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Coping with angina pectoris following diagnosis Kent, Marjorie Anne 1985

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COPING WITH ANGINA PECTORIS FOLLOWING DIAGNOSIS By MARJORIE ANNE KENT B.N., Dalhousie University, 1976 A THESIS SUBMITTED IN PARTIAL FIJIJILIMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE I N N U R S I N G in THE FACULTY OF GRADUATE STUDIES (The School of Nursing) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1985 © Marjorie Anne Kent, 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 his 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 Nursing  The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date September 25, 1985 i i ABSTRACT COPING WITH ANGINA PECTORIS FOLLOWING DIAGNOSIS The purpose of this study was to determine how angina pectoris patients experience and cope with their chronic illness following diagnosis. Qualitative methodology, using phenomenological theory, was used to guide the study. The study was conducted with a convenience sample of six male angina patients, ranging in age from 42 to 72 years, with recency of diagnosis from two to thirty-four months. None of these subjects were known to have had a myocardial infarction (MI). Using a semi-structured interview guide with open-ended questions, the investigator interviewed each subject at home, on two occassions. Data coding and analysis were approached using the constant comparative method developed by Glaser and Strauss (1967). The findings of the study revealed angina patients progressing through four phases of coping experience as they adjusted to their illness and its concomitant need for risk modification. These phases were identified as: (1) I n i t i a l Coping Response; (2) Managing Specific Adjustment Areas; (3) Secondary Coping Response; and (4) Awareness of Resulting Changes. The findings supported the use of a chronic illness framework adapted from Strauss et a l . (1984) for identifying some of the adjustment areas encountered and coping strategies u t i l i z e d by the angina patients investigated. Nurses and other health professionals are - i i i -angina p a t i e n t s i n v e s t i g a t e d . Nurses and other h e a l t h p r o f e s s i o n a l s are i n a c r i t i c a l p o s i t i o n to a s s i s t angina p a t i e n t s i n coping w i t h t h e i r i l l n e s s . The phases o f coping experience i d e n t i f i e d i n t h i s study may serve as a u s e f u l guide to help these h e a l t h p r o f e s s i o n a l s assess the nature o f problems and concerns r e l a t e d to coping w i t h angina so that b e t t e r adjustment i n d a i l y l i f e w i l l ensue. - i v -TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v i i AC^OWI£IX5MENTS v i i i CHAPTER ONE - INTRODUCTION Background to the Study 1 Statement to the Problem 2 Conceptual Framework 3 Definition of Terms 5 Purpose of the Study 6 Assumptions 6 CHAPTER TWO - REVIEW OF RELATED LITERATURE The Coping Process 7 Meaning of Coping 7 Coping Styles and Strategies 9 Dimensions of Coping 10 The Intrapsychic Dimension 10 The Behavioural Dimension 11 The Social Dimension 12 The Meaning of Illness 13 Threat 13 Loss 15 Gain 16 Ins ignif icance 16 Coping with Chronic Illness 17 Coping with Coronary Artery Disease 21 Coping with ML 22 Anxiety 23 Denial 23 Depression 24 Aggressive Sexual Behaviour 24 Relationship to Angina Patients 25 - V -Coping with Angina Pectoris 26 Summary 27 CHAPTER THREE - METHODOLOGY Introduction: An Overview 28 The Research Setting 29 Sample Selection 29 Data Collection 31 Data Coding and Analysis 32 Reliablity and Validity Issues 33 CHAPTER FOUR - FINDINGS OF THE STUDY AND DISCUSSION I. Initial Coping Response 37 Downplaying 38 Reflecting Back 40 Responses Unique to Specific Individuals 42 II. Managing Specific Adjustment Areas 44 Interactions with Others 45 Health Professionals 45 Family 48 Others 50 Regimen Management 54 Evaluating Regimens 54 Diet Regimens 58 Exercise Regimens 60 Medication Regimens 62 Symptom Control 67 Fatigue 67 Angina Pain 68 Discovering Limitations 69 Job-Related Concerns 72 Effect on Job Performance 72 Dealing with Stress 73 Retirement/Financial Concerns 73 - v i -Attendant Psychological Concerns 76 Frustration 76 Acceptance 79 Future Implications 83 III. Secondary Coping Response 87 Basic Strategies for Illness in General 87 Taking Control 88 Normalizing 90 Continuation of Downplaying 91 Information Seeking 94 Basic Strategies for Specific Adjustment Areas 97 Coping with Fatigue 98 Managing Chest Pain 98 Eliminating Stress at Work 101 IV. Awareness of Resulting Changes 103 Concrete Changes Made 103 Changes Experienced 104 Physical Change 104 Psychological Change 105 CHAPTER FIVE - SUMMARY, CONCLUSIONS AND IMPLICATIONS FOR NURSING Summary and Conclusions 108 Implications for Nursing Practice 114 Implications for Nursing Education 118 Implications for Nursing Research 119 Summary 120 BIBLIOGRAPHY 121 APPENDICES 126 Appendix I - A Framework for Understanding the Experiences of Chronically 111 Persons 127 Appendix II - Physician Consent Form 128 Appendix III - Participant Information Letter 129 Appendix IV - Participant Consent Form 131 Appendix V - Participant Information Letter 132 Appendix VI - Data Collection Tool 134 Appendix VII - Sample Interview Guide 135 Appendix VIII - Relationship of Findings to Phases and Common Reference Points 136 - v i i -LIST OF TABLES Page Table 1 Characteristics of Subjects 35 Table 2 Phases and Common Reference Points 37 - v i i i -ACKNOWLEDGEMENTS I would l i k e to extend a s p e c i a l thanks to a l l o f the p a r t i c i p a n t s who so w i l l i n g l y shared t h e i r personal experiences. T h e i r input was in v a l u a b l e as i t provided c o n s i d e r a b l e depth and humanity to the data c o l l e c t e d . The w i l l i n g n e s s o f my Thesis Committee (Mrs. C a r o l J i l l i n g s and Miss Margaret K l i n g e r ) i n p r o v i d i n g such h e l p f u l guidance and encouragement, d e s p i t e t h e i r other commitments, was g r e a t l y a p p r e c i a t e d . L a s t l y , I would l i k e to express my s i n c e r e a p p r e c i a t i o n to my parents, f a m i l y and f r i e n d s who never ceased to o f f e r support and encouragement during t h i s research p r o j e c t . - 1 -CHAPTER ONE INTRODUCTION Background to the Study Coronary artery disease (CAD) is a significant form of chronic illness and represents one of the leading causes of mortality in Canada (Canada, 1983). Angina pectoris is a symptom of this chronic disease process. A diagnosis of angina pectoris serves as an indicator of a chronic health problem requiring specific medical therapies and l i f e - s t y l e alterations to reduce the risk of incurring a myocardial infarction (MI). It has been found that risk factors such as heredity, diet, sedentary l i f e - s t y l e , cigarette smoking, hypertension, personality type and stress may contribute to the angina patient's potential to develop an MI (Fardy, Bennett, Reitz, & Williams, 1980). Knowledge of the implications of having angina then, in terms of it s life-threatening connotation, may result in a disturbing emotional experience influencing the a b i l i t y to cope in both home and work environments. The psychological implications related to having angina are not specifically addressed in the literature. There is however an abundance of literature concerning the psychological responses of MI patients. For example, common emotional reactions to MI such as anxiety, denial and depression have been identified (Cay, 1982; Granger, 1974; Hackett & - 2 -Cassem, 1982; S c a l z i , 1973) . Granger (1974) f u r t h e r e x p l a i n s that d i f f i c u l t y i n a d j u s t i n g t o MI can occur i f these responses become too prolonged, too severe, or occur at an i n a p p r o p r i a t e stage during the recovery p e r i o d . Strauss et a l . (1984) i d e n t i f y major adjustment areas r e l a t e d to c h r o n i c i l l n e s s i n g e n e r a l . Some of these areas i n c l u d e : c o n t r o l l i n g p h y s i c a l symptoms; implementing p r e s c r i b e d regimens; coping w i t h change i n the course of the disease; and d e a l i n g w i t h attendant p s y c h o l o g i c a l , m a r i t a l and f a m i l i a l concerns. Coping w i t h the many dimensions of a ch r o n i c i l l n e s s such as CAD and i t s r e l a t e d syndrome, angina may t h e r e f o r e i n f l u e n c e the consequences o f the management of symptoms and s o c i a l r e l a t i o n s h i p s . Although a l i t e r a t u r e review revealed s t u d i e s which mainly described the experiences of i n d i v i d u a l s w i t h CAD and MI, research to date has not i n v e s t i g a t e d i n d i v i d u a l s s p e c i f i c a l l y diagnosed w i t h angina p e c t o r i s . This suggests t h a t a study of the i l l n e s s experience o f i n d i v i d u a l s w i t h angina p e c t o r i s should s t a r t w i t h the most obvious data s o u r c e — t h e angina p a t i e n t s themselves. Knowledge o f how these i n d i v i d u a l s experience and d e a l w i t h t h e i r angina w i l l a s s i s t nurses and other h e a l t h care p r o f e s s i o n a l s working w i t h angina p a t i e n t s to p r e d i c t and prevent problems r e l a t e d to coping w i t h angina, and to plan more e f f e c t i v e care regarding s p e c i f i c adjustment areas. Statement of the Problem The problem i n v e s t i g a t e d i n t h i s study was: How do i n d i v i d u a l s diagnosed w i t h angina p e c t o r i s experience and cope w i t h t h e i r i l l n e s s ? i - 3 -1. What are the experiences of individuals with angina following diagnosis? 