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Spouses’ experiences of having a mate in the Intensive Care Unit following coronary artery bypass graft… Cozac, JoAnn Lee 1985

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SPOUSES' EXPERIENCES OF HAVING A MATE IN THE INTENSIVE CARE UNIT FOLLOWING CORONARY ARTERY BYPASS GRAFT SURGERY BY JOANN LEE COZAC B.S.N. , The University of Saskatchewan, 1983 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept this thesis as conforming to the required siandard THE UNIVERSITY OF BRITISH COLUMBIA July 1985 ® JoAnn Lee Cozac, 1985 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available for reference and study. I further agree that permission for extensive copying of t h i s thesis for scholarly purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or publication of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 i i ABSTRACT The Spouses' Experiences of Having a Mate in the Intensive Care Unit Following Coronary Artery Bypass Graft Surgery It is generally recognized that a serious i l lness with concurrent hospitalization in an ICU wil l have an impact on family members. Few researchers, however, have described the ways in which spouses are affected when their mates are hospitalized in an ICU. Therefore, this study aimed to describe and explain the spouses' experiences of having a mate in an ICU following coronary artery bypass graft surgery. Kleinman's conceptual framework guided the development of the research question and provided the focus for data collection and analysis. Kleinman proposes that an understanding of the c l ient ' s perspective is necessary for the provision of effective health care. A qualitative research method based on the theoretical perspective of phenomenology was used to answer the research question. The spouses' viewpoints were e l ic i ted through unstructured interviews. The sample consisted of seven spouses, four women and three men. The spouses were interviewed on two occasions, once while their mate was s t i l l in the ICU and once shortly following their mate's discharge from the ICU. A total of 13 in-depth interviews were conducted over a 3 month period. Data were analyzed simultaneously with and following data col lect ion. Responses that were similar were grouped together into i i i categories. After the data were examined and sorted into categories, the researcher defined the theme that dominated each category. The themes that emerged from the data were c l a r i f i ed , validated, and/or rejected by the participants during subsequent interviews. As relationships between the categories were identi f ied, the important aspects of the spouses' experiences became apparent. The findings revealed that the spouses located the ICU experience within the context of their experience with their mate's coronary artery bypass graft surgery. The spouses understood and made sense of the ICU experience by attaching meaning to specific events that related to the entire surgical experience. They perceived the surgical experience as consisting of three dist inct but interrelated phases: pre-surgery; waiting during surgery; and post-surgery. During each phase, the spouses described and explained how they reacted to and coped with each new situation. These two themes, "reaction to the situation" and "coping with the s i tuat ion," appeared as threads throughout the entire surgical experience. By organizing the data in relation to phases and themes, the researcher was able to meaningfully understand and communicate the spouses' entire surgical experience. In view of the study findings, implications for nursing practice, education and research are delineated. iv TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i i ACKNOWLEDGEMENTS ix CHAPTER ONE INTRODUCTION 1 Background to the Problem 1 Conceptual Framework 6 Problem Statement 10 Purpose of the Study 12 Objectives of the Study 12 Theoretical and Methodological Perspectives of the Study 12 Definition of Terms 15 Assumptions 16 Limitations of the Study 16 Summary 15 Organization of the Thesis 17 CHAPTER TWO METHODOLOGY 19 Introduction 19 Selection of Participants 19 Cr i ter ia for Selection 20 Selection Procedure 21 Description of Participants 24 V Page Ethical Considerations 26 Data Collection 28 Data Analysis 33 Step One: Discrimination 34 Step Two: Definition 35 Step Three: Identification 35 Step Four: Integration 35 Summary 36 CHAPTER THREE THE PROCESS OF DATA ANALYSIS 37 Introduction 37 Step One: Discrimination 37 Step Two: Definition 39 Step Three: Identification 40 Step Four: Integration 44 Summary 45 CHAPTER FOUR PRESENTATION AND DISCUSSION OF RESEARCH FINDINGS 46 Introduction 46 Reaction to the Situation 48 Coping with the Situation 49 Pre-Surgery Experience 52 Reaction to the Situation 52 Coping with the Situation 56 vi Page Generating Hope 56 Seeking Information 58 Helping Mate 59 Remaining Near Mate 60 Waiting During Surgery Experience 61 Reaction to the Situation 62 Coping with the Situation 63 Generating Hope 64 Distracting Self 65 Post-Surgery Experience 67 Reaction to the Situation 67 Coping with the Situation 79 Generating Hope 80 Seeking Information 84 Helping Mate 91 Remaining Near Mate 95 Developing a Support Network 98 Reorganizing Roles and Responsibilities 106 Summary 108 CHAPTER FIVE SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR NURSING 112 Summary 112 v i i Page Conclusions 116 Implications for Nursing Practice 118 Implications for Nursing Education 123 Implications for Nursing Research 124 REFERENCES 126 APPENDICES Appendix A: Certif icate of Approval 142 Appendix B: Letter to Director of Nursing Service 143 Appendix C: Physician Information Letter 145 Appendix D: Patient Information and Consent Form . . . 147 Appendix E: Spouse Information and Consent Form 149 Appendix F: Interview Guide 151 v i i i LIST OF TABLES Page TABLE 1. Phases and Themes 43 TABLE 2. Summary of Research Findings 116 ix ACKNOWLEDGEMENTS I wish to express my appreciation to the members of my committee for their guidance and encouragement throughout this study. Dr. Joan Anderson, committee chairperson, has contributed s ignif icantly to my knowledge about qualitative research as i t relates to the phenomenological perspective. Linda Rose has provided constructive comments and practical help during each stage of the research process. Judy Lynam has consistently provided helpful suggestions and warm support during the development of this thesis. As a committee they have been understanding and helpful. My appreciation is also extended to the administrative, medical, and nursing staff of the study hospital for their kind co-operation and support of my research project. In particular, I would l ike to thank the head nurse of the cardiac teaching unit for f ac i l i t a t ing access to the study sample. A special thanks is also due to Carol Litke for her s k i l l f u l typing of this thesis. I am also grateful to the spouses who participated in this study and candidly shared their experience with me. In extending to them my sincere thanks, I add the hope that their care wil l be enhanced as a result of this effort. F ina l ly , I lovingly acknowledge my dear family for their continued support of my academic endeavors. 1 CHAPTER ONE Introduction Background to the Problem Coronary artery disease ranks as the leading cause of death in Canada (Canada, 1982a). While the disease can result in sudden death for some, others may experience years of symptoms such as chest pain and decreased exercise tolerance. Most Canadians undergo years of medical treatment by diet , exercise and medication to control these symptoms and remain functional in employment and/or familial roles. In addition to medical treatment, surgical procedures for treating coronary artery disease have been developed in recent years. These surgical procedures, which entail creating new pathways for blood to the ischemic myocardium, have alleviated or improved symptoms of coronary artery disease and dramatically extended the lives of thousands of people who would otherwise have died (Loop, 1983a). Increased ava i lab i l i ty of these procedures and decreased mortality rates due to advancements of modern medical technology, sc ient i f ic knowledge and surgical expertise (Loop, 1983b; Ochsner & M i l l s , 1978; Rahimtoola et a l . , 1981), have made coronary artery bypass graft surgery a common, sophisticated and effective pa l l ia t ive procedure for persons suffering from coronary artery disease (Andreoli, Fowkes, Zipes & Wallace, 1979; Brockman, 1975). However, despite the extremely high success rate, coronary artery 2 bypass graft surgery is s t i l l considered to be a 1ife-threatening event that may result in d i sab i l i ty of unknown duration. In 1962, Sabiston performed the f i r s t aortocoronary bypass operation (Oschsner & M i l l s , 1978). In 1974 in Canada, 2,462 patients underwent coronary artery bypass graft surgery (Canada, 1977). By 1978, this number had increased to 4,603 (Canada, 1982b). Thus, coronary artery bypass graft surgery has come to represent a large proportion of the total surgical procedures performed in many hospitals. Persons undergoing coronary artery bypass graft surgery are transferred to an intensive care unit (ICU) following the operation. Their spouses subsequently join them there. Roberts (1976) states that a c r i t i c a l l y i l l patient enters the ICU in a biological c r i s i s , while the family enters the same ICU in a psychological c r i s i s . Illness or surgery may be a tota l ly new experience for spouses, their f i r s t experience of an ICU with its bewildering atmosphere and unfamiliar devices. In the ICU, the nurse's attention focuses primarily on the patient, whose condition demands constant monitoring and care. While providing this care, the nurse comes in contact with the spouse, and has an opportunity to influence the spouse's experience posit ively. However, in reviewing the l i terature , the researcher was unable to find any systematic investigation that described the spouse's experience, from a 3 personal point of view, of having a mate in the ICU following coronary artery bypass graft surgery. A discrepancy in the spouse's and nurse's perceptions of this experience may result in a barrier to appropriate and timely nursing interventions. Nurses must find out what these discrepancies are so they will be able to negotiate care that is acceptable to both cl ient and nurse. Thus, the researcher fe l t an understanding of a spouse's subjective experience of having a mate in the ICU following coronary artery bypass graft surgery would assist nurses in the provision of effective nursing care to both patient and spouse. A review of the l iterature did reveal that families who experience having a c r i t i c a l l y i l l family member in an ICU do have special needs (Breu & Dracup, 1978; Cammarano, 1980; Daley, 1980; Dracup & Breu, 1978; Gil l i s , 1981; Molter, 1976, 1979; Prowse, 1983; Rasie, 1980; Wilson, 1975). The review further revealed that spouses v i s i t ing their mates in the hospital in general, and the ICU in part icular , are confronted with many occurrences which they may experience as stressful (Breu & Dracup, 1978; Doerr & Jones, 1979; Fowler Byers, 1983; Gardner & Stewart, 1978; Potter, 1979; Roberts, 1976). Thus, the patient's spouse also requires attention because the mate's c r i t i c a l condition combined with the unfamiliar sights, sounds and smells of the ICU may cause fears and anxieties that adversely affect the spouse's health status and coping a b i l i t i e s . Given the nature of the l i fes ty le changes required following 4 coronary artery bypass graft surgery, the spouse plays an important supportive role during both the intensive care phase of hospitalization and the recovery phase of the i l lness . However, Fowler Byers (1983) and Roberts (1976) suggest that family members experiencing fears and anxieties are unable to provide support, either to each other or to the patient. The nurse and other health professionals may be able to decrease these fears and anxieties i f they fu l ly understand the spouse's experience in the ICU. The impact of i l lness has been reported to have a striking effect on family members (Litman, 1974; Rudy 1980); and the response of the family members, who play an important role in the patient's l i f e , wil l influence the patient's immediate and long term recovery (Croog, Levine, & Lurie, 1968; Egger, 1980; G i l l i s , 1981; Hicks Kuenzi & Fenton, 1975; Litman, 1974; Olsen, 1970; Richardson, 1945; Roberts, 1976; Rudy, 1980; Sikorski, 1982; Speedling, 1980). Thus, family members can either promote or impair the recovery process. Rasie (1980) suggests that a calm family member can help a patient deal with fears about his or her own environment and i l lnes s . Croog et a l . (1968) recognize the importance of family members by stating, "even neurotic individuals can adjust to severe cardiac impairment i f they are constantly integrated in a strong, supportive, reasonable but not overprotective, healthy family structure, which accepts and understands the i l lness" (p. 135). 5 Thus, the responses of the spouse to the ICU may affect his/her mate's recovery and return to normal functioning. Although nurses and other health care professionals attempt to understand the spouse's experience during the intensive care phase of a mate's hospitalization, their perceptions arise from a professional viewpoint, whereas the perception of spouses, most of whom are not health care professionals, may di f fer . Munhall (1982) claims that individuals experience their own " rea l i ty , " and are autonomous. She reports that individuals interpret their own experiences and give meaning to them, and that although these experiences can be shared, they can differ from another's " rea l i ty . " In a study by Irwin and Meier (1973), perceptions of supportive measures used in helping relatives of oncology patients were compared between relatives and health professionals. Although a small sample was used, a comparison of the relatives ' responses to those of health care professionals showed a significant difference in how supportive behaviors were perceived. In another study Carey (1973) found significant differences between the perceptions of patients and health professionals with respect to the importance of having a chaplain available to patients at a l l times. The above studies indicate that differences usually exist between perceptions of health professionals and family members of patients. Thus, the present study was designed to systematically explore the experience of the intensive care phase of 6 hospitalization as perceived by spouses of coronary artery bypass patients. The information gained will contribute to the understanding of spouses' experiences with their mates' coronary artery bypass graft surgery and, more speci f ica l ly , the intensive care phase of hospitalization as an aspect of the experience. It is hoped that the information gained wil l be ut i l ized by nurses and other health care professionals to assist spouses to prepare for and cope with the intensive care hospitalization period of their mate, and to aid spouses in preparing for the recovery process of their mate following surgery in order that a more favorable outcome for both patient and spouse can be achieved. The information gained wil l also contribute to the development of nursing theory about the spouse's perspective, which serves as a guide to nursing practice. Conceptual Framework Since nurses are responsible for assisting patients' relatives in coping with new and often d i f f i cu l t situations (Bedsworth & Molen, 1982), nurses should have an understanding of the experiences of the relat ives . Relatives, particularly spouses, have been reported to be profoundly affected by their mate's i l lness (Klein, Dean, & Bogdonoff, 1967; Larter, 1976; Skelton & Dominian, 1973) because of the interdependent relationship that exists between a husband and a wife that is "unparalleled by any other in our society" (Si lva, 1977, p. 39). Although nurses frequently come in contact with spouses in the ICU, the contact is brief . It is often d i f f i cu l t during this brief 7 encounter to assess the spouses' needs. As a result , nursing interventions aimed at assisting spouses to cope may be based on the needs of the spouse as perceived by the nurse. However, to best help spouses cope during the intensive care hospitalization period of their mate, nurses must have some knowledge about the spouse's perspective so that energy of nurses and other health professionals is usefully directed and total patient care is accomplished (Molter, 1979). Kleinman (1978) introduced a conceptual framework which acknowledges the importance of discovering the c l ient ' s perspective, and addresses the problems that arise when discrepancies occur between the professional's and c l ient ' s perception and interpretation of a particular sickness episode. Kleinman's conceptual framework guided the development of the research question in this study, and provided the focus for data collection and analysis. Kleinman (1978) conceptualizes the health care system as a sociocultural system consisting of three dist inct but interacting systems within which sickness is experienced and reacted to. These are the professional, which consists of sc ient i f ic medicine and "professionalized indigenous healing traditions" (Kleinman, 1978, p. 87); the popular, which consists of the individual , the family, the social network, and the community ac t iv i t ie s ; and the folk, which consists of non-professional healing special ists . See Figure 8 1 for a graphic representation of Kleinman's conceptualization of the interrelated systems of the health care system. ! ' 1 SOCIOCULTURAL SYSTEMS Care ( I n d i v i d u a l a n d F a m i l y - B a s e d ) Care Sys tem(s ) System(s) (Professional) Figure 1: Health Care System (Kleinman, 1978, p. 422) Each system contains and constructs i ts own "c l in i ca l r ea l i t i e s " which includes an organization of i t s bel iefs , expectations, roles , relationships and transaction settings (Kleinman, 1978). How individuals construct " c l i n i c a l rea l i t i e s " and respond to sickness is "cul tural ly shaped in the sense that how we perceive, experience, and cope with disease is based on our explanations of sickness, explanations specific to the social positions we occupy and systems of meaning we employ" (Kleinman, Eisenberg, & Good, 1978, p. 252). These explanations, according to Kleinman, influence our expectations and perceptions of sickness. 9 Kleinman et a l . (1978) describe sickness as a complex phenomenon consisting of biological , psychological, and sociocultural aspects. The concepts of "disease" and " i l lness " are conceptualized as constituting sickness. This disease/illness dist inction is made in an attempt to explain and understand sickness (Kleinman et a l . , 1978). Disease, which is commonly associated with the professional system, is defined as "the malfunctioning or maladaptation of biologic and psychophysiologic processes in the individual" (Kleinman et a l . , 1978, p. 252). Thus, individuals in the professional system perceive, explain and respond to disease in terms of b iological , psychological, and physiological theories. I l lness , on the other hand, is pr incipal ly associated with the popular system. "Illness represents personal, interpersonal, and cultural reactions to disease or discomfort" (Kleinman et a l . , 1978, p. 252). Thus, i l lness denotes the "experience" of disease. It is the way individuals in the popular system perceive, explain, and respond to disease (Kleinman, 1978). Kleinman (1978) states that a l l attempts to understand sickness and its treatment can be thought of as explanatory models. Explanatory models are ways of experiencing and perceiving an episode of sickness and its treatment, and therefore influence the behavior that perception evokes. Kleinman (1978) states that explanatory models can be e l i c i ted as coherent accounts of real i ty even though they may change, contain contradictions, and have varying degrees of logical development. Kleinman (1978) also reports that individuals in each system have their own explanatory models for a particular sickness which may "complement, compete with, or distort one another" (Kleinman, 1978, p. 421). Interactions between various divisions of the health care system involve transactions or exchanges between the differing explanatory models. Kleinman (1978) suggests that an understanding of the c l i ent ' s explanatory model may decrease the conf l icts , d i f f i cu l t ie s and misunderstandings that arise due to discrepancies between the explanatory models held by cl ients and health care professionals. Kleinman's conceptual framework (1978) directed the researcher to examine the experiences associated with the ICU from the spouse's perspective, since the spouse's experiences wil l l ike ly be different than those of the professionals. Spouses of patients who are in the ICU following coronary artery bypass graft surgery are members of the popular system. They have explanatory models based on their experience with i l lness that can be understood by e l i c i t ing their perceptions. Nurses must understand the spouse's explanatory model in order to improve c l in i ca l communication and provide effective nursing care. Problem Statement With the development of intensive care units around 1965 (West, 1975), the goal of providing the c r i t i c a l l y i l l patient with 11 individualized and closely monitored care was achieved (Potter, 1979). However, these special care units have a stress-creating potential for a l l who come in contact with them, including the c r i t i c a l l y i l l patient's family members (Egger, 1980; Potter, 1979; West, 1975). Several authors from the f ields of nursing, social work, psychiatry, and medicine have identified the importance of meeting the needs of these people (Breu & Dracup, 1978; Chandler, 1982; Cooper, 1976; Fowler Byers, 1983; Gardner & Stewart, 1978; Hoover, 1979; McPhee, 1983; Rasie, 1980; Stockdale Warmbrod, 1983; Wallace, 1971). Fowler Byers (1983) suggests that when the needs of family members are not being met, the family members may be unable to cope or to provide support to the patient. The ICU environment with its unfamiliar sights, sounds, and smells may cause fears and anxieties that adversely affect the health status and coping ab i l i t i e s of the spouse. Since the spouse's knowledge, attitude and ab i l i ty to cope during the i n i t i a l postoperative period may be crucial to the patient's successful recovery, understanding the spouse's experience is a v i ta l aspect of care of the coronary artery bypass patient. E l i c i t i n g the spouse's perspective on the mate's intensive care hospitalization period wil l add an important dimension to current knowledge. This study, therefore, addresses the following question: What is the spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery? 12 Purpose of the Study To understand the intensive care hospitalization experience from the spouse's perspective, this study proposes to: describe the spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery. Objectives of the Study The specific objectives of this study were the following: 1. to describe the thoughts, feelings, and actions of spouses whose mates were in the ICU following coronary artery bypass graft surgery; 2. to describe the spouses' concerns about any aspects of the intensive care phase of their mates' hospitalization; 3. to identify ways in which nurses can assist spouses to prepare for and cope with their mates' intensive care hospitalization period. Theoretical and Methodological Perspectives of the Study A qualitative research method based on the theoretical perspective of phenomenology was used to answer the research question of this study. Filstead (1970) reported that qualitative methodology allows the researcher to interpret the world from the participant's perspective rather than from the preconceived, r i g id ly structured, and highly quantified techniques devised by the researcher. Qualitative research is a systematic study of the natural, everyday world of human l i f e experience, and is considered useful 13 when studying unexplored phenomena (Leininger, 1985; Swanson & Chenitz, 1982). This approach was selected because, although the l i terature reviewed substantiates the notion that c r i t i c a l i l lness has an impact on the family members (Litman, 1974; Rudy, 1980), there was l i t t l e research to indicate that the spouse's perspective was understood. E l i c i t i n g the spouses' perspective of how they experienced the intensive care hospitalization period wil l add an important dimension to current knowledge. Phenomenology is a philosophy, an approach, and a type of research method with specific goals (Knaack, 1984; Oi ler , 1982; Ornery, 1983). The phenomenological approach is an inductive, descriptive research method (Ornery, 1983; Stern, 1980) that focuses on understanding human behavior and human experience (Knaack, 1984). The goal of phenomenological research is to understand human experience from the perspective of those being studied, in order to see l i f e as those individuals see i t (Davis, 1978; Knaack, 1984; Oi le r , 1982; Ornery, 1983). This approach emphasizes the meaning social acts have for individuals who perform them and who l ive in a rea l i ty created by their subjective interpretations of these acts (Davis, 1978). Thus, emphasis is placed on the individual 's inner or subjective understanding of events, behaviors and surroundings in order to learn how individuals interpret and give meaning to a particular situation (Rist, 1979). A researcher u t i l i z ing the phenomenological method approaches subjects with an open mind and accepts the subjective descriptions 14 of the meaning of the experience for those being studied without trying to make i t f i t a preconceived definition of the phenomenon (Knaack, 1984; Ornery, 1983). Phenomenology is considered appropriate for this study since an attempt is being made to understand the experience of having a mate in the ICU following coronary artery bypass graft surgery, from the perspective of the spouse. This approach wil l allow the spouses being studied to share the meaning they give to their experience, in the manner in which they view i t . The phenomenological approach is congruent with Kleinman1s (1978) conceptual framework, since both emphasize that individuals perceive and give meaning to the rea l i ty they experience in everyday l i f e . They also emphasize the importance of understanding the perspective of the individual . Kleinman (1977) states that the phenomenological approach can involve "comparison of how sickness is socia l ly constructed in the popular everyday world and in professional settings" (p. 12). Thus, Kleinman's conceptual framework (1978) and the phenomenological approach allow knowledge to be gained about a spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery, from the spouse's viewpoint. Understanding how spouses in the popular arena of the health care system attach meaning to this experience wil l provide nurses with new knowledge to guide nursing practice. 