In a r e c e n t w o r k , t h e s e same a u t h o r s ( 1 9 8 4 ) d e f i n e d e p r e s s i o n a s " d e s o l a t i o n , s a d n e s s , o r r e s e n t m e n t i n t h e weeks a f t e r i n f a r c t i o n " ( p . 4 3 8 ) . T h e y a l s o d e s c r i b e f e e l i n g v u l n e r a b l e a s a d i f f i c u l t y d u r i n g e a r l y c o n v a l e s c e n c e . The f e e l i n g s d e s c r i b e d w i t h i n a l l o f t h e s e w o r k s e c h o t h e s e n t i m e n t s o f the women i n t h i s s t u d y . One a s p e c t o f t h e women 's l o s s o f p r e d i c t a b i l i t y was the d i f f i c u l t y i n t e r p r e t i n g b o d i l y c u e s a f t e r MI w h i c h g e n e r a t e d f e e l i n g s o f c o n f u s i o n a n d a n x i e t y a n d a n i n c r e a s e d a w a r e n e s s o f t h e p r e c a r i o u s n e s s o f t h e i r h e a l t h s t a t u s . T h i s f i n d i n g i s d o c u m e n t e d i n t h e l i t e r a t u r e . M u l l e n ( 1 9 7 8 ) n o t e d a p r o c e s s o f b e i n g " s e l f - c o n s c i o u s l y aware o f b o d i l y s e n s a t i o n s " ( p . 3 0 1 ) a f t e r M I . She i d e n t i f i e d t h e p r o b l e m a s a d i f f i c u l t y i n " i n t e r p r e t i n g vague i n d i c a t o r s " ( p . 3 0 1 ) . Newton a n d S i v a r a j a n ( 1 9 8 2 ) s p e a k a b o u t p a t i e n t s ' new a t t e n t i o n t o e a c h a n d e v e r y a c h e a n d p a i n f o r a p o s s i b l e c o n n e c t i o n t o t h e i r h e a r t c o n d i t i o n . The l i t e r a t u r e s u g g e s t s t h a t t h i s d i f f i c u l t y i s ' n o t an u n u s u a l r e s p o n s e f o r men a n d women p o s t - M I . H o w e v e r , i t seems a p p r o p r i a t e t o s u r m i s e i f p a t i e n t s a r e e q u i p p e d w i t h p r e c i s e a n d d e t a i l e d i n s t r u c t i o n s , s o r t i n g o u t v a r i o u s b o d i l y s e n s a t i o n s w o u l d become l e s s d i f f i c u l t a n d l e s s a n x i e t y p r o v o k i n g . As d i s c u s s e d i n t h e p r e v i o u s s e c t i o n , t h e w o m e n ' s p e r c e p t i o n s o f t h e i r l o s s o f h e a l t h y s t a t e were i n f l u e n c e d by t h e vague a n d p r o s c r i p t i v e n a t u r e o f t h e a d v i c e t h e y were g i v e n p r i o r t o l e a v i n g h o s p i t a l . Once home, t h e women p e r c e i v e d a n e e d f o r s p e c i f i c , c o n c r e t e i n f o r m a t i o n a b o u t t h e i r h e a r t c o n d i t i o n a n d t h e i r c a r d i a c r e h a b i l i t a t i o n . I t was t h e women 's p e r c e p t i o n t h a t t h i s n e e d was n o t met a n d t h a t t h i s l a c k c o n t r i b u t e d t o t h e i r f e e l i n g s o f l o s s o f p r e d i c t a b i l i t y . T h e s e f i n d i n g s s t a n d i n s h a r p c o n t r a s t t o t h e r e c o m m e n d a t i o n s i n t h e c a r d i a c r e h a b i l i t a t i o n l i t e r a t u r e . T h i s l i t e r a t u r e f r e q u e n t l y a n d s t r o n g l y u r g e s p r a c t i t i o n e r s t o p r o v i d e t h e i r p o s t - M I 81 p a t i e n t s w i t h s p e c i f i c , d e t a i l e d , w r i t t e n i n s t r u c t i o n s p a r t i c u l a r l y c o n c e r n i n g p h y s i c a l a c t i v i t y a t home ( D e l a n e y -N a u m o f f , 1 9 8 1 ; H a c k e t t & C a s s e m , 1 9 8 4 : Newton & S i v a r a j a n , 1 9 8 2 ; S i v a r a j a n , 1 9 8 2 ; W e n g e r , 1 9 8 2 ) . The d e v e l o p m e n t o f " t h e c o n c e p t o f i n d i v i d u a l i z e d p r e s c r i p t i v e e x e r c i s e i n r e h a b i l i t a t i o n " ( W e n g e r , 1 9 8 2 , p . 1 1 5 3 ) h a s made t h i s a w o r k a b l e g o a l b e c a u s e t h e a c t i v i t y i s p r e s c r i b e d i n t h e same manner a s a m e d i c a t i o n ; the f r e q u e n c y , d u r a t i o n , a n d i n t e n s i t y a r e p r e c i s e l y s t a t e d b a s e d upon t h e p a t i e n t ' s a b i l i t i e s , n e e d s , a n d i n t e r e s t s . F u r t h e r , a s t r e s s e x e r c i s e t e s t p r i o r t o o r s o o n a f t e r d i s c h a r g e e n a b l e s t h e h e a l t h c a r e p r o f e s s i o n a l t o t e a c h t h e p a t i e n t how t o a s s e s s h i s o r h e r r e s p o n s e s t o a c t i v i t y , u s i n g c o n c r e t e g u i d e l i n e s ( S i v a r a j a n , 1 9 8 2 ) . H o w e v e r , M u l l e n ( 1 9 7 8 ) f o u n d t h a t , o n c e home, p a t i e n t s w e r e , f o r t h e most p a r t , on t h e i r own t o work t h r o u g h " t h e vague a n d o m i n o u s w a r n i n g , ' t a k e i t e a s y ' " ( p . 2 9 8 ) . S i v a r a j a n ( 1 9 8 2 ) a g r e e s a n d a s s e r t s t h a t t h i s e a r l y t i m e p e r i o d a t home b e t w e e n h o s p i t a l i z a t i o n a n d e n r o l l m e n t i n a s t r u c t u r e d r e h a b i l i t a t i o n programme i s c h a r a c t e r i z e d by i n s u f f i c i e n t i n f o r m a t i o n a n d r e p r e s e n t s a n i d e n t i f i a b l e g a p i n h e a l t h c a r e s e r v i c e s . Newton a n d S i v a r a j a n ( 1 9 8 2 ) s t a t e t h a t i n f o r m a t i o n i s a m a j o r n e e d i n t h e e a r l y d i s c h a r g e p h a s e . T h e y a l s o r e m a r k t h a t p a t i e n t s a r e o f t e n t o l d t o " r e l a x " w i t h o u t t h e n e c e s s a r y g u i d e l i n e s t o e n a b l e them t o f o l l o w t h r o u g h . T h i s s t u d y o f f e r s s u p p o r t f o r t h e f i n d i n g s c o n c e r n i n g l a c k o f i n f o r m a t i o n i n t h e e a r l y c o n v a l e s c e n c e p h a s e a t home. I t seems t h a t the w i d e l y a d v o c a t e d g o a l t o p r o v i d e p a t i e n t s w i t h s p e c i f i c , d e t a i l e d , w r i t t e n i n s t r u c t i o n s so t h a t t h e y a r e w e l l e q u i p p e d t o c o p e e f f e c t i v e l y w i t h t h e i r MI i l l n e s s e x p e r i e n c e i s n o t c o n s i s t e n t l y a c h i e v e d i n p r a c t i c e . One c a n o n l y s p e c u l a t e a s to why t h e women i n t h i s s t u d y f e l t d i s s a t i s f i e d w i t h t h e i n f o r m a t i o n t h e y r e c e i v e d f r o m t h e p r o f e s s i o n a l s e c t o r . In H a c k e t t a n d C a s s e m ' s s t u d y o f b l u e v e r s u s w h i t e - c o l l a r w o r k e r s w i t h MI ( 1 9 8 4 ) , t 'hey f o u n d t h a t b l u e - c o l l a r w o r k e r s a s k e d f e w e r q u e s t i o n s a n d were l e s s k n o w l e d g e a b l e t h a n t h e w h i t e - c o l l a r p a t i e n t s . The b l u e - c o l l a r p a t i e n t s c o n s e q u e n t l y f e l t a n x i o u s a n d u n c e r t a i n a n d h e l p l e s s , u l t i m a t e l y r e s u l t i n g i n a p o o r e r r e h a b i l i t a t i o n o u t c o m e . C o u l d t h i s c h a i n o f e v e n t s be a p p l i e d t o t h e women i n t h i s s t u d y ? Is t h e r e a p a r a l l e l b e t w e e n b l u e - c o l l a r w o r k e r s a n d women? B l u e -c o l l a r w o r k e r s may s h a r e w i t h women a s i m i l a r power r e l a t i o n s h i p t o t h e p h y s i c i a n w h i c h c o u l d a f f e c t t h e e x c h a n g e o f i n f o r m a t i o n . C o r e a ( 1 9 8 5 ) a r g u e s t h a t d i f f e r e n c e s i n s o c i a l c l a s s i n f l u e n c e t h e q u a l i t y o f d o c t o r - p a t i e n t i n t e r a c t i o n s a s do commonly h e l d sex r o l e s t e r e o t y p e s . C o r e a c o n t e n d s t h a t s e x i s t b e l i e f s a b o u t women n o t o n l y a f f e c t p h y s i c i a n s ' p e r c e p t i o n s a b o u t w o m e n ' s h e a l t h p r o b l e m s b u t a l s o " t h e w i l l i n g n e s s o f p h y s i c i a n s t o g i v e p a t i e n t s v i t a l i n f o r m a t i o n " ( p . 8 1 ) . C o r e a ' s work t h e n s u g g e s t s t h a t t h e r e may w e l l be a p a r a l l e l b e t w e e n b l u e - c o l l a r w o r k e r s w i t h MI a n d women w i t h MI v i s a v i s t h e i n f o r m a t i o n p r o v i d e d . T h e r e a r e c e r t a i n l y no c l e a r c u t a n s w e r s a n d most p r o b a b l y many e x p l a n a t i o n s f o r t h i s f i n d i n g i n t h i s a n d o t h e r s t u d i e s . F o r e x a m p l e , women 's p e r c e p t i o n s c o u l d be a l t e r e d by t h e i l l n e s s e x p e r i e n c e . T h i s f i n d i n g c o u l d a l s o be i n d i c a t i v e o f a gap i n h e a l t h c a r e s e r v i c e s f o r b o t h women a n d men s i m i l a r to t h e one r e f e r r e d t o by S i v a r a j a n ( 1 9 8 2 ) . The women i n t h i s s t u d y i d e n t i f i e d t h r e e c o n c e r n s r e l a t e d to l o s s o f p r e d i c t a b i l i t y : ( a ) t h e p o s s i b i l i t y o f a r e p e a t MI, (b ) t h e p o s s i b i l i t y o f s u d d e n d e a t h , a n d ( c ) t h e p o t e n t i a l f o r r e t u r n i n g t o n o r m a l , w h i c h i n v o l v e d c o m p a r i n g t h e m s e l v e s w i t h o t h e r s i n s i m i l a r s i t u a t i o n s . T h e s e c o n c e r n s a r e c o n s i s t e n t w i t h t h e l i t e r a t u r e . W i s h n i e e t a l . ( 1 9 7 1 ) i d e n t i f i e d f e a r o f r e - i n f a r c t i o n a n d f e a r o f s u d d e n d e a t h i n t h e i r e a r l y s t u d y . Cay ( 1 9 7 8 ) a l s o names f e a r o f d e a t h a n d r e - i n f a r c t i o n a n d a d d s c o n c e r n a b o u t t h e l o s s o f e s t a b l i s h e d l i v i n g p a t t e r n s . M u l l e n ( 1 9 7 8 ) r e p o r t e d t h a t h e r s u b j e c t s a s k e d q u e s t i o n s c o n c e r n i n g "how w e l l he w i l l l i v e ? " a n d "what c a n be s a l v a g e d f r o m h i s f o r m e r way o f l i f e ? " ( p . 2 9 8 ) . The p r o c e s s o f c o m p a r i n g o n e s e l f w i t h o t h e r s t o m e a s u r e p r o g r e s s t o w a r d s r e t u r n i n g t o n o r m a l , a s f o u n d i n t h i s s t u d y , was a l s o n o t e d i n t h e l i t e r a t u r e . M u l l e n ' s ( 1 9 7 8 ) s u b j e c t s c o m p a r e d i n o r d e r t o p r e d i c t how t h e y w o u l d p r o g r e s s i n t h e i r r e h a b i l i t a t i o n . She c o n c l u d e d t h a t c o m p a r i n g o n e s e l f w i t h o t h e r s was u s e d " n o r m a t i v e l y " ( p . 