2. How do individuals with angina cope with their i l lness following diagnosis? Conceptual Framework Strauss et a l . describe a framework for understanding the d i f f i cu l t i e s faced by the chronically i l l and how they cope with these d i f f i c u l t i e s . The framework emphasizes the social and psychological aspects of l i v i n g with chronic i l lnes s , as opposed to viewing i l lness s t r i c t l y in medical terms. In order to understand the daily experiences of chronically i l l persons, especially those l i v ing at home, this framework suggests ways to think systematically about the experiences of the chronically i l l . These authors claim that any disease is regarded as potential ly evoking multiple problems of dai ly l i v i n g . These problems may be related to: "1 . the prevention of medical crises and their management once they occur; 2. the control of symptoms; 3. the carrying out of prescribed regimens and the management of problems attendant on carrying out the regimens; 4. the prevention of, or l i v i n g with, social i solat ion caused by lessened contact with others; 5. the adjustment to changes in the course of the disease, whether i t moves downward or has remissions; - 4 -6. the attempts at normalizing both interaction with others and style of l i f e ; 7. funding—finding the necessary money—to pay for treatments or to survive despite partial or complete loss of employment; 8. confronting attendant psychological marital and family problems" (Strauss et a l . , 1984, p. 16). Patients must establish basic coping strategies when dealing with these key problems. Often the strategies require the assistance of family, friends and others who serve as various agents by rescuing, protecting, assisting and controlling individuals during the course of their i l l n e s s . In addition, the strategies require certain kinds of organizational or family arrangements for coping with the key problems (Strauss et a l . , 1984). For example, the parents of a diabetic child may teach friends and neighbours to be alert for signs of an oncoming coma. The man with a cardiac condition may make an agreement with his wife that i f she recognizes signs of fatigue in him, she w i l l warn him. Otherwise, he may run out of energy or develop chest pain. In addition to much trust and considerable interactional s k i l l , the establishment and maintenance of such arrangements may require certain medical, financial and familial resources. If these resources and a b i l i t i e s are deficient, significant consequences, which relate to the unsuccessful efforts organized to manage the key problem, may result. In summary, the major components of Strauss' framework which are necessary for understanding the experiences of chronically i l l - 5 -individuals include: key problems; basic strategies; and organizational and family arrangements and their consequences. In describing Strauss' framework i t is also important to emphasize the part the individual's perception of events plays in the experience of chronic i l l n e s s . Because this framework looks at the social and psychological problems faced by the chronically i l l and their families, i t may be adapted as a useful guide for studying individuals with angina pectoris as they experience their illness (Appendix I ) . By identifying some of the key problems and adjustment areas encountered by angina patients and by describing the coping strategies they use, an increased understanding of their experience may ensue. Definition of Terms In this study, the following definitions applied: 1. Coronary artery disease (CAD) - a disease process resulting from pa r t i a l or complete occlusion of one or more coronary arteries causing impairment of blood supply to the heart (Gazes, 1983). 2. Myocardial Infarction (MI) - a coronary occlusion, with resulting infarction of myocardial tissue, which is usually due to CAD (Gazes, 1983). 3. Angina Pectoris - a syndrome of CAD which is often manifested by paroxysms of pain in the anterior chest related to a disproportion between myocardial oxygen requirement and oxygen supply (Gazes, 1983). - 6 -4. Social and psychological problems - the nonmedical concerns encountered by angina patients as they live their lives in the face of their chronic illness (Strauss et a l . , 1984). 5. Adjustment areas - the l i f e - s t y l e changes (prescribed and non-prescribed) which are necessary for angina patients to make in relation to l i v i n g with their i l l n e s s . 6. Coping - the manner in which adjustments are made in response to diagnosis and management of one's i l l n e s s . Purpose of the Study The purpose of this study was to describe and explain how angina patients experience and cope with their i l l n e s s . Assumptions The researcher approached this study with the following assumptions: 1. A new diagnosis of angina pectoris has meaning for the adult and this meaning has an effect on the person's l i f e . 2. Individuals are willing and able to communicate this meaning to others. 3. Individuals may or may not become involved with making changes to their l i f e - s t y l e following a diagnosis of angina pectoris. 4. Adjusting to these changes may have a significant impact on the individual's way of l i f e . - 7 -CHAPTER TWO REVIEW OF RELATED LITERATURE When surveying the literature related to the study questions, three major areas were selected for review due to their relevance in explaining and describing the experiences of individuals coping with angina. These areas are: (1) the coping process; (2) coping with chronic illness; and (3) coping with coronary artery disease (CAD) and its related syndromes, myocardial infarction (MI) and angina pectoris. The Coping Process Meaning of Coping Coping has been defined in various ways by different authors. One psychologist, Richard Lazarus, describes coping as "strategies for dealing with threat or harm" (Lazarus, 1966, p. 151). Lazarus and Launier (1978) further explain these strategies as action-oriented and intrapsychic efforts expended by individuals to manage environmental and internal demands which overtax their resources. These authors also identify four modes of coping which a person may use for altering a troubled person-environment relationship or for controlling the emotion related to the situation. These modes include: (1) information seeking; (2) direct action such as fight or fli g h t ; (3) inhibition from - 8 -actions which may be impulsive, dangerous or embarrassing; and (4) intrapsychic modes where attempts are made to ignore or withdraw attention from the threat, minimize i t and seek r e l i e f in fantasy. Lazarus and Launier (1978) imply that the use of these modes varies according to the situation and is influenced by such factors as degree of uncertainty, degree of threat, presence of conflict and degree of helplessness. Murphy (1962) views coping more broadly. She emphasizes the problem-solving aspect of coping where efforts are aimed at mastering new situations or problems in order to meet l i f e demands and goals. This view of coping is more general as i t includes both threatening situations as well as those in which coping is synonymous with problem-solving. Murphy seems to view coping as a challenge. She refers to mastery as the aim of coping in meeting problems and d i f f i c u l t i e s , while Lazarus is mainly concerned with the process of coping with threat. Lipowski (1970) takes advantage of both views when conceptualizing coping in relation to physical i l l n e s s . He sees the sick person not only dealing with situations that provide conflict and threat, but also as adjusting to the tasks and challenges of his l i f e through application of psychological resources. This view of coping seems to have relevance for angina patients who must deal with such threats as chest pain, decreased energy levels, and possible progression of their disease. They must also adapt to tasks and challenges related to l i v i n g with their illness such as risk modification and job maintenance. - 9 -Coping Styles and Strategies According to Lazarus (1966), coping behaviours are possible ways of dealing with conditions of harm or threat. They are characterized by one's coping style as well as the coping strategies used (Lipowski, 1970). Lipowski (1970) describes coping style as an individual's characteristic way of perceiving, thinking, problem-solving and acting when organic disease develops. He goes on to explain that coping strategies are developed from both an individual's coping style as well as the situational variables. Previously established strategies which have served similar functions in earlier stressful situations are l i k e l y to be used f i r s t . When these are not sufficient, new strategies are developed. According to Hamburg and Adams (1967), such strategies, i f effective, are l i k e l