15 Definition of Terms The following terms are defined to c lar i fy their use in this study: 1. Coronary artery bypass graft surgery - heart surgery which creates new pathway(s) for oxygen-rich blood to bypass blockages or major narrowings in the coronary arteries (American Heart Association, 1976). 2. Mate - an individual who has experienced coronary artery bypass graft surgery. 3. Spouse - an individual who is the husband or wife of the mate, resides with the mate, and v i s i t s the mate in the Intensive Care Unit. 4. Intensive Care Unit - a highly specialized area within the hospital where mates are transferred for constant surveillance and treatment after having undergone coronary artery bypass graft surgery. 5. Experience - the response to having a mate in the ICU following coronary artery bypass graft surgery including: thoughts, feelings, and actions, and the meaning these have for the spouse; and the concerns about any aspect of the intensive care phase of hospital ization. 6. Concerns - the worries expressed and questions asked during an interview by the spouse relating to the experience of the ICU and the event of the mate's major surgery. 16 Assumptions Assumptions related to this study are: 1. It is assumed that the husband-wife dyad is a significant relationship and that an experience requiring hospitalization in an ICU for one person will have considerable impact on the other. 2 . The spouse's knowledge, attitude and ab i l i ty to cope during the mate's i n i t i a l postoperative period following coronary artery bypass graft surgery is crucial to the mate's recovery. 3. Spouses whose mates have undergone coronary artery bypass graft surgery wil l have common experiences related to the intensive care phase of hospitalization. 4. Spouses whose mates have undergone coronary artery bypass graft surgery wil l be able to identify and be wil l ing to articulate their experiences by offering honest descriptions. Limitations of the Study The location of the study was limited to the Intensive Care Units of one large Vancouver hospital . Therefore, any specific characteristics of this setting may influence the spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery. Summary The purpose of this study is to explore, from the spouse's point of view, the experience of having a mate in the ICU following coronary artery bypass graft surgery. Spouses of coronary artery 17 bypass patients may have specific feelings, thoughts, and reactions during the intensive care phase of hospitalization. Since nurses have the opportunity to help the spouse, they must understand the spouse's experience in order to provide appropriate care. However, i t was found that l i t t l e research had been conducted into spouses' experiences, making a need to describe the spouse's experience during the mate's stay in the intensive care unit following coronary artery bypass graft surgery evident. This knowledge may assist nurses and other health care professionals in providing the necessary guidance and support in the early recovery period to spouses with subsequent beneficial effects on the patient. Organization of the Thesis In this introductory chapter, the problem and background to the problem, conceptual framework, the study purpose, the study objectives, the study theoretical and methodological perspectives, definition of terms, assumptions, and limitations have been stated. Chapter Two outlines the research methodology, and discusses details related to selection of participants, ethical considerations, data collection and data analysis. In Chapter Three, data analysis wil l be described in greater deta i l . Chapter Four presents spouses' accounts of their experiences during the intensive care hospitalization period of their mates, the researcher's analysis, and l i terature relevant to the spouses' accounts. In the final chapter, the findings are summarized, implications for nursing 18 practice, education, and research are identif ied, and recommendations for further research arising from this study are made. 19 CHAPTER TWO Methodology Introduction A qualitative research method based on the theoretical perspective of phenomenology was selected to answer the research question because the purpose of this study was to understand the intensive care hospitalization experience from the spouse's perspective. Various authors have reported that when the purpose of a research study is to increase understanding of human behavior from the participant's perspective, phenomenology is the method of choice (Bogdon & Taylor, 1975; Davis, 1978; Ornery, 1983; Rist , 1979). Thus, the researcher considered the phenomenological research methodology to be the most suitable approach to answering the research question posed in this study. This chapter begins with an explanation of the c r i t e r i a and method of selecting participants. The ethical considerations pertaining to the mates' and spouses' rights will follow. F inal ly , the process of simultaneous data collection and analysis wil l be described. Selection of Participants A purposive sampling technique was used in this study. The process of purposive sampling required the researcher to select particular individuals who showed the presence of a desired characteristic (Polit & Hungler, 1983). The purpose of purposive 20 sampling is to ensure collecting data from individuals with experiences specific to the research study in question. Therefore, the participants in this study were selected because their current experience with the ICU made them especially knowledgeable in the areas dealt with by this study. These individuals were chosen because i t was fe l t that their personal experience qualified them as rel iable sources of information. The researcher was interested in spouses of patients who were undergoing coronary artery bypass graft surgery because stat is t ics (Canada, 1977, 1982b) indicate that the incidence of this particular operation is on the increase and that health professionals are therefore becoming exposed to these particular individuals more often. The researcher also decided to select spouses of patients undergoing scheduled or elective surgery rather than emergency surgery. The reason for this was to confine the study to spouses who had been aware that hospitalization would occur. It was fe l t that spouses confronted with their mates undergoing emergency surgery would probably undergo different experiences. Al l spouses who met the study c r i t e r i a were included in the study, regardless of previous experience with the ICU as a patient or v i s i tor . C r i t e r i a for Selection The researcher decided that although the mates would not be included in the interviews, their written consent was necessary. This was because the husband-wife dyad is assumed to be a significant relationship, and, since the spouse's experience in the 21 ICU would involve discussion of the mate and perhaps the relationship, i t was fe l t that the mate should be asked to consent and should be allowed to withdraw that consent at any time. For these reasons, selection c r i t e r i a were defined for both mate and spouse. Mates were selected according to the following c r i t e r i a : 1. The mate must be admitted to an acute care hospital for the f i r s t time to undergo elective coronary artery bypass graft surgery during the time period for mate selection into the study. 2. The mate must be transferred to an Intensive Care Unit following coronary artery bypass graft surgery. 3. The mate must be able to understand, speak and read English, regardless of ethnic background. 4. The mate must be married and reside with his/her spouse. Spouses selected to participate in the study were required to meet the following c r i t e r i a : 1. The spouse must v i s i t or intend to v i s i t the mate while the mate is in the Intensive Care Unit. 2. The spouse must be old enough (nineteen in Brit ish Columbia) to legally sign a consent form. 3. The spouse must be able to understand, speak and read English, regardless of ethnic background. Selection Procedure After receiving approval from the University of Brit ish Columbia Behavioural Sciences Screening Committee (see Appendix A), 22 a letter requesting permission to conduct the study was sent to the identified hospital (see Appendix B). The study was conducted at a large metropolitan teaching hospital that routinely provides treatment to patients in the ICU immediately following coronary artery bypass graft surgery. The hospital was conducting a teaching program for coronary artery bypass graft patients and their spouses at the time of participant selection. This program included a video which describes the equipment and care patients receive in the ICU following the operation. The hospital requested that the researcher obtain verbal permission to conduct the study from the directors of the department of anaesthesiology and the ICU. After permission was obtained, the researcher met with the head nurse of the cardiac teaching unit to further explain the study and to request her cooperation in the selection of mates who met the specific c r i t e r i a . Mates undergoing coronary artery bypass graft surgery were admitted and discharged from this unit, with temporary stays in the ICU and Step Down Unit following the operation. Letters outlining the purpose, nature and implications of the study were sent to the hospital 's cardio-thoracic surgeons (see Appendix C). Names of potential participants were sought through telephone contact with the head nurse. The researcher then contacted the mate's cardiothoracic surgeon by telephone to respond 23 to any comments or questions he had with respect to the mate and the study. Mates who met the sampling c r i t e r i a were approached by the researcher after their admission. The researcher introduced herself to them and stated she was a graduate student in nursing, currently conducting a research study. The researcher explained that working in the ICU had alerted her to the need for family centered nursing and the importance of understanding spouses' experience in order to provide adequate nursing care to patients and families. The researcher further explained that she now had the opportunity to develop an understanding of the spouse's experience, and at the same time contribute to nursing's knowledge and professional advancement. The researcher indicated that nursing care directed to spouses might be improved i f their ICU experience was better understood. The researcher explained her position in relation to the staff. She also explained why the mate had been selected as a study subject and where she had obtained the name. Each mate was then asked to sign a consent granting permission for the researcher to approach his/her spouse (see Appendix D). At the hospital 's request, a copy of this consent was placed on the mate's chart. The spouse was then contacted and the researcher explained the purpose, nature and implications of the study. Potential participants were assured there were no risks involved. They were 24 also told their contribution as a study participant would benefit nursing in general, and future care of spouses in particular. The spouses were also informed that a report in the form of a thesis would be written from al l the information received, and that these results of the study might be published in order to promote an understanding of the spouse's experience in having a mate in the ICU following coronary artery bypass graft surgery. Al l spouses were approached by the researcher in the mate's room during v i s i t ing hours on the second day after the mate had been admitted to hospital . The letter of information and consent (see Appendix E) was given to each spouse and signed prior to the mate going for coronary artery bypass graft surgery. Two days after their mates' surgery, spouses were contacted by phone to arrange for a convenient interview time. This allowed the spouse sufficient time to experience the ICU setting before being asked to reflect upon the experience. It also enabled the researcher to obtain data while the spouse's mate was s t i l l in the ICU. Description of Participants The study sample, which was obtained over a three month period, was composed of seven spouses, four women and three men. Spouse age ranged from 39 to 64 with a mean age of 55. Al l spouses spoke English and were married. The years of married l i f e between the spouses and their mates, who had coronary artery bypass graft 25 surgery, ranged from 12 to 43 with a mean of 31 years. Four of the seven participants were born in Canada. Of the three born outside Canada, one was born in England, one in Germany, and one in India. The spouse born in India immigrated to Canada 5 years ago and the others immigrated 30 years ago. Four of the spouses lived in the Vancouver area and three individuals did not. The researcher had or ig inal ly planned to only include in the study spouses who lived within the Vancouver area because they would be accessible for interviews and because i t was fe l t their perceptions of their experience might differ from those who lived outside the Vancouver area. However, as the study progressed, spouses from outside the Vancouver area were included in the study because they were available and wil l ing to participate. Two of these individuals subsequently demonstrated that their experiences were similar to those who lived in the Vancouver area. However, the third spouse had additional concerns as a direct result of l iv ing outside the Vancouver area. The spouses represented a variety of professions. This was considered appropriate for this study because the researcher aimed to discuss the spouse's experience regardless of profession. Four spouses had had past experience with the ICU occurring from one month to seven years previous to the study period. As indicated ear l ier , a hospital video which describes equipment and the care patients receive in the ICU following 26 coronary artery bypass graft surgery is routinely shown to al l patients and their families prior to the patient going for surgery. However, five of the spouses did not view the video. The reasons were varied. Two spouses believed the video would increase their mates' anxiety; one fe l t i t would increase her own anxiety; and the other two spouses were not given an opportunity to view the video. One spouse asked to terminate participation in the study prior to the second interview due to unexpected complications in the course of her mate's recovery which made the spouse unavailable for interviewing. Ethical Considerations The research proposal was submitted to the University of Brit ish Columbia Behavioural Sciences Screening Committee for ethical review and approval prior to contacting the identified hospital . Copies of the research proposal were then submitted to the Research Committee of the hospital for ethical review and approval. Suggestions made by the committee were accepted and incorporated into the design of the research study. For example, the researcher or ig inal ly planned that each mate who met the specific c r i t e r i a would receive from the head nurse a letter of information about the study which had been prepared by the researcher. This letter of information was to be signed by the mate and returned to the head nurse i f the mate was in agreement to 27 meeting with the researcher to discuss the study further. The researcher would then receive the names of the mates who were in agreement to meeting with the researcher. However, this method for contacting mates was altered at the request of the hospital Research Committee, who suggested the researcher contact the mates in person after receiving from the head nurse the names of the mates who met the specific c r i t e r i a . The purpose, nature, and implications of the study were explained to the mate and his/her spouse separately or together by the researcher, depending upon i f both were present when the researcher arrived at the hospital . Time was taken with the mate and spouse to emphasize that participation, nonparticipation, or withdrawal from the study at any time would have no bearing on their current or future medical or nursing care. Confidentiality of a l l information received, the right to refuse to answer questions, and anonymity in reporting of information was explained, assured and recorded on the consent forms. The mates and spouses were informed that access to the data would be limited to the researcher and the three members of her research committee. They were also informed that names would not be written on the data collection sheets and that transcriptions would be coded, to ensure that only the researcher had access to the participants' identi t ies . A verbal explanation and written consent informed the participants that they could request erasure of any tape or portion 28 of a tape at any time during the study. The participants were also assured that the information received would be used only for the purpose stated to them. The mates and spouses were informed verbally and in writing that the tapes would be erased after the thesis had been written. They were also informed that there were no financial benefits to participating in the study, nor were there any r i sks . If the mate and his/her spouse agreed to participate, the researcher read the identified consent forms to each individual , asked i f there were any questions, and then requested that they read and sign the consent form in the researcher's presence. The Research Committee at the hospital was assured by the researcher that the results of the study would be available to them upon completion of the project. Data Collection In qualitative research, data collection and analysis occur concurrently (Glaser & Strauss, 1967). However, they wil l be discussed separately in order to promote a clearer understanding of each. In-depth interviewing was used to collect data about the spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery. Interviews provide an opportunity for the researcher to not only gain in-depth information, but also to explore and c lar i fy issues (Sweeney & O l i v i e r i , 1981). Interviews 29 yield descriptive data which enable the researcher to see the world from the participant's viewpoint, and provide participants with the opportunity to express their views about their experience in their own words (Bogdon & Taylor, 1975). Kleinman's (1978) conceptual framework provided direction for the type of questions asked. A semi-structured interview guide (see Appendix F) with open-ended questions was developed and used during the interviews to allow the participants a free response (Notter, 1978) rather than a response restricted to or guided by alternatives (Brink & Wood, 1983). The semi-structured interview is a f lexible strategy for discovering information (Lofland, 1971), because i t provides specific topics to be explored and allows the researcher freedom to pursue any response of special interest generated by the participants throughout the interview (Treece & Treece, 1982). Thus, the semi-structured interview guide provides an opportunity to e l i c i t the participants' perceptions of their experience. It also allowed the researcher to explore those participant's responses that were not clearly understood. The interviews did not follow a set pattern. Clarifying questions were asked also, in order to promote c la r i f i ca t ion and/or elaboration of the spouse's response. The interview guide was adapted from the review of the work of other researchers who have used a similar method (Breu & Dracup, 1978; Gauchie, 1982; Hampe, 1973; Potter, 1979; Rasie, 1980; Roberts, 1976). The questions posed to a l l spouses were designed 30 to examine the spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery. The content of the second interview was based upon analysis of the f i r s t interview, because the purpose of the second interview was to gather additional information and c lar i fy information gained from the f i r s t interview. Lofland (1971) suggests the researcher provide participants with an introduction prior to the interview in order to c lar i fy what is expected of them. Thus, prior to each interview the researcher reiterated the purpose of the study and the confidentiality of the data. The researcher also explained that since she was seeking an understanding of the spouse's experience in the ICU, a l l responses were correct. This was done in order to obtain the trust and confidence of the participants. The researcher established rapport with the participants so that they would feel more at ease and perhaps be more wil l ing and able to respond. The researcher created a pleasant and friendly atmosphere by in i t i a t ing informal conversation and allowing for free expression of thoughts and feelings. Since the researcher fe l t that familiar surroundings would provide the security necessary to promote the spouse's comfort during the interview, the researcher preferred to conduct the interviews in the participant's home. However, when asked where they would l ike to meet, most fe l t that distractions at home would interfere with the interview. Thus, ten 31 interviews were conducted in a large, private teaching room in the hospital and two interviews were conducted in the privacy of the participant's home. Conducting the interviews in a private place reassured the spouses of their anonymity and allowed the interviews to occur without interruption. Since mates are only in the ICU for a limited time, the f i r s t spouse interview occurred when the spouse's mate was in the ICU. The second interview occurred from 3 to 14 days following the f i r s t interview, at a mutually convenient time. This time period was chosen so the experience would s t i l l be fresh in the spouse's mind. Each participant was