3 0 0 ) . Cowie ( 1 9 7 8 ) i n h i s s t u d y o f t h e p a t i e n t ' s p e r c e p t i o n o f h i s h e a r t a t t a c k n o t e d t h a t h i s s u b j e c t s c o m p a r e d t h e m s e l v e s w i t h o t h e r s i n a v a r i e t y o f ways i n o r d e r t o " t y p i f y " o r " n o r m a l i z e " t h e i r M I . I t s e e m s , t h e n , t h a t b o t h men a n d women use t h i s c o m p a r i s o n p r o c e s s to g a u g e t h e i r p r o g r e s s p o s t - M I . In t h i s s t u d y , c o m p a r i n g o n e s e l f w i t h o t h e r s was v i e w e d by t h e r e s e a r c h e r a s i n d i c a t i v e o f t h e w o m e n ' s f e e l i n g s o f u n p r e d i c t a b i l i t y . Cowie a n d M u l l e n s e e t h i s p r o c e s s somewhat d i f f e r e n t l y , i d e n t i f y i n g i t a s a c o p i n g s t r a t e g y . T h i s p r o c e s s f i t s e q u a l l y w e l l i n t o e i t h e r c o n c e p t u a l c a t e g o r y . The d e s c r i p t i o n o f l o s s o f p r e d i c t a b i l i t y i n t h i s s t u d y i s c o n s i s t e n t w i t h m e n ' s e x p e r i e n c e w i t h MI a s r e c o r d e d i n t h e c u r r e n t p r o f e s s i o n a l l i t e r a t u r e . The n e e d f o r i n f o r m a t i o n , h o w e v e r , i s a somewhat s u r p r i s i n g f i n d i n g c o n s i d e r i n g t h e e x t e n s i v e e v i d e n c e t h a t p r o f e s s i o n a l s c a n a n d do p r o v i d e p a t i e n t s w i t h p r e c i s e a n d d e t a i l e d i n s t r u c t i o n s . I f women r e c e i v e l e s s h e l p f u l i n f o r m a t i o n t h a n men, a s a r g u e d i n t h i s s e c t i o n , t h i s d i f f e r e n c e c o u l d i n c r e a s e t h e i n t e n s i t y o f the l o s s e x p e r i e n c e f o r women. L a c k o f E n e r g y I t was f o u n d i n t h i s s t u d y t h a t l a c k o f e n e r g y i s a p r o m i n e n t f e a t u r e i n d a i l y l i f e a f t e r a h e a r t a t t a c k . T h i s l a c k o f e n e r g y r e i n f o r c e d t h e w o m e n ' s s e n s e o f l o s s o f p r e d i c t a b i l i t y . T h e s e e n e r g y c h a n g e s r e m i n d e d t h e women o f t h e p r e c a r i o u s n e s s o f t h e i r h e a l t h s t a t u s . A l s o , a s t h e y a t t e m p t e d t o l e a r n t h e i r new a c t i v i t y l i m i t s , t h e y f e l t t h e y were l i v i n g w i t h i n a n u n f a m i l i a r s e l f . E n e r g y c h a n g e s p o s t - M I a r e w e l l e s t a b l i s h e d i n t h e l i t e r a t u r e . B o t h t h e d e l e t e r i o u s e f f e c t s o f i m m o b i l i t y a n d t h e s y m p a t h e t i c a r o u s a l due t o t h e p s y c h o l o g i c a l s t r e s s o f t h e i l l n e s s e x p e r i e n c e a r e n o t e d i n t h e l i t e r a t u r e t o o p e r a t e i n c o n c e r t t o e f f e c t t h i s e n e r g y d r a i n ( C a s s e m & H a c k e t t , 1 9 7 7 ; W e n g e r , 1 9 7 9 ; W e n g e r , 1 9 8 2 ) . W i s h n i e e t a l . ' s ( 1 9 7 1 ) e a r l y r e s e a r c h i d e n t i f i e d w e a k n e s s a s t h e most d i s t r e s s i n g c o m p l a i n t v o i c e d by t h e i r s u b j e c t s who i n t e r p r e t e d t h i s symptom a s e v i d e n c e o f w o r s e n i n g o f t h e i r h e a r t c o n d i t i o n . The d e s c r i p t i o n o f w e a k n e s s i n W i s h n i e e t a l . ' s s t u d y i s s i m i l a r t o t h e d e f i n i t i o n o f l a c k o f e n e r g y i n t h i s s t u d y . " H o m e c o m i n g d e p r e s s i o n , " a c o n c e p t i n t r o d u c e d by C a s s e m a n d H a c k e t t ( 1 9 7 7 ) t o d e s c r i b e t h e i r s u b j e c t s ' e m o t i o n a l r e s p o n s e to r e t u r n i n g home a n d f a c i n g the r e a l i t i e s o f d a y - t o -d a y l i f e f o l l o w i n g M I , i s a l s o a n a l o g o u s t o l a c k o f e n e r g y i n t h i s s t u d y . In s u b s e q u e n t p a p e r s , t h e s e r e s e a r c h e r s ( H a c k e t t & C a s s e m , 1 9 8 2 , 1984) d e f i n e " h o m e c o m i n g d e p r e s s i o n " a s a r e s p o n s e , " t h e s u b j e c t i v e s e n s e o f d e p l e t i o n a l o n g w i t h w e a k n e s s a n d e a r l y f a t i g u e " ( p . 4 3 9 ) w h i c h i s o f t e n p e r c e i v e d a s c a r d i a c d e c l i n e . Newton a n d S i v a r a j a n ( 1 9 8 2 ) a t t r i b u t e t h e m a r k e d f a t i g u e t o t h e a d d e d p s y c h o l o g i c a l s t r e s s o f home a d j u s t m e n t t o t h e i l l n e s s a n d t h e i n c r e a s e d p h y s i c a l demands o f p e r f o r m i n g a c t i v i t i e s o f d a i l y l i v i n g . C o r n e t t a n d W a t s o n ( 1 9 8 4 ) n o t e t h a t t h e f a t i g u e i s b o t h u n a n t i c i p a t e d a n d t r o u b l i n g . T h e s e d e s c r i p t i o n s c o i n c i d e w i t h t h e women 's p e r c e p t i o n s i n t h i s s t u d y . One p o i n t o f d i v e r g e n c e i s t h a t t h e women i n t h i s s t u d y d i d n o t seem t o v i e w e n e r g y l a c k a s a n i n d i c a t o r o f c a r d i a c d e t e r i o r a t i o n , b u t r a t h e r , a c c e p t e d t h i s symptom a s p a r t o f t h e MI t r a j e c t o r y , a l b e i t a somewhat u n e x p e c t e d a n d d i s c o u r a g i n g p a r t . A l s o , t h e women 's a c c o u n t s d e v e l o p e d t h e s e e n e r g y c h a n g e s more f u l l y t h a n i s a p p a r e n t i n t h e l i t e r a t u r e . F o r e x a m p l e , t h e women e x p l a i n e d how t h e i r l a c k o f e n e r g y a f f e c t e d t h e i r a p p r o a c h t o a c t i v i t i e s w h i c h now i n c l u d e d a t h i n k i n g t h r o u g h p r o c e s s t o a s s e s s w h e t h e r o r n o t t h e a c t i v i t y c o u l d o v e r e x t e n d t h e i r l i m i t s a n d a d v e r s e l y a f f e c t t h e i r h e a r t . 86 L a c k o f A n t i c i p a t e d S u p p o r t The women i n t h i s s t u d y e x p e r i e n c e d a l a c k o f a n t i c i p a t e d s u p p o r t f r o m t h e i r f a m i l i e s , e s p e c i a l l y t h e i r h u s b a n d s . T h i s f i n d i n g i s c o n g r u e n t w i t h t h e g e n e r a l t h r u s t o f t h e r e c e n t l i t e r a t u r e c o n c e r n i n g women w i t h M I . Women's l i t e r a t u r e a d d r e s s i n g t h e t r a d i t i o n a l s o c i a l i z a t i o n o f men a n d women p u t s t h i s f i n d i n g i n t o p e r s p e c t i v e . One c o u l d assume f r o m c u r r e n t c a r d i a c r e h a b i l i t a t i o n l i t e r a t u r e t h a t t h e r e s p o n s e s o f s p o u s e s o f p a t i e n t s w i t h MI a r e u n i f o r m l y c h a r a c t e r i z e d by o v e r - s u p p o r t , b u t t h i s f i n d i n g i s b a s e d upon s t u d i e s o f f e m a l e s p o u s e s . D e l a n e y - N a u m o f f ( 1 9 8 1 ) s t a t e s t h a t s p o u s e s e i t h e r i n c r e a s e t h e MI p a t i e n t ' s d e p e n d e n c y o r e f f e c t a p r e m a t u r e r e t u r n t o a c t i v i t y . T h i s s t u d y a n d B o o g a a r d ' s ( 1 9 8 4 ) r e c e n t c o m p a r a t i v e s t u d y o f r e h a b i l i t a t i o n p o s t - M I i n men a n d women a r e e v i d e n c e t h a t s u p p o r t may be a f u n c t i o n o f w h e t h e r t h e s p o u s e i s a h u s b a n d o r a w i f e . The l i t e r a t u r e e x t e n s i v e l y d e s c r i b e s w i v e s a s " o v e r p r o t e c t i v e " a n d " o v e r s o l i c i t o u s " t o w a r d s t h e i r h u s b a n d s w i t h MI ( C o r n e t t & W a t s o n , 1 9 8 4 ; C r o o g , 1 9 8 4 ; C r o o g & L e v i n e , 1 9 8 2 ; D e l a n e y -N a u m o f f , 1 9 8 1 ; W i s h n i e , 1 9 7 1 ) . In C r o o g a n d L e v i n e ' s ( 1 9 8 2 ) s t u d y , t h e w i v e s p r o v i d e d s u p p o r t by h e l p i n g t h e i r h u s b a n d s to f o l l o w t h e i r m e d i c a l r e g i m e n , t o a v o i d s t r e s s s i t u a t i o n s i n t h e home, a n d by a s s u m i n g t h e i r h u s b a n d s ' f o r m e r d u t i e s a r o u n d t h e h o u s e . In t h i s s t u d y , t h e women were d i s a p p o i n t e d i n t h e q u a l i t y o f s u p p o r t t h e y r e c e i v e d . In B o o g a a r d ' s ( 1 9 8 4 ) s t u d y t h e men b u t n o t t h e women were " w a i t e d o n . " F o r t h e women i n t h i s s t u d y , a c o n f l i c t s i t u a t i o n e x i s t e d b e t w e e n t h e o p p o s i n g demands o f t h e i r work a s homemakers a n d t h e i r own c a r d i a c r e h a b i l i t a t i o n . I t i s i n t e r e s t i n g a n d p e r h a p s r e l a t e d t h a t none o f t h e women i n t h i s s t u d y was e n r o l l e d i n a s t r u c t u r e d c a r d i a c r e h a b i l i t a t i o n p r o g r a m m e . T h e s e f i n d i n g s l e n d s u p p o r t t o Newton a n d S i v a r a j a n ' s ( 1 9 8 2 ) c o n t e n t i o n s a n d B o o g a a r d ' s ( 1 9 8 4 ) f i n d i n g s . Newton a n d S i v a r a j a n c l a i m t h a t l i m i t i n g a c t i v i t i e s w i t h i n t h e home t o s e l f - c a r e d u r i n g e a r l y c o n v a l e s c e n c e may be p r o b l e m a t i c b e c a u s e t h e r o l e demands do n o t c e a s e d u r i n g r e c o u p e r a t i o n . In B o o g a a r d ' s s t u d y , a p p r o x i m a t e METS ( m e t a b o l i c e q u i v a l e n t s ) , the s t a n d a r d m e a s u r e m e n t o f e n e r g y e x p e n d i t u r e , were c o m p u t e d f o r a c t i v i t i e s p e r f o r m e d d u r i n g t h e i n i t i a l p e r i o d a t home a f t e r M I , a n d women s c o r e d h i g h e r . Men a n d women d i f f e r e d i n t h e t y p e s o f p h y s i c a l a c t i v i t i e s p e r f o r m e d : men s p e n t t h e i r t i m e r e s t i n g , r e l a x i n g , a n d w a l k i n g a b o u t t h e h o u s e , w h e r e a s women were e n g a g e d i n l i g h t h o u s e w o r k . I n t e r e s t i n g l y , t h e women d i d n o t p e r c e i v e t h e i r h o u s e w o r k a s work o r I n c r e a s e d a c t i v i t y . A l s o , 50% o f t h e men a n d 10% o f t h e women s u b s e q u e n t l y a t t e n d e d a s t r u c t u r e d c a r d i a c r e h a b i l i t a t i o n p r o g r a m m e . Women's l a c k o f p a r t i c i p a t i o n i n s u c h p r o g r a m m e s c o u l d be r e l a t e d t o t h e i r d i f f i c u l t i e s w i t h t h e i r work a s homemakers a f t e r M I . I f women a r e s p e n d i n g t h e i r t i m e a n d e x p e n d i n g t h e i r e n e r g y on h o u s e w o r k , t h e n t h e y may n o t s e e t h e m s e l v e s a s h a v i n g e n o u g h t i m e a n d e n e r g y l e f t f o r p a r t i c i p a t i o n i n p h y s i c a l r e h a b i l i t a t i o n . T h e s e f i n d i n g s , w o m e n ' s c o n f l i c t s i t u a t i o n w i t h i n t h e home a n d t h e i r l a c k o f p a r t i c i p a t i o n i n s t r u c t u r e d c a r d i a c r e h a b i l i t a t i o n p r o g r a m m e s , make s e n s e o f S t e r n e t a l . ' s ( 1 9 7 7 ) r e s e a r c h that found that women wi th MI are even more " type A" than men w i t h MI. In a l a t e r r e - e x a m i n a t i o n of t h i s f i n d i n g , S t e r n (1984) d e f i n e s " type A" b e h a v i o u r as "an a c t i o n emotion complex" which i n c l u d e s "a c h r o n i c i n c e s s a n t s t r u g g l e " ( p . 