y to broaden an individual's problem-solving capability. Lipowski (1970) distinguishes between two types of coping styles: cognitive and behavioural. Under "cognitive coping styles," he describes two different ways of cognitive functioning in relation to physical i l l n e s s . They are: (1) minimization and (2) vigilant focusing. Minimization refers to a tendency to ignore, deny or rationalize the personal significance of one's illness and i t s consequences, regardless of the nature and severity of the illness. Vigilant focusing, on the other hand, refers to persistent efforts to reduce uncertainty concerning one's illness by seeking a l l relevant - 10 -information and constantly trying to make sense out of the illness experience. Lipowski (1970) describes "behavioural coping styles" as predominant action tendencies which different individuals exhibit in response to il l n e s s . These include: (1) tackling, where active measures are sought in response to challenges and tasks posed by an illness; (2) capitulating, characterized by passiveness toward combating illness and achieving maximum recovery; and (3) avoiding, where active attempts are made to escape from the demands of one's ill n e s s . Dimensions of Coping Lipowski (1969) describes coping in response to physical illness in terms of three dimensions: (1) the intrapsychic; (2) behavioural; and (3) social. The Intrapsychic Dimension This aspect of coping refers to the perceptual, cognitive and emotional components of one's total response to il l n e s s . Individuals often i n i t i a l l y respond to their disease with the perception of bodily change (perceptual component).. They may habitually overreact to pain or disregard or even deny i t s significance. Evaluation of this perception (cognitive component) can differ from one individual to another, as influenced by personality type, knowledge level, cultural background, current emotional state and so forth. - 11 -Olin and Hackett's (1964) study illustrates how MI patients may vary in the way they evaluate serious symptoms of disease. For example, their study revealed that the subjects who correctly suspected a heart attack delayed seeking medical help for their chest pain, on average, 10.3 hours, which was twice that of those patients who did not suspect a heart attack. Once illness is medically confirmed, individuals may respond with a whole spectrum of emotions (emotional component) such as anxiety, depression and grief. These emotional reactions may become pathological due to their intensity and inappropriateness to the situation (Lipowski, 1969). The Behavioural Dimension This aspect of coping response to disease refers to actual coping behaviours (Lipowski, 1969). Coping behaviours may be adaptive or maladaptive (Lazarus, 1966, 1968; Lipowski, 1969). Adaptive coping in response to illness is most desirable and may include such behaviours as seeking expert advice, cooperating with therapeutic regimes and developing alternate sources of satisfaction. Maladaptive coping, on the other hand, may include such behaviours as withdrawal, passive surrender to il l n e s s , over-dependence on others, self-destructive behaviours and so on. Other events occuring in a person's l i f e , such as the problems and concerns he is having to deal with and the emotions he is experiencing, may also be associated with less effective coping (Lazarus, 1974). - 12 -Coping behaviours may be influenced by: (1) intrapersonal factors such as a person's age, personality and intelligence; (2) disease-related factors such as the nature, duration and rate of the pathological process; and (3) environmental factors such as the quality of current interpersonal relationships as well as physical milieu (Lipowski, 1969, 1970). The relative importance of these factors w i l l undoubtedly vary from case to case and therefore must be evaluated in each patient. The Social Dimension This aspect of coping response to illness concerns the patient's interactions with others and in particular his family and health professionals (Lipowski, 1969). The ease with which a person accepts himself as being i l l depends on the kind, severity, and duration of disease as well as on psychological and sociocultural factors. For example, the angina patient who views illness as a weakness and as a loss of independence, may have a d i f f i c u l t time accepting his i l l n e s s . Being i l l may also involve social consequences. Disapproval by others may be seen i f one's sick role is thought to be exaggerated or prolonged. On the other hand, the sick role may be encouraged by some family members who wish to play a stronger, supporting and controlling role. - 13 -The Meaning of Illness Central to an individual' s coping response to illness is the meaning which he attaches to i t . It is believed that the personal meaning or appraisal of a l l the information received by the patient in relation to his illness is directly related to his coping response (Hamburg & Adams, 1967; Lazarus, 1968; Lipowski, 1969, 1970; Miller, 1983). In her study measuring coping responses of medical/surgical patients, Graydon (1984) found that patient coping was not influenced by an objective assessment of the severity of the medical diagnosis but rather by the patient's personal appraisal of his il l n e s s . Lipowski (1969) states that the personal significance attached to one's illness strongly influences both the emotional and behavioural aspects of his coping response. An attempt to understand why patients feel and act in a particular manner then can involve an assessment of their subjective interpretations of the events related to their il l n e s s . Lipowski indentifies four broad categories of personal meaning of events related to il l n e s s . They are: (1) threat; (2) loss; (3) gain; and (4) insignificance. Threat Threat implies anticipation of personal danger or harm in relation to an event whose occurence could cause physical or mental anguish (Lazarus, 1966; Lipowski, 1969). Hamburg (1967) explains that - 14 -the salience of a given factor, such as illness, to one's motives and values and the conflict among these motives and values is v i t a l to one's appraisal of threat. His studies of patients with severe illness a l l center on major transitions requiring alterations in way of l i f e . He found that i n i t i a l l y efforts were made to minimize events. Later, in their wish to overcome the threat of illness, these same patients became highly motivated to face the reality of their illness and deal with i t constructively. It has been suggested that one deals with the knowledge of a life-threatening illness in stages (Crate, 1965; Kubler-Ross, 1969; Pattison, 1977; Weisman, 1972). Although these authors are not in complete agreement as to the nature of the stages of life-threatening il l n e s s , there does seem to be some general consensus that the incorporation of the threatening aspects of an illness is essential to reduce anxiety following confirmation of the diagnosis. For example, angina patients may react with alarm when they begin to experience increased episodes of chest discomfort. As a result, their perception of threat may intensify as they interpret such symptoms as precursors of an ominous event such as a heart attack. The coping strategies used by such individuals, in order to reduce their anxiety related to this anticipated danger, may range from unconscious use of defense mechanisms (such as denial or danger), to intake of sedatives or alcohol, to compulsive overwork, and so on. Loss When associated with illness, loss may refer to deprivation of significant needs and values including self-esteem, security, and satisfaction with body parts and functions (Lipowski, 1969). The emotional response to actual or potential loss can take the form of a grief reaction (Dovenmuehle & Verwoerdt, 1962; Engel, 1964; Lindemann, 1944; Lipowski, 1969; Pranulis, 1972; Reiser, 1959). Lindemann (1944, 1961) states that grieving is a pattern of reaction to loss and that grieving reactions of hospitalized patients may be perceived as a loss of function. He offers two explanations: (1) grieving can be seen as a particular form of role transition where societal and familial role functions must be redesigned on a major scale; (2) there is a psychological reaction called forth by the anticipation of a threatening situation with the rehearsal of future-oriented coping strategies related to anxiety-arousing events. This is similar to grief. It is possible that people with angina may view their illness as a loss of potential for certain a c t i v i t i e s and role functions. In coping with the l i f e - s t y l e alterations related to their illness, these patients must work through this loss as well as the malfunction within their bodies and the anticipatory threat of possible death (Dovenmuehle & Verwoerdt, 1962) . - 16 -Gain The concept of gain related to illness refers to a sense of r e l i e f associated with the satisfaction derived from dependence upon others, the a b i l i t y to take control of others by using one's illness to arouse their guilt and/or the ensuing respite from roles and responsibilities (Lipowski 1969, 1970). For example, the angina patient who is struggling with deciding when to retire may be relieved when his doctor