interviewed twice by the researcher, with the exception of one individual as indicated ear l ier . Each interview ranged from 30 to 90 minutes in length with an average time of 45 minutes. Thus, data were obtained through 13 in-depth interviews with 7 spouses having a mate hospitalized in the ICU following coronary artery bypass graft surgery over a 3 month period. Al l interviews were taped to ensure accurate reporting, and the tapes were transcribed immediately following each interview. None of the participants objected to having the interviews taped and none of them requested that the tape be turned off or erased. They reported that the presence of the tape recorder did not inhibit them in any way. Many mates and spouses expressed pleasure that spouses were recognized as important and that health professionals were 32 interested in helping spouses to prepare for and cope with their ICU experience. The researcher had no d i f f i cu l ty in gaining the cooperation of the mates and their spouses. The spouses confirmed the researcher's assumption that spouses would be able to identify their experiences and be wil l ing to articulate them. Everyone contacted expressed interest and a willingness to take part in the study. None of the spouses approached refused to participate but some spouses doubted their ab i l i ty to be helpful to the researcher. Spradley (1979) suggests that most participants are i n i t i a l l y unsure that they know enough and that the researcher is real ly interested in what they have to say. He emphasized the importance of the researcher expressing interest to the participants. Therefore, although some spouses fe l t they had l i t t l e to offer, assurance from the researcher that there were no right or wrong ways to respond made individuals wil l ing to participate. At the end of each interview, the researcher made the participants aware of the importance of their contribution to the research study. Although many spouses were tearful during the interview, they were wi l l ing to talk. Most spouses expressed pleasure at being able to help the researcher's learning and indicated they found i t helpful to talk about their experience. One spouse stated, "I think talking about [the ICU experience] has helped quite a b i t . It has brought everything out in the open. It probably helped me to cope much better with the s i tuat ion." 33 The researcher attempted to obtain a sample size that provided the data necessary to discover and saturate categories. Stern (1980) describes saturation of categories to mean that data are collected until the researcher is satisfied that no new information is being obtained that would explain a particular category discovered. The researcher stopped hearing new information after interviewing the f i f th spouse but decided to interview two more spouses in order to confirm that no new data were being heard. Diers (1979) reports that the end of a study of this nature is arbitrary. It can be reached when categories have been saturated as much as possible or when the time l imit set for the study has been reached. The researcher f e l t , however, that sufficient data needed to understand the important aspects of the spouses' experiences had been collected. Data Analysis As Glaser and Strauss (1970) state, " in qualitative work there is no clear l ine between data collection and analysis, except during periods of systematic ref lection" (p. 291). Thus, data analysis was not isolated from data col lect ion. Throughout the data collection process, the researcher attempted to "make sense" of the intensive care hospitalization experience of the spouse whose mate is in the ICU following coronary artery bypass graft surgery. Data analysis refers to the process used to make sense of the data in order to learn from the participants' responses what was not 34 previously understood (Bogdon & Taylor, 1975). More speci f ical ly , qualitative analysis is "the nonnumerical organization and interpretation of observations for the purpose of discovering important underlying dimensions and patterns of relationships" (Polit & Hungler, 1983, p. 620). The open-ended questions used during data collection e l ic i ted a large amount of descriptive data from the participants which created a challenge during analysis. However, open-ended questions are essential i f the phenomenon under study is complex or the relevant dimensions are unknown (Warren, 1978). Thus, the researcher looked for ways to systematically analyze the spouses' experiences in order to reduce the volumes of data into meaningful conceptual terms that would lead to a better understanding of the spouses' ICU experience. The researcher's approach to analyzing the data was guided by the work of Diers (1979), Gauchie (1982), Giorgi (1975), and Stern (1980), who made expl ic i t the principles of qualitative research for analysis of data. The four steps below outline the researcher's method of data analysis. Step One: Discrimination The data transcribed from the semi-structured interviews were examined for similar and dissimilar parts. Responses that were similar were grouped together into categories. Categories are data which appear to cluster together (Stern, 1980). Differentiating l ike pieces of data from others has been referred to as discrimination (Diers, 1979; Giorgi , 1975). 35 Step Two: Definition After the data were examined and sorted into as many categories as possible, the researcher defined or stated as simply as possible the theme that dominated each category. The term "theme" refers to similar recurring responses that the data were grouped around. Step Three: Identification After the researcher organized the spouses' explanations into categories that reflected their ICU experience, she began to look for relationships among the categories. She continued to examine, compare, and contrast the data until the relationships were identi f ied. As interrelationships were identif ied, many of the developed categories were clustered together to form yet another category which was at a higher level of abstraction. Ray (1985) describes the process by which a researcher "uncovers the constituents of an experience" (p. 89) as identi f icat ion. Step Four: Integration After the categories were organized in a manner that would best describe the spouses' ICU experience, the researcher proceeded to examine the emerging categories in relation to the l iterature and the conceptual framework. The l iterature was selectively reviewed and integrated into the categories in order to compare the researcher's findings with those in the l i terature. The process of data analysis wil l be discussed in greater detail in Chapter Three. 36 Summary This chapter has described the methodology used to explore the spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery. Following a brief introduction to the methodology, the c r i t e r i a for the selection of the participants and the selection procedure for obtaining the participants were described. The participants themselves were described along with the method used to secure consent from the mates and the spouses for the study. F ina l ly , the processes of data collection and analysis were discussed as they relate to the phenomenological method of qualitative research. CHAPTER THREE The Process of Data Analysis Introduction In Chapter Two, a method of analyzing the spouses' accounts of their ICU experiences into an organizing framework that best described the common ICU experience of the spouses was introduced. As indicated ear l ier , the method of data analysis was adapted from the qualitative research works of Diers (1979), Gauchie (1982), Giorgi (1975) and Stern (1980), with selections and revisions made to enable the researcher to apply and communicate the process of analyzing the data. In this chapter, the process of how the data collected were analyzed wil l be explained in detail so that the reader wil l more fu l ly understand the results of the study. The discussion wil l follow the researcher's analytic approach. For the purpose of c l a r i t y , the four steps of the process will be presented separately in this discussion. However, because data collection and analysis occurred simultaneously, the process of data analysis was a dynamic rather than a linear process. Step One: Discrimination After each interview, the tapes were transcribed and the transcriptions were duplicated. One was used as a working copy and the original was left untouched for the researcher to consult when necessary for the context of specific responses. As each transcription arrived, i t was read through to get a sense of the whole (Giorgi, 1975), then examined slowly and 38 carefully l ine by line for similar and dissimilar comments expressed by the participants. A system of color coding (Gauchie, 1982) was developed as the researcher began to group l ike responses together. For example, a spouse's comment about relationships was coded with a blue dot, and comments relating to information seeking were coded with a yellow dot. The researcher then collected a l l the data with the same color dot and grouped them together on a reference sheet with the color of the dot indicated in the upper left hand corner. These reference sheets provided an overview of the data by organizing and displaying the data in the various categories. Three numbers were recorded on the reference sheet beside each comment. The numbers referred to the specific participant, the number of the interview, and the page number of the transcribed interview. The researcher fe l t this approach faci l i tated sorting of the data and also organized the responses into a form suitable for analysis. During this step, not only was each piece of datum compared with every other piece of datum in the same interview, but as more data were collected they were compared with existing categories of data on the reference sheets. Stern (1980) refers to this method as continuous comparative analysis. Objectively and systematically, data were either assigned to existing categories or used to generate a new category. 39 Step Two: Definition The second step of defining the categories was closely associated with the f i r s t step of discrimination. As the researcher organized the spouses' accounts into categories, she stated the theme that dominated each color coded category by defining appropriate concept labels for each category. Concepts are abstractions of concrete events which represent ways of perceiving phenomena (Norris, 1982). Concepts have many levels of abstraction and each level of abstraction includes relating concepts which are conceptualized at a lower level of abstraction (Norris, 1982). Although the various concept labels varied in relation to level of abstraction, they were stated as simply as possible and often in terms the spouses had used themselves. For example, comments such as, "I don't know how anybody gets through i f they haven't got another member of the family or a close friend at the time to support them," "I had a lot of support from my family," and "Being with the other families was a big support," were grouped together on a reference sheet with a red dot and defined as "support." Thus, "support" was the theme that dominated that particular category. After the concept labels had been defined for al l existing categories, the important aspects of the spouse's experience became apparent. In order to establish i f the generated themes did in fact represent the spouse's perspective, the themes that emerged determined the nature of the second interview with the participant 40 spouses. For example, the concept of support needed to be c l a r i f i e d , validated, and/or rejected. During the second interview, the researcher sought information concerning the importance, nature, source and ava i lab i l i ty of support. Thus, participants who generated the data were asked to support or reject the researcher's analysis of that data. Step Three: Identification An abundant number of categories evolved during steps one and two. The researcher began to compare these categories and look for relationships between them. As relationships were identi f ied, various categories collapsed to form one category conceptualized at a higher level of abstraction by the researcher. For example, obtaining information from the l ibrary, watching hospital video on the ICU, and asking questions, became "seeking information," while faith in God, confidence in physicians, belief that mate is getting the best care possible, and comparing, became "generating hope." In addition, seeking information, generating hope, developing a support network, distracting self , remaining near mate, helping mate, and reorganizing roles and responsibil i t ies became properties of the concept "coping categories." Thus, the researcher identified relationships between categories that seemed to cluster or connect together (Stern, 1980). Diers (1979) reports that reworking the categories again and again is the major portion of data analysis. Clustering of categories at this point is a more theoretical form of 41 analysis than the earl ier clustering of s imilar i t ies and differences among the data. The researcher sought additional information from the spouses to be certain the categories were saturated (Stern, 1980). For example, with respect to the category of "coping strategies," the researcher continued asking questions until she heard nothing new about that aspect of the experience. The researcher also continued to explore with the spouses during the second interview, topics related to the already formed concepts for the purpose of altering, verifying, and/or rejecting the developing framework. Some categories required modification and were divided to form other categories. For example, as the researcher developed a ful ler understanding of the spouse's ICU experience, i t became apparent that the category "comparing" was part of the categories "generating hope" and "determining mate's progress." It became clear that comparing needed to be subsumed under both categories because the spouses reported comparing their mate's condition to that of other patients in an attempt to generate hope and determine their mate's progress. In the course of examining the data analysis worksheets, the researcher identified a series of events or phases that each spouse experienced. A phase is "one of several periods whose beginning and end are usually marked by some important change" (Lofland & Lofland, 1984, p. 105). The phases, which were experienced in a time 42 sequence, centered around the event of coronary artery bypass graft surgery. Although the researcher had or ig inal ly planned to study only the spouses' ICU experience, the participants explained the meaning of their ICU experience by discussing i t within the context of the total surgical experience. It became apparent that the spouses perceived the ICU experience as one event among others that contributed to the experience of having a mate who was undergoing coronary artery bypass graft surgery. The phases, which were experienced by a l l spouses, were identified as the pre-surgery experience, waiting during the surgery experience, and the post-surgery experience. These separate yet related phases seemed to yield a meaningful way for the spouses to interpret and make sense of their experience. The researcher also noted several conceptual categories that appeared to cluster together into two major themes. Although the spouses progressed through the phases over a period of time, i t became clear that the two major themes of "reaction to the situation" and "coping with the situation" existed throughout the entire surgical experience. Kaplan (1962) refers to the concept of situation as a "segment of experience" (p. 19). He states that new situations create a new set of circumstances in which an individual is required to make an adjustment. During each phase the participants were faced with a new situation. The spouses described their psychosocial reactions to each situation and how they coped 43 with the various aspects of each situation. Coping "refers to dealing with situations that present a threat to the individual so as to resolve uncomfortable feelings" (Mil ler , 1983, p. 16). It seemed that the spouses used specific coping strategies to deal with the various aspects of the entire surgical experience. Thus, the manner in which the spouses made adjustments in order to deal with the psychosocial reactions created by the new situations, can be thought of as coping. Grasping the tota l i ty of how significant aspects of an experience f i t together and form the participant's viewpoint is the major challenge of qualitative research (Leininger, 1985). By structuring the data in terms of phases and themes, the researcher was able to meaningfully understand and communicate the spouses' experience of having a mate who was undergoing coronary artery bypass graft surgery. The organizing framework presented below was generated from the spouses' accounts to organize and make sense of their related surgical experience. Table 1 Phases and Themes Phases Themes Pre-Surgery Experience Waiting During Surgery Experience Post-Surgery Experience Reaction to the Situation Coping with the Situation 44 Step Four: Integration As the study proceeded and the developed categories became clear, the researcher selectively examined existing l iterature and integrated relevant aspects of other authors' writings with the findings of the present study. The l iterature was used to help explain the significant aspects of the experience. For example, Lange's (1978) discussion on hope as a complex human experience that wards off despair during uncertain times, became supportive data for the present study. It helped explain why generating hope was an important coping strategy for the spouses throughout the entire experience. The l iterature was carefully examined, used as data and integrated into the findings of the study in order to explain the spouses' related experience (Stern, 1980). During this step, the researcher also integrated Kleinman's (1978) conceptual framework with the phases and themes of the experience to enrich understanding of the popular system of the health care system. The spouses' psychosocial reactions and the manner in which they coped with these reactions, in relation to each phase of the surgical experience, contributed to the development of the spouses' explanatory models. Kleinman (1978) stresses the importance of understanding how individuals perceive and deal with an i l lness experience. By integrating the two major themes with the three phases of the surgical experience, the researcher was able to interpret from the spouses' perspective the psychological and sociocultural aspects of this particular surgical experience. 45 As stated in Chapter One, the spouse, as a member of the popular system, has certain bel iefs , expectations, roles and explanatory models in experiencing and perceiving an episode of sickness (Kleinman, 1978). Since the professional system, with its bel iefs , expectations, roles and explanatory models interacts with the popular system, any documented or discovered discrepancies between the systems were discussed and woven through the description of the experience. Thus, Kleinman's (1978) conceptual framework provided direction for the researcher to analyze the participant's subjective experience within the broader sociocultural context. Summary This chapter has described the method used during the process of data analysis. Using supportive data, the researcher i l lustrated the four steps of data analysis derived from the qualitative research work of Diers (1979), Gauchie (1982), Giorgi (1975), and Stern (1980). The process of analysis permitted development of an organizational framework which described the spouse's experience of having a mate who was undergoing coronary artery bypass graft surgery, in a meaningful way which has both accuracy and appl icabi l i ty . In the following chapter, an elaboration on the developed organizational framework with integration of the participants' accounts, conceptual framework and pertinent l i terature wil l be presented in order to enhance understanding of the spouses' experience. 46 CHAPTER FOUR Presentation and Discussion of Research Findings Introduction The purpose of this chapter is to present and integrate the findings from this study with the conceptual framework and l i terature relevant to the spouses' accounts in order to enhance the understanding of the spouses' experience of having a mate in the ICU following coronary artery bypass graft surgery. The discussion wil l be highlighted with verbatim excerpts from the participants' accounts to sensitize the reader to the spouses' viewpoints (Knafi & Howard, 1984). Although the experience of each spouse was described in a unique manner, consistent with his/her particular personality, similar phases and themes occurred repeatedly in the spouses' accounts. This finding is consistent with Lipowski's (1969) assumption that although every episode of i l lness is a unique experience, common trends may be found. The participants located the ICU experience within the context of their experience with their mate's coronary artery bypass graft surgery. The spouses described their ICU experience as one event among others which comprised the entire surgical experience rather than as a discrete, independent incident. While the spouses talked about their experience in the ICU, they made reference to prior events such as deciding to proceed with surgery, waiting for the 47 surgery and waiting during the surgery. They wanted to describe the significant events related to their ICU experience. One spouse stated, "Can I go right back and maybe you ' l l begin to understand what this whole thing to me is a l l about. Have you got lots of time?" From the data analysis i t was evident that the spouse's surgical experience could be viewed as comprising three phases that contributed to the experience of having a mate who was undergoing coronary artery bypass graft surgery: 1. pre-surgery experience 2. waiting during surgery experience 3. post-surgery experience Throughout the phases, the themes of "reaction to the situation" and "coping with the situation" occurred. As indicated in Chapter Three, the concept of situation refers to a "segment of experience" (Kaplan, 1962, p. 15). Each phase represented a new situation for the spouses. The participants described and explained how they reacted to and coped with the new set of circumstances created by each new situation. Lipowski (1969) discusses the importance of understanding how individuals experience a particular i l lness and how they cope or f a i l to cope with i t . The relationship between the two major themes identified by the spouses is articulated clearly in Lipowski's (1969) concept of the "total human response" (p. 1198). Lipowski (1969) reports that how an individual experiences a particular i l lness episode, what i t means to him/her, 48 and how this meaning influences the individual 's behavior and interaction with others are a l l integral components of the "total human response" to a particular i l lness episode. The researcher conceptualized the psychosocial impact of the surgical experience upon the spouses as "reaction to the s i tuat ion," and the behavior the spouses used to deal with the surgical experience as "coping with the s i tuat ion." The following paragraphs introduce the two identified themes. The relationship and interaction between the themes and the phases wi l l be further explained in the presentation of the spouses' accounts. Reaction to the Situation It is generally acknowledged that the psychological and social aspects of an individual 's i l lness experience needs to be understood and should influence the interventions health professionals direct toward individuals (Lipowski, 1969). Kleinman (1978) views sickness as an abstract concept consisting of psychological and sociocultural aspects. As the participants described and explained their experience with their mate's coronary artery bypass graft surgery, the psychosocial impact of the surgical experience upon their everyday lives became apparent. The spouses' descriptions focused upon their thoughts, feelings, behaviors, philosophy, and interaction with others during the three phases of the surgical experience. Lipowski (1969) describes the psychological reaction to i l lness as including an intrapsychic and a social aspect. The 49 intrapsychic aspect refers to what individuals perceive, fee l , and think, whereas