4 5 7 ) . He r e f e r s to the women i n h i s 1977 s tudy as " super women." S t e r n ' s d e s c r i p t i o n f i t s w i t h post-MI women's needs to m a i n t a i n househo ld a c t i v i t i e s to the apparent d e t r i m e n t of t h e i r c a r d i a c r e h a b i l i t a t i o n . S h a e v i t z ' s (1984) book, The Superwoman Syndrome, c o n t r i b u t e s to an u n d e r s t a n d i n g of t h i s dilemma between home and h e a l t h . S h a e v i t z ' s c h a r t t i t l e d "How T r a d i t i o n a l Men and Women 'Saw' The Home" <p.28-30) , o u t l i n e s the d i f f e r e n c e s between men and women due to t r a d i t i o n a l sex r o l e s o c i a l i z a t i o n . Some of these d i f f e r e n c e s are p a r t i c u l a r l y a p p l i c a b l e to women w i t h MI and are as f o l l o w s : 1. T r a d i t i o n a l women f i n d i t d i f f i c u l t to r e l a x i n t h e i r own homes, whereas t r a d i t i o n a l men see the home as a p l a c e of refuge from the s t r e s s e s of the o u t s i d e w o r l d . 2. T r a d i t i o n a l women f e e l r e s p o n s i b l e f o r the h o u s e h o l d , whereas t r a d i t i o n a l men do n o t ; i f a n y t h i n g , they " h e l p o u t . " 3. T r a d i t i o n a l women are now-and-deta i1 o r i e n t e d , s e e i n g t h i n g s tha t need to be done immedia te ly , whereas t r a d i t i o n a l men are fu ture and macro o r i e n t e d . 4. T r a d i t i o n a l women complete 95 per cent of household t a s k s , whereas t r a d i t i o n a l men complete 5 p e r c e n t or l e s s of the t a sks to keep a househo ld f u n c t i o n i n g . S t a t i s t i c s on t i m e s p e n t on h o u s e w o r k b e a r o u t t h e s e d i f f e r e n c e s . F o r i n s t a n c e , P o g r e b i n ( 1 9 8 3 ) c o n c l u d e s f r o m an e x a m i n a t i o n o f s e v e r a l w o r k s t h a t " o n the a v e r a g e w i v e s do 70 p e r c e n t o f t h e h o u s e w o r k w h i l e h u s b a n d s a n d c h i l d r e n do 15 p e r c e n t " ( p . 1 4 5 ) . S t u d i e s on women w o r k i n g o u t s i d e t h e home were i n c l u d e d i n t h i s d e t e r m i n a t i o n . In t h i s s t u d y , t h e women 's a g e s , t h e i r p r i m a r y f o c u s on the home, a n d t h e i r own a s s e s s m e n t o f t h e m s e l v e s a s t r a d i t i o n a l women i n d i c a t e t h e y were most l i k e l y t r a d i t i o n a l l y s o c i a l i z e d . In v i e w o f t h e d i f f e r e n c e s i n how t r a d i t i o n a l l y s o c i a l i z e d men a n d women s e e t h e home, i t i s q u i t e u n d e r s t a n d a b l e t h a t women w i t h M I , o n c e home, e x p e r i e n c e a c o n f l i c t s i t u a t i o n b e t w e e n h o u s e h o l d demands a n d t h e i r own c a r d i a c r e h a b i l i t a t i o n . The f i n d i n g s o f t h i s a n d B o o g a a r d ' s ( 1 9 8 4 ) s t u d y s u g g e s t t h a t women c o n t i n u e t o f e e l r e s p o n s i b l e f o r t h e h o u s e h o l d no m a t t e r what h a p p e n s t o t h e m . A l s o , g i v e n t h e s t a t i s t i c s on u s u a l t i m e t r a d i t i o n a l men s p e n d on h o u s e w o r k , one w o n d e r s why s u p p o r t i n t e r m s o f d o i n g h o u s e w o r k i s e v e n a n t i c i p a t e d . I t seems q u i t e a d i f f i c u l t o b j e c t i v e , t h e n , t o c r e a t e a t h e r a p e u t i c e n v i r o n m e n t o f r e s t a n d r e l a x a t i o n a t home f o r women w i t h M I . The women i n t h i s s t u d y a s s e r t e d t h a t t h e s i t u a t i o n w o u l d h a v e b e e n r e v e r s e d i f t h e i r h u s b a n d s , r a t h e r t h a n t h e y , were t h e MI p a t i e n t s . The women p r e d i c t e d t h a t t h e y w o u l d p r o v i d e f u l l s u p p o r t i f t h e i r h u s b a n d s h a d s u f f e r e d a h e a r t a t t a c k . I t s e e m s , t h e n , t h a t t h e women e x p e c t e d t o be n u r t u r e d f o l l o w i n g t h e i r h e a r t a t t a c k i n t h e same way t h a t t h e y w o u l d n u r t u r e t h e i r h u s b a n d s i f t h e y e x p e r i e n c e d a h e a r t a t t a c k , b u t i n s t e a d e x p e r i e n c e d a d o u b l e s t a n d a r d . The c a r d i a c l i t e r a t u r e r e v i e w e d to t h i s p o i n t i n t h i s d i s c u s s i o n d e m o n s t r a t e s a n d v a l i d a t e s t h i s p r e d i c t i o n o f f u l l s u p p o r t . Women, a s s p o u s e s o f MI p a t i e n t s , t e n d t o be o v e r - s u p p o r t i v e . In C r o o g a n d L e v i n e ' s ( 1 9 8 2 ) r e s e a r c h , t h e w i v e s c l e a r l y p r o m o t e d t h e i r h u s b a n d s ' c a r d i a c r e h a b i l i t a t i o n on e m o t i o n a l a n d p h y s i c a l l e v e l s . C r o o g ( 1 9 8 4 ) l a t e r s t a t e s t h a t t h e f a m i l y ( m e a n i n g f a m i l y w i t h a w i f e ) p r o v i d e s " e m o t i o n a l a n d s o c i a l s u p p o r t , s e r v i c e s , a n d m a t e r i a l a i d " ( p . 6 3 4 ) . The women 's l i t e r a t u r e s h e d s some l i g h t on t h e r e a s o n s f o r t h i s d i f f e r e n c e i n n u r t u r a n c e b e t w e e n t h e s e x e s a n d women 's e m o t i o n a l r e s p o n s e t o l a c k o f n u r t u r a n c e . As t h e women i n t h i s s t u d y s u g g e s t , t r a d i t i o n a l s o c i a l i z a t i o n a n d m e n ' s r e s u l t a n t a t t i t u d e s a n d l a c k o f s k i l l s a c c o u n t f o r t h e s e d i f f e r e n c e s . S h a e v i t z ( 1 9 8 4 ) n o t e s t h a t t r a d i t i o n a l men a r e o n l y m i n i m a l l y aware o f what n e e d s t o be done i n t h e home a n d p o s s e s s few h o m e m a k i n g s k i l l s . F u r t h e r , she c o n t e n d s t h a t men a r e " m a c r o o r i e n t e d " a n d t h i s o r i e n t a t i o n c r e a t e s a p r o b l e m when men a r e a s k e d t o do h o u s e w o r k w h i c h r e q u i r e s a n e y e f o r d e t a i l . The r e s u l t i s t h a t women i n t e r p r e t m e n ' s l e s s p r e c i s e o r i e n t a t i o n a s a r e l u c t a n c e t o h e l p o u t . A l s o , p a r t o f t h e male i d e o l o g y i s t h a t " w o r k " comes f i r s t a n d " w o r k " d o e s n o t h a p p e n i n t h e home. P o g r e b i n ( 1 9 8 3 ) p o i n t s o u t t h a t e x p e c t a t i o n s a s w e l l a s t r a d i t i o n a l s o c i a l i z a t i o n a r e i n v o l v e d . " H o u s e w o r k i s t h e o n l y ; a c t i v i t y a t w h i c h men a r e a l l o w e d t o be c o n s i s t e n t y i n e p t . . . " ( p . 1 4 3 ) . I t seems t h a t when t r a d i t i o n a l s o c i a l i z a t i o n h a s o c c u r r e d l a c k o f s u p p o r t i s n o t s u r p r i s i n g . The e m o t i o n a l r e s p o n s e t o l a c k o f a n t i c i p a t e d s u p p o r t f rom t h e i r h u s b a n d s i n t h i s s t u d y was d i s a p p o i n t m e n t , d i s i l l u s i o n m e n t a n d f r u s t r a t i o n . S h a e v i t z (1984) p o i n t s o u t t h a t "men a r e l e s s n u r t u r i n g " a n d women r e s p o n d by f e e l i n g " u n f a i r l y t r e a t e d a n d u p s e t b e c a u s e t h e y d o n ' t g e t b a c k what t h e y g i v e t o t h e m " ( p . 3 6 ) . S h a e v i t z a d d s t h a t men a r e n o t c o m f o r t a b l e w i t h d e p e n d e n c y a n d o f t e n w i t h d r a w when t h e i r w i v e s n e e d them most b e c a u s e o f a n i n a b i l i t y to d e a l w i t h i n t e n s e e m o t i o n a l s i t u a t i o n s . The r e s u l t i s t h a t women f e e l " r e j e c t e d , u p s e t , a n d d i s a p p o i n t e d " ( p . 3 6 ) . E i c h e n b a u m a n d O r b a c h ( 1 9 8 3 ) s t a t e t h a t women 's s o c i a l r o l e d i c t a t e s t h a t t h e y must " d e f e r t o o t h e r s " a n d " h a v e e m o t i o n a l a n t e n n a e " t h a t l e a d t o a n t i c i p a t i n g t h e n e e d s o f o t h e r s . The r e s u l t i s " a n i m b a l a n c e i n g i v i n g " ( p . 9 ) . L o s s o f e x p e c t e d n u r t u r a n c e " c a u s e s t r e m e n d o u s p a i n , c o n f u s i o n , d i s a p p o i n t m e n t , r a g e a n d g u i l t . . . " ( p . 5 2 ) . The women i n t h i s s t u d y c e r t a i n l y r e s p o n d e d i n a c c o r d a n c e w i t h t h e s e d e s c r i p t i o n s , a n d t h e men, t h e i r h u s b a n d s , a l s o b e h a v e d i n a n a p p a r e n t l y c h a r a c t e r i s t i c a l l y n o n - n u r t u r a n t p a t t e r n . F u r t h e r , e x p e c t i n g s u p p o r t f r o m a t r a d i t i o n a l l y s o c i a l i z e d man i n t e r m s o f d o i n g h o u s e w o r k seems s a d l y u n r e a l i s i t i c , w h i l e a l a c k o f s u p p o r t i s more l i k e l y t o o c c u r . A n o t h e r e x p l a n a t i o n f o r l a c k o f s u p p o r t may r e l a t e b o t h t o m e n ' s " m a c r o o r i e n t a t i o n " a n d t h e i n v i s i b i l i t y o f M I . B e c a u s e men a r e n o t t u n e d i n t o s u b t l e n u a n c e s a n d d e t a i l s , t h e i r w i v e s ' MI i l l n e s s e x p e r i e n c e may be d i f f i c u l t t o d i s c e r n a n d t h e r e f o r e e a s y t o d i s m i s s . M u l l e n ( 1 9 7 8 ) , B o o g a a r d ( 1 9 8 4 ) a n d P i n n e o ( 1 9 8 4 ) s p e a k t o t h i s i n v i s i b i l i t y a n d i t s e f f e c t on s u p p o r t . P i n n e o s t a t e s t h a t t h e MI "may n o t be r e a d i l y a c c e p t e d o r i t may be e a s i l y f o r g o t t e n a n d o l d . p a t t e r n s o f f a m i l y i n t e r a c t i o n o r e x p e c t a t i o n s o f t h e p a t i e n t r e s u m e d " ( p . 