advises him to do so for health reasons. There are times when individuals are not consciously aware of the meaning of their i l l n e s s . They may lament in good faith the fact that they are i l l , yet their behaviour may indicate r e l i e f rather than loss. In general, when subjective gains related to illness outweigh the losses, patients are lik e l y to develop emotional disturbances when their condition improves (Lipowski, 1969). Insignificance Insignificance means that there is a relative lack of personal importance associated with one's symptoms of illness (Lipowski, 1969). For example, i n i t i a l symptoms of angina such as fatigue may be disregarded by the angina patient i f they do not pose any significant threat to him. Coping With Chronic Illness Coping with chronic illness may be different from coping with other types of illnesses, especially those of an acute nature (Craig, & Edwards, 1983; Dimond & Jones, 1983; Miller, 1983). F i r s t of a l l , chronic illness differs from acute illness in a number of dimensions (Dimond & Jones, 1983). Chronic illness is permanent and irreversible, while acute illness usually leads to recovery. The acutely i l l person is also permitted to depend on family and others to relieve some of his responsibilities, as i t is understood that this w i l l be only temporary. In chronic illness, dependency over a long period of time is not apt to be accepted by either the individual or others (Dimond & Jones, 1983). Once chronic illness is confirmed by a physician, the affected individual's social and personal obligations must be redefined so that they are more in keeping with the individual's actual capabilities (Dimond & Jones, 1983). As chronic illness begins to progress, the individual may lose control of activities of daily l i v i n g and bodily function. He may also f o r f e i t his identity as a healthy person and succumb to lack of physical and social stimulation (Craig & Edwards, 1983). The impact of such losses w i l l depend upon the individual's subjective appraisal of their meaning. In other words, this i n i t i a l appraisal of chronic illness is affected by the personal meaning of that illness for the individual. The individual's perception and ensuing response to symptoms of his - 18 -chronic illness are influenced by the function of the nature of the symptoms (Kasl & Cobb, 1966). In some cases, a person may experience continuous, and sometimes frightening and disturbing, symptoms. The significance attributed to these symptoms and the decision to report them depends on many factors, some of which include previous modes of dealing with illness symptoms in the past (viz., coping style), the response of others to continuous reporting of symptoms (viz., interpersonal relationships) and the knowledge that reporting such symptoms w i l l be beneficial (viz., cognitive capacity). In other cases, individuals may control their symptoms by refraining from ac t i v i t i e s that they know w i l l bring on symptoms (Dimond & Jones, 1983). For example, the angina patient may avoid heavy l i f t i n g in order to prevent chest pain from occuring. Some chronic conditions remain stable only when therapeutic regimens are followed. In these situations, individuals may respond to symptoms more closely by adhering to treatment regimens. In effect, the chronically i l l person must be a manager of his own care and therefore must have sufficient knowledge to make appropriate decisions related to his il l n e s s . For example, a chronically i l l person might have to decide whether to continue taking prescribed medications i f he continues to feel well, sees no change in symptoms from taking the medications, yet experiences uncomfortable side effects from them. Such decisions must have an appropriate balance between the benefits of risk reduction and the cost of compliant behaviour (Kasl, 1974). Some chronic illnesses may require major - 19 -changes i n l i f e s t y l e (such as smoking, d ie t and phys ical a c t i v i t y ) i n addit ion to fo l lowing a medical regimen. Even i f these changes are recognized as necessary for r i s k reduction, they may be d i f f i c u l t to comply w i th , depending on the i r s ign i f icance fo r the ind iv idua l (Dimond & Jones, 1983). Certain coping responses have been associated w i th chronic i l l n e s s . Craig and Edwards (1983) i den t i f y four which are commonly u t i l i z e d : (1) minimizing the seriousness of losses re su l t i ng from the chronic i l l n e s s through use of defense mechanisms such as den ia l , p roject ion and d i sassoc iat ion of emotions; (2) using personal and extra-personal resources, s im i l a r to v i g i l a n t focusing as described e a r l i e r ; (3) set t ing concrete goals and expectations using r e a l i s t i c problem-solving s k i l l s ; and (4) using hope to provide meaning to l i f e . M i l l e r ' s (1983) study of adults wi th chronic health problems reveals s im i l a r f indings. She dist inguishes between two major categories of coping strategies which the subjects used i n dealing wi th the i r i l l n e s s : (1) approach st rateg ies, most common of which had to do with seeking information and enhancing s p i r i t u a l l i f e and (2) avoidance st rateg ies, of which the most frequently used were den ia l , repression and suppression, minimization of i l l n e s s symptoms and the i r consequences, and withdrawal from others. Both Chodoff (1962), i n h i s study of pat ients wi th mult ip le s c l e ro s i s , and Busse (1962), i n h i s comments about emotional complications of chronic i l l n e s s , p a r t i c u l a r l y i den t i f y the use of den ia l as a means of f i gh t i ng the c o n f l i c t s associated w i th chronic i l l n e s s . Chodoff remarks on the tendency fo r chron ica l l y i l l persons to - 20 -become egocentric and more dependent on others. Busse further explains that the recognit ion of th i s dependency may lead to exhib i t ions of increased i r r i t a b i l i t y and anger. Gorman and Anderson (1982) see denia l as an e f fec t i ve coping mechanism. In t he i r study of chronic renal disease pat ients , they found that the use of denial helped these pat ients adjust to the impact of diagnosis by al lowing them time to deal w i th complex emotional feel ings and incorporate the chronic i l l n e s s into the i r l i v e s . As previously discussed, the emotional response to loss i n r e l a t i o n to phys ica l i l l n e s s may take the form of a g r i e f react ion. This g r i e f react ion has also been associated wi th coping responses to chronic i l l n e s s where ind iv iduals undergo a period of mourning before they are able to accept losses i n the form of a l tered body image and/or loss of body funct ion (Chodoff, 1962; Craig & Edwards, 1983). In s pec i f i c , Crate i den t i f i e s f i v e stages of coping w i th chronic i l l n e s s i n keeping wi th the gr iev ing process described by Engel (1964). The pattern of events include: (1) d i sbe l i e f ; (2) developing awareness; (3) reorganization of re lat ionsh ips with others; (4) reso lut ion of the loss ; and (5) i den t i t y change. Once the f i n a l stage i n the process i s reached, the ind i v idua l i s more able to l i v e with his/her i l l n e s s and i n some way can cope with i t by coming to terms with i t s l im i t a t i on s . Although chronic i l l n e s s i s both permanent and i r r e ve r s i b l e , the rate of progression may vary, as i t re lates to plateaus and remissions. Chronical ly i l l persons must learn to adjust to the l im i ta t i on s of t he i r i l l n e s s at i t s various stages by cont inual ly appraising the i r s i tuat ion and the effectiveness of the i r coping. - 21 -Coping with Coronary Artery Disease A primary aim in this section is to develop an understanding of coping strategies used by patients with CAD and i t s related syndromes. Reiser (1951) addresses the psychological consequences related to CAD in general. He explains that patients with CAD have to integrate the awareness of the illness into their self-concept. Their a b i l i t y to objectively accept a r e a l i s t i c appraisal of their limitations depends on their personality structure, the specific meaning of heart disease, and the attitudes assumed by those about them. Reiser contends that reactions of depression, due to feelings of hopelessness and anxiety or guilt over needs of dependency, may represent a threat that leads to irrational denial and self-destructive behaviour. Niven (1976) discusses potential problems associated with CAD and their management within a framework of three phases of chronic il l n e s s . These phases are: (1) the period from onset of symptoms to diagnosis during which denial of symptoms due to heart disease and rationalization concerning their etiology are prominent; (2) the period from diagnosis to stabilization of the disease process requiring compliance with necessary medical therapy and changes in l i f e - s t y l e ; and (3) the chronic adjustment period following stabilization u n t i l recovery or death. Niven describes common d i f f i c u l t i e s related to work, sexuality and avocational activities as being associated with this latter phase. These problems are often manifested