the social aspect encompasses an individual 's interaction with others. The meaning of i l lness results from a combination of the perceptual, emotional, and cognitive components (Lipowski, 1969). Thus, i t seemed appropriate for the researcher to organize several conceptual categories such as thoughts, feelings, philosophy, and interaction with others into one major theme called "reaction to the situation" because the categories were similar in substance. They represented the spouses' reactions to the various phases of the surgical experience. The researcher noted that the spouses discussed at great length the fear of losing their mate. They became emotional as they described l iv ing with their mate who has heart disease, which is accepted as a life-threatening i l lness . The spouses also discussed their fear of coronary artery bypass graft surgery, which is considered by many individuals to be a life-threatening event. It became apparent that the spouses perceived coronary artery bypass graft surgery to be a life-threatening treatment for a life-threatening i l lnes s . Coping with the Situation During the interviews, the participants described the manner in which they dealt with the threatened loss of a mate undergoing coronary artery bypass graft surgery during the various phases of the surgical experience. Lazarus (1966) uses the term "coping" to 50 refer to strategies used to deal with a threat. Threat refers to an anticipation of personal danger or harm, whether rea l i s t i c or not, which may cause mental or physical suffering (Lazarus, 1966; Lipowski, 1969). The meaning that is attached to an experience determines the threat posed by that experience (Perlin & Schooler, 1978). Other authors have defined coping differently. Coping has also been referred to as "the things that people do to avoid being harmed by l i fe-s tra ins" (Pearlin & Schooler, 1978, p. 2). Lazarus and Launier (1978) have attempted to narrow the scope of the concept of coping by writing that coping refers to action-oriented and intrapsychic efforts to manage or reduce environmental and internal demands which exceed an individual 's resources. The spouses' processes of coping with the stress of everyday l iv ing became a common theme in the participants' accounts. Understanding how family members cope with stressful situations is important because empirical evidence is linking coping to successful individual adjustment (McCubbin et a l . , 1980). Lipowski (1970) suggests that an individual 's actions related to the i l lness experience can be subsumed under the concept of "coping behavior." Thus, the spouses' actions such as generating hope, seeking information, remaining near mate, developing a support network, helping mate, reorganizing roles and responsibi l i t ies , and distracting self were grouped together under the theme "coping with the s i tuat ion." 51 Lazarus and Launier (1978) suggest that coping strategies are intended to serve two main functions, namely, altering stressful relationships between the individual and the environment, and regulating the emotional reaction resulting from the person-environment relationship. Coping strategies may also improve an individual 's ab i l i ty to deal with situations in a constructive manner (Brailey, 1984). McCubbin et a l . (1980) report that four hypotheses have been suggested in the family-oriented coping studies they reviewed. They state that coping behaviors have been said to decrease the presence of vulnerabil ity factors, such as emotional ins tab i l i ty of a family member; strengthen or maintain family resources which protect the family from harm or disruption; reduce or eliminate stressor events and their specific hardships; and influence the environment by doing something to change the social circumstances. Pearl in and Schooler (1978) state that coping strategies are e l ic i ted to change the situation, control the meaning of the experience, and/or control the emotional distress created by the experience. It has also been proposed that coping strategies are influenced by the individual 's meaning of the i l lness experience (Lipowski, 1970). Thus, i t seemed that by using coping strategies the spouses were attempting to prevent, control, or minimize the psychosocial impact of the surgical experience. 52 The description and discussion that follow use the identified phases and themes as an organizing framework for presenting the spouses' accounts. Pre-Surgery Experience During their pre-surgery experience, the spouses discussed their ambivalence towards coronary artery bypass graft surgery as a treatment for the mate's heart disease. The pre-surgery phase included the time spent deciding to proceed with surgery and waiting for the surgery. During this time, fear of losing the mate emerged as a common spousal reaction, while generating hope, seeking information, helping mate, and remaining near mate were voiced as important coping strategies. Reaction to the Situation The spouses who considered coronary artery bypass graft surgery as an option for treating their mate's heart disease had either just dealt with the shock of a heart attack, or were watching their mate's condition deteriorate to the point where treatment by diet , exercise, and medication were not controlling symptoms. They saw themselves as having no alternative. The reason given for having the surgery was that i t was the last resort. The reason seemed to just i fy their decision to proceed with the surgery. One spouse commented: It was very d i f f i cu l t to resign myself to the fact that this surgery was going to happen. I had terr ible doubts and fears. 53 I eventually sort of calmed down and accepted i t . There was no other way out, there would have to be surgery. Although the spouses were aware that the success rate of coronary artery bypass graft surgery is exceptionally high, they perceived i t as a threat to their mate's l i f e . To them, surgery meant taking a chance that l i f e may or may not change for the better. While the expectation of a longer, healthier l i f e for the mate was expressed, they feared the poss ib i l i ty of death or d i sab i l i ty . One spouse expressed her feeling that, "Though I was happy that he could be helped, I was terr ib ly afraid of the operation." Thus, the decision to undergo coronary artery bypass graft surgery was a d i f f i cu l t one for the spouses as they considered the r i sks . One spouse expressed her concerns: Things could go wrong and you could be the odd one that could be the unlucky one. It was d i f f i cu l t for me to accept that and say O.K. , go ahead with the surgery. I didn't want to take that r i sk . I had a lot of doubts and fears. Fear has been defined as "a client-expressed or client-confirmed response of focused apprehension toward the presence of a recognized, usually external threat or danger to one's limb, autonomy, self-image, or community with others" (Jones & Jakob, 1981, p. 23). Hewitt (1984) reports that a threat of "the worst" is a powerful source of fear. The fear the spouses described that was associated with the threatened loss of their mates due to the unknown outcome of surgery, played a large role in the decision of 54 whether or not to undergo open heart surgery. This fear decreased only after the spouses had contact with their mates in the ICU following the operation. After the decision had been made to proceed with coronary artery bypass graft surgery, the spouses began waiting for the surgery. Although this period of time varied among the study participants, i t appeared most d i f f i cu l t for those whose mate's surgery had been delayed for any length of time. A study by Gil l i s (1984) demonstrated that spouses of coronary artery bypass graft surgery patients identified waiting for surgery as the most stressful aspect of the hospitalization experience. Gullo, Cherico, and Shadick (1974) reported that the outcome of a life-threatening i l lness remains uncertain for an unknown period of time and death is perceived as one of several possible outcomes. The spouses indicated that during this time they lived in constant fear that their mate would suffer a massive myocardial infarction and die before the operation. The following comment was made: It was very d i f f i cu l t for me to accept what was happening and that you knew he was sort of s i t t ing on a time bomb and he could have an attack at any time before the operation and i t could be the end. Similarly, another spouse described his feelings: There was fear in the fact that when I would go to work knowing her condition, the doctor told me that she had a very serious heart disease, and I would phone a couple of times to see how 55 she was. There was that fear that, you know, maybe she would get a heart attack and I would come home and find her on the floor and who knows, maybe even dead. It seemed that because the spouses' mates were in danger of dying from a heart attack, the spouses began to eagerly look forward to their mates' surgery. To them, coronary artery bypass graft surgery meant an opportunity for their mates to obtain re l i e f from angina, regain health, and avoid the prospects of a heart attack. One spouse verbalized these feelings: The doctors told us not that long ago that [my husband] couldn't have another heart attack and l i v e . And we didn't know whether he was going to make i t until surgery. So in a way we were quite happy when he had surgery because i f he had had another one he wouldn't have lived through i t . However, despite the high hopes for a successful operation, and the desperate need to have their mates undergo coronary artery bypass graft surgery, the fear of the operation was not eliminated. As a result , one spouse described the operation as "both a blessing and a curse." Another spouse described i t this way: The doctor assured me that the success rate is quite high, l ike 98%. In 1983, he said that i t was almost 99% in this hospital . Though that sounds very good and I wanted him to have the operation, I rea l ly thought he was going to die during the operation. You know there is always that chance. That was my worst fear and I didn't sleep well for weeks. 56 Thus, during this aspect of the surgical experience, fear continued to be a commonly expressed theme. However, this fear, which was related to the prospect of a heart attack, never decreased for some of the spouses. Even after the operation they feared a recurrent myocardial infarction. Coping with the Situation During their pre-surgery experience, the spouses took active measures to cope with the emotional reactions arising from their mate's heart disease and impending surgery. Coping strategies such as generating hope, seeking information, helping mate, and remaining near mate were alternative ways the spouses dealt with the threat of losing their mate. The threatening nature of heart disease and coronary artery bypass graft surgery resulted in the spouses taking certain actions aimed at preventing, minimizing or controlling the impact of the anticipated threats. Lazarus (1966) refers to a l l strategies for dealing with threat as coping. Generating hope. Generating hope emerged as an important way spouses coped with the implications of their mate's heart disease and impending surgery. Hope is a combination of feelings and thoughts which center on the belief that there are solutions to an individual 's needs and problems (Lange, 1978). Hope makes l i f e tolerable and meaningful during times of stress or transition (Korner, 1970; Lange, 1978; McGee, 1984). Korner (1970) refers to hope as a method of coping. He states the purpose of hope is to 57 ward off despair and permit the individual to deal with any situation in which his/her needs are not being met. Hope permits "desired future gratif ication to serve as an immediate re l i e f for current discomfort" (Korner, 1970, p. 136). Faith in God was a key factor in generating hope for many of the spouses. Hope was also generated by believing that the "odds" of the surgery were in their favor. Some of the spouses repeatedly made references to a person they knew who was "better off than ever" as a result of the surgery. Since the outcome of surgery was uncertain, this seemed to be an important factor in generating hope because seeing these individuals meant there was l iv ing proof that the operation can be successful. Korner (1970) points out that the more uncertain the outcome, the more an individual needs a defense against his/her fears and anxieties. "Hope induces a feeling of 'assumed certainty 1 that the dreaded wil l not happen, that despair wil l not occur" (Korner, 1970, p. 135). Al l of the spouses discussed their feelings of hope and need to practise positive thinking. They talked about "hoping that everything would be right and that there would be a good future." None of the spouses remarked that they fe l t hopeless. Molter (1979) ut i l ized a l i s t of 45 'need' statements which she had relatives of c r i t i c a l l y i l l patients rank in order of significance. To feel there is hope was the highest ranking category. Hope was found to be the universal need identified as 58 very important by a l l relat ives . The reason for this finding could be that hope is always associated with important personal issues and is of fundamental importance to the lives of a l l individuals (Korner, 1970). Seeking information. Seeking information related to coronary artery disease and coronary artery bypass graft surgery was an act ivi ty that consumed much of the spouses' time. One spouse took a Cardiopulmonary Resuscitation (CPR) course "just in case" she would need to use i t . Information was sought from several sources such as the family physician, the l ibrary, individuals they knew who had undergone heart surgery, and the B.C. Heart Foundation. It became evident in the accounts that the spouses knew and actively sought what information they wanted. However, this information was sometimes d i f f i cu l t to obtain. This point is i l lustrated in the account that follows: I had been going to the l ibrary before the operation and reading great big books. Some I understood and some I didn't . Al l of the books that I found in the l ibrary went on that you didn't need surgery and I could find nothing on surgery. Nothing on bypasses. I wish I were a l i t t l e bit more informed. Lazarus and Launier (1978) identify information seeking as a coping strategy individuals use to feel more in control of a s ituation. Since the spouses were closely involved in decision-making regarding surgery, their search for information was aimed at 59 obtaining sufficient knowledge in order to make appropriate decisions related to their mate's i l lness . Thus, seeking information helped the spouses to cope with their feelings of ambivalence towards the surgery. The information sought was also directed at trying to be better prepared for what was to come. One spouse stated, "My brother-in-law just had open heart surgery and I was rea l ly curious about everything. So I talked to his wife and tried to prepare myself that way." Helping mate. Helping mate was conceptualized by the researcher as a coping strategy because i t was a way in which the spouses appeared to deal with the threat of losing their mate. Since their mates experienced shortness of breath or chest pain with act iv i ty , the spouses had a compelling desire to do a l l they could to help their mate and prevent the symptoms from appearing. The spouses' knowledge about angina and its consequences may have e l ic i ted this particular coping strategy. However, sometimes the spouse's need to be helpful interfered with the mate's sense of independence and self reliance. One spouse admitted that his mate resented some of his help: When we found out about her heart condition, the doctor said that although she had to exercise, she couldn't do anything strenuous. So I sort of def initely took over. I did the washing and cleaning, and matter of fact there were times when she was a l i t t l e upset because I was doing too much and she fe l t that she was s t i l l capable. 60 Family members "rely on their own judgment, wisdom, and ingenuity for controlling symptoms" (Strauss et a l . , 1984, p. 49). Strauss et a l . (1984) identify types of "assisting agents" that carry out various tasks in order to control an i l l member's physical symptoms. Although protective agents were not c learly defined, their tasks were related to preventing injury and worsening of the i l lnes s . The participant spouses acted as protective agents toward their mates. They attempted to prevent the mate's i l lness from worsening. Several authors have reported that the wives of myocardial infarction patients demonstrate an overprotective attitude (Bilodeau & Hackett, 1971; Frank, Heller, & Kornfeld, 1972; Mil ler & Brewer, 1969). One participant discussed the dilemma of wanting to be helpful but not overprotective. I want to do what's right and I don't want to be overprotective. I don't want to nag or do too much, and yet at the same time, I don't want to forget to do anything either. Wright (1983) reports that "a certain amount of protection is good; more than that is detrimental" (p. 403). She points out that whether an individual is overprotective or not depends upon who is doing the judging. In other words, spouses perceived the help they were giving their mate as meeting the needs of the mate and controlling their symptoms at the same time. They did not view themselves as being overprotective. Remaining near mate. A l l of the spouses coped with fear during the pre-surgery phase by remaining near the mate, feeling a strong 61 need to be near the mate as much as possible and for as long as possible. The participants stated they worried about the mate and were unable to concentrate when they were not in the mate's presence. By remaining near the mate they fe l t more comfortable just knowing the situation. One spouse described his feelings: After my wife had her heart attack, I spent more time in the house with her. I used to go out and do some work in the workshop or go work in the yard. But after she had her heart attack, well , I just couldn't concentrate on things outside. I spent more time with her, we would go for walks. There were things I wanted to do, but I just put them off to do later . My main concern was to be with her. During the pre-surgery phase of their surgical experience, spouses were confronted with deciding to proceed with surgery and waiting for the surgery. They coped with the fear of losing their mate by generating hope, seeking information, helping mate, and remaining near their mate. With hopes for a successful operation, the spouses began the second phase of the surgical experience: waiting during surgery. Waiting During Surgery Experience The spouses did not mention the hospital admission or the time in hospital prior to their mate's surgery. Thus, this phase covers only the time spouses spent waiting while their mates were having coronary artery bypass graft surgery. Although the time was spent 62 differently by a l l of the spouses, they al l agreed that this was an extremely anxiety-provoking time. During this phase, the spouses coped by generating hope and distracting self . Reaction to the Situation Al l of the spouses agreed that their most d i f f i cu l t time during this experience was waiting while their mate was undergoing coronary artery bypass graft surgery. This finding supports KathoVs (1984) conclusion that the intraoperative period is the most stressful time for family members of surgical patients. Kathol (1984) offers a possible explanation. She points out that during this time, spouses are to ta l ly isolated from their mates and have no knowledge about their mate's condition. The spouse's accounts revealed that the time spent waiting during their mate's surgery was almost unbearable. One spouse said, "From the time of the operation until you hear from the doctor was the hardest part for me." It seemed what made this time so agonizing for the spouses was not knowing what was happening or what the outcome would be. Although the fear of losing the mate continued to be a predominant thought for the spouse, they talked about the anxiety of waiting. One spouse stated, "The anxiety of waiting, you know. You wonder i f he is going to make i t through. It was rea l ly d i f f i cu l t for me." One spouse described his feeling this way: It 's the waiting around that rea l ly gets you down. I remember we sat and sat and sat. We just sat there and toughed i t out. 63 I went around four-thirty and i t was about a quarter to nine before the doctor came out to see us. So you see, I was getting quite anxious just wondering what was going on. A review of the l iterature indicated that fear and anxiety are closely related. Jones and Jakob (1981) examined and differentiated between fear and anxiety. "The c r i t i c a l aspect which differentiated fear from anxiety was seen to be the c l i ent ' s awareness and identif ication of the object of dread and apprehension" (Jones & Jakob, 1981, p. 23). They defined anxiety as "a vague, uneasy sense of worry, nervousness, or anguish which is a reaction to an anticipated (often non-specific) danger to one's expectations" (Jones & Jakob, 1981, p. 23). The anxious individual has not as yet expressed the underlying feeling involved, such as fear, grief , confl ict or insecurity (Jones & Jakob, 1984). Thus, an individual experiencing anxiety is unable to identify the specific source of the threat or what is threatened (Yocom, 1984). The spouses waiting during their mate's surgery knew the benefits and risks of the operation. However, at this time they did not clearly articulate what they were afraid of or what was actually being threatened. Coping with the Situation As indicated ear l ier , a l l spouses agreed that waiting during surgery was an extremely anxiety provoking time. They attempted to alleviate or attenuate the uncomfortable feelings experienced as a result of this period of uncertainty by generating hope and distracting self . 