4 6 3 - 4 6 4 ) . T h i s a t t r i b u t e o f t h e MI e x p e r i e n c e may c o m b i n e w i t h m e n ' s " m a c r o o r i e n t a t i o n " to c o n t r i b u t e t o l a c k o f s u p p o r t . A n o t h e r f i n d i n g i n r e l a t i o n t o l a c k o f s u p p o r t was t h e w o m e n ' s p e r c e p t i o n t h a t t h e i r MI i l l n e s s e x p e r i e n c e was v i e w e d by t h e i r h u s b a n d s a s l e s s v a l i d a n d l e s s s i g n i f i c a n t b e c a u s e t h e y a r e women. G i v e n t h a t h o u s e w o r k i s n o t v a l u e d i n o u r s o c i e t y ( C o r e a , 1 9 7 7 ; D e c k a r d , 1 9 8 3 ; W i l s o n , 1982) a n d i s n o t e v e n c o n s i d e r e d " r e a l w o r k " ( P o g r e b i n , 1 9 8 3 ; W i l s o n , 1 9 8 2 ) , t h e n i t f o l l o w s t h a t t h e s e d e s c r i p t o r s a l s o a p p l y t o t h e h o m e m a k e r . T r a d i t i o n a l l y s o c i a l i z e d women g e t t h e i r i d e n t i t y f r o m h o u s e w o r k a n d h o u s e w o r k i s i d e n t i f i e d w i t h them ( S h a e v i t z , 1 9 8 4 ) . F u r t h e r , t h e o r i e s o f power r e l a t i o n s h i p s w i t h i n t r a d i t i o n a l homes c l e a r l y l o c a t e t h e power w i t h t h e b r e a d w i n n e r a n d p o w e r l e s s n e s s w i t h t h e homemaker ( P o g r e b i n , 1 9 8 3 ) . A l o g i c a l e x t e n s i o n o f t h i s i s t h e i n v a l i d a t i o n o f a woman 's e x p e r i e n c e w i t h MI a n d t h e b e l i e f t h a t when a woman h a s a n M I , h e r e x p e r i e n c e i s l e s s s i g n i f i c a n t t h a n i t w o u l d be f o r a man. F o r some o f t h e women i n t h i s s t u d y , t h e l a c k o f a n t i c i p a t e d s u p p o r t n e g a t i v e l y i m p a c t e d on t h e i r m a r r i a g e s . M a r i t a l c o n f l i c t i s d o c u m e n t e d a s a p o s t - M I s e q u e l a i n t h e l i t e r a t u r e . W i s h n i e e t a l . ( 1 9 7 1 ) f o u n d t h a t s e r i o u s m a r i t a l c o n f l i c t was a d e f i n i t e p o t e n t i a l p r o b l e m . McLane e t a l . ( 1 9 8 0 ) c o n c l u d e d f r o m t h e i r l i t e r a t u r e r e v i e w t h a t m a r i t a l c o n f l i c t was a p r e v a l e n t p o s t - M I o u t c o m e . B o t h p a p e r s c a l l f o r more r e s e a r c h t o c l a r i f y t h e n a t u r e o f m a r i t a l d i s c o r d p o s t - M I . A l t h o u g h t h e f a m i l y i s w i d e l y a n d s o u n d l y c i t e d i n the l i t e r a t u r e a s a p i v o t a l f o r c e i n c a r d i a c r e h a b i l i t a t i o n ( A c k e r , 1978; B o o g a a r d , 1984; C a y , 1978; C o r n e t t & W a t s o n , 1984; C r o o g , 1984; D e l a n e y - N a u m o f f 1981), l a c k o f a n t i c i p a t e d s u p p o r t , e s p e c i a l l y f r o m t h e w o m e n ' s h u s b a n d s , was n o t e d t o a d v e r s e l y a f f e c t t h e women 's c a r d i a c r e h a b i l i t a t i o n . The women e x p e n d e d b o t h p h y s i c a l a n d p s y c h o l o g i c a l e n e r g y t h a t was n o t d i r e c t e d t o w a r d s t h e i r r e h a b i l i t a t i o n . T h i s l a c k o f s u p p o r t a n d the r e s u l t a n t e m o t i o n a l a n d p h y s i c a l wear a n d t e a r may e x p l a i n S t e r n e t a l . ' s (1977) f i n d i n g s o f i n c r e a s e d a n x i e t y a n d d e p r e s s i o n i n p o s t - M I women a n d B r o w n ' s a n d R a w l i n s o n ' s (1975) f i n d i n g t h a t women t e n d e d t o m a i n t a i n t h e s i c k r o l e l o n g e r f o l l o w i n g c a r d i a c b y p a s s s u r g e r y . S t e r n e t a l . ' s (1977) a n d C h i r i k o s ' a n d N i c k e l ' s (1984) f i n d i n g s t h a t women were l e s s l i k e l y t h a n men t o r e t u r n t o m a r k e t work c a n t o o be l i n k e d t o l a c k o f s u p p o r t f o r women a s MI p a t i e n t s . An a d d i t i o n a l c o n t r i b u t i n g f a c t o r a f f e c t i n g r e h a b i l i t a t i o n o u t c o m e s f o r women may be t h e i r l a c k o f p a r t i c i p a t i o n i n s t r u c t u r e d r e h a b i l i t a t i o n p r o g r a m m e s a s was n o t e d i n t h i s a n d B o o g a a r d ' s (1984) s t u d y . G r i f f o e t a l . (1983) f o u n d t h a t women 's c o m p l i a n c e t o p h y s i c a l r e h a b i l i t a t i o n was a p r o b l e m w h i c h a f f e c t e d t h e b e n e f i t d e r i v e d . In a n i n f o r m a l c o n v e r s a t i o n w i t h t h e d i r e c t o r o f a L o w e r M a i n l a n d c a r d i a c r e h a b i l i t a t i o n p r o g r a m m e , women 's p a r t i c i p a t i o n was d i s c u s s e d . The d i r e c t o r s t a t e d t h a t women g i v e many r e a s o n s why t h e y c a n ' t m a i n t a i n t h e i r c o m m i t m e n t t o a p r o g r a m m e , f o r e x a m p l e , c h i l d r e n , h u s b a n d s , m e a l s . She n o t e d f u r t h e r t h a t women were l a t e r t h a n men t o s e a r c h o u t p r o g r a m m e s . T h i s l a c k o f p a r t i c i p a t i o n i n r e h a b i l i t a t i o n p r o g r a m m e s , a s d i s c u s s e d a t t h e b e g i n n i n g o f t h i s s e c t i o n , may be r e l a t e d t o t h e women 's c o n f l i c t s i t u a t i o n b e t w e e n t h e c o m p e t i n g demands o f the h o u s e h o l d a n d t h e i r own r e h a b i l i t a t i o n . L a c k o f a n t i c i p a t e d s u p p o r t f i t s w i t h t h e c u r r e n t s t u d i e s c o n c e r n i n g women w i t h M I . The w o m e n ' s l i t e r a t u r e p r o v i d e s i n s i g h t i n t o t h e r e a s o n s f o r t h i s f i n d i n g f o r women. W i t h i n t h e c a r d i a c l i t e r a t u r e , t h e f a m i l y i s v i e w e d a s a p i v o t a l f o r c e a f f e c t i n g r e h a b i l i t a t i o n a n d s p o u s a l o v e r - s u p p o r t i s t h e n o r m . T h i s l i t e r a t u r e i s l a r g e l y b a s e d u p o n s t u d i e s o f women a s s p o u s e s o f MI p a t i e n t s . I t i s s u g g e s t e d t h a t l a c k o f s u p p o r t may a c c o u n t f o r t h e f i n d i n g s i n t h e l i t e r a t u r e a b o u t w o m e n ' s p a r t i c i p a t i o n i n s t r u c t u r e d r e h a b i l i t a t i o n p r o g r a m m e s a n d u l t i m a t e l y t h e p o o r e r r e h a b i l i t a t i o n o u t c o m e s n o t e d f o r women w i t h M I . Change i n U s u a l R o l e E n a c t m e n t C h a n g e s i n homemaker r o l e e n a c t m e n t were u p s e t t i n g f o r t h e women i n t h i s s t u d y . The women e x p e r i e n c e d f e e l i n g s o f g u i l t a n d a s e n s e o f l o s s o f p o w e r a n d a u t h o r i t y i n r e l a t i o n t o g i v i n g o v e r t h e i r h o u s e h o l d r o l e s t o t h e i r h u s b a n d s a n d f a m i l i e s . When women a r e t r a d i t i o n a l l y s o c i a l i z e d , t h e y p u t t h e n e e d s o f o t h e r s f i r s t a n d f e e l g u i l t y i f t h e y d o n ' t ( S h a e v i t z , 1 9 8 4 ) . W i t h i n t h e l i t e r a t u r e c o n c e r n i n g women w i t h M I , g u i l t i s i d e n t i f i e d a s a n e m o t i o n a l c o n c o m i t a n t t o g i v i n g o v e r u s u a l h o u s e h o l d r o l e s t o h u s b a n d s a n d f a m i l i e s o r t o n o t m e e t i n g t h e n e e d s o f o t h e r s ( B o o g a a r d , 1 9 8 4 ; Newton & S i v a r a j a n , 1 9 8 2 ) . B o o g a a r d ' s ( 1 9 8 4 ) women n o t o n l y f e l t g u i l t y , b u t a l s o r e s i s t e d h e l p f r o m t h e i r f a m i l i e s . T h i s g u i l t r e a c t i o n h e l p s t o e x p l a i n the o v e r t l y c o n t r a d i c t o r y s t a n c e s o f t h e women i n t h i s s t u d y . The women f e l t a l a c k o f a n t i c i p a t e d s u p p o r t a n d y e t were n o t c o m f o r t a b l e when t h e i r h u s b a n d s t o o k o v e r . A p p a r e n t l y , men do n o t e x p e r i e n c e g u i l t when t h e i r w i v e s t a k e on t h e i r f o r m e r h o u s e h o l d r o l e s ( C r o o g & L e v i n e , 1 9 8 2 ) . F o r men , t h e l o s s o f b r e a d w i n n e r a n d s e x u a l r o l e s i s i d e n t i f i e d a s t h e i r m a j o r p o s t - M I l o s s e s , a n d t h e r e f o r e most t h r e a t e n i n g t o t h e i r s e l f - c o n c e p t ( W i s h n i e e t a l . , 1 9 7 1 ; C a s s e m & H a c k e t t , 1 9 7 7 ) . C h a n g e s i n u s u a l r o l e e n a c t m e n t t h e n a p p e a r t o be f i r m l y a t t a c h e d t o s e x r o l e s o c i a l i z a t i o n , a n d t h e r e f o r e , d i f f e r e n t f o r women t h a n f o r men p o s t - M I ( W i s h n i e e t a l . , 1 9 7 1 ; C a s s e m & H a c k e t t , 1 9 7 7 ) . T r a d i t i o n a l l y s o c i a l i z e d women d e r i v e t h e i r i d e n t i t y f r o m a n d f e e l r e s p o n s i b l e f o r t h e h o u s e h o l d . F u r t h e r , t h e h o u s e h o l d f u n c t i o n s a s t h e i r p r i m e s o u r c e o f power a n d c o n t r o l ( W i l s o n , 1 9 8 2 ; S h a e v i t z , 1 9 8 4 ) . B e c a u s e o f t h e s e p e r c e p t i o n s , a c h a n g e i n t h i s u s u a l r o l e e n a c t m e n t t h r e a t e n s w o m e n ' s s e l f - e s t e e m . The f e e l i n g s o f l o s s o f power a n d a u t h o r i t y e x p r e s s e d by t h e women i n t h i s s t u d y a r e t h u s e x p l a i n e d . S t r a t e g i e s f o r C o n t r o l In t h i s s t u d y , t h e women u s e d a w i d e r a n g e o f s t r a t e g i e s t o g a i n c o n t r o l o v e r t h e i r e x p e r i e n c e d l o s s e s . F rom t h e c a r d i a c r e h a b i l i t a t i o n l i t e r a t u r e , one w o u l d e x p e c t e x e r c i s e t o be t h e p r e d o m i n a n t s t r a t e g y s e l e c t e d a n d u s e d by p o s t - M I p a t i e n t s . Wenger ( 1 9 8 2 ) s t a t e s t h a t , a l t h o u g h t h e r e i s no c l e a r e v i d e n c e t h a t e x e r c i s e a l t e r s t h e n a t u r a l p r o g r e s s i o n o f t h e h e a r t d i s e a s e a f t e r M I , t h e r e a r e n u m e r o u s b e n e f i t s . O v e r a l l p a t i e n t s f e e l b e t t e r : more c o n f i d e n t , l e s s d e p e n d e n t , l e s s d e p r e s s e d a n d a n x i o u s , a n d p o s s e s s a n i n c r e a s e d s e l f - e s t e e m . C a s s e m a n d H a c k e t t ( 1 9 8 4 ) s t a t e t h a t a s t r u c t u r e d c a r d i a c r e h a b i l i t a t i o n programme i s t h e b e s t means t o c o u n t e r a c t p o s t - M I d e p r e s s i o n . As t h i s s t u d y , B o o g a a r d ' s ( 1 9 8 4 ) s t u d y , a n d G r i f f o e t a l . ' s ( 1 9 8 4 ) s t u d y f o u n d , women t e n d n o t t o p a r t i c i p a t e i n p h y s i c a l r e h a b i l i t a t i o n p r o g r a m m e s . The d i r e c t o r o f a l o c a l L o w e r M a i n l a n d p r o g r a m m e , c i t e d i n t h e p r e v i o u s s e c t i o n , a d d s t h a t l a c k o f p a r t i c i p a t i o n i s r e l a t e d t o p e r c e i v e d home r e s p o n s i b i l i t i e s . C r o o g ( 1 9 8 4 ) p o i n t s o u t t h a t t h e s e p r o g r a m m e s a r e g e n e r a l l y n o t b e i n g w e l l u t i l i z e d . T h i s s t u d y o f f e r s s u p p o r t f o r t h i s a s s e r t i o n . A l s o , g i v e n t h e b e n e f i t s , women 's l a c k o f p a r t i c i p a t i o n seems most u n f o r t u n a t e . T h e r e i s s u p p o r t i n t h e l i t e r a t u r e f o r t h e f i n d