by anxiety, depression, and - 22 -hypochondriacal complaints, noncompliance with treatment and withdrawal from a c t i v i t i e s (Niven, 1976). Dovenmuehle and Verwoerdt (1962) studied depressive symptomatology as i t applied to patients with various forms of CAD such as arteriosclerotic heart disease, MI and cardiac heart failure. It was found that 64 percent of the subjects had depressive symptoms of a moderate or severe degree. These investigators suggest that the severity of the depressive reaction is related not only to the severity of the physical disease but also to the frequency of hospitalizations which served as a stimulus to which the subjects responded with depressive affect. Coping with MI The majority of studies concerning coping reactions to heart disease focus on patients who have suffered an MI. Because individuals with angina pectoris are at risk to develop MI (Levenson, Kay, Monteferrante & Herman, 1984) and may be involved with similar l i f e - s t y l e changes (Fardy, Bennett, Reitz, & Williams, 1980), the research concerning MI patients may be applicable to individuals with angina pectoris. In spite of differing individual reactions to MI, a consistent pattern of response has been identified (Scalzi 1973): anxiety; denial; depression; and aggressive sexual behaviour. - 23 -Anxiety Anxiety post MI has been explained i n response to fear of dependency and poss ible death (Cay, 1982; Cleveland & Johnson, 1962; Hackett & Cassem, 1982). Anxiety i s s i gn i f i can t as i t forms the basis for other behavioural responses to MI ( S c a l z i , 1973). For example, how ind iv iduals perceive t he i r MI as a threat w i l l influence the anxiety they experience and therefore how they cope with that anxiety. They may become angry and ho s t i l e or withdraw into a state of depression. According to Cay (1982), anxiety i s frequently disguised i n the form of hypochondriases, overdependence and aggression. Denial This response i s often used to a l l e v i a t e the anxiety ( S c a l z i , 1973). Hackett and Cassem (1982) studied a group of MI patients who cons i s tent ly denied that t he i r hearts were severely damaged and that they feared death. The "major deniers" i n the group refused to acknowledge any concerns, e i ther about the i r disease or about t he i r being able to return to the i r former way of l i f e and work. The " p a r t i a l deniers, " on the other hand, tended to minimize any fear they might have experienced and ra t i ona l i zed symptoms of t he i r heart attacks as ind igest ion, muscle s t r a i n and so f o r th . Denial may be prognost ical ly favourable f o r acute MI pat ients (Hackett & Cassem, 1974; Sheehan & Hackett, 1978; So lof f & Ba r te l , 1979). In f ac t , many physicians support - 24 -denial of illness rather than encouraging their patients to immediately face the r e a l i t i e s of their illness (Beisser, 1979). Depression After the shock of what has happened to the MI patient begins to subside, rea l i t y sets in. It becomes more d i f f i c u l t to use denial as the MI patient begins to think about how his way of l i f e w i l l have to change (Scalzi, 1973). Holding on to the things that the ML patient knows w i l l soon have to be changed or given up w i l l cause depression to develop. Depression may also result from feeling anger and guil t for having maintained certain l i f e - s t y l e habits that may have caused the heart attack (Scalzi, 1973). Hackett and Cassem (1982) claim that depression, following an MI, results from a sense of weakness and vulnerability leading to concern about a b i l i t y to function in previous roles. It may be reflected in terms of an over concern with physical symptoms and medications (Cay, 1982). Aggressive Sexual Behaviour This is a common behavioural response in male patients following an MI (Rosen & Bibring, 1966; Scalzi, 1973). Inappropriate sexual behaviour results from anxiety which, as a consequence, causes the patient to regress to a more sexually immature developmental level (Scalzi, 1973). Such behaviour tends to counteract the anxiety that results from threats to v i r i l i t y and self-image. - 25 -Relationship to Angina Patients A pattern of behavioural response similar to MI patients may also possibly be experienced by individuals following their diagnosis of angina. For example, angina patients who i n i t i a l l y minimize the seriousness of their illness may be using this form of denial as a means of dealing with life-threatening anxieties. Depression may set in once these patients realize the extent to which their way of l i f e must be altered. Male angina patients in particular, may exhibit inappropriate sexual behaviours as a way of handling anxieties concerning their masculinity and self-concept. Although anxiety, denial, depression and aggressive sexual behaviour are normal reactions to MI and perhaps angina, they can become maladaptive i f they are too prolonged, too severe or occur at an inappropriate stage during the recovery period (Granger, 1974; Scalzi 1973). For example, the angina patient who continues to deny the seriousness of his heart disease may discontinue his medications or engage in excessive physical activity despite the presence of symptoms. Such coping responses would be inappropriate and therefore may be seen as maladaptive. Even patient attitude can affect coping during recovery from a heart attack. In a recent study of patients following their f i r s t heart attack, researchers found a positive correlation between the heart attack victims' frame of mind and their speed of recovery (Bainerman, 1985). Subj ects who attributed the occurence of the MI and the success - 26 -i n coping with i t to external ly determined factors such as fate or s o c i a l pressure, planned and pract ised less changes, r e l i e d less on help from spouses and physicians and returned to work and other functioning at a s i g n i f i c a n t l y slower rate when compared to the rest of the sample. On the other hand, patients who related the MI to in terna l factors such as previous behaviour, planned and car r ied out adaptive coping strategies (reduced work pressures and da i l y phys ica l exercise) and made greater use of family and phys ic ians ' help. I t seems that the better a v i c t im can evaluate the part previous behaviour played in the attack, the more e f fec t i ve h i s coping and the greater his chances are for rapid recovery. Coping w i th Angina Pector i s The only documentation on coping related s p e c i f i c a l l y to angina was found i n a study of denia l among unstable angina patients (Levenson, Kay, Monteferrante, & Herman, 1984). The invest igators concluded that denial i s an independent predictor of rapid medical s t a b i l i z a t i o n of angina patients admitted to a coronary care un i t (CCU). Thomas and her associates however question whether supporting denia l exhibited by cardiac patients tends to encourage maladaptive behaviour fo l lowing discharge from the CCU (Thomas et a l . , 1983). They found that patients i n a CCU w i l l i n g l y share the i r concerns when given the opportunity and tend to elaborate on these concerns more frequently than they deny - 27 -them. The researchers suggest that these f i n d i n g s may be explained by an increased p u b l i c awareness o f CCU's which may decrease p a t i e n t ' s i n i t i a l f e a r s of these c l i n i c a l s e t t i n g s . Summary I t i s evident that the ways i n which people cope w i t h the st r e s s e s and challenges of i l l n e s s are i n f l u e n c e d by m u l t i p l e f a c t o r s r e f l e c t i n g t h e i r s p e c i f i c d i s p o s i t i o n s , as w e l l as by c h a r a c t e r i s t i c s o f t h e i r t o t a l s i t u a t i o n during a given episode o f i l l n e s s and i t s d i f f e r e n t phases. The permanency o f chr o n i c i l l n e s s seems to cause a f f e c t e d i n d i v i d u a l s to focus t h e i r a t t e n t i o n on coping w i t h the ensuing changes and l i m i t a t i o n s to t h e i r way o f l i f e . C e r t a i n coping responses have been a s s o c i a t e d w i t h v a r i o u s forms o f chronic i l l n e s s . In p a r t i c u l a r , a n x i e t y , d e n i a l and depression have been i d e n t i f i e d i n r e l a t i o n t o MI p a t i e n t s . Much of the research t o date r e l a t e d to CAD has focussed on MI p a t i e n t s . Much l e s s a t t e n t i o n has been paid to angina p a t i e n t s who have not yet in c u r r e d an MI. An increased understanding o f how such angina p a t i e n t s cope w i t h the i m p l i c a t i o n s r e l a t e d to t h e i r i l l n e s s would o f f e r a more v a l i d b a s i s to set p r i o r i t i e s f o r both h o s p i t a l and community teaching and r i s k -r e d u c t i o n programs. The a c t u a l concerns of angina p a t i e n t s could then be addressed i n order to help them cope w i t h the changes that occur f o l l o w i n g d i a g n o s i s . - 28 -CHAPTER THREE ^THODOLOGY Introduction: An Overview A qua l i t a t i ve methodology, using phenomenological theory, was used fo r t h i s study. Phenomenology i s concerned with understanding human behaviour from the i nd i v i dua l ' s own frame of reference (Bogdan & Taylor, 1975) and