64 Generating hope. It 's a serious operation. Your l i f e is real ly on the l ine . It 's not l ike fixing a broken leg or something l ike that. They actually stop the heart and manipulate i t . You just hope that i t gets going again. During this time, the spouses continued to be hopeful. They generated hope by believing in God and having confidence in the mate's surgeon. Faith is an affective component of hope (Lange, 1978). "Faith is a positive belief that unknown forces can be rel ied on" (Lange, 1978, p. 179). Each spouse believed their mate's surgeon was "the best." Edwards (1982) suggests that the "unabashed adoration" patients have for heart surgeons may be the main factor in establishing confidence in their physician. Having confidence in their mate's surgeon helped minimize the spouse's fear (Thurer, Levine, & Thurer, 1980). Thurer et a l . (1980) contribute to the understanding of the importance of having confidence in the surgeon. Their comment supports the researcher's findings: This exaggerated positive regard [for surgeons] may have been an unconscious method of endearing oneself to one's doctor, so that the doctor may try harder. Certainly the patient does not wish to anger the surgeon, as he or she could very well take revenge on the operating table. Perhaps this esteem represented a way of minimizing the cognitive dissonance of being cut and probed by a less than perfect being, one capable 65 of human error. Or perhaps i t was a reaction formation to a probable, but repressed, feeling of ambivalence toward an inherently contradictory figure who may be a bearer of bad news, one who may engender suffering and death (p. 287). Distracting self. Mil ler (1983) writes about methods of self-distraction as strategies individuals use to deal with "otherwise continuous thoughts about an i l lness" (p. 27). Waiting during their mate's surgery became tolerable as the spouses diverted their attention from the life-threatening surgery in progress to other facets of l i v i n g . During this phase, the spouses chose to work or spent the time in fellowship with others. It was a time they did not want to be alone. These self-distracting strategies were deliberately selected in order to occupy their minds with something other than the surgery. While his wife was undergoing surgery, one spouse from out of town spent his time in the waiting room with other patients' family members. He said: A man I met was s i t t ing there and talking to me. I suppose that made i t a bit easier because i f I was alone things would be running through my mind, and he kind of took things off my mind by te l l ing me about his wife. And then there was this other gentleman. His wife was in and he was a real card. He joked about things and not everybody was so serious about things you know. We laughed and exchanged conversation, and I think i t ' s important. I think i t i s . Rather than s i t t ing 66 alone and waiting and waiting and waiting for the doctor, i t sort of takes your mind off what the doctor is going to say. However, one spouse's self-distracting strategy was not as effective as planned. She stated, "I went to work that day to keep my mind off i t . It didn't keep i t off i t but i t helped pass the time." Another spouse was surprised at how easily she could be distracted and almost fe l t guilty about i t . I had periods during those hours when I was even playing cards with my family and stuff, and I was actually enjoying the game. And then I thought, what am I doing enjoying this game when my husband is having open heart surgery now. So then I would be what I thought a responsible wife should be and be very concerned, and then I'd do something else that distracted me and I'd be very surprised that I was distracted. Buchanan (1984) refers to a conscious, deliberate, temporary inattention to a stressful situation as suppression. Suppression, which is a necessity, is usually achieved through distraction by physical exertion, hobbies, outside interests, and other people (Buchanan, 1984). Buchanan (1984) goes on to say: Suppression can only follow confrontation. It is not avoidance for i t does not balk at responsibi l i ty, nor does i t hurt others, nor does i t have long-term detrimental results . It is the healthy need to take a break from despair, (p. 84) 67 During the second phase of their surgical experience, the spouses coped with the emotional reactions experienced by generating hope and distracting self . By the time the spouses entered the ICU, they had already developed coping strategies to deal with their emotional reactions. However, changes occurred in how the spouses reacted to, and coped with, the post-surgery phase of the surgical experience. Post-Surgery Experience The post-surgery experience consisted of the spouses' experience in the ICU following their mates' coronary artery bypass graft surgery. While recognizing that each spouse's manner of reacting to the situation was unique, i t was nevertheless possible to identify reactions which were common to most of the individuals in the study. The spouses did not appear to progress through a series of successive stages, but rather experienced each response to varying degrees at the same time. The spouses coped during this phase of the surgical experience by generating hope, seeking information, helping mate, remaining near mate, developing a support network, and reorganizing roles and responsibi l i t ies . Reaction to the Situation After obtaining information from the surgeon regarding the results of the coronary artery bypass graft operation and the status of their mates' condition, spouses entered the ICU to v i s i t their mates. 68 Al l of the spouses perceived the ICU to be a place where their mates would receive "special care after surgery." They understood their mate's condition to be c r i t i c a l , which required "being on the monitor and continuous watching." One spouse described i t this way: I knew after he came out of surgery they would have to watch him closely just to make sure that there was no emergency and that things did not go wrong. I knew he needed special care because he would be a very sick man when he came out of surgery. He wouldn't be able to do a thing for himself, he would be too weak. However, despite the spouses' preconceived notions about the seriousness of their mates' operation, i t was during that f i r s t v i s i t to the ICU that the spouses came face-to-face with the rea l i ty of the seriousness of having coronary artery bypass graft surgery. The following comments were made: You know that you're going to be going into the Intensive Care Unit, but I don't think that you real ly realize how bad the period is until you see a l l those machines and everything going around there, and a l l those tubes that they have coming out. You don't realize how serious i t real ly is and to what extent they have to go to when they have a serious operation l ike that. Similarly, another spouse described her feelings: The realization of just how major that surgery is I think al l came to me when I saw him. Although I understood i t and I 69 thought about i t before, I never real ly understood i t fu l ly until I saw him in the Intensive Care Unit. The gravity and inescapable rea l i ty of the situation seemed to "h i t hardest" when the spouses entered the ICU and saw their mates with their surgical dressings, in and amongst the ICU equipment. Prior to this time, the spouse had talked or read about the surgery. Two spouses even viewed the hospital video on equipment and the care patients receive in the ICU following coronary artery bypass graft surgery. However, only after actually seeing their mate in the ICU did they understand the seriousness of what their mate had just gone through. Buchanan (1984) reports that people can only maximize their coping ab i l i t i e s once they acknowledge, at least to themselves, the rea l i ty of the situation. The i n i t i a l response to the ICU was described by the spouses as an extremely emotional time. Regardless of their preparation or past experience in the ICU, they described being in a state of shock. One spouse who had previously visited her husband in the ICU when he had a heart attack explained: Surgery is a different thing altogether. There are no vis ible signs other than being pale i f you have a heart attack. You don't have scars and tubes and things. You only have one heart monitor. I was shocked to see a l l this . It seemed the more unexpected their mate's appearance was, the greater the degree of shock. One spouse described i t best: 70 The f i r s t v i s i t was a real shocker. Seeing a l l those tubes and wires and everything and a l l the nurses scurrying around doing the different things, i t ' s quite a shock to your system right off the bat. I think the problem is you don't know exactly what to expect, so you walk in there and real ly i t ' s quite a shock to you. You don't know what's happening. Al l of the spouses described the shock of seeing their mate "looking l ike dead" when they f i r s t saw him/her in the ICU. One spouse expressed these feelings: When you walk in and see them, i t is quite a bit of a shock. They look, I guess you could best describe i t l ike dead. You know, they l i e there dead f l a t , the machine breathes for them and they have a terr ible color. They look bluish. They look to me just l ike I think a cadaver would look. The spouses' i n i t i a l reaction may have been shock because i t was a confirmation of their worst fears. Gullo et a l . (1974) reported that even though individuals have suspicions about the nature of an i l lness , they are s t i l l shocked when their suspicions are confirmed. They state i t is not so much a feeling of surprise, but rather a feeling of being " tota l ly overwhelmed." It has been suggested that family members v i s i t ing an ICU can remain in shock for hours or even days (Delaney-Naumoff, 1980), and that from shock individuals emerge to a recognition of the seriousness of the situation (Gullo et a l . , 1974). As indicated ear l ier , i t was during 71 that f i r s t v i s i t that the spouses realized the seriousness of having coronary artery bypass graft surgery. Although spouses expressed a sense of re l i e f that the mate had survived the operation, the fear of losing the mate continued to plague them. One spouse who received "good news" that the surgery had been successfully performed stated: When the doctor came up he told me, he said that surgery went very well . So I was relieved to know that because he said that sometimes things go wrong and they don't know why. But he said that surgery went very well . Well, now I knew that part, but even at this stage I knew something could happen. Another spouse, whose news regarding his mate's surgery was not as encouraging, commented: I'm very grateful my wife got through surgery because [the doctor] told us the poss ib i l i t ies that there was danger that something could maybe happen. In [my wife's] case they didn't do two. They should have done f ive , but they only did three. That was because they were too small or something, the doctor said. So I feel that er, matter of fact I think we ought to be prepared at a l l times and hope i t doesn't happen, but you know she could maybe have a heart attack or something at any time. Thus, regardless of the outcome of the surgery, the fear of losing the mate had not decreased. Roberts (1978) points out that fear occurs and remains in existence as long as an individual does not know what to expect in a given situation. 72 Fear was also associated with the equipment in the ICU and the unknown implications of touching the equipment. Most of the spouses reported fear of "doing harm." One spouse stated: I walked into the room and sort of just stopped at the bed, afraid to go forward because there are so many wires coming out and you think i f I knock one of those, what is going to be the result . However, this reaction was only experienced during the i n i t i a l encounter with the ICU. Most of the spouses reported that this fear decreased as their knowledge and famil iar i ty with the equipment increased, and with the constant reassurance from health care professionals. A significant decrease in fear was reported by one of the spouses: Gradually the horror show of that f i r s t entry into intensive care sort of gradually lessens and lessens. You sort of just accept what i s . You are no longer afraid of the tubes that are there and you don't mind going straight to him and holding him, or even touching a tube and getting i t unhooked i f i t ' s getting hooked up, or holding his hand i f he's kinking the tube or something. There is no longer that sort of fright of everything. From their accounts, i t became evident that the spouses were frightened by the ICU equipment because there was l i t t l e that looked or sounded familiar . They stated that with repeated exposure to the 73 ICU and explanations from health care professionals, the equipment was demystified, the ICU environment became familiar, and their fears were minimized. However, anxiety continued to be a persistent feeling because although the spouses fe l t threatened, the object of threat could not be readily identi f ied. One spouse said, "I had a funny feel ing, maybe apprehension. I didn't know how he was going to be or what I was going to find when I went in there." The spouses' anxiety resulted in somatic manifestations such as anorexia and insomnia. The participants also stated that they never fe l t comfortable in the ICU's crowded f a c i l i t i e s . Although the spouses attempted to stand quietly in an area so as not to disturb anything or anyone, they reported feeling that they were " in the way" and "bothering the nurses." These feelings persisted throughout the intensive care hospitalization period of their mate. Comments such as the following were made: "A person is just in the way real ly of the staff who are trying to do a good job," and "I l ike to do things for [my husband], but real ly one tends to always get the feeling one is in the way of professionals." Another spouse described i t this way: Today I was in there and they were bringing in a patient from the operating room and the nurse said, "Mr. S. would you excuse us for a minute. We're bringing in a patient, but you can come back after." So even i f they weren't talking to [my wife] they'd be wanting to get by for the next patient and I always 74 fe l t that I was in the way. You know, there was once or twice when the nurse had to come and get blood or something and again I would have to kind of move away, and I was always feeling I may be intruding and in the way. When individuals feel left out or do not feel capable of or responsible for doing anything, they feel helpless (Lange, 1978). The spouses talked about their feeling of helplessness. One spouse expressed these feelings: It 's very hard on spouses too, you know, seeing them the way they are with a l l those tubes and everything running through them, and seeing how sick they are, and knowing there's nothing you can do to help them other than just stand there and hold their hand. You feel so helpless. Lange (1978) views helplessness similar to Roberts (1976), who defines helplessness as "the conviction that everything that can be done has been done, which results in an inabi l i ty to mobilize energy and effort for intervening in i l lness" (p. 162). Thus, helplessness is a sense of being overwhelmed by the loss of control over the situation (Lange, 1978). Mil ler (1983) considers helplessness and powerlessness as synonymous terms. She states that powerlessness, which occurs for a variety of reasons, is "a perception that one's own actions wi l l not affect an outcome" (p. 3). Since the spouses were experiencing the threatened loss of their mate and had no way of controlling or avoiding the threatened loss, they fe l t helpless. 75 For many individuals, the experience of i l lness and treatment results in the feeling of helplessness (Lange, 1978). Many spouses also reported that their mates were on their minds constantly and that they were unable to concentrate on anything else such as their work or driving. It seemed they had l i t t l e interest in anything else except what was related to the mate. Their conversations with friends, family, and health care professionals centered around the mates. Act iv i t ies such as acquiring information and reorganizing their dai ly routine a l l focused on the mate. They also reported that they were not interested in participating in any social ac t iv i t i e s . It seemed they were too fatigued and preoccupied with thoughts of the mate to enjoy social contacts. They verbalized that they were just content to v i s i t their mates as frequently and for as long as possible. Most of the spouses even stated that they were so preoccupied with the mate that they became oblivious to the ICU surroundings. One spouse talked about his reaction: I think that everyone is so involved with their own spouse that you just don't hear anything else that is going on. Once you're in there with her, you seem to be in a world of your own. You may glance over at the other patients, but real ly I don't think you know that they exist . You are just concentrating on your wife and you forget the rest of the world, rea l ly . Lindemann (1944) indicated that preoccupation is a manifestation of anticipatory grief . Anticipating grief has been 76 defined as a grief reaction which occurs in individuals threatened with the possible loss of a loved one (Aldrich, 1974; Lindemann, 1944). Since coronary artery disease and coronary artery bypass graft surgery are tradit ional ly accompanied by the threat of death (Rakoczy, 1977), spouses may experience anticipatory grief reactions. However, a spouse's preoccupation with the thoughts of his/her mate could reflect the importance of the event to the individual . Within some families, the seriousness and importance of an i l lness is relative to other family problems (Jacobson & Eickhorn, 1964). Warren (1978) offers another possible explanation. She points out that when individuals are i l l they become dependent on those who care for them. As a result , family members may react by making the individual the center of their attention and do whatever they can to help. Anthony (1970) agrees, reporting that i l l individuals become special and their family members suffer with them and share with them in the self-preoccupation imposed by i l lnes s . Thus, spouses may be preoccupied with thoughts of their mates because of the i l lness i t s e l f and not because they are experiencing anticipatory grief . However, one of the spouses did express feelings of anticipatory grief : I was te l l ing my son the feeling I had when the nurse told me that machine respirator was doing a l l the breathing for him and we said, "Is he not breathing on his own?" And he said, "No, he is not breathing. The respirator is doing i t a l l for him at 77 the moment." I rea l ly sort of fe l t at that point then, that he was dead. I could not reach him, that was the sort of feeling that I had, because he was unconscious. There was no communication. I just could not reach him anyway. He was dead. He was so white, sort of, you know, so cold, and i t was l ike experiencing what or what part ia l ly what i t would possibly be l ike i f he had to die. [My son] said, "Why did you feel that he was dead? His heart was beating and i t ' s just the machine that was helping him to breathe." But when I don't see a person breathing, I say that person is dead. But at the same time there is at the back of my mind far away, I thought he is dead, but he is sort of dead on a very temporary basis. He wil l come back and that was a sort of consolation for me. And I thought when a person real ly does die that must be terr ib ly , l ike suffocating. I don't know how to describe i t to you. What must the depths of feeling be l ike when you real ly lose a person and there is no coming back. And that's the rea l i ty that hits you at that time when they are so deeply unconscious and they're so cold and they look so clear and white when they come out of surgery. So I guess you sort of get just a taste of what the sorrow could be, what grief could be l ike . Just a short glimpse of what i t would probably be l ike . Aldrich (1974) points out that anticipatory grief occurs prior or in anticipation of a loss. As a result , the concept of 78 anticipatory grief may be applicable to individuals experiencing a life-threatening situation. The spouses' accounts revealed that only one spouse identified anticipatory grief in response to her mate's appearance in the ICU. The spouses also indicated that this was a time for reassessing pr ior i t ie s in their l i f e . They spoke of appreciating l i f e more now, and "having another chance to make the best of l i f e . " One spouse described i t this way: You a l l of a sudden reassess your whole pr ior i t i e s . You never gave i t too much thought before, you're not that old at 55. But, my goodness, I think now that you shouldn't work always for the future. That day may never come. In a few years we'll do this and we'l l do that. Let's enjoy i t while we s t i l l have i t . You might not have each other later. Confrontation with a serious i l lness experience alters one's approach to the future (Gullo et a l . , 1974). The "brush with death" (Gullo et a l . , 1974, p. 62) resulted in a greater appreciation of l i f e and new l i f e goals. Some spouses even talked about the positive benefits which resulted from the surgical experience: It [surgical experience] makes me realize how fortunate we are. It could have gone the other way. It makes me appreciate l i f e more and i t makes me want to be good because here we are, we've been saved. I'm not a bad l i t t l e fellow, but from now on we are going to practise a l l good clean l i v ing . 79 Similarly, another spouse described her feelings: It 's been a very educational and learning time for me. Prior to my husband's heart attack, I knew nothing about the heart. We just have one and i t ' s great, but I now know more about the heart than probably the average person knows. Al l of us are heading towards heart attacks just by our diets alone before we even have a cigarette, i f you choose to have a cigarette. I regret not learning sooner but I've learned i t now. I don't know i f you can help other people with your knowledge because sometimes people have to go through i t themselves to real ly appreciate l i f e . Gullo et a l . (1974) report that individuals who are able to perceive that they have profited in some way from the i l lness experience are less l ike ly to encounter severe problems of adjustment during the recovery process. Coping with the Situation During the post-surgery experience, the spouses identified a number of coping strategies used to deal with the situation. Although coping is a "highly individualized defense against threats aroused in highly individualized situations" (Pearlin & Schooler, 1978, p. 2), the coping strategies the spouses used during their mate's stay in the ICU were similar. The participants described generating hope, seeking information, helping mate, remaining near mate, developing a support network, and reorganizing roles and 80 responsibi l i t ies as strategies used to cope during this time. Pearlin and Schooler (1978) refer to specific coping efforts as behaviors, cognitions, and perceptions that individuals use to deal with the " l i fe-s tra ins" they encounter. They also report that the "right" personality characteristics wil l help an individual deal with external threats. In fact, evidence indicates that psychological disposition is most effective in helping people to deal with situations over which they have l i t t l e control (Pearlin & Schooler, 1978). However, i t is also evident that a repertoire of coping strategies is more eff icient in helping an individual deal with emotional situations than the nature of any one coping element (Pearlin & Schooler, 1978). Generating hope. The spouses generated hope by believing in God, believing in themselves, believing their mate was receiving the best health care possible, and by comparing their mate's progress to that of other patients in the ICU. Mil ler (1983) reports that hope is derived from spiri tual well-being. By believing in God, the spouses were able to generate hope when i t was so desperately needed. One spouse commented, "I think believing in God is one of the main things. You have to draw strength from somewhere." Having a relationship with God alleviates aloneness and provides individuals with the ab i l i ty to cope with stress and overcome i t (Mi l ler , 1983). One spouse described i t this way: 81 And of course the greatest support, in fact the support, is the faith that one has. Because there's a God above looking after al l of us. In spite of one's doubts and fears that he's not going to pull through, God wil l help us through. We a l l have to go through pain in l i f e , and i f we accept that he is watching over us and won't give us more than we can bear, and with that hope i t becomes easier. When you turn to God things become easier. It is amazing what a quick prayer can do for you. It gives you that strength to pick yourself up and face i t again. Some spouses stated that the surgical experience had caused them to return to religious help and prayer. A possible explanation is that having faith gave them a sense of control during this uncertain time (Mil ler , 1983). Two of the spouses interviewed, who did not believe in God, rel ied on inner strength. They recognized that they had coped in the past with stressful situations and could cope now because they had "to carry on." One spouse stated: I can do most things. I know about finances and a l l that kind of stuff. When we bui l t our house, I did most of the contracting and that kind of stuff. So I'm not helpless. I would probably feel that for a while i f something happened to him, but I think I could pull myself together and manage. I feel that most women have a lot of strength when they have to, 82 myself included. I rea l ly think so. We have something extra that men don't have. I believe that. When i t comes to the crunch, we always come through. I rea l ly believe that. From the accounts given by the participants, i t was evident that the spouses continued to cope with the surgical experience by having confidence in the health care professionals and believing their mates were receiving the best health care possible. Hope appeared to be generated by the spouse believing their mates were in "capable hands" should something happen. Although some comments included nurses, most mentioned their strong faith in their mates' physicians. The following comments are presented to demonstrate the confidence expressed by the spouses about the providers of health care: "I have so much faith in the doctors and in the nursing staff that I real ly feel at ease." "I just put my faith in the people here and I hope that the right things are