i n g o f t h i s s t u d y t h a t a s s i g n i n g c a u s e f o r MI p a t i e n t s i s a s t r a t e g y f o r c o n t r o l b e c a u s e i t h e l p s p a t i e n t s t o make s e n s e o f t h e i r i l l n e s s e x p e r i e n c e ( C o w i e , 1 9 7 8 ; M u l l e n , 1 9 7 8 ) . C a s s e m a n d H a c k e t t ( 1 9 8 2 ) c o n c e p t u a l i z e d e n i a l a s a means o f m i n i m i z i n g t h e n e g a t i v e a s p e c t s a n d c a p i t a l i z i n g on t h e p o s i t i v e a s p e c t s o f t h e MI i l l n e s s e x p e r i e n c e . In t h i s way , d e n i a l may be i n t e r p r e t e d a s a s t r a t e g y f o r c o n t r o l a s d e f i n e d i n t h i s s t u d y . The women i n t h i s s t u d y u s e d s i m i l a r t a c t i c s , b o t h i n u s i n g hope a s a s t r a t e g y a n d i n u s i n g p e r s o n a l p h i l o s o p h i e s , s u c h a s n o t d w e l l i n g on t h e i r MI a n d f e e l i n g f o r t u n a t e . S i m i l a r i t i e s a r e n o t e d b e t w e e n t h e s t r a t e g i e s f o r c o n t r o l named i n t h i s s t u d y a n d t h e l i t e r a t u r e . H o w e v e r , p h y s i c a l r e h a b i l i t a t i o n , t h e m a j o r s t r a t e g y a d v o c a t e d i n t h e c a r d i a c r e h a b i l i t a t i o n l i t e r a t u r e , was n e i t h e r i d e n t i f i e d n o r s e l e c t e d a s a s t r a t e g y f o r c o n t r o l by t h e women i n t h i s s t u d y . Summary T h i s c h a p t e r d i s c u s s e d the f i n d i n g s o f t h i s s t u d y w i t h i n t h e c o n t e x t o f t h e c u r r e n t p r o f e s s i o n a l l i t e r a t u r e . The i n t e n t was t o c o m p a r e t h e f i n d i n g s o f t h i s s t u d y w i t h t h e p r e s e n t u n d e r s t a n d i n g o f t h e MI i l l n e s s e x p e r i e n c e , a n u n d e r s t a n d i n g d e r i v e d l a r g e l y f r o m s t u d i e s o f men p o s t - M I . S i m i l a r i t i e s a n d d i s s i m i l a r i t i e s w i t h i n t h e MI e x p e r i e n c e were d i s c u s s e d . Women's l i t e r a t u r e was u s e d to make s e n s e o f t h e d i v e r g e n t f i n d i n g s i n w o m e n ' s e x p e r i e n c e w i t h M I . The n e x t c h a p t e r s u m m a r i z e s t h i s s t u d y , d r a w s c o n c l u s i o n s f r o m t h e s e f i n d i n g s , a n d o u t l i n e s t h e i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , e d u c a t i o n , a n d r e s e a r c h . C H A P T E R 6 Summary , C o n c l u s i o n s , a n d I m p l i c a t i o n s f o r N u r s i n g I n t r o d u c t i o n C h a p t e r 6 s u m m a r i z e s t h i s s t u d y a n d d r a w s c o n c l u s i o n s f r o m t h e f i n d i n g s d e l i n e a t e d a n d d i s c u s s e d i n C h a p t e r 5 . I m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , n u r s i n g e d u c a t i o n , a n d n u r s i n g r e s e a r c h a r e t h e n o u t l i n e d . Summary o f t h e S t u d y T h i s s t u d y was d e s i g n e d t o d e s c r i b e a n d e x p l o r e women's p e r c e p t i o n s o f t h e i r i l l n e s s e x p e r i e n c e w i t h M I . D e s p i t e t h e s t a t i s t i c a l e v i d e n c e e s t a b l i s h i n g t h e s i g n i f i c a n c e o f t h i s h e a l t h p r o b l e m f o r women, t h e r e i s a d e a r t h o f e m p i r i c a l k n o w l e d g e a b o u t MI i n r e l a t i o n t o women. T h i s l a c k o f e x p l o r a t i o n o f MI i n r e l a t i o n t o women i s a t t r i b u t a b l e t o t h e p o p u l a r myth t h a t MI h a p p e n s t o men o n l y a n d to t h e more f u n d a m e n t a l p r o b l e m o f m a l e - d o m i n a t e d m e d i c i n e a n d h e a l t h s c i e n c e s r e s e a r c h . I t was a r g u e d by t h i s r e s e a r c h e r t h a t u s i n g r e s e a r c h on men w i t h MI t o g u i d e women 's c a r d i a c r e h a b i l i t a t i o n c o u l d r e s u l t i n h e a l t h c a r e t h a t f a i l e d t o a d d r e s s t h e s p e c i a l n e e d s o f women. K l e i n m a n e t a l . ' s E x p l a n a t o r y M o d e l ( 1 9 7 8 ) was u s e d a s t h e c o n c e p t u a l f r a m e w o r k f o r t h i s s t u d y . T h i s model d i r e c t s h e a l t h c a r e p r o f e s s i o n a l s t o e l i c i t t h e p a t i e n t ' s p o i n t o f v i e w a n d t o c o n s i d e r t h e t o t a l phenomenon o f i l l n e s s , o r t h e i l l n e s s e x p e r i e n c e , a n d n o t j u s t t h e d i s e a s e e n t i t y . T h i s a p p r o a c h f a c i l i t a t e s t h e p l a n n i n g a n d p r o v i s i o n o f h e a l t h c a r e , i n t h i s i n s t a n c e , n u r s i n g c a r e , t h a t i s a p p r o p r i a t e t o a n d e f f e c t i v e f o r women. The p h e nomenological method was s e l e c t e d as the r e s e a r c h methodology f o r t h i s s t u d y . I t was d e t e r m i n e d to be s u i t a b l e f o r i n v e s t i g a t i n g the meaning of the MI i l l n e s s e x p e r i e n c e f o r women. The phenomenological method c o n s i d e r s the i n d i v i d u a l s who are e x p e r i e n c i n g the phenomenon under s t u d y as the e x p e r t w i t n e s s e s , the b e s t s o u r c e s f o r a c c u r a t e and r i c h d a t a . U s i n g t h i s methodology, the r e s e a r c h e r was a b l e t o view the MI i l l n e s s e x p e r i e n c e from the s u b j e c t s ' p e r s p e c t i v e and to h e l p the women to a c c u r a t e l y d e s c r i b e t h e i r p e r c e p t i o n s . Both the s t u d y ' s c o n c e p t u a l framework and the s e l e c t e d methodology a re congrue n t w i t h the n u r s i n g p r o f e s s i o n ' s v a l u i n g of the i n d i v i d u a l and i t s unique n u r t u r a n t f u n c t i o n . The l i t e r a t u r e r e v i e w not o n l y f u r t h e r s u b s t a n t i a t e d the need f o r r e s e a r c h on t h i s t o p i c of MI i n r e l a t i o n to women, but a l s o l o c a t e d t h i s s t u d y w i t h i n the body of c u r r e n t p r o f e s s i o n a l l i t e r a t u r e p e r t a i n i n g to MI, and l e d to the c o n c l u s i o n , from the few a v a i l a b l e s t u d i e s , t h a t women's post-MI e x p e r i e n c e may be both d i f f i c u l t and d i f f e r e n t than men's. Because c u r r e n t c o n c e p t s i n c a r d i a c r e h a b i l i t a t i o n , as p r e s e n t e d i n the l i t e r a t u r e , are based l a r g e l y upon an u n d e r s t a n d i n g of men's e x p e r i e n c e w i t h MI, i t was a s s e r t e d t h a t an u n d e r s t a n d i n g of women's e x p e r i e n c e w i t h MI would p r o v i d e a more v a l i d b a s i s f o r n u r s i n g p r a c t i c e . The d a t a were c o l l e c t e d by means of 11 i n t e n s i v e i n t e r v i e w s w i t h 8 women over a 3 month p e r i o d . The i n t e r v i e w s were semi-s t r u c t u r e d , w i t h l o o s e guidance p r o v i d e d by Kleinman e t a l . ' s (1978) s i x q u e s t i o n s (Appendix C ) . The i n t e r v i e w s were 100 a u d i o t a p e d a n d t h e n t r a n s c r i b e d v e r b a t i m . D a t a c o l l e c t i o n a n d d a t a a n a l y s i s o c c u r r e d s i m u l t a n e o u s l y . The r e s e a r c h e r ' s m a j o r r o l e was t o a s s i s t t h e women 's e x p l o r a t i o n o f the m e a n i n g to them o f t h e i r MI i l l n e s s e x p e r i e n c e . When c o n s i s t e n t t h e m e s were b e i n g i d e n t i f i e d a n d v a l i d a t e d a n d the. d a t a c o l l e c t e d were d e t e r m i n e d t o be s u f f i c i e n t l y i n - d e p t h a n d r i c h , t h e i n t e r v i e w s s t o p p e d . The s t u d y ' s a n a l y t i c f r a m e w o r k i s t h e r e s e a r c h e r ' s i c o n c e p t u a l i z a t i o n a n d i n t e r p r e t a t i o n o f t h e d a t a a n d i s d e r i v e d f r o m t h i s p r o c e s s o f a n a l y s i n g t h e s t u d y ' s d a t a a n d r e f i n i n g t h a t a n a l y s i s o v e r t i m e . The women 's a c c o u n t s d e s c r i b e t h e n a t u r e a n d m e a n i n g o f t h e i r i l l n e s s e x p e r i e n c e w i t h MI a n d t h e i m p a c t o f t h e i r MI on t h e i r e v e r y d a y l i v e s . The c o r e theme t h a t e m e r g e d f r o m t h e d a t a was l o s s . The women c o n s t r u c t e d t h e i r a c c o u n t s a r o u n d t h e many s i g n i f i c a n t c h a n g e s i n t h e i r l i v e s s i n c e t h e e v e n t o f t h e i r M I . In s o d o i n g , t h e y were g r i e v i n g t h e l o s s e s i n h e r e n t i n t h e s e c h a n g e s . T h e r e f o r e , t h e s t u d y ' s a n a l y t i c f r a m e w o r k i s e s s e n t i a l l y a l o s s f r a m e w o r k ( r e f e r t o F i g u r e 1, p . 3 3 ) . The f i r s t a s p e c t o f t h e w o m e n ' s MI i l l n e s s e x p e r i e n c e was a l o s s o f h e a l t h y s t a t e , w h i c h r e p r e s e n t e d t h e i r s h i f t f r o m h e a l t h t o i l l n e s s . The MI p a i n e x p e r i e n c e was a s i g n i f i c a n t c a t a l y s t f o r t h i s r e d e f i n i t i o n o f t h e m s e l v e s a s i l l i n d i v i d u a l s . T h i s p a i n e p i s o d e was f o u n d t o be u n i q u e l y a n d d i v e r s e l y e x p r e s s e d a n d e x p e r i e n c e d by t h e women. The vague a n d p r o s c r i p t i v e n a t u r e o f t h e a d v i c e g i v e n t o t h e women by t h e p r o f e s s i o n a l s e c t o r a l s o c o n t r i b u t e d to t h e women 's s e n s e o f l o s s o f h e a l t h y s t a t e . The c e n t r a l l o s s e x p e r i e n c e d by t h e women was a l o s s o f p r e d i c t a b i l i t y t h a t was c h a r a c t e r i z e d by f e e l i n g s o f u n c e r t a i n t y 101 a n d a n a w a r e n e s s o f the p r e c a r i o u s n e s s o f the r e c o v e r y p r o c e s s f r o m a n M I . A s p e c t s o f t h e c e n t r a l l o s s o f p r e d i c t a b i l i t y were a d i f f i c u l t y i n t e r p r e t i n g b o d i l y c u e s a n d a n e e d f o r s p e c i f i c , c o n c r e t e i n f o r m a t i o n a n d t h e p e r c e p t i o n t h a t t h i s n e e d was n o t m e t . The p e r v a s i v e a n d p o t e n t l o s s o f p r e d i c t a b i l i t y g a v e r i s e t o t h r e e c o n c e r n s : ( a ) t h e p o s s i b i l i t y o f a r e p e a t M I , (b ) the p o s s i b i l i t y o f s u d d e n d e a t h , a n d ( c ) t h e p o t e n t i a l f o r r e t u r n i n g t o n o r m a l . T h i s l a s t c o n c e r n i n v o l v e d a p r o c e s s o f c o m p a r i n g t h e m s e l v e s w i t h o t h e r s . L o s s o f p r e d i c t a b i l i t y was f e l t p a r t i c u l a r l