describes experience as i t i s l i ved (O i l e r , 1982). I t provides the means to serve nurs ing ' s goal i n understanding human behaviour i n greater depth than i s poss ible from other methods of inquiry aimed at pred ict ion and contro l (O i le r , 1982; R i s t , 1979). Phenomenology views a l l phenomena under study as s o c i a l l y constructed, with importance placed on inner or subjective understanding of events, behaviours and surroundings (R i s t , 1979). The invest igator as w e l l as the subject brings to the s i tua t i on background information through which the s i tua t i on i s interpreted. Bias i s not eliminated but rather i s recognized and incorporated by the researcher who constructs and interprets the experience shared with the pa r t i c ipant (Davis, 1978; R i s t , 1979). To ensure that the phenomenon i s being investigated as i t i s t r u l y experienced, the researcher must approach the phenomenon to be explored w i th no preconceived categories (Ornery, 1983). A l l data are accepted as given. The phenomenological approach was viewed as being compatible with the framework devised by Strauss et a l . (1984) i n that i t o f fers a means - 29 -of increasing understanding of the actual feelings and daily experiences of individuals diagnosed with angina. Phenomenology, used as a methodology, was conducive for identifying possible adjustment areas of angina patients and for identifying their coping strategies in l i v i n g with their chronic il l n e s s . Finally, use of the phenomenological perspective was conducive for understanding the angina patient's perception of his illness and for understanding how this perception influences subsequent behaviours. The Research Setting The investigation was conducted in the privacy of the homes of consenting subjects who met the selection c r i t e r i a . Sample Selection The sample for investigation was selected through consultation with four cardiologists and one general practitioner within the greater Vancouver area (Appendix II). Patients selected for the study were required to meet the following c r i t e r i a : (1) the patient, male or female, was under 60 years of age; (2) the patient was able to speak and read English; (3) the patient was diagnosed with angina pectoris, but had no evidence of MI, as determined by his cardiologist; and (4) the patient was not requiring hospitalization for his cardiac symptoms. Based on the selection c r i t e r i a , a sample of six subjects was obtained within a five month period. Because of time constraints and - 30 -d i f f i c u l t y wi th subject recru i tment , the c r i t e r i o n r e l a t e d to age was modi f ied to permit o lder subjects to be included in the study. Recency of d iagnos is a l s o v a r i e d in the sample from two months to approximately three years . None of the subjects asked to terminate t h e i r p a r t i c i p a -t i o n and i t was not necessary to omit any of them from the study. The procedure f o r obta in ing the sample included four s t e p s : (1) a l e t t e r o f informat ion and consent (appendix I I I , IV) was given to p o t e n t i a l subjects by t h e i r c a r d i o l o g i s t or general p r a c t i t i o n e r dur ing a rout ine v i s i t ; (2) i f subjects were in te res ted in the study, they gave permission f o r t h e i r phys ic ian to provide t h e i r names and telephone numbers to the i n v e s t i g a t o r ; (3) the i n v e s t i g a t o r then contacted the p o t e n t i a l subjects by telephone to d iscuss the study and to determine w i l l i n g n e s s to take part in the study; (4) i f the subjects agreed to p a r t i c i p a t e , a home v i s i t was arranged. Because of d i f f i c u l t y i n r e c r u i t i n g a la rge enough sample fo r the study, two o f the subjects whose names were g iven to the researcher by t h e i r c a r d i o l o g i s t s were contacted by telephone a f t e r r e c e i v i n g a l e t t e r of informat ion by m a i l , exp la in ing the nature of the study (Appendix V ) . F i v e i n d i v i d u a l s refused bo p a r t i c i p a t e in the study. Three o f these persons f e l t that they could not make any s i g n i f i c a n t c o n t r i b u t i o n s to the study. The other two people had j u s t been diagnosed with angina p e c t o r i s and f e l t that they could not deal w i th the interv iews due to t h e i r upset f e e l i n g s at t h i s t ime. A v e r b a l explanat ion o f the study was g iven to each subject at the beginning of the i n i t i a l home v i s i t . Once intent to p a r t i c i p a t e was - 31 -e s t a b l i s h e d , w r i t t e n consents were obtained p r i o r to the commencement of the i n t e r v i e w s . Data C o l l e c t i o n In t h i s i n v e s t i g a t i o n , data c o l l e c t i o n commenced w i t h the i n t e r v i e w . P a r t i c i p a n t s i n the study were p u r p o s e f u l l y interviewed and observed w i t h the i n t e n t o f gathering r e l e v a n t data regarding t h e i r experiences coping w i t h angina. A data c o l l e c t i o n t o o l was developed by the i n v e s t i g a t o r to f a c i l i t a t e and organize the i n t e r v i e w procedure (Appendix V I ) . Observable behaviours were a l s o examined u s i n g the f o l l o w i n g c a t e g o r i e s : v e r b a l ( c h a r a c t e r i s t i c s o f speech, focus o f co n v e r s a t i o n ) ; and non-verbal ( a c t i v i t y , eye contact, body language, appearance). Four broad open-ended questions were used to o b t a i n data concerning the thoughts, f e e l i n g s and a c t i o n s o f subjects i n r e l a t i o n to t h e i r i l l n e s s (Appendix V I I ) . This semistructured i n t e r v i e w guide provided s u f f i c i e n t d i r e c t i o n so that s p e c i f i c content areas could be covered, enabling comparisons to be made between i n t e r v i e w s . At the same time, f l e x i b i l i t y i n the s t r u c t u r e o f the guide was p o s s i b l e a l l o w i n g f o r s h i f t s i n sequence or t o p i c s according to the preferences and needs o f the s u b j e c t s . Each i n t e r v i e w was audiotaped. A l l subjects were assured that the contents o f , the taped i n t e r v i e w s would be kept i n s t r i c t e s t confidence and th a t t h e i r anonymity would be respected. None of the subjects objected to the t a p i n g . Each i n t e r v i e w commenced w i t h a few - 32 -minutes of s o c i a l conversation for the purpose of developing rapport and easing any apparent anxiety. Two interviews were conducted with each subject in the study. The second interview which followed with in three to four weeks of the f i r s t was carr ied out in order to c l a r i f y previous responses and compare them with those of the other subjects. The researcher chose to conduct the interviews of the subjects p r i va te l y i n the fami l i a r and comfortable surroundings of the subjects ' own homes. Frequently, the spouses of the subjects would j o i n in the conversation at the end of the interview. The interviews ranged i n length from 30 to 60 minutes with a mean length of 45 minutes. A f ter conducting each interview, the researcher took note ( in pr ivate) of any verbal or non-verbal behaviours of the subjects. Sections of each tape were also reviewed to obtain a general o ve ra l l impression of the mater i a l . Notations were made of any ideas or recurrent themes. The data c o l l e c t i o n period encompassed approximately f i v e months. I t took two months to r ec ru i t the f i r s t subject. Idea l ly , with th i s type of methodology, data c o l l e c t i on ceases when consistent themes emerge fol lowing the saturat ion of categories developed (Glaser & Strauss, 1967; Stern, 1980). This was not possible i n th i s study due to the time constraints of the researcher. - 33 -Data Coding and A n a l y s i s F o l l o w i n g the data c o l l e c t i o n phase o f the i n v e s t i g a t i o n , the tape-recorded i n t e r v i e w s were t r a n s c r i b e d and the raw data were examined, sorted and coded i n t o c a t e g o r i e s . In order to systematize the coding process, each item o f data was a l l o t t e d a category, cut from the t r a n s c r i p t and placed i n t o an envelope l a b e l l e d w i t h the corresponding category. For example, many o f the s u b j e c t s commented on being f r u s t r a t e d because o f v a r i o u s a c t i v i t y r e s t r i c t i o n s r e l a t e d to t h e i r angina, e.g., c l i m b i n g h i l l s , s h o v e l l i n g snow, c a r r y i n g out the garbage, mowing the lawn, and so f o r t h . These raw data were then coded as " f r u s t r a t i o n r e l a t e d to p h y s i c a l l i m i t a t i o n s " and placed i n an envelope l a b e l l e d as such. Three numbers were noted on each item of raw data, i n d i c a t i n g the p a r t i c u l a r s u b j e c t , the number of the i n t e r v i e w and the exact page number o f the t r a n s c r i p t . An e x t r a copy was made of each t r a n s c r i p t . The i n v e s t i g a t o r then proceeded to d e f i n e and des c r i b e each category by examining the contents o f each envelope. The c a t e g o r i e s were reviewed a number o f times u n t i l the concepts and p r o p e r t i e s could be