done, and I'm sure they are." "If anything goes wrong i t is unforeseen. They can make a mistake just l ike I can, but they do everything possible to recti fy their mistakes. I am fu l l of confidence in them." One spouse said: After having this operation, I knew she needed special care because i t ' s quite a shock to your system. I knew she had to be monitored on the different machines to make sure that everything is functioning properly and i f something does go wrong the nurses and the doctors are there. They can rect i fy or they can do something to help her along. And i f anything 83 goes wrong then there is somebody there, a trained person that knows exactly what to do and how to help her. By believing in their caregivers, individuals can obtain sufficient moral support and courage to face a l l problems with a state of emotional balance (Kraines, 1943). To sustain hope, individuals attempt to make sense of their rea l i ty by scanning the environment for clues (Lange, 1978). By believing they have grounds for hope, they are reassured (Lange, 1978). The spouses also generated hope by believing their mates were doing better than other patients. They began to compare their mate's condition with that of someone less fortunate. One spouse said, "It ' s nice to see the other patients because there is always somebody worse than you are." By seeking a frame of reference, the spouses compared their mates' recovery with that of others and were inspired with hope. The spouses also evaluated their mate's progress in relation to his/her previous condition. As the spouses compared their mate's present condition to his/her past condition, they were able to orientate themselves and make sense of their mate's recovery. Pearlin and Schooler (1978) report that by making positive comparisons, individuals are attempting to control the meaning of the situation. Since the meaning that is attached to an experience determines the threat posed by that experience (Pearlin & Schooler, 1978), by judging their mate's condition to be less severe than 84 another patient 's , the spouses were able to perceive the experience as less threatening and more hopeful. The way in which an individual perceives rea l i ty is the cognitive component of hope (Lange, 1978). The cognitive component of hope protects the affective components of hope from threatening rea l i ty facts (Lange, 1978). Thus, by interpreting and giving meaning to their experience in a cognitive way, the spouses were able to deal with their emotional reactions. Thus, generating hope emerged as an important coping strategy the spouses used to deal with the uncertainties of their post-surgery experience. Seeking information. The spouses continued to spend a great deal of time acquiring information about their mates' condition and the ICU environment. Individuals who are feeling helpless use "seeking information" as a coping strategy to feel more in control of a situation (Lazarus & Launier, 1978; Moos & Tsu, 1977). The spouses sought information from several sources such as the researcher, health care professionals, other patients' family members, and their mate. Although the spouses wanted to know about the purpose of each machine, they were mainly interested in seeking information about their mate's progress. The questions raised by the spouses indicated that they sought specific information about their mate's progress, but some had mixed feelings about hearing the answers to their questions. One spouse said: 85 I asked [the doctor] what advantage is there to this operation. Is i t going to, you know, make everything l ike i t was. I t ' s a question I have and yet I don't want to rea l ly go into i t . I want to know and yet I don't want to know. However, the participants a l l agreed that i f their mates were recovering poorly, they would want to know the truth. The spouses' accounts indicated that during this time they sought information about their mate's present condition, how their mate spent the night, v i ta l signs, medications, diet , removal of equipment, and estimated time of discharge from the ICU. It became evident that the spouses needed the information explained to them in a variety of ways, repeated often, and in terms that would help them understand the situation. It also became apparent that while a l l spouses wanted information about the ICU prior to their encounter with i t , some did not take advantage of viewing the hospital video on the care and equipment patients receive in the ICU following coronary artery bypass graft surgery. One spouse said, "I didn't want to watch the video. I'm a real chicken." The physicians were perceived by many of the spouses to be the most important source of information. Two spouses were uncertain about the nurse's role in relation to providing information. The following comments were made: "I don't know i f the nurses are allowed to t e l l you how they are actually doing," and "I always thought that i f you want to know more about the patient, you have to 86 refer to the doctor, but [my daughter] says the nurses wi l l explain to you i f you ask." The participants reported that the health care professionals were always wil l ing to answer their questions about their mate's progress. However the spouses stated that they only approached certain health professionals with their questions. If they perceived the health professional to be unapproachable, their questions went unanswered. The following comments were made: Usually I do ask questions, but I didn't ask today. I think i t a l l depends on who's s i t t ing there, what nurse is s i t t ing there. Some are very friendly and talkative and down to earth, and some just keep writing and minding their own business, so I didn't ask. Similarly, another spouse described her feelings: [The nurse] said maybe you should speak to [the doctor] again, so that he can explain to you what is going on. And at that point this guy came along, he happened to come into the room. And the nurse whispered something to him, and he said, "I've spoken to her." After a few minutes he came to me and said, "Are you getting a l l the answers to your questions?" I didn't quite l ike his attitude. It was very cold, that attitude. So whatever questions I may have wanted to ask would not come out, because I thought, "You wouldn't understand i f I asked you. So what's the point of me talking to you." So my answer is yes, i t ' s O.K. 87 The participants indicated that not only did they not understand the meaning of what they saw in the ICU, but they also did not have the knowledge and confidence to communicate with health care professionals. One spouse fe l t that i f he had asked, health care professionals would have told him what he needed to know. He said: My daughter told me I should ask what's that machine or what's that, or how's her heart, and does that indicate her blood pressure and the likes of th i s . And some people maybe do. I feel that I'm afraid to do that. I think the nurses would t e l l me how she fe l t and her blood pressure and how her heart i s . I guess i t is just , I didn't think I was shy, but maybe I don't know how to ask questions, specially with medical people l ike doctors and nurses. Inconsistent or inadequate information coupled with inabi l i ty to communicate with the mate's caregivers contributed to spouses' feelings of helplessness. The spouses continued to seek information from individuals who had already experienced coronary artery bypass graft surgery, either as a patient, or as a family member. However, they now sought information related to the ICU environment and recovery from coronary artery bypass graft surgery. Although these individuals were accessible sources of information, spouses were not always satisfied with what they learned from them. One spouse expressed his feelings: 88 We talked to other families when they were s i t t ing in the lounge, and we talked to other people that had this operation, before we came into hospital . We talked to some of them and asked them how things were going. Really, you don't learn much from them because everybody seems to play down everything. I guess they don't want to t e l l you how things are. And the people in the lounge there, they don't do that much talking. They don't seem to want to talk about the operation. And even some of the patients who had had the operation and were up here recuperating, even they didn't have that much to say. So rea l ly , you don't learn much from them. In their attempt to regain a sense of having some control, the spouses rel ied heavily on environmental cues to determine how their mates were progressing. Instead of depending solely on verbal communication with others, the spouses determined progress by comparing the mate's condition to that of other patients, observing for removal of equipment, and comparing the mate's present and previous status. One spouse spoke in defense of comparing: Although the doctor on the video says never compare your case with the next one because there is always a difference, you do. It is very hard not to compare because you meet over there in waiting time in between v i s i t s and you hear them say, "Oh my guy is doing f ine , he's out of intensive care," but my guy is s t i l l struggling in intensive care. You are beginning to 89 think, is my man rea l ly going to make it? And i t is d i f f i cu l t not to compare when you see these guys in the Intensive Care Unit. The guy that was operated on just the day before my husband and he's on his way out of intensive care, and my guy hasn't passed the f i r s t stage yet. Many of the participants indicated that they watched their mate's monitors as well as the monitors of the other patients, trying to obtain clues about their mate's condition. Although the monitors became an important source of information, they had d i f f i cu l ty interpreting the meaning of what they saw and heard. For example, one spouse said, "When I heard the bells and stuff today, I immediately thought something is wrong. His heart is stopping." One spouse described i t this way: We were told what the machines were measuring. That one recording those figures is the blood pressure and that's the pulse. Then you say, O.K. the pulse is normal around about 70 or 65. Then you see the blood pressure, what is the normal blood pressure around about 40 or something over 20. Any figures around about that or a l i t t l e higher or lower, you think f ine. He's not too bad, acceptable. But when you go in and see these figures are way out, you wonder what's happening. Since the monitors were an important source of information for the spouse, when they were not registering correctly, the spouse had d i f f i cu l ty in deciding how seriously i l l the mate was. One spouse 90 who rel ied heavily on the information from the monitors was upset when she was told the machine was inaccurate. She stated: The nurse must have realized we were a bit worried looking at the figures, and he came up and said, "Don't worry about the machine registering l ike that." You know, i f that machine is giving you vi ta l information about the patient's pulse and blood pressure, i t should be accurate a l l of the time. Why should i t keep going haywire? Then I say, how rel iable is that machine rea l ly . It happened so much that we began to wonder is the reading coming out now real ly the reading or is the machine playing up again. Then I would ask the nurse, "Is the machine registering correctly?" The participants also questioned information that was not compatible with the meaning they had assigned to their observations. One spouse described the following occurrence: When [my husband] began to talk a b i t , he wasn't very coherent and i t was d i f f i cu l t to sort of understand what he was saying and his movements were slow. I put i t down to intravenous and the things that were in him. Then i t began to worry me because he wasn't very coherent and sometimes he'd talk a bit of rubbish, and i t made me wonder what's going on. Has the anesthesia been too much for him, has i t affected his brain? Has he got brain damage? Is he going to be l ike this always? Has he had a stroke or something? And then I asked the nurse. 91 I said, "Did he have a stroke? Why is he l ike that?" She said no and reassured me that he hadn't. But even though she said that, you s t i l l have your doubts. Are the nursing staff hiding something from me? Are they not giving me the fu l l facts because they don't want to upset me? I mean, I can see what is going on, and people who've had a stroke behave l ike this . So he must have had a stroke. Even though the spouse had been reassured, she was s t i l l afraid because the information given was not what she needed to deal with her fear. The spouses, as active participants in the surgical experience, sought information from several sources in an active manner in order to determine the mate's progress and gain a sense of control in the ICU setting. They also sought ways in which they could become actively involved in the care of their mate. Helping mate. During the post-surgical experience, the spouses coped with their feelings of helplessness by attempting to be helpful to their mates. A l l of the spouses reported that they would do anything to help their mates, and at the same time, stay out of the health professionals' way. One spouse stated, "If I can make him comfortable in any way while I'm there and stay out of the nurses' way and let them do their job, then that's all I care about." Although a l l spouses desired to help their mates, some were uncertain about how to help. However, the majority of the spouses 92 reported they had the opportunity to participate in their mates' care, and identified the ways in which they had been helpful to their mates. Some talked about becoming involved in the physical care, such as bathing and shaving their mate. Others talked about the emotional help they had given their mates, such as encouragement and support. One spouse stated, "Everytime I went there, I knew what was expected of me, and the best thing to do was to keep her calm and not to get her more upset then she was." Another spouse commented that her presence and loving concern were important and essential to her mate's recovery. She said: The kind nurses wi l l attend to him and give him his medications to ease his suffering, his physical pain; but with what he is going through, he needs me there with him when he's going through i t . And i f he is not going to have me come and support him every day, he's going to feel terr ib ly alone, and he wil l have an added pain, an emotional pain. With respect to the extent of involvement that they wanted or were capable of, the spouses were able to recognize their strengths and weaknesses. They knew they lacked nursing knowledge about c r i t i c a l care, but they fe l t that they could communicate better with their mate than the health professionals could. One spouse said, "She would t e l l me things she wouldn't t e l l a nurse." The spouses also reported that i f the health professionals experienced d i f f i cu l t i e s in getting their mate to cooperate, they could 93 communicate with their mate and encourage them to cooperate. One spouse described her feelings this way: I think i f there is anything that the spouse could do to help the patient along and therefore help the doctors along, I would do i t , perhaps in talking to him, you know. I mean maybe through fear or something, the patient will just l i e there and won't respond. Maybe they are going through so much that they think, "What is the point?" They get frustrated. They just don't cooperate any more. We don't know what is going through their mind, so the only thing to do is to encourage him. So then I take i t upon myself in the course of my chatting with him and te l l ing him to get better soon. I bring up different things and say, whatever the doctors and nurses are te l l ing you, you must do exactly what they t e l l you because i f you don't cooperate with them, you're not going to come out from here, you're going to be longer in here. You must do what they ask you to do and then you ' l l get better. As stated ear l ier , individuals experiencing an i l lness require the assistance of family members to help them with their day-to-day l i v i n g . Strauss et a l . (1984) refer to protective agents as those individuals who help the i l l member by protecting him/her from harm and further worsening of the i l lness . During the post-surgery phases, the spouses continued to help their mates by acting as protective agents. They appeared to be attempting to protect their 94 mates in order that their condition would not worsen and their recovery would be fac i l i t a ted . Protecting their mate consisted of acting strong, withholding information, and avoiding potentially disturbing topics of communication. Al l of the spouses talked about "putting on a front" for their mate and "acting strong." This means that they would present themselves as strong, competent, and able to deal with the situation (Geary, 1979). They did not want their mates to know how fatigued and scared they were because they did not want to upset them. The following comments were made: Especially now, I tend to take more care and be very much aware of looking neat and fresh each time I walk into the intensive care unit . Even though I'm feeling t ired and just about ready to collapse, I've got to go into the washroom and I've got to tidy myself up and make myself look fresh, because i f he's going to see me haggard and t i red , i t is going to upset him. You don't want him to know that you are going through a rough period as well . Similarly, another spouse said: You've got to put up a good front no matter how lousy you feel before surgery, during, and whenever. You can f a l l to pieces now and then on your own, but you pull yourself together again before you see him. Geary (1979) reports that acting strong also serves an individual function. She states that as a result of acting strong, 95 individuals view themselves as competent and capable. The researcher noted that the spouses took pride in their ab i l i ty to control their emotions in front of their mates. However, they also reported that putting on a front for their mate was a " t e r r i f i c struggle" and consumed a great deal of energy. Some of the spouses wanted to spare their mates worry, and therefore, restricted the flow of information. While many of the spouses preferred not to openly discuss "bad news" in the mate's presence, others withheld information that might be potentially disturbing to the mate. One spouse said: They didn't do a t r ip le bypass as planned. They only did two because one vein was a l i t t l e small. I s t i l l haven't mentioned anything to [my wife] because, you know, she's doing so good and you don't l ike to say well , you only got a double bypass and not the t r i p l e . During this phase, the spouses attempted to be helpful to their mates and protect them from anything that could have a potentially adverse effect on the recovery process. Remaining near mate. When an individual is admitted to an ICU, family members remain nearby because they feel more comfortable knowing the situation and are also more l ike ly to receive information from health care professionals i f they are present (West, 1975). During the post-surgery phase, a l l of the spouses coped by remaining near their mates. It seemed to be d i f f i cu l t for 96 the spouses to be away from their mates for any length of time. One spouse said, "I want to be here a l l the time and I never wander away farther than just down the street to the restaurant and back again." This finding is consistent with Geary (1979) who also found that relatives of patients in the ICU cope by remaining near the patient. The spouses spent long hours in the waiting room. At this particular hospital , the waiting room is located on a different floor from the ICU. Although i t was a space the spouses needed to be with their families or the families of other patients, some spouses thought i t should be located just outside the ICU. The following comments were made: "I mean right outside there, there's no waiting room," and "I thought there should be a place right outside for someone to s i t . There i sn ' t even a seat out there." However, others fe l t the location of the waiting room did not create any problem. One spouse stated the following in defense of i ts location. It is just one floor away which didn't seem l ike a problem. In fact, I think i t is better because you know you are s i t t ing in the lounge there and talking to somebody or reading a book and then i t ' s time to go down and see how she's doing again, so you get up and walk around and down the stairs , and i t kind of gives you a l i t t l e more courage. It gives you time to think about what you are doing. The accounts further indicated that changes were made to enable the spouse to spend more time with their mate. For example, the 97 spouses from out of town relocated while others took time off from work in order to remain near their mate. One spouse stated, "I'm very fortunate to be temporarily unemployed so that I can v i s i t my husband any time of the day or night that I am allowed to . " Va i l lo t (1970) contends that hope is inspired in an i l l individual by having the family near. Remaining near the patient signifies that family members have not given up on the patient and they consider him/her to be s t i l l part of the family (Geary, 1979). By remaining near their mate, the spouses were actively demonstrating their support to their mate. At this particular hospital , v i s i t ing hours are from twelve noon to eight-thirty at night. Although the spouses appreciated the f l e x i b i l i t y in v i s i t ing during this time period, they reported that i t was important for them to see their mates when they wanted to and for as long as they wanted. As indicated in the following accounts, spouses know the amount of time they need to remain near their mate in order to f ac i l i t a te their ab i l i ty to cope. The f i r s t night I was allowed to see him about one half-hour after he returned from surgery and I didn't want to leave and I had to leave and I didn't want to. I wanted to be by his side. I didn't want to do anything else. Similarly, another spouse stated: I rea l ly think that being in there for five minutes, especially the f i r s t day, that's probably long enough anyway, because you 98 get a l l choked up and your stomach starts having butterf l ies , and you start to feel a l i t t l e bit afraid sometimes. So real ly , I think that's long enough. Thus, the amount of time needed to spend with the mates varied from one spouse to another. S t i l lwel l (1984) states that family members v i s i t ing in an ICU may have d i f f i cu l ty believing what is happening, which may influence the frequency with which they need to v i s i t their i l l relat ive. The spouses voiced that their presence was not only valued by their mates, but that i t was "important to their recovery." However, they reported that i f health professionals were busy with the mates or i f the mate was t i red , they were wil l ing to v i s i t at a more convenient time. I knew my husband wanted me to stay and he was feeling pretty good. He wanted me there. And i f I ever fe l t he was too t i red , and I hope I used good judgement, then I always got out of there because I know i t ' s important that he doesn't get over t i red . While the spouses provided comfort and support to their mates, they attempted to deal with the post-surgery phase of the surgical experience by drawing on the support of others. Developing a support network. Support has been defined as any action or behavior that assists an individual in dealing with the demands of a particular situation (Tolsdorf, 1976). Support may be 99 tangible, in the form of financial aid or temporary housing, or i t may be intangible, in the form of encouragement, soc iabi l i ty , or emotional support (Crauen and Wellman, 1973). Bott (1971) defines a network as " a l l or some of the social units (individuals and groups) with whom a particular individual or group is in contact" (p. 320). The participants' accounts revealed that health care professionals, other patients' family members, close friends, and relatives represented a number of individuals in the network who provided support for them during the post-surgical experience. While Hopson and Adams (1976) claim that the effective use of support can change