y i n r e l a t i o n t o e n e r g y , a n t i c i p a t e d s u p p o r t f r o m t h e i r h u s b a n d s , a n d r o l e e n a c t m e n t . I t was f o u n d t h a t l a c k o f e n e r g y was a p r o m i n e n t f e a t u r e i n d a i l y l i f e a f t e r MI f o r women. T h i s l a c k r e i n f o r c e d t h e women 's f e e l i n g s o f l o s s o f p r e d i c t a b i l i t y . In a d d i t i o n t o e n e r g y c h a n g e s , t h e women a l s o e x p e r i e n c e d a d i s a p p o i n t i n g l a c k o f s u p p o r t , e s p e c i a l l y f r o m t h e i r h u s b a n d s . The women r e p o r t e d a p u s h - p u l l d y n a m i c b e t w e e n t h e c o m p e t i n g demands o f t h e i r p e r c e i v e d h o u s e h o l d r e s p o n s i b i l i t i e s a n d t h e i r own h e a l t h n e e d s r e l a t e d t o t h e i r M I . T h i s c o n f l i c t s i t u a t i o n m i g h t e x p l a i n t h e i r l a c k o f p a r t i c i p a t i o n i n s t r u c t u r e d c a r d i a c r e h a b i l i t a t i o n p r o g r a m m e s . F u r t h e r , t h e women p r e d i c t e d a n d were u p s e t t o r e a l i z e t h a t i f t h e i r h u s b a n d s s u f f e r e d a h e a r t a t t a c k t h e s e men w o u l d r e c e i v e more s u p p o r t t h a n t h e y were a b l e t o g i v e . A d d i t i o n a l l y , t h e women f e l t t h a t t h e i r MI i l l n e s s e x p e r i e n c e was v i e w e d a s l e s s v a l i d a n d s i g n i f i c a n t b e c a u s e t h e y a r e women. C h a n g e s i n homemaker r o l e e n a c t m e n t were d e s c r i b e d a s u n c o m f o r t a b l e by t h e women. The women e x p e r i e n c e d g u i l t a s 102 w e l l a s a l o s s o f power a n d a u t h o r i t y when t h e i r homemaker t a s k s were a s s u m e d by t h e i r h u s b a n d s a n d f a m i l i e s . F i n a l l y , i n t h i s s t u d y t h e women were f o u n d to use a wide r a n g e o f s t r a t e g i e s t o g a i n c o n t r o l o v e r t h e i r e x p e r i e n c e d l o s s e s . T h e s e s t r a t e g i e s i n c l u d e d a s s i g n i n g a c a u s e f o r t h e i r M I , f e e l i n g h o p e f u l , a n d r e l y i n g on p e r s o n a l p h i l o s o p h i e s a n d p a s t e x p e r i e n c e . The f i n d i n g s o f t h i s s t u d y were d i s c u s s e d i n r e l a t i o n t o t h e c u r r e n t 1 i t e r a t u r e p e r t a i n i n g t o M I . The p u r p o s e o f t h i s d i s c u s s i o n was t o c o m p a r e women 's e x p e r i e n c e w i t h M I , a s a s c e r t a i n e d i n t h i s s t u d y , w i t h t h e c u r r e n t u n d e r s t a n d i n g o f t h e MI e x p e r i e n c e f o r men a s r e c o r d e d i n t h e l i t e r a t u r e . T h i s d i s c u s s i o n c o n c l u d e d t h a t t h e r e a r e c o m m o n a l i t i e s b u t a l s o s i g n i f i c a n t d i f f e r e n c e s b e t w e e n m e n ' s a n d women 's e x p e r i e n c e w i t h M I . Women's l i t e r a t u r e p u t s t h e s e u n i q u e f i n d i n g s i n t o a c l e a r e r p e r s p e c t i v e . C o n c l u s i o n s The c o n c l u s i o n s d r a w n f r o m t h e f i n d i n g s o f t h i s s t u d y a r e a s f o l l o w s : 1. Women e x p l a i n t h e i r MI i l l n e s s e x p e r i e n c e i n t e r m s o f e x p e r i e n c e d l o s s e s . 2. Women's n e e d f o r i n f o r m a t i o n f o l l o w i n g MI i s n o t m e t . 3. L a c k o f e n e r g y , i s a p r o m i n e n t f e a t u r e o f t h e MI i l l n e s s e x p e r i e n c e f o r women. 4. T r a d i t i o n a l s e x r o l e s o c i a l i z a t i o n s e t s t h e s t a g e f o r p o t e n t i a l p r o b l e m s i n w o m e n ' s c a r d i a c r e h a b i l i t a t i o n , e s p e c i a l l y i n r e l a t i o n t o s u p p o r t a n d r o l e e n a c t m e n t . 103 5 . A l t h o u g h the women were a b l e to a r t i c u l a t e a wide v a r i e t y o f s t r a t e g i e s t o g a i n c o n t r o l o v e r t h e i r e x p e r i e n c e d l o s s e s , p h y s i c a l r e h a b i l i t a t i o n , t h e s t r a t e g y most s t r o n g l y r e c o m m e n d e d i n t h e c a r d i a c l i t e r a t u r e , was n o t e v e n once i d e n t i f i e d . T h e r e f o r e , p h y s i c a l r e h a b i l i t a t i o n i s n o t a s e l e c t e d s t r a t e g y f o r c o n t r o l o v e r e x p e r i e n c e d l o s s e s f o r women w i t h M I . I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e The f i n d i n g s a n d c o n c l u s i o n s o f t h i s s t u d y s u g g e s t a number o f i m p l i c a t i o n s f o r n u r s e s i n v o l v e d i n t h e a s s e s s m e n t , p l a n n i n g , i m p l e m e n t a t i o n , a n d e v a l u a t i o n o f t h e n u r s i n g c a r e o f women w i t h MI a n d a r e a s f o l l o w s : 1. C l e a r l y , t h e n u r s i n g c a r e o f women w i t h MI must be f a m i l y - c e n t e r e d i n o r d e r t o a d d r e s s t h e f i n d i n g s a n d c o n c l u s i o n o f t h i s s t u d y c o n c e r n i n g s u p p o r t a n d r o l e e n a c t m e n t a n d , t h e r e f o r e , t o p r o v i d e e f f e c t i v e a n d m e a n i n g f u l c a r e f o r women w i t h M I . As one women so s t r o n g l y u r g e d : I t h i n k when a woman h a s a h e a r t a t t a c k , t h e man, t h e h u s b a n d , a n d i f t h e r e a r e a n y c h i l d r e n , t h e r e s h o u l d be some c l a s s , some s o m e t h i n g t h a t c a n r e a l l y make them aware what h a s h a p p e n e d , what i s e x p e c t e d o f t h e m , how i t a c t u a l l y h a s t o g o . 2 . B e c a u s e women e x p l a i n t h e i r i l l n e s s e x p e r i e n c e w i t h MI a s a l o s s p h e n o m e n o n , i t i s i m p o r t a n t f o r n u r s e s t o a s s e s s women w i t h MI u s i n g t h e c o n c e p t s o f l o s s a n d g r i e f . F o r e x a m p l e , what i s t h e n a t u r e o f t h e l o s s e x p e r i e n c e ? What s p e c i f i c l o s s e s a r e i n v o l v e d ? The l o s s e s i d e n t i f i e d i n t h i s s t u d y p r o v i d e n u r s e s w i t h a g u i d e t o t h e a s s e s s m e n t o f i n d i v i d u a l l o s s e s f o r women w i t h M I . 104 3. The s t u d y ' s c o n c l u s i o n r e l a t e d to lack of i n f o r m a t i o n g i v e s nurses a c l e a r mandate to a s ses s s p e c i f i c l e a r n i n g needs , e s p e c i a l l y once the p a t i e n t i s d i s c h a r g e d home from h o s p i t a l . What does t h i s p a t i e n t need to know about a c t i v i t y a t home? Does-she know what a c t i v i t i e s are p e r m i t t e d ? Can she determine i f she i s o v e r e x t e n d i n g her l i m i t s ? 4. The f i n d i n g s and c o n c l u s i o n s about l ack of energy p o s t -MI d i r e c t nurses to a s ses s energy changes p r i o r to d i s c h a r g e and then a g a i n when the p a t i e n t i s a d j u s t i n g to the home env i ronment . Because of the p h y s i o l o g i c a l and p s y c h o l o g i c a l bases f o r energy d e p l e t i o n , the nurse s h o u l d c o l l e c t s p e c i f i c da ta about a c t i v i t y t o l e r a n c e and p o t e n t i a l s t r e s s o r s i n the home environment i n o r d e r to f a c i l i t a t e an easy t r a n s i t i o n from h o s p i t a l to home. 5. P l a n n i n g s h o u l d i n c l u d e n u r s i n g i n t e r v e n t i o n s to inc rea se s u p p o r t , to meet the p a t i e n t ' s and f a m i l y ' s e d u c a t i o n a l needs , to deve lop the women's s t r a t e g i e s f o r c o n t r o l over t h e i r e x p e r i e n c e d l o s s e s , e s p e c i a l l y p h y s i c a l r e h a b i l i t a t i o n , and to h e l p women to a n t i c i p a t e normal p h y s i c a l and p s y c h o l o g i c a l re sponses to MI. F u r t h e r , an approach emphas iz ing d o ' s r a t h e r than d o n ' t s , p r e s c r i p t i o n s r a t h e r than p r o s c r i p t i o n s , and s p e c i f i c , p r e c i s e r a t h e r than vague a d v i c e i s i n d i c a t e d . 6. In r e l a t i o n to implementing n u r s i n g c a r e , nurses need to deve lop s k i l l i n t e a c h i n g women and f a m i l i e s , in problem s o l v i n g w i t h women and f a m i l i e s , and i n p r o v i d i n g empath ic , o p t i m i s t i c , and s u p p o r t i v e n u r s i n g c a r e . 7. T h i s s tudy d i r e c t s nurses to e v a l u a t e the pre sent c a r d i a c r e h a b i l i t a t i o n programmes in r e l a t i o n to the s p e c i a l 105 n e e d s o f women. N u r s e s s h o u l d s e r i o u s l y c o n s i d e r s e t t i n g up s t r u c t u r e d c a r d i a c r e h a b i l i t a t i o n p r o g r a m m e s f o r women, t a i l o r e d t o meet women 's n e e d s . S u c h p r o g r a m m e s c o u l d be d e s i g n e d to f u n c t i o n a s a c o m b i n e d s u p p o r t a n d p h y s i c a l r e h a b i l i t a t i o n g r o u p . The f i n d i n g s a n d c o n c l u s i o n s f r o m t h i s s t u d y p r o v i d e a b a s i s f o r n u r s e s t o d e v e l o p a p i v o t a l r o l e i n c a r i n g f o r women w i t h MI t h a t c o u l d s i g n i f i c a n t l y a n d p o s i t i v e l y i m p a c t upon women 's c a r d i a c r e h a b i l i t a t i o n . I m p l i c a t i o n s f o r N u r s i n g E d u c a t i o n The f o l l o w i n g i m p l i c a t i o n s f o r n u r s i n g e d u c a t i o n a r e d r a w n f r o m t h i s s t u d y : 1. I t i s e v i d e n t f r o m t h i s s t u d y t h a t n u r s e s must be p r e p a r e d t o t e a c h p a t i e n t s w i t h MI a n d t h e i r f a m i l i e s a s r e c o m m e n d e d i n t h e l i t e r a t u r e c o n c e r n i n g c a r d i a c r e h a b i l i t a t i o n . T h i s p r e p a r a t i o n s h o u l d t h e n i n c l u d e c o n t e n t i n p a t h o p h y s i o l o g y a n d p s y c h o l o g y r e l a t e d t o M I , , a s w e l l a s c l i n i c a l p r a c t i c e i n t h e a p p l i c a t i o n o f t h e p r i n c i p l e s o f t e a c h i n g a n d l e a r n i n g . 2 . N u r s e s must d e v e l o p s k i l l i n i n t e r v i e w i n g a n d i n t h e p h y s i c a l a s s e s s m e n t o f p a t i e n t s w i t h M I . T h i s s k i l l i s p a r t i c u l a r l y e s s e n t i a l f o r n u r s e s i n t h e c o m m u n i t y , i n t h e i d e n t i f i c a t i o n o f a c t u a l a n d p o t e n t i a l p r o b l e m s a n d t h e a d j u s t m e n t o f c a r e p l a n s . 