described i n d e t a i l . D e s c r i p t i o n s o f the c a t e g o r i e s were then copied onto reference cards so that they could be more e a s i l y compared and contras t e d w i t h each other. As the process continued, more and more data were m e a n i n g f u l l y grouped under l a r g e r a b s t r a c t concepts. This overview o f data coding and a n a l y s i s i l l u s t r a t e s a p p l i c a t i o n of the method o f constant comparative a n a l y s i s developed by Gl a s e r and Strauss (1967). - 34 -R e l i a b i l i t y and V a l i d i t y Issues To t e s t the v a l i d i t y o f the data g a t h e r i n g instrument, two c a r d i a c p a r t i c i p a n t s from a l o c a l c a r d i a c r e h a b i l i t a t i o n program were inte r v i e w e d . I t was found that the data gathered from t h i s p i l o t study were adequate f o r the purpose o f t h i s study. D i e r s (1979) s t a t e s t h a t there i s more concern f o r the r e l i a b i l i t y o f the data sources and/or the recorder than there i s f o r t h i s q u a l i t a t i v e type o f study design. To ensure r e l i a b i l i t y of the f i n d i n g s f o r t h i s study, a data g a t h e r i n g t o o l was used and a l l i n t e r v i e w s were audiotaped. Immediately f o l l o w i n g each i n t e r v i e w , s p e c i f i c n o t a t i o n s were made by the i n v e s t i g a t o r concerning the subj e c t s ' observable behaviours so th a t accurate r e c a l l could be maintained. Despite the v a r i a b i l i t y i n recency of d i a g n o s i s , a l l o f the subjects were able to provide c l e a r d e s c r i p t i o n s o f t h e i r i l l n e s s experience. None o f the respondents were h e s i t a n t to d i s c l o s e t h e i r r e a c t i o n s and i n f a c t a l l were w i l l i n g to f r e e l y d i s c u s s t h e i r thoughts and f e e l i n g s . Because the i n v e s t i g a t o r was aware that her personal biases might a f f e c t the o b j e c t i v i t y o f the study, she attempted to u t i l i z e the t h e s i s committee as o b j e c t i v e resources to monitor her personal impressions. A standardized procedure was used f o r data c o l l e c t i o n , coding and a n a l y s i s as a l r e a d y described. This systematic approach provided a degree of r e l i a b i l i t y to the study. 35 CHAPTER JOUR FINDINGS OF THE STUDY AND DISCUSSION Based on the methodology described i n Chapter Three, data were obtained from a study sample consist ing of s i x male subjects ranging i n age from 42 to 72 years with a mean age of 59.2 years. Of the s i x subjects, three were working, two were r e t i r ed and one was unemployed and receiv ing welfare assistance. Five of the subjects were married and l i v i n g w i th the i r spouses. Two of these subjects each had a c h i l d res id ing at home. One of the subjects was divorced and l i v i n g alone. Character i s t ics of the subjects, s pec i f i c to age, mar i t a l and work status and recency of diagnosis are shown i n Table 1. Table 1 Character i s t ics of Subjects Subj ect Age Ma r i t a l Status Work Status Recency of Diagnosis i n Months 1 56 M E 9 2 60 M E 9 3 62 M R 34 4 63 M E 10 5 72 M R 2 6 42 D U 5 Note: M = married; D = divorced; E = employed; R = r e t i r e d ; u = unemployed. 36 Although participants attached different meanings to certain aspects of th e i r i l l n e s s experience, a l l subjects described s i m i l a r frames of reference which highlighted t h e i r response to angina. These reference points provided the investigator with a means to analyze and understand the data. The re s u l t i n g phases which served as a guiding time frame were not ar b i t r a r y but, rather, they accurately r e f l e c t e d the participants' experiences i n coping with t h e i r i l l n e s s . In other words, from the common reference points arose phases of the subjects' coping experience. Data analysis resulted i n emergence of four phases of the coping experience: 1. i n i t i a l coping rsponse; 2. managing s p e c i f i c adjustment areas; 3. secondary coping response; 4. awareness of resu l t i n g changes. Table I I shows the common reference points f o r each phase of coping experience following the onset of angina symptoms. Appendix VIII demonstrates the relationship of the categories of findings to these reference points. In t h i s chapter, participants' descriptions of t h e i r coping experiences w i l l be presented according to the phases and common reference points i d e n t i f i e d i n Table I I . The ways i n which these angina patients cope with t h e i r i l l n e s s and th e i r i d e n t i f i e d concerns and adjustment areas w i l l become evident i n the following descriptive accounts. Participants' accounts w i l l be discussed i n r e l a t i o n to the conceptual framework and l i t e r a t u r e review. This discussion w i l l allow a comparison to be made between personal, empirical and theoretical viewpoints. 37 Table 2 Phases and Common Reference Points I. I n i t i a l Coping Response Downplaying Reflecting back II. Managing Specific Adjustment Areas Interactions with others Regimen management Symptom control Job-related concerns Attendant psychological concerns III. Secondary Coping Response Basic strategies (for illness in general) Basic strategies (for specific adjustment areas) IV. Awareness of Resulting Changes Concrete Changes made Changes experienced I. I n i t i a l Coping Response The phase of i n i t i a l coping response followed the onset of symptoms of angina pectories. A l l of the subjects generally had been experiencing angina symptoms such as fatigue on exertion and chest 38 pain, as part of t h e i r coronary artery disease, p r i o r to being diagnosed. When th e i r angina was medically confirmed, the subjects gradually began to r e a l i z e that they had a "condition," as some of the subjects described i t , and attempted to make sense of t h e i r i l l n e s s . The common frames of reference which highlighted t h i s phase were downplaying and r e f l e c t i n g back. Responses unique to s p e c i f i c subjects were also found. Downplaying A l l of the subjects i n t i t i a l l y downplayed any unusual symptoms they might have had even before t h e i r angina was medically confirmed. They did t h i s as long as severe or persistent chest pain did not occur to interfere with t h e i r usual a c t i v i t i e s . One subject commented. I f my heart was r e a l l y that bad, I wouldn't be able bo run and play as hard as I am. So then you put i t out of your mind even though there i s s t i l l some pain there. Many of the subjects would almost forget about the pain after i t subsided. One man explained. Act u a l l y I didn't do anything about i t because i t didn't dawn on me exactly what i t meant. A l l I knew I had a pain and once I was over the pain, I more or less put i t out of my mind. Two of the subjects suspected that the pain they experienced was related to t h e i r heart yet they continued to downplay i t s significance. One of them commented. 39 Well I had an inkling of what the pain was but I didn't want to say anything. I thought i t was maybe just one of those things because i t went away as quickly as i t came. This downplaying of symptoms and delay in seeking medical attention may be viewed as a similar coping behaviour found among M.I. patients when confronted with symptoms that they sometimes even suspect as cardiac (01in & Hackett, 1964). One subject tended to ignore his symptoms both prior to and following diagnosis, thinking "they would pass" or that he could "shake them off." Two of the participants i n i t i a l l y rationalized their symptoms as being due to overwork. Another misinterpreted his chest pain as part of his weight problem. He stated. "I was thinking i t was my weight because I was so desperately trying to lose weight." S t i l l another subject attributed his symptoms to being "normal" for him. He stated. My activities were becoming more and more restricted and I was out of breath and so on but I just thought i t was me again. Didn't think i t was anything related to the heart. Nothing serious. The behaviours indentified as downplaying in this phase may be likened to a kind of cognitive coping style which Lipowski (1970) terms minimization. According to this type of cognitive functioning, i t may be possible to view the subjects exhibiting responses indicating a tendency to ignore, deny, misinterpret or rationalize the personal 40 significance of their illness and i t s symptoms. It appeared that this minimization persisted only u n t i l symptoms became severe and frequent enough to interfere with everyday a c t i v i t i e s . When the subjects realized that their a c t i v i t i e s were becoming restricted, the real i t y of their illness began to set in. One subject put i t in this way. Well, I didn't believe them u n t i l I couldn't do the things I wanted to. Then I realized I had a problem. Reflecting Back A l l six subjects provided a vivid description of the circumstances surrounding their diagnosis as an i n i t i a l response during the f i r s t interview. They moved from a past to present time frame and were able to r e c a l l , in detail, the onset of their symptoms and their reactions to them. The subject who had had angina for approximately three years did not elaborate as much as the others in this area. Most of the subjects commented on how they i n i t i a l l y sought medical attention when their chest pain became severe or persistent. One man described his f i r s t experience with chest pain in the following manner. The f i r s t time that I experienced i t , i t was so painful in the center of my chest, my whole shoulder and arm, I could feel i t right down to my wrist. And as a matter of fact I went to the hospital emergency to have i t looked at. I knew there was something seriously wrong. 