feelings of powerlessness to feelings of self worth, McGee (1984) proposes that the perceived helpfulness of others constitutes an important dimension of hope. By developing a support network, the spouses were better able to cope during this time. This finding is consistent with the results of Tolsdorf's (1976) research work. Tolsdorf (1976) found "network mobilization" to be an important coping mechanism medical patients used following their perception of stress. Many spouses did not perceive the role of the nurse as providing support for family members; they believed that nurses were there to provide nursing care to the mate only. One spouse remarked, "As long as he's getting looked after, I shouldn't even worry about myself." However, although al l of the spouses agreed that the care of their mate was the "key thing," they also fe l t the 100 need for support from health care professionals. One spouse said, "It seems l ike everybody is so involved with the patient, and the wife or husband I'm quite sure is stressed out too." Another spouse verbalized her need for support this way: I see the nurse as being concerned about the spouse or the family, because the family is going through a lot of suffering as well just seeing their loved one over there suffering. The family is worried, but i f you get back reassurance from the nursing staff attending your husband or family member that's i l l , i t helps you. You don't go away so terr ib ly in despair, you know what's happening and you are part of i t . Especially, I take my own case, my husband and I are so close that i f either one is lying there, the other one is going through a hard time. And to get concerned nursing staff also looking after the feelings of the other half of the pair , then you don't feel cut off. You are treating the patient and bringing him back to l i f e , but there is another part of that same person who is sick in a different way and therefore also needs treatment by kindness, understanding or even perhaps a touch on the arm which means I care. Research has emphasized the role of social support in protecting individuals against the effects of stressors, and promoting an individual 's recovery from stress (McCubbin et a l . , 1980). Cobb (1976) reports that social support is a major factor in 101 helping individuals adapt to a stressful l i f e event. Norbeck (1981) agrees and adds that individuals are responsive to social support during times of stress and c r i s i s . Social support has been conceptualized as information leading the individual to believe that he/she "is cared for and loved, esteemed, and a member of a network of mutual obligations" (Cobb, 1976, p. 300). Thus, the information exchanged provides an individual with emotional support, leading the individual to believe that he/she is cared for and loved; esteem support, leading the individual to believe he/she is esteemed and valued; and network support, leading an individual to believe he/she belongs to a network involving mutual obligation and understanding (McCubbin et a l . , 1980). The spouses expressed a desire to receive support from the nurses, but perceived this to be unrealistic in the present health care system. I always thought the nurses were there just for the patient, not for the family. I don't see them as being supportive to the family, and that is not to say that they are not. It 's just that I haven't had much contact with them. They are professional people doing a great, great job in this hospital. My husband's care was exceptional, but they have so much to do, and under our present system, I'm not sure whether they would have the time to take care of the spouse too. Despite these feelings, health care professionals were reported as an important source of support. The specific kinds of support received from them came in the form of kindness, consideration, 102 understanding and reassurance. The spouses also indicated that being able to verbalize their experience and having someone l isten was invaluable. It helps to talk about the experience that you are going through. Especially i f you can get somebody who rea l ly l i s tens , you know. It 's not everybody you feel you can be free to talk with about your feelings. But when you talk about i t , i t ' s a big release and generally lessens the burden. Although the spouses had positive feelings towards the nursing staff they perceived the f i r s t nurse that took care of their mate as being "the best," " t e r r i f i c , " "real ly special , " and a "super human being," while the others "didn't seem to quite match up." One spouse described i t this way: The very f i r s t nurse that was at my husband's bedside when I saw him, I just loved her dearly. She was so supportive. I'm sure no matter which nurse had been standing there at that time, I would have loved. But, she was so compassionate, and so kind, and went out of her way to make me feel comfortable. I ' l l always remember her. Every nurse my husband had was real special . They were a l l excellent. But the f i r s t one was the best. However, i t seemed that although the spouses needed support from health care professionals, they needed the support of those who knew them best. As a result they sought the support of family members and friends. 103 When you feel very alone, you want somebody whom you rea l ly know. Because the nurse is kind and good, but she doesn't know you. You need somebody who rea l ly knows you and real ly understands what you're about. Why you are the way you are at the moment, and what sort of support you rea l ly need. It is only very close friends or family members who are real ly close to you that can give you that support, that understanding, that love that you need at this time. The comfort and support received from friends and family members was perceived to be the greatest source of support. The support received from them was nonspecific. The spouses were comforted by just being with them. For many spouses, the time they needed support the most was when they visited their mate in the ICU. For various reasons, family members were not always available to support the spouse during v i s i t ing hours. The participants mentioned the need to have a close friend with them at this time, but knew that was not in keeping with hospital regulations. As a result , they visited on their own. One spouse explained: I don't l ike going on my own to see him. Although I have to go when my son is at work, I watch the clock for my son to come. It seems that a l l I see going on with him is easier to take when I've got somebody with me. They restr ict the v i s i t ing to family members only and I take that to mean immediate family l ike sons, daughters, or wife. But there are times when I f e l t , when my son was at work, that i t would be helpful i f there could be a real ly very, very close friend with me. But restr ict ing i t to immediate family l ike when there is only one son, one ch i ld , when the child is not there, I'm left completely on my own. The family members who were perceived as a source of support were also seen as a source of stress. Some spouses referred to them as an "added burden." It seemed that during this time the spouses were too much in need of support to give much support beyond the needs of their mate. The following comments were made: For me i t was as I would imagine for any other parent, i t was an added sort of feeling of concern for the feelings of your ch i ld . You are concerned for what your child is going through. You see the sufferings of that child and that is an added hurt to you because of your husband's condition. You try to get him to talk as well about his feelings so that you can support him as well . So you get sort of l ike a double burden, but then also a shared burden. Similarly, another spouse described her feelings: Most of our children are [out of town]. And so there was just one son here and he was very supportive. But i f they'd a l l been here, I probably would have fe l t the burden because each one would need you. They'd be worried about their dad and everything. I would have fe l t spread too thin. 105 A research study that investigated the stress, support, and coping of medical patients, also demonstrated that stress originated from within the support network (Tolsdorf, 1976). While the spouses attempted to give as well as receive support, Tolsdorf (1976) found that individuals withdrew from the stress-producing portion of their support network in order to avoid the additional stress. The participants also reported receiving support from other patients' family members, particularly from those who had or were experiencing a similar stress situation. Other patients' spouses were perceived as being helpful because they offered encouragement and rea l ly "knew what i t ' s l i k e . " One spouse stated, "It gave you strength to know that you weren't alone, that there were other people in the same predicament you were, so i t helps you along quite a b i t . " Another spouse stated: We a l l sat there. There were two ladies whose husbands had been i n . And everybody is sort of mingling. And i t makes you feel l ike you're not alone. There're other people with problems and they a l l seem to be coming through alr ight, and there's no reason why you shouldn't. Thus the development of a support network appeared to be an essential aspect of helping the spouses cope with the stresses associated with the post-surgical experience. Reorganizing home routines and usual patterns of functioning appeared to be another way the spouses coped with the present situation. 106 Reorganizing roles and responsibilities. 01 sen (1970) points out that, Serious i l lness often precipitates a c r i s i s within the family, throwing the highly organized family system into disequilibrium. Established roles and rules must change to meet the c r i s i s , and the family needs to reorganize to gain a new equilibrium, (p. 169) Changes in roles and responsibil i t ies occurred for a l l of the spouses during the post-surgical experience. Role is defined as a "set of behaviors characteristic of or expected of an individual who is interacting with or reacting to another individual within the context of a particular social stratum or setting" (Bal i s tr iar i & J i r i cka , 1984, p. 180). Changes in roles and responsibil i t ies are reported to be common family occurrences following the i l lness of a family member (Anthony, 1970; Be l l , 1979; Brown, 1979). Usual patterns of family functioning may also be altered as a result of the i l lness of one family member ( J i l l ings , 1981). Meleis (1975) discussed role transition and reported that individuals add or delete roles from a preexisting set of roles when a health-illness transition occurs. The spouses discussed the roles they retained, relinquished, and acquired. It seemed that by reorganizing, the spouses were able to remain near their mates, and, at the same time, f u l f i l l their roles and responsibi l i t ies . Many spouses reported a disruption in their daily routines and the "mad rush" they were now experiencing. They spent long hours in 107 the hospital and stated they "did not have time" and "were not in the mood" to do anything in the house. They seemed too fatigued and disinterested to do anything that was not related direct ly to their mates. However, some responsibi l i t ies were considered essential and could not be deferred regardless of time and energy. I knew i f I didn't do the laundry I'd have problems because I was going to work the rest of the week. I knew i t had to be done, i t wasn't something I could say, oh forget that, I ' l l do i t when [my husband] is out of the hospital . That was something that had to be done. Many of the spouses stated they would "catch up on things they hadn't done" and resume their routines when their mate returned home from the hospital . Shifts occurred in long-established patterns of day functioning. Several spouses reported an increase in roles and responsibi l i t ies that previously had been shared or done by their mate. Such act iv i t ies included laundry, preparing meals, banking, and driving. Although these role changes were perceived to be temporary, some spouses recognized the benefits of being familiar with each other's responsibi l i t ies . One spouse made this comment: [My wife] is so well organized l ike you would not believe. She's the banker, she's handled a l l the money, she's handled a l l the business, a l l the affairs , everything. Now she comes into hospital and I want to phone one of her friends. I don't 108 even know where the phone book i s . A simple thing l ike that. The worst thing I have ever done is to rely on her l ike that, not looking over one another's shoulders. Now I've been doing a course on banking, how much we got and how much we owe. None of the spouses in the study had children l iv ing at home, but one spouse was responsible for the care of her elderly mother. She found this to be an added strain on her ab i l i ty to cope with her mate's i l lnes s . At times she experienced d i f f i cu l ty in getting help with the care of her mother. She said, I look after my mother, she's 80. I now have to make sure I get her somewhere to be looked after before I go to the hospital , because she can't see too well and her memory is rea l ly bad, so I daren't leave her alone. So i t is finding someone to come in or take her out besides worrying about everything else. In order to deal with day-to-day l iv ing during the post-surgery experience, the spouses reorganized their roles and responsibil i t ies to accommodate the changes imposed upon them. Summary This chapter has presented and discussed the spouses' experiences of having a mate in the ICU following coronary artery bypass graft surgery. The study found that the ICU experience is perceived to be one facet of the spouses' experience with their mate's coronary artery bypass graft surgery. The spouses described 109 and explained the surgical experience as consisting of three phases: pre-surgery; waiting during surgery; and post-surgery. The process of accepting open heart surgery as a solution to their mate's deteriorating condition was described as an important aspect of the surgical experience. During the interview process, the spouses attempted to attach meaning to their mate's coronary artery disease and its surgical treatment. It became evident that the spouses perceived coronary artery bypass graft surgery to be a life-threatening treatment for a life-threatening i l lness . The process of making sense of the ICU experience also involved an examination of the events that occurred prior to the intensive care phase of their mate's hospitalization. By making reference to prior events such as waiting for the surgery and waiting during the surgery, the spouses were able to interpret and attach meaning to the entire surgical experience. Throughout the interviews, the spouses described and explained the emotional impact of the entire surgical experience upon them. They discussed their reaction to the new set of circumstances created by each phase of the surgical experience. While fear of losing their mate occurred throughout the entire surgical experience, the participants' accounts revealed that spouses experience the greatest amount of anxiety while they are waiting during their mate's surgery. Kathol (1984) also found the intraoperative period to be the most stressful time for family members of surgical patients. The spouses also reported experiencing a variety of reactions during the post-surgery phase of the surgical experience. They described feelings of shock, helplessness, and being in the way. These findings support the research work of Mil ler (1983). Mil ler (1983) reports that threatening experiences and the uncertainty that accompanies i l lness may lead individuals to experience a sense of loss of control . The inab i l i ty of individuals to exert control over their environment results in uncomfortable feelings such as helplessness (Mil ler , 1983). In order to alleviate their perceived lack of control and deal with their emotional reactions, the spouses developed a repertoire of coping strategies. During the interviews, the spouses described the manner in which they dealt with the threatened loss of their mate during each phase of the surgical experience. The theme of "coping with the situation" emerged from the analysis of data and was largely supported by the research work of Lazarus and Launier (1978). Lazarus (1966) describes coping as a l l the strategies individuals use to deal with a threat. The coping strategies the spouses used to deal with the threatened loss of their mate were intended to alter the stressful situation or modify the emotional reaction e l i c i ted as a result of the stressful situation (Lazarus & Launier, 1978). Although the coping strategies varied somewhat during each phase, they were described as important aspects of the surgical experience that the spouses needed to explain. I l l Kleinman (1978) states that a l l attempts to understand sickness and its treatment can be thought of as explanatory models. By e l i c i t i n g the spouses' perceptions of their experience with their mate's coronary artery bypass graft surgery, the researcher was able to gain a better understanding of the spouses' explanatory model associated with a life-threatening i l lness experience. Kleinman (1978) proposes that e l i c i t i n g the c l i ent ' s explanatory model wi l l enhance health professionals' understanding of the c l ient ' s perspective and fac i l i t a te c l in i ca l communication and cl ient satisfaction with care. In this chapter the emergent findings were presented and discussed concurrently using pertinent l iterature in order to enhance understanding of the spouses' experience. The following chapter presents a summary and the conclusions of the study, as well as implications for nursing practice, education, and research. 112 CHAPTER FIVE Summary, Conclusions, and Implications for Nursing Summary y In this f inal chapter a summary of the study is presented, major conclusions are drawn, and implications for nursing practice, education, and research are delineated. This study was designed to gain an understanding of a spouse's experience of having a mate in the ICU following coronary artery bypass graft surgery. It was recognized that a serious i l lness with concurrent hospitalization in an ICU wil l have an impact on family members. Few researchers, however, have described the ways in which spouses are affected when their mates are hospitalized in an ICU. Therefore, this study aimed to describe and explain the spouses' perceptions of their experience with an ICU. It was further recognized that knowledge based on research about the spouses' perspective would provide a valid basis for decision making in the areas of c l in i ca l practice, education, administration, and research. Kleinman's (1978) conceptual framework guided the development of the research question and provided the focus for data collection and analysis. Kleinman conceptualizes the health care system as a sociocultural system consisting of three dist inct but interacting systems within which sickness is experienced and reacted to. These are the professional, the popular, and the folk. Each system may interpret and explain the same sickness episode differently. Kleinman has proposed that a l l attempts to understand sickness and its treatment can be thought of as explanatory models. Explanatory models are ways of experiencing and perceiving an episode of sickness and i ts treatment, and therefore, influence the behavior that perception evokes. Explanatory models can be e l ic i ted from individuals in each system of the health care system for a particular sickness episode. When individuals from the various systems interact, their explanatory models may conflict and impede the delivery of health care (Kleinman, 1978). By e l i c i t i n g the c l i ent ' s explanatory models, health professionals can predict conflicts which may arise when interactions between the popular and professional systems occur. Recognition of the differing explanatory models and attempts to negotiate between the discrepant explanatory models of clients and health professionals should prevent major conflicts and misunderstandings in health care transactions (Kleinman, 1978). Thus, Kleinman's conceptual framework directed the researcher to e l i c i t the spouses' explanatory models by exploring their perspective of their experience with the ICU. To determine the spouses' perspective, a qualitative research method based on the theoretical perspective of phenomenology was used. The phenomenological approach is congruent with Kleinman's conceptual framework since both emphasize that individuals perceive and give meaning to the rea l i ty they experience in everyday l i f e . 114 By u t i l i z ing a phenomenological perspective, the researcher was able to understand the spouses' ICU experience from their point of view. The researcher e l ic i ted the spouses' viewpoints through semi-structured interviews. The study sample consisted of seven spouses, four women and three men, whose mates were hospitalized in an ICU following coronary artery bypass graft surgery. The interviews were tape-recorded in order to have accurate verbatim accounts of the interviewee's responses. The spouses were interviewed on two occasions, once while their mate was s t i l l in the ICU and once shortly following their mate's discharge from the ICU. Data were collected using a semi-structured interview guide adapted from the work of other researchers (see Appendix F) . Additional questions were generated from the spouses' accounts in order to obtain c lar i f i ca t ion and/or elaboration of the spouses' responses. A total of 13 in-depth interviews were conducted over a 3 month period. During each interview, the participants explained how they interpreted and gave meaning to events that occurred prior to and during their mate's hospitalization in the ICU. The spouses' perspective of their experience became evident as they described and explained how they reacted to and coped with their mates' coronary artery bypass graft surgery. Data were analyzed simultaneously with and following data col lect ion. Responses that were similar were grouped together into categories. After the data were examined and sorted into 115 categories, the researcher defined the theme that dominated each category. The themes that emerged from the data were c l a r i f i ed , validated, and/or rejected by the participants during subsequent interviews. As relationships between the categories were identi f ied, the important aspects of the spouses' experiences became apparent. The findings revealed that the spouses located the ICU experience within the context of their experience with their mate's coronary artery bypass graft surgery. The spouses understood and made sense of the ICU experience by attaching meaning to specific events that related to the entire surgical experience. They perceived the surgical experience as consisting of three dist inct but interrelated phases: pre-surgery; waiting during surgery; and post-surgery. During each phase, the spouses described and explained how they reacted to and coped with each new situation. These two themes, "reaction to the situation" and "coping with the s i tuat ion," appeared as threads throughout the entire surgical experience. By organizing the data in relation to phases and themes, the researcher was able to meaningfully understand and communicate the spouses' entire surgical experience. A summary of the research findings are presented in Table 2 . 116 Table 2 Summary of Research Findings Phases Reaction to the Situation Coping with the Situation Pre-Surgery Ambivalence Fear Generating Hope Seeking Information Helping Mate Remaining Near Mate Waiting During Surgery Fear Anxiety Generating Hope Distracting Self Post-Surgery Shock Relief Fear Anxiety In the Way Helpless Preoccupation with Mate Generating Hope Seeking Information Helping Mate Remaining Near Mate Developing a Support Network Reorganizing Roles and Responsibilities Conclusions Interview responses from spouses whose mates have been hospitalized in an ICU following coronary artery bypass graft surgery have been presented and discussed in Chapter Four. In view of the study discussion, the following conclusions can be drawn: 1. Spouses of patients undergoing coronary artery bypass graft surgery have explanatory models which can only be understood by exploring their perspective of the i l lness experience. When given the opportunity, spouses are able to describe and explain important aspects of the experience and their meaning. 