3 . M o s t i m p o r t a n t l y , t h i s s t u d y d i r e c t s n u r s i n g e d u c a t o r s to p r o v i d e c o u r s e work i n women 's h e a l t h i s s u e s to s e n s i t i z e n u r s e s t o t h i s f i e l d o f s t u d y a n d t o e q u i p n u r s e s w i t h t h e u n d e r s t a n d i n g n e c e s s a r y t o f a c i l i t a t e c h a n g e s i n women 's h e a l t h 106 care . I m p l i c a t i o n s fo r N u r s i n g Research The f i n d i n g s and c o n c l u s i o n s from t h i s s tudy p o i n t to a number of i m p l i c a t i o n s f o r f u r t h e r r e s e a r c h i n r e l a t i o n to women wi th MI. S e l e c t e d i m p l i c a t i o n s f o r n u r s i n g r e s e a r c h a r e : 1. The a rea of l a c k of i n f o r m a t i o n r e q u i r e s f u r t h e r i n v e s t i g a t i o n . Are there d i f f e r e n c e s i n i n f o r m a t i o n g i v i n g and r e c e i v i n g between men and women w i t h MI? What v a r i a b l e s are a s s o c i a t e d wi th e f f e c t i v e i n f o r m a t i o n g i v i n g and r e c e i v i n g ? 2. The f i n d i n g s and c o n c l u s i o n s c o n c e r n i n g l a c k of a n t i c i p a t e d support suggest fu ture r e s e a r c h . How does support vary w i t h f a m i l y c i r c u m s t a n c e s ? What sources f o r suppor t f i t w i t h women's needs pos t-MI? 3. A l s o , because the women i d e n t i f i e d such a wide range of s t r a t e g i e s f o r c o n t r o l , i t would be u s e f u l to i n v e s t i g a t e s t r a t e g i e s per se i n o r d e r to expand the p r o f e s s i o n a l s e c t o r ' s p e r s p e c t i v e and to i s o l a t e s t r a t e g i e s that are p a r t i c u l a r l y e f f e c t i v e f o r women. summary In c o n c l u s i o n , i t i s e v i d e n t tha t MI in r e l a t i o n to women r e q u i r e s c o n t i n u e d i n v e s t i g a t i o n . T h i s s tudy suggest s tha t u n d e r s t a n d i n g women's e x p e r i e n c e w i t h MI i s n e c e s s a r y to augment and i n c r e a s e the v a l i d i t y of the c u r r e n t knowledge base f o r c a r d i a c c a r e . E l i c i t i n g women's p e r c e p t i o n s of t h e i r MI i l l n e s s e x p e r i e n c e makes use of the most v a l u a b l e da ta source a v a i l a b l e to unders tand t h i s i l l n e s s phenomenon. REFERENCE L I S T 108 REFERENCE L I S T A c k e r , J . E . ( 1 9 7 8 ) . P s y c h o l o g i c a l a s p e c t s o f c a r d i a c r e h a b i l i t a t i o n . A d v a n c e s i n C a r d i o l o g y . ££, 116-119. A n d e r s o n , J.M. ( 1 9 8 1 ) . The e x p l o r a t i o n o f 4two d i s t i n c t i v e r e s e a r c h p a r a d i g m s a n d t h e i m p l i c a t i o n s f o r r e s e a r c h t r a i n i n g . A d d r e s s t o c o n f e r e n c e , R e s e a r c h - A b a s e f o r t h e f u t u r e ? S c o t l a n d : U n i v e r s i t y o f E d i n b u r g h . B e n g t s s o n , C , H a l l s t r o m , T., & T i b b l i n , G. ( 1 9 7 3 ) . S o c i a l f a c t o r s , s t r e s s e x p e r i e n c e a n d p e r s o n a l i t y t r a i t s i n women w i t h i s c h a e m i c h e a r t d i s e a s e c o m p a r e d t o a p o p u l a t i o n s a m p l e o f women. A c t a Med S c a n d . 5 ( 4 1 ) , 8 2 - 9 2 . B o o g a a r d , M.A.K. ( 1 9 8 4 ) . R e h a b i l i t a t i o n o f t h e f e m a l e p a t i e n t a f t e r m y o c a r d i a l i n f a r c t i o n . N u r s i n g C l i n i c s o f N o r t h America,, i £ ( 3 ) , 4 3 3 - 4 4 0 . • Bro w n , J . S . , & R a w l i n s o n , M. ( 1 9 7 5 ) . R e l i n q u i s h i n g t h e s i c k r o l e f o l l o w i n g open h e a r t s u r g e r y . J o u r n a l o f H e a l t h and S o c i a l B e h a v i o u r . 1£(3>, 12-27. B y r n e , D.G. ( 1 9 8 2 ) . P s y c h o l o g i c a l r e s p o n s e s t o i l l n e s s a n d outcome a f t e r s u r v i v e d m y o c a r d i a l i n f a r c t i o n : A l o n g - t e r m f o l l o w - u p . J o u r n a l o f P s y c h o s o m a t i c R e s e a r c h . 26.(2), 105-112. Cassem, N.H., & H a c k e t t , T.P. ( 1 9 7 7 ) . P s y c h o l o g i c a l a s p e c t s o f m y o c a r d i a l i n f a r c t i o n . M e d i c a l C l i n i c s o f N o r t h A m e r i c a . £1(4), 7 1 1 - 7 2 1 . Cay, E.L. ( 1 9 7 8 ) . P s y c h o l o g i c a l a p p r o a c h i n p a t i e n t s a f t e r a m y o c a r d i a l i n f a r c t i o n . A d v a n c e s i n C a r d i o l o g y . g±, 120-125. Cay, E., V e t t e r , N., & P h i l i p , A. ( 1 9 7 2 ) . P s y c h o l o g i c a l s t a t u s d u r i n g r e c o v e r y f r o m an a c u t e h e a r t a t t a c k . J o u r n a l o f P s y c h o s o m a t i c R e s e a r c h . 16_, 4 2 5 - 4 3 5 . C h i r i k o s , T.N., & N i c k e l , J . L . ( 1 9 8 4 ) . D i s a b i l i t y f r o m c o r o n a r y h e a r t d i s e a s e i n women. Women and H e a l t h . 2.( 1 ) , 55-74. C o r e a , G. ( 1 9 7 7 ) . Iks hidden m a l p r a c t i c e . How A m e r i c a n rog<aicjn,e m i s t r e a t s women a s p a t i e n t s a n d p r o f e s s i o n a l s . New Y o r k : W i l l i a m Morrow. C o r n e t t , S . J . , & W a t s o n , J . E . ( 1 9 8 4 ) . C a r d i a c r e h a b i l i t a t i o n : An i n t e r d i s c i p l i n a r y a p p r o a c h . New Y o r k : J o h n W i l e y & S o n s . C o w i e , B. ( 1 9 7 6 ) . The c a r d i a c p a t i e n t ' s p e r c e p t i o n o f h i s h e a r t a t t a c k . S o c i a l S c i e n c e and M e d i c i n e . 10. 87-96. C r o o g , S.H. ( 1 9 8 4 ) . The h e a r t p a t i e n t a f t e r h o s p i t a l i z a t i o n : S o c i a l a n d p s y c h o l o g i c a l f a c t o r s i n l i f e a f t e r a h e a r t a t t a c k . C o n n e c t i c u t M e d i c i n e . 48 ( 1 0 ) , 6 3 3 - 6 3 7 . C r o o g , S.H., & L e v i n e , S. ( 1 9 8 2 ) . L i f e a f t e r a h e a r t a t t a c k . New Y o r k : Human S c i e n c e s P r e s s , I n c . C r o o g , S.H., L e v i n e , S., & L u r i e , Z. ( 1 9 6 8 ) . The h e a r t p a t i e n t a n d t h e r e c o v e r y p r o c e s s : A r e v i e w o f t h e d i r e c t i o n s o f r e s e a r c h i n s o c i a l a n d p s y c h o l o g i c a l f a c t o r s . S o c i a l S c i e n c e a n d M e d i c i n e . 1 ( 2 ) , 111-164. D a v i s , A . J . ( 1 9 7 8 ) . The p h e n o m e n o l o g i c a l a p p r o a c h f o r n u r s i n g r e s e a r c h . I n N.L. C h a s k a ( E d . ) , The n u r s i n g p r o f e s s i o n : V i e w s t h r o u g h t h e m i s t ( p p . 1 8 6 - 1 9 7 ) . New Y o r k : McGraw-H i l l . D e c k a r d , B.S. ( 1 9 8 3 ) . Women's movement. New Y o r k : H a r p e r & Row. D e l a n e y - N a u m o f f , M. ( 1 9 8 1 ) . L o s s o f h e a r t . I n J.A. W e r n e r -B e l a n d , ( E d . ) , g r i e f r e s p o n s e s t o l o n g - t e r m i l l n e s s and d i s a b i 1 i t v ( p p . 8 5 - 1 1 4 ) . R e s t o n , V i r g i n i a : R e s t o n P u b l i s h i n g . E i c h e n b a u m , L., & O r b a c h , S. ( 1 9 8 3 ) . U n d e r s t a n d i n g women. A f e m i n i s t p s y c h o a n a l y t i c a p p r o a c h . New Y o r k : B a s i c B o o k s . F o g e l , C.S., & Woods, N.F. ( 1 9 8 1 ) . H e a l t h c a r e o f women - A  n u r s i n g p e r s p e c t i v e . T o r o n t o : C.V. Mosby. G a r r i t y , T.F. ( 1 9 7 3 ) . V o c a t i o n a l a d j u s t m e n t a f t e r f i r s t m y o c a r d i a l i n f a r c t i o n : C o m p a r a t i v e a s s e s s m e n t o f s e v e r a l v a r i a b l e s s u g g e s t e d i n t h e l i t e r a t u r e . S o c i a l S c i e n c e a n d M e d i c i n e . 7, 7 0 5 - 7 1 7 . G a r r i t y , T., Somes, G.W., & M a r x , M.B. ( 1 9 7 8 ) . F a c t o r s i n f l u e n c i n g s e l f - a s s e s s m e n t o f h e a l t h . S o c i a l S c i e n c e and  M e d i c i n e . 12. 7 7 - 8 1 . G i o r g i , A. ( 1 9 7 5 a ) . An a p p l i c a t i o n o f p h e n o m e n o l o g i c a l method i n p s y c h o l o g y . I n A. G i o r g i , C. F i s c h e r , & E. M u r r a y ( E d s . ) , PMgMesne s t u d i e s on p h e n o m e n o l o g i c a l p s y c h o l o g y . Volume I I ( p p . 8 2 - 1 0 3 ) . P i t t s b u r g h : Duquesne U n i v e r s i t y P r e s s . G i o r g i , A. ( 1 9 7 5 b ) . C o n v e r g e n c e a n d d i v e r g e n c e o f q u a l i t a t i v e a n d q u a n t i t a t i v e methods i n p s y c h o l o g y . I n A. G i o r g i , C. F i s h e r , & E. M u r r a y ( E d s . ) , Duauesne s t u d i e s i n p s y c h o l o g y . Volume I I ( p p . 7 2 - 7 0 ) . P i t t s b u r g h : Duquesne U n i v e r s i t y P r e s s . 1 10 G r i f f o , R., V e c c h i o , C , C o b e l l i , F., A p a s i c h , C . , A s s a n d r i , J . , T r a m a r i n , R., & L a r o v e r e , M.T. ( 1 9 8 3 ) . R e h a b i l i t a t i o n o f women w i t h a r e c e n t m y o c a r d i a l i n f a r c t : The r e s u l t s and c o m p a r i s o n w i t h men. A c h Mai C o e u r . 76 ( 3 ) , 2 8 5 -293. H a c k e t t , T.P., & Cassem, N.H. ( 1 9 8 2 ) . P s y c h o l o g i c a l a s p e c t s o f c a r d i a c r e h a b i l i t a t i o n . C o p i n g w i t h c a r d i a c d i s e a s e . A d v a n c e s In C a r d i o l o g y . 3 J _ , 262-217. H a c k e t t , T.P., & Cassem, N.H. ( 1 9 8 4 ) . P s y c h o l o g i c a l a s p e c t s o f r e h a b i l i t a t i o n a f t e r m y o c a r d i a l i n f a r c t i o n a n d c o r o n a r y a r t e r y b y p a s s s u r g e r y . I n N.K. Wenger & H.K. H e l l e r s t e i n ( E d s . ) , R e h a b i l i t a t i o n o f t h e c o r o n a r y p a t i e n t ( p p . 4 3 7 -4 5 1 ) . New Y o r k : J o h n W i l e y & S o n s . H a y n e s , S.G., & F e i n l e l b , M. ( 1 9 8 0 ) . Women, work a nd c o r o n a r y h e a r t d i s e a s e : P r o s p e c t i v e f i n d i n g s f r o m t h e Fr a m i n g h a m h e a r t s t u d y . A m e r i c a n J o u r n a l o f P u b l i c H e a l t h . 70_(2), 133-141. H i n o h a r a , S. ( 1 9 7 0 ) . P s y c h o l o g i c a l a s p e c t s i n r e h a b i l i t a t i o n o f c o r o n a r y h e a r t d i s e a s e . S c a n d i n a v i a n J o u r n a l o f RshafrU 1 t a t l o p , M e d i c i n e , 2 ^ , 5 3 - 5 9 . H u r s t , J.W., K i n g I I I , S.B., W a l t e r , P.F., F r i e s i n g e r , G.C., & E d w a r d s , J . E . ( 1 9 8 2 ) . A t h e r o s c l e r o t i c c o r o n a r y h e a r t d i s e a s e : a n g i n a p e c t o r i s , m y o c a r d i a l i n f a r c t i o n , a n d o t h e r m a n i f e s t a t i o n s o f m y o c a r d i a l I s c h e m i a . I n J.W. H u r s t , R.B. L o g u e , C.E. R a c k l e y , R.C. S c h l a n t , E.H. S o n n e n b l i c k , A.G. W a l l a c e , & N.K. Wenger ( E d s . ) , The h e a r t ( 5 t h e d . ) ( p p . 