2. A spouse's experience with an ICU is located within the context of the entire i l lness experience. If the spouse's ICU experience is 117 to be understood, i t must be examined in relation to the entire i l lness experience rather than as a discrete, independent event. 3. Spouses of patients undergoing coronary artery bypass graft surgery experience a variety of reactions in response to the various aspects of the surgical experience. They u t i l i ze a repertoire of strategies to cope, but s t i l l require assistance to deal with these reactions. 4. Spouses of patients undergoing coronary artery bypass graft surgery are in need of support during the post-surgical experience. Health care professionals, other patients' family members, close friends, and relatives represent a number of individuals who provide support for them during this time. 5. Spouses of patients undergoing coronary artery bypass graft surgery may not in i t i a te conversation with health professionals. This does not mean they have no questions or concerns, but rather that they lack the knowledge and confidence to communicate with health professionals, that they perceive health professionals as not approachable, or that they simply do not want to "bother" the health professionals. 6. Spouses of patients undergoing coronary artery bypass graft surgery report waiting during surgery as the most d i f f i cu l t aspect of the entire surgical experience. 7. A life-threatening i l lness is not an isolated experience for the patient only. The surgical experience was associated with 118 changes for the spouse. Al l spouses reported experiencing changes in their roles and daily routines as a result of the surgical experience. 8. Despite exceptionally high success rates, coronary artery bypass graft surgery is perceived by spouses to be a life-threatening treatment for their mate's 1ife-threatening i l lness . Thus, deciding to proceed with coronary artery bypass graft surgery is a d i f f i cu l t decision for spouses to make. 9. The findings indicate that the spouse's fear of the ICU environment decreased as their knowledge and famil iar i ty with the equipment increased, and with constant reassurance from health care professionals. However, the fear associated with the poss ib i l i ty of losing their mate remained constant throughout the entire surgical experience regardless of the outcome of surgery. 10. Spouses of patients undergoing coronary artery bypass graft surgery need information explained to them in a variety of ways, repeated often, and in terms that help them understand the situation. Implications for Nursing Practice The purpose of this study was to understand the spouses' ICU experience in order to provide a valid basis for appropriate and timely nursing interventions. The findings of the study suggest several implications for nursing practice, which are not new or unique but are nonetheless important. 119 The findings suggest that a patient's life-threatening i l lness has an appreciable impact on his/her spouse. Since spouses influence and are influenced by their mates' i l lness (Litman, 1974; Olsen, 1970), a thorough nursing assessment should include an assessment of the spouses' perception of the i l lness experience and their needs. It should not be assumed that spouses perceive their mate's i l lness the same way health professionals do. In order for the nurse to determine the impact of the current situation upon the spouse, an ongoing assessment is necessary. Assessment of spouses of coronary artery bypass patients should include gathering information about their understanding of their mate's i l lness , the impact of the situation, and strategies used to cope with the situation. Planning for spouses of coronary artery bypass patients should include measures to promote the spouse's ab i l i ty to cope with the situation. Health professionals must know the usual reactions to a given situation, the typical coping strategies used to deal with the situation, and their role in f ac i l i t a t ing the coping process. Sensit ivity to the effects that hospital regulations and routine actions have on spouses may result in alterations with positive consequences for patients and spouses (Moos & Tsu, 1977). Nursing care should be planned with this information in mind. It is important to remember that a combination of coping strategies can more effectively help a spouse deal with the situation than a singly 120 used coping strategy (Pearlin & Schooler, 1978). However, spouses should not be encouraged to use a particular coping strategy just because i t worked for someone else. Thus, with effective planning, spouses can be better prepared to deal with the impact of a mate's i l lnes s . Spouses may be resourceful in the strategies they use to deal with the impact of the mate's i l lness . However, since spouses are unfamiliar with the ICU and the mate's condition is uncertain, they rely on the interventions of health professionals to help them cope with the situation. Nursing interventions should consist of creating a climate where spouses feel comfortable voicing their fears or concerns and asking questions. A spouse's f i r s t v i s i t to see his/her mate in an ICU is an extremely emotional time. Spouses need information about what to expect when they v i s i t their mate in the ICU. However, the information they receive may not condition them to see their mate unresponsive and surrounded by unfamiliar equipment (Owens, 1981). During this time spouses need reassurance that their mate is doing well . They also need to be encouraged not to be afraid of coming near the bed and touching their mate. Since v i s i t ing can be stressful , the nurse should validate with the spouse what his/her needs are at this particular time. With each v i s i t , nurses should provide information that is relevant to the spouse. In order to provide appropriate 121 information, spouses must be given the opportunity to articulate, from their point of view, what is important for them to know at that time. Providing information based only on a professional perspective may result in ineffective nursing care. Nurses should be mindful of the d i f f i cu l t i e s of learning in a stressful situation, and recognize that spouses may require the same explanation on consecutive v i s i t s to the ICU. Spouses may also need information explained to them in different ways. For example, findings in this study showed that while viewing the hospital video on the equipment and care patients receive in the ICU may decrease anxiety in some spouses, others refused to view the video because they believed i t would increase their anxiety. As indicated ear l ier , spouses v i s i t ing their mate in the ICU may not in i t ia te conversation with health professionals because they perceive health professionals to be unapproachable or because they do not want to bother them. Thus, i t is important for health professionals to remember that communication occurs verbally and nonverbally. It is recommended that an effort be made to communicate to the spouse, both verbally and nonverbally, that health professionals are there to provide care to the patient and his/her spouse. Spouses of patients undergoing coronary artery bypass graft surgery see themselves as protectors of their mates. They are anxious about their uncertain future and want to prevent their 122 mate's i l lness from worsening. Health professionals should acknowledge this role as a way in which spouses cope with the threatened loss of their mate. Since spouses "act strong" and avoid potentially disturbing topics of communication in their mate's presence, i t is suggested that nurses attempt to spend a few minutes with the spouse away from his/her mate's bedside. During this time nurses can answer questions, correct any misconceptions, and provide an opportunity for spouses to describe their reaction to what they have just seen and heard. Nurses may anticipate that spouses need to remain near their mate and be helpful to their mate in order to cope with the situation. However, nurses should avoid assuming that a l l spouses require similar involvement to f ac i l i t a te their coping. The spouses' perspective of what their own needs are must be taken into account. Requests for f lexible v i s i t ing privileges and involvement in patient care may require negotiations to occur between health professionals and the spouse. Kleinman et a l . (1978) suggest that in order for a mutual understanding to be reached between the popular and professional systems, both wil l have to explain their perception of the situation. Discrepancies between the explanatory models wil l have to be negotiated in order to reduce dissatisfaction with nursing care. Thus, i f the plan for nursing care is to be truly comprehensive, nurses must l isten to the concerns of the 123 spouse from the spouse's perspective and take these into account in the provision of nursing care. Implications for Nursing Education Nursing education should prepare the nurse to provide nursing care to spouses of patients experiencing a 1ife-threatening i l lnes s . Spousal relationships and the effect of the threat of loss on the spouse should be emphasized. Nurses must be prepared to assess spouses' reactions to the threatened loss of their mates and help spouses cope with their reactions. Ski l l s in assessing, planning, intervening and evaluating with spouses of seriously i l l patients should be part of a l l nursing programs. Al l nursing programs need to prepare students to e l i c i t the spouses' perspective of a particular episode of i l lness in order to gain a better understanding of their point of view. Nursing students should also be prepared to explain their point of view to the spouse. The students need to understand that an episode of i l lness may be perceived differently by spouses and health care professionals, and that these discrepancies may impede the delivery of mutually satisfying nursing care. Nursing students must realize that once there is a mutual understanding of why individuals respond to a situation in a specific way, then negotiations related to treatment and expected outcomes can occur. Cl inical strategies for negotiating between explanatory models in order to f ac i l i t a te mutually satisfying nursing care should be taught to students in a l l 124 levels of nursing education. The importance of working together to decrease conflicts and misunderstandings that occur between the various sectors of the health care system must be emphasized. The concepts of fear and hope should be included in nursing curricula and identified in the phases of the spouse's surgical experience. Opportunity should be provided for the student to provide nursing care to a spouse in each phase of the surgical experience. Implications for Nursing Research This study has provided further knowledge about the spouses' perspective which has contributed to the overall understanding of the effect of coronary artery bypass graft surgery on the spouse. In view of the findings, several areas for further study are suggested. In an effort to further c lar i fy the spouse's experience of having a mate in the ICU, a replication of this study might be conducted with modification of the sample. Perhaps the ICU experience is different for spouses of patients diagnosed with other disease conditions. Perhaps spouses of trauma patients or patients who are admitted to an ICU as a result of complications have a different experience with the ICU. Further investigations using in-depth exploration of the spouse's perspective could provide valuable insight into the ICU experience of a spouse whose mate has an acute or chronic condition. 125 This study provided data on how spouses retrospectively perceived the waiting period prior to and during surgery. Subsequent studies conducted during the actual waiting period would add to the body of knowledge about the spouse's experience prior to cardiac surgery. Further research is also needed to explore how and when spouses should be prepared for the ICU phase of their mate's hospitalization. It is clear that this is an extremely emotional time. Perhaps the amount, kind, mode of delivery and/or time of delivery of information will decrease the impact of the spouse's i n i t i a l contact with the ICU. Such knowledge is essential to the planning of effective nursing care. 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McLane (Eds.), Classif ication  of nursing diagnoses: Proceedings of the f i f th national  conference (pp. 352-355). St. Louis: The C. V. Mosby Company. 143 APPENDIX B Letter to Director of Nursing Service Dear I am a registered nurse and at present I am a student in the Master of Science in Nursing Program at the University of Brit ish Columbia. I am doing a study to describe the spouse's experience of having a mate in the Intensive Care Unit following coronary artery bypass graft surgery. My interest in this area developed through exposure to the spouses of my patients during my c l in ica l experience. I have worked in intensive care units for six years, and speci f ical ly with patients having coronary artery bypass graft surgery for three years. I believe that i f nurses are more aware of the spouse's experience, we can more effectively prepare others to cope during this period of hospitalization. To conduct this study, I plan to use the case study method in order to gain an in-depth understanding of the spouse's experience. I plan to interview the spouses of patients who have undergone coronary artery bypass graft surgery while the patient is s t i l l in the Intensive Care Unit and one to two days following transfer from the Intensive Care Unit. This study has been approved by the University of Brit i sh Columbia Behavioural Sciences Screening Committee. May I have your permission to conduct my study at your hospital? The reason I have selected your hospital is that the hospital has a well established intensive care unit for the care of patients having coronary artery bypass graft surgery. Therefore, obtaining my sample would be fac i l i ta ted due to the presence of this specialized unit in the hospital. In consultation with my thesis committee, I have planned methods for contacting patients, spouses and physicians. If these approaches are not in keeping with hospital procedure, please advise me so an approach acceptable to the hospital can be developed. I can be reached at the above address or phone I anticipate collecting and analyzing the data during the months of September to December 1984. I would be happy to share the results of my study with you. 144 Thank you for your time and consideration. I wil l be cal l ing your office in a few days for an appointment to discuss the study with you in further deta i l . Respectfully, JoAnn Cozac 145 APPENDIX C Physician Information Letter Dear Dr. My name is JoAnn Cozac. I am a registered nurse and at present I am a student in the Master of Science in Nursing Program at the University of Brit i sh Columbia. I am doing a study to describe the spouse's experience of having a mate in the Intensive Care Unit following coronary artery bypass graft surgery. My interest in this area developed through exposure to the spouses of my patients during my c l in i ca l experience. I have worked in intensive care units for six years, and speci f ica l ly with patients having coronary artery bypass graft surgery for three years. From my c l in i ca l experience, I have found that nurses need to know more about the spouse's experience during their mate's stay in the Intensive Care Unit following coronary artery bypass graft surgery. I believe that i f nurses are more aware of the spouse's experience, we can more effectively prepare others to cope during this period of hospitalization. To conduct this study, I plan to use the case study method in order to gain an in-depth understanding of the spouse's experience. I plan to interview the spouses of patients who have undergone coronary artery bypass graft surgery, while the patient is s t i l l in the Intensive Care Unit and one to two days following transfer from the Intensive Care Unit. This study has been approved by the University of Brit ish Columbia Behavioural Sciences Screening Committee and the hospital Nursing Research Committee. I wi l l be approaching patients who meet the following c r i t e r i a : 1. The patient must be admitted to undergo coronary artery bypass graft surgery during the time period for patient selection into the study. 2. The patient must be transferred to the Intensive Care Unit following coronary artery bypass graft surgery. 3. The patient must be able to understand, speak, and read English regardless of ethnic background. 4. The patient must l ive in the Vancouver area. 146 5. The patient must be married and reside with his/her spouse. After the head nurse of the cardiac teaching unit notifies me of patients under your care who meet my c r i t e r i a , I wil l contact you to discuss any questions or comments you may have about the study. Patients wil l then be approached in order that I may explain the purpose, nature, and implications of the study to them, before seeking their written consent to approach their spouses concerning participation in my study. I anticipate collecting and analyzing the data during the months of September to December 1984. I would be happy to share the results of my study with you. If you have any questions, please contact me at.the University of Brit ish Columbia, School of Nursing* Respectfully, JoAnn Cozac 147 APPENDIX D The Spouses' Experiences of Having a Mate in the Intensive Care Unit Following Coronary Artery Bypass Graft Surgery Patient Information and Consent Form My name is JoAnn Cozac. I am a registered nurse and at present I am a student in the Master of Science in Nursing Program at the University of Brit i sh Columbia. I am doing a study to describe the feelings, thoughts and reactions spouses have when their mate is in the Intensive Care Unit following surgery l ike yours. Therefore, I would l ike to talk to your spouse about what i t is l ike for him/her when you are in the Intensive Care Unit. From my experience as a nurse working in the Intensive Care Unit and my readings, I have found that nurses need to know more about what spouses feel when their mates are hospitalized in an intensive care unit . I believe that i f nurses are more aware of what spouses are experiencing, we can more effectively prepare others to cope during this period of hospitalization. I would l ike your permission to ask your spouse to participate in this study. If you agree, I wil l approach your spouse in person to explain the purpose, nature, and implications of the study. I wi l l then obtain your spouse's consent i f he/she is agreeable to participating in this study. If your spouse is agreeable to participating in this study, I wi l l interview him/her twice while you are in hospital. The interviews wil l be tape-recorded, but your name or your spouse's name wil l not be used anywhere on the tapes. The tapes wil l be made available only to myself and my three professors at UBC. The tapes wil l be erased after my report has been written. No names wil l be disclosed in my report. A l l information received wil l be confidential and grouped so that individual contributions wil l not be identi f iable . THERE ARE NO FINANCIAL BENEFITS TO PARTICIPATING IN THIS STUDY. YOUR DECISION TO GRANT PERMISSION OR NOT TO GRANT PERMISSION FOR ME TO APPROACH YOUR SPOUSE WILL NOT AFFECT YOUR CURRENT OR FUTURE MEDICAL OR NURSING CARE. YOU ARE FREE TO WITHDRAW YOUR CONSENT AT ANY TIME. YOUR SPOUSE IS ALSO FREE TO WITHDRAW FROM THE STUDY AT ANY TIME. PLEASE FEEL FREE TO ASK ANY QUESTIONS YOU MAY HAVE ABOUT THIS STUDY. 148 If you have any questions, please contact me at the University of Brit ish Columbia, School of Nursing L * * * * * * * * * * I, the undersigned, give permission to JoAnn Cozac, RN, BSN (MSN student) to approach my spouse in person to explain the purpose, nature, and implications of her study. I acknowledge receiving a copy of this consent. Patient's signature: Witnessed: Date: 149 APPENDIX E The Spouses' Experiences of Having a Mate in the Intensive Care Unit Following Coronary Artery Bypass Graft Surgery Spouse Information and Consent Form My name is JoAnn Cozac. I am a registered nurse and at present I am a student in the Master of Science in Nursing Program at the University of Brit ish Columbia. I am interested in learning about the feelings, thoughts and reactions of spouses while their mate is in the Intensive Care Unit, following coronary artery bypass graft surgery. Speci f ica l ly , I am interested in talking with you about what the experience is l ike for you during your mate's stay in the Intensive Care Unit. Most people find i t helpful to talk over their feelings with a health professional. In addition, I believe that i f nurses are are aware of the feelings, thoughts and reactions that spouses have, we can more effectively prepare others to cope with this period of hospital ization. Please feel free to ask any questions you may have about this study. This letter is to inquire i f you are wil l ing to participate in my study. I would l ike to interview you once or more often, and tape record the conversation. We wil l decide together how many interviews wil l take place. Each interview wil l be approximately one to two hours, and wil l be arranged at a time most convenient for you. The tapes of the interview wil l be available only to myself and my three professors at UBC. The tapes wil l be destroyed after the written thesis is completed. You may request that the tape recorder be turned off for any part of the interview. You may also request any tape or portion of a tape to be erased at any time during the study. THERE ARE NO FINANCIAL BENEFITS TO PARTICIPATING IN THIS STUDY. YOUR DECISION TO PARTICIPATE OR NOT TO PARTICIPATE IN THIS STUDY WILL NOT AFFECT THE CURRENT OR FUTURE MEDICAL OR NURSING CARE OF YOUR MATE. YOU ARE FREE TO WITHDRAW FROM THE STUDY AT ANY TIME, AND THIS ACTION WILL NOT AFFECT THE TREATMENT OF YOUR MATE. YOUR MATE IS ALSO FREE TO WITHDRAW HIS/HER CONSENT AT ANY TIME. YOU ALSO HAVE THE RIGHT TO REFUSE TO ANSWER ANY QUESTIONS. PLEASE FEEL FREE TO ASK ANY QUESTIONS YOU MAY HAVE ABOUT THIS STUDY. 150 Al l information received is confidential . Your name wil l not be included in the study materials. However, the overall results of the study may be published to promote an understanding of the concerns of spouses whose mates are in the Intensive Care Unit following coronary artery bypass graft surgery. If you have any questions, please contact me at the University of Brit ish Columbia, School of Nursing ^ * * * * * * * * * * I, understand the nature of this study and give my consent to participate. I acknowledge receiving a copy of this consent. Signed: Witnessed: Date: APPENDIX F Interview Guide* 151 The interview wil l begin with an examination of the purpose of the interview and the amount of time available for the interview. Demographic Data: In i t ia l s of Spouse: Spouse's Age: Patient's Age: Spouse's Sex: Educational Level: Occupation: Years of Married L i fe : Birthplace: Years in Canada: Prior Experience in the ICU Setting: F irs t Interview Sample Questions: Sample Questions: 1. How often have you visited your mate? What was that l ike for you? What did you expect i t to be like? 2 . How do you feel before you v i s i t your mate? How do you feel when you leave? 3. What treatment did you expect your mate to receive in the Intensive Care Unit? What treatment did you see him/her receive? 4. What is your understanding of the purpose of your mate's stay in the Intensive Care Unit? 152 5. Did you have contact with other patients and/or their families? 6. What has been the most d i f f i cu l t for you during your mate's hospitalization in the Intensive Care Unit? 7. Were there any areas of your everyday l i f e that were changed by this experience? In what way? 8. Who do you see as a support for you during this time? 9. How involved would you l ike to be in your mate's care? 10. What things do nurses do that you find particularly helpful for yourself during your mate's stay in the Intensive Care Unit? * The sample questions have been adapted from: Breu and Dracup (1978); Gauchie (1972); Hampe (1973); Potter (1979); Rasie (1980); and Roberts (1976). 

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