1 0 0 9 - 1 1 4 9 ) . New Y o r k : J . B . L i p p i n c o t t . J o h a n s s o n , S., B e r g s t r a n d , R., U l v e n s t a m , G., V e d i n , A., W i l h e l m s s o n , C , W e d e l , H., W i l h e l m s e n , L., & A b e r s , A. ( 1 9 8 4 ) . Sex d i f f e r e n c e s i n p r e i n f a r c t i o n c h a r a c t e r i s t i c s a n d l o n g t e r m s u r v i v a l among p a t i e n t s w i t h m y o c a r d i a l i n f a r c t i o n . A m e r i c a n J o u r n a l o f E p i d e m i o l o g y . JJjL<4), 6 1 0 -623. K l e i n m a n , A. ( 1 9 7 7 ) . L e s s o n s f r o m a c l i n i c a l a p p r o a c h t o m e d i c a l a n t h r o p o l o g i c r e s e a r c h . M e d i c a l A n t h r o p o l o g y N e w s l e t t e r . 8 ( 4 ) . 11-15. K l e i n m a n , A., E i s e n b e r g , L., & Good, B. ( 1 9 7 8 ) . C u l t u r e , i l l n e s s a n d c a r e . A n n a l s o f I n t e r n a l M e d i c i n e . 8 J H 2 ) , 251 -258. L o f l u n d , J . , & L o f l u n d , L. ( 1 9 8 4 ) . A n a l y z i n g s o c i a l s e t t i n g s . B e l m o n t , C a l i f o r n i a : W a d s w o r t h . M a r i e s k i n d , H . J . ( 1 9 8 0 ) . Women i n t h e h e a l t h s y s t e m . S t . L o u i s : C.V. Mosby. McLane, M. , K r o p , H., & M e h t a , J . ( 1 9 8 0 ) . P s y c h e - s e x u a l a d j u s t m e n t a n d c o u n s e l l i n g a f t e r m y o c a r d i a l i n f a r c t i o n . A n n a l s o f I n t e r n a l M e d i c i n e . 9_2_, 514-5 19. Moss, A . J . , De C a m i l l a , J . , D a v i s , H. ( 1 9 7 6 ) . The e a r l y p o s t -h o s p i t a l p h a s e o f m y o c a r d i a l i n f a r c t i o n . C i r c u l a t i o n . 54. 58 - 6 4 . M u l l e n , D.P. ( 1 9 7 8 ) . C u t t i n g b a c k a f t e r a h e a r t a t t a c k : An o v e r v i e w . H e a l t h E d u c a t i o n M o n o g r a p h s . §.(3), 295-31 1. O i l e r , C. ( 1 9 8 2 ) . The p h e n o m e n o l o g i c a l a p p r o a c h i n n u r s i n g r e s e a r c h . N u r s i n g R e s e a r c h . 3 J . ( 3 ) , 178-181. Ornery, A. ( 1 9 8 3 ) . P h e n o m e n o l o g y : A method f o r n u r s i n g r e s e a r c h . A d v a n c e s i n N u r s i n g S c i e n c e . 5.(2), 4 9-62. P a p a d o p o u l o s , C , Beaumont, C , S h e l l e y , S.D., & L a r r i m o r e , P. ( 1 9 8 3 ) . M y o c a r d i a l i n f a r c t i o n a n d s e x u a l a c t i v i t y o f t h e f e m a l e p a t i e n t . A r c h i v e s o f I n t e r n a l M e d i c i n e . 1£3_(8), 1528-1530. P a t r i c k , C.H., P a l e s c h , Y.Y., F e i n l e i b , M., & B r o d y , J.A. ( 1 9 8 2 ) . Sex d i f f e r e n c e s i n d e c l i n i n g c o h o r t d e a t h r a t e s f r o m h e a r t d i s e a s e . A m e r i c a n J o u r n a l o f P u b l i c H e a l t h , 1 2.(2), 161-166. P e t e r , T., L u x t o n , M., & H a r p e r , R. ( 1 9 7 4 ) . F a c t o r s a f f e c t i n g m o r t a l i t y i n women w i t h a c u t e m y o c a r d i a l i n f a r c t i o n : A r e v i e w o f a f o u r - y e a r c o r o n a r y c a r e e x p e r i e n c e . R o v a l A u s t r a l i a n C o l l e g e o f P h y s i c i a n s . £, 211-212. P i n n e o , R. ( 1 9 8 4 ) . L i v i n g w i t h c o r o n a r y a r t e r y d i s e a s e . N u r s i n g C l i n i c s o f N o r t h A m e r i c a . J_9_(3), 4 59-467. P o g r e b i n , L.C. ( 1 9 8 3 ) . F a m i l y p o l i t i c s . L o v e and power on an i n t i m a t e f r o n t i e r . New Y o r k : M c G r a w - H i l l . R i s t , R.C. ( 1 9 7 9 ) . On t h e means o f k n o w i n g q u a l i t a t i v e r e s e a r c h i n e d u c a t i o n . New Y o r k U n i v e r s i t y E d u c a t i o n Q u a r t e r l y . 17-21 . R o s e n b e r g , L., M i l l e r , D.R., Kau f m a n , D.W., H e l m r i c h , S.P., Van de C a r r , S., S t o l l e y , P.D., & S h a p i r o , S. ( 1 9 8 3 ) . M y o c a r d i a l i n f a r c t i o n i n women u n d e r 50 y e a r s o f a g e . J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n . 2£&(20), 2 8 01-2806. R u z e k , S. ( 1 9 7 8 ) . The women's h e a l t h movement. New Y o r k : P r a e g e r . S a l o n e n , J . T . ( 1 9 8 2 ) . O r a l c o n t r a c e p t i v e s , s m o k i n g a nd r i s k o f m y o c a r d i a l i n f a r c t i o n i n young women: A l o n g i t u d i n a l s t u d y i n e a s t e r n F i n l a n d . A c t a S c a n d Med. 2 1 2 ( 3 ) . 141-144. 112 S c a l z i , C . C . , & Burke , L . E . (1982) . M y o c a r d i a l i n f a r c t i o n : B e h a v i o u r a l re sponses of p a t i e n t and spouse . In S . L . U n d e r h i l l , S . L . Woods, ' E . S . S i v a r a j a n , & C . J . Halpenny ( E d s . ) , C a r d i a c N u r s i n g (pp. 571-581) . P h i l a d e l p h i a : J . B . L i p p i n c o t t . S h a e v i t z , M . H . ( 1984). The superwoman syndrome. New. York : Warner Books. S i v a r a j a n , E . S . (1982) . C a r d i a c r e h a b i l i t a t i o n : A c t i v i t y and e x e r c i s e program. In S . L . U n d e r h i l l , S . L . Woods, E . S . S i v a r a j a n , & C . J . Halpenny ( E d s . ) , C a r d i a c n u r s i n g (pp. 551-561) . P h i l a d e l p h i a : J . B . L i p p i n c o t t . S p e e g l e , E . K . , Bayer , L . R . , & Greene , W.A. (1979) . Conva le scent d i s c o m f o r t f o l l o w i n g acute c o r o n a r y e v e n t s . Nurs i ng R e s e a r c h . 2J.(3), 132-138. Canada. , S t a t i s t i c s Canada. Canada, 1982. 8 4 - •203. Ottawa: Government of S t a t i s t i c s Canada, 1982. 84- 206. Ottawa: Government of Canada. S t e r n , M . J . (1984) . P s y c h o s o c i a l r e h a b i l i t a t i o n f o l l o w i n g m y o c a r d i a l i n f a r c t i o n and c o r o n a r y a r t e r y bypass s u r g e r y . In N . K . Wenger & H . K . H e l l e r s t e i n ( E d s . ) , R e h a b i l i t a t i o n of the c o r o n a r y p a t i e n t (pp . 453-471) . New Y o r k : John Wi ley & Sons . S t e r n , M . J . , P a s c a l e , L . , & Ackerman, A . (1977) . L i f e adjustment p o s t m y o c a r d i a l i n f a r c t i o n . A r c h i v e s of I n t e r n a l  M e d i c i n e . 137(12), 1680-1685. S tevenson , J . S . (1979) . Women's h e a l t h r e s e a r c h : Why, what and so what? C . N . R . V o i c e . F a l l , 2-3 . Swanson, J . M . , & C h e n i t z , W.C . (1982) . Why q u a l i t a t i v e r e s e a r c h i n n u r s i n g ? N u r s i n g O u t l o o k . 30. 241-245. Swar tz , H . , & J acobs , J . (1979) . Q u a l i t a t i v e S o c i o l o g y . A method to the madness. London: C o l l i e r M a c m i l l a n . S z k l o , M. (1984) . E p i d e m i o l o g y of c o r o n a r y hear t d i s ea se in women. In E . B. G o l d ( E d . ) , The chang ing r i s k of d i s ea se i l l women: An e p i d e m i o l o g i c a l approach (pp. 233-241 ) . M a s s a c h u s e t t s : Col lamore P r e s s . S z k l o , M . , T o n a s c i a , J . , & G o r d i s , L . (1976) . P s y c h o s o c i a l f a c t o r s and the r i s k of myocard i a l i n f a r c t i o n s i n white women. American J o u r n a l of E p i d e m i o l o g y . lp_3_(3), 312-320. 1 13 W a l d r o n , S. ( 1 9 7 8 ) . Type A b e h a v i o u r p a t t e r n and c o r o n a r y h e a r t d i s e a s e i n men and women. S o c i a l S c i e n c e and  M e d i c i n e . 12B. 167-170. Wenger, N.K. ( 1 9 7 9 ) . R e h a b i l i t a t i o n a f t e r m y o c a r d i a l i n f a r c t i o n . J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n . 2 4 2 ( 2 6 ) . 2 8 7 9 - 2 8 8 1 . Wenger, N.K. ( 1 9 8 2 ) . R e h a b i l i t a t i o n o f t h e p a t i e n t w i t h s y m p t o m a t i c a t h e r o s c l e r o t i c c o r o n a r y h e a r t d i s e a s e . I n J.W. H u r s t , R.B. L o g u e , C.E. R a c k l e y , R.C. S c h l a n t , E.H. S o n n e n b l i c k , A.G. W a l l a c e , & N.K. Wenger ( E d s . ) , The h e a r t ( 5 t h e d . ) ( p p . 1 1 4 9 - 1 1 7 0 ) . New Y o r k : J . B . L i p p i n c o t t . W i l s o n , S . J . ( 1 9 8 2 ) . Women t h e f a m i l y a n d t h e economy. T o r o n t o : M c G r a w - H i l l R y e r s o n . W i 1 s o n - B a r n e t t , J . ( 1 9 7 9 ) . A r e v i e w o f r e s e a r c h i n t o t h e e x p e r i e n c e o f p a t i e n t s s u f f e r i n g f r o m c o r o n a r y t h r o m b o s i s . I n t e r n a t i o n a l J o u r n a l o f N u r s i n g S t u d i e s . j£, 183-198. W i s h n i e , H.A., H a c k e t t , T.P., & Cassem, N.H. ( 1 9 7 1 ) . P s y c h o l o g i c a l h a z a r d s o f c o n v a l e s c e n c e f o l l o w i n g m y o c a r d i a l i n f a r c t i o n . J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n . 2 1 5 . ( 8 ) . 1292-1296. A P P E N D I X B Q9fl5enA Form I v o l u n t e e r t o p a r t i c i p a t e i n P e n n y D u n n ' s t h e s i s s t u d y e n t i t l e d "Women 's P e r c e p t i o n s o f T h e i r I l l n e s s E x p e r i e n c e W i t h M y o c a r d i a l I n f a r c t i o n " . I u n d e r s t a n d t h a t t h e p u r p o s e o f t h i s s t u d y i s t o l e a r n how women v i e w t h e i r h e a r t a t t a c k e x p e r i e n c e . I h a v e r e c e i v e d t h e " P a t i e n t I n f o r m a t i o n L e t t e r " w h i c h o u t l i n e s what 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 a n d how c o n f i d e n t i a l i t y w i l l be m a i n t a i n e d . P e n n y Dunn h a s a n s w e r e d my q u e s t i o n s a b o u t h e r s t u d y . I u n d e r s t a n d t h a t my d e c i s i o n w h e t h e r o r n o t t o p a r t i c i p a t e o r to w i t h d r a w a t a n y t i m e W i l l h a v e no e f f e c t w h a t s o e v e r on my f u t u r e h e a l t h c a r e . d a t e s i g n a t u r e 1 16 APPENDIX C Sample Q u e s t i o n s f o r I n i t i a l I n t e r v i e w 1. What d o e s i t mean t o you t o have had a h e a r t a t t a c k ? 2. T e l l me a b o u t y o u r i l l n e s s . What h a s i t b e e n l i k e f o r you t o have h ad a h e a r t a t t a c k ? 3. How h a s i t a f f e c t e d y o u r e v e r y d a y l i f e ? f a m i l y r e l a t i o n s h i p s , r e l a t i o n s h i p s w i t h f r i e n d s , a c q u a i n t a n c e s d a l l y a c t i v i t i e s f e e l i n g s , o u t l o o k on l i f e l e i s u r e a c t i v i t i e s work a c t i v i t i e s 4. How do you t h i n k you w i l l be f e e l i n g one t o two months f r o m now? 5. What do you see y o u r s e l f d o i n g one t o two months f r o m now? 6 . What a r e y o u r c o n c e r n s a b o u t y o u r i l l n e s s ? a b o u t y o u r r e c o v e r y ? a b o u t d e a l i n g w i t h y o u r i l l n e s s ? 1 17 APPENDIX D K e y : 1) A c h a n g e i n s p e a k e r i s i n d i c a t e d fay 10 d o t s . 2 ) The same women s p e a k i n g a t a d i f f e r e n t p o i n t i n t h e i n t e r v i e w p r o c e s s i s p r e s e n t e d fay d o u b l e s p a c i n g o n l y (no d o t s ) b e t w e e n t h e e n t r i e s . 

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