41 Another man explained. I got the f l u and then I was i n bed one night and the pain d i dn ' t go away and I thought th i s was not normal. I'm not doing anything and there i s nothing s t r e s s f u l . . . . I t wouldn't go away so that i s when I ended up i n ho sp i t a l . Following diagnosis, two of the par t ic ipants were than able to a t t r i bu te previous phys ica l symptoms to the i r angina. One of them commented. When I look back, I th ink tha t ' s when I d id s ta r t complaining about th i s pa in . I can go back about ten years or more. Many of the part ic ipants re f lected back to the i r previous phys ical c a p a b i l i t i e s , comparing them to what they were presently doing. This seemed to provide them with a type of yardst ick for measuring the sever i ty of the i r i l l n e s s . One man re lated i t in th i s way. Now the only thing that I found i s the phys ica l . That ' s a whole new b a i l game. There's no way I could do what I d id before say espec ia l l y i n the l a s t year. . . . I 've been go l f i ng fo r 15 years and now I'm bushed when I 've f in i shed 18 holes. I used to play 36 holes a day. Once the par t ic ipants rea l i zed they were experiencing changes i n the i r bodi ly functioning re lated to feel ings of discomfort, they seemed to attempt to attach meaning to these cues. They did th i s by reviewing the onset of t he i r angina symptoms and by making comparisons to previous phys ica l c a p a b i l i t i e s . Such behaviours may be comparable to another mode of cognit ive 42 funct ioning, re lated to bodi ly disease or in jury, described by Lipowski (1970) as v i g i l a n t focusing. In t he i r attempts to make sense from the i r symptoms, many of the subjects seemed to exh ib i t pers i s tent e f fo r t s to r e f l e c t upon any relevant information from the i r past which might help them understand the onset and progression of the i r i l l n e s s . Lipowski (1970) claims that an i nd i v idua l usual ly displays e i ther v i g i l a n t focusing or minimization as a p re fe ren t i a l mode of coping s t y l e i n response to i l l n e s s . Although the actual extent of each coping s ty le may vary from ind iv idua l to i nd i v idua l and at d i f fe rent stages i n an i l l n e s s i n the same person, Lipowski states that ind iv idua l s , depending on t he i r personal i ty type, c h a r a c t e r i s t i c a l l y display only one preferred s ty le regardless of the nature and sever i ty of the i r i l l n e s s . In th i s study, the angina patients investigated seemed to d i sp lay both forms of cognit ive coping s t y le at d i f f e ren t times. They i n i t i a l l y appeared to downplay the seriousness of the i r i l l n e s s (minimization) u n t i l they became aware that the changes i n t he i r body functioning were s i g n i f i c a n t l y a f fec t i ng t he i r usual a c t i v i t i e s . This r e a l i z a t i o n seemed to t r i gger attempts to reduce uncertainty about the subjects ' i l l n e s s ( v i g i l a n t focusing) leading them to seek information explaining the changes i n bodi ly functioning which were i n te r fe r i ng w i th t he i r phys ica l c a p a b i l i t i e s . Responses Unique to Spec i f i c Indiv iduals Although some of the i n i t i a l coping responses i den t i f i ed were unique to only one subject, they s t i l l represented s i gn i f i c an t data of 43 relevance for the study. For example, one of the par t ic ipants explained that he experienced a fee l i ng of r e l i e f when h is symptoms were diagnosed as angina. For the past 10 to 15 years, he had experienced unusual pains and fatigue for which no doctors had offered any concrete explanation. Therefore, he f e l t an enormous sense of r e l i e f when he f i n a l l y discovered what was wrong wi th him. He explained. " I t was almost a r e l i e f to me—to be re l ieved of that anxiety to f i nd out what i t was." The oldest subject of 72 years had always believed that his heart was " i n better condit ion than normal" and that he was going " t o l i v e to be 110." He then expressed how surprised he was on hearing that he had angina. " I t came as a b i t of a surprise that there was something wrong wi th my heart, me of a l l people." A unique response fo l lowing diagnosis was expressed by s t i l l another subject. He f e l t a sense of regret over cer ta in l i f e - s t y l e habi ts , be l iev ing that they had strongly contributed to him developing angina. Maybe carry ing around th i s extra weight, the heart was doing extra work. . . . When I qu i t smoking eight years ago, t ha t ' s when I put the weight on. . . . Oh yes. I regretted the 30 odd years I smoked c igarettes too. Right then I regretted i t . You see I found out I had angina, i f I could turn the clock back, I would never do that again. The common and unique responses i den t i f i ed in r e l a t i on to the subjects ' onset of angina may be seen as rather complex. The par t ic ipants not only responded emotionally wi th new thoughts and 44 feel ings but they also had to work though a process, of r e a l i z i n g the s ign i f icance of t he i r condition- and then interpret ing i t s sever i ty and po ten t i a l impact on the i r way of l i f e . These responses may be s im i l a r , i n part , to the gr iev ing pattern of react ion to loss which Lindemann (1944, 1961) describes i n r e l a t i on to hosp i ta l i zed pat ients . Lindemann explains that there may be a psychological react ion ca l l ed f o r th by the ant i c ipa t ion of a threatening s i tua t i on re lated to one's i l l n e s s . The psychological responses demonstrated by the subjects may have evolved as part of a process of in terpret ing the i r i l l n e s s as a loss of potent ia l f o r cer ta in l i f e - s t y l e a c t i v i t i e s and ro le functions. The coping responses displayed by these part ic ipants may represent the i r way of working through such losses as we l l as the changes i n the i r body functioning re lated bo the i r angina. I I . Managing Spec i f i c Adjustment Areas A f te r being diagnosed with angina, the subjects began to r ea l i ze the meaning and s ign i f i cance of t he i r new i l l n e s s . They were than faced with a need to adjust to cer ta in demands and l im i ta t ions on a c t i v i t y re lated to l i v i n g w i th angina. Within th i s phase, the subjects i den t i f i ed f i v e major areas of adjustment. These adjustment areas included: (1) interact ions with others; (2) managing regimens; (3)symptom contro l ; (4) managing job- re lated concerns; and (5) managing attendent psychological concerns. 45 Interactions with Others This common reference point related to the subjects' interactions with health professionals and family members as well as their preference for discussing their illness with others. Health Professionals Having sought out medical care in response to their symptoms, the subjects came in contact with various health professionals. Most of the participants' interactions appeared to be with physicians. Two of the subjects stated that they were generally satisfied with the treatment they received. One attributed this satisfaction to the approach he used with his physician. He remarked. I generally have a few questions to ask and i t appears to me that doctors don't want to burden people with information that might not be welcome and as I pointedly ask about, for example, what I do about a l l this fat and what alternative treatment might there be and how long might this treatment last? I ask these questions pointedly and they are good at answering them. Another subject was less satisfied, especially with the manner his doctor used to inform him about his angina. He explained. I think the f i r s t doctor could have told me in a different way. . . . He might have said to me, well you have got to lose weight and you should exercise and don't have any caffeine but he didn't have to say—the way he put i t was that I had angina and i f these medications didn't cure me, the next step would be an operation. I thought maybe he could have handled i t differently but maybe he's right in scaring me into losing weight. 46 As a result however, this subject did become motivated to make some important l i f e - s t y l e changes related to his i l l n e s s . He made changes to his diet, lost weight, attempted to reduce his exposure to stress and maintained regular attendence in a structured exercise program. The same subject who had expressed r e l i e f on f i n a l l y learning that his symptoms could be attributed to a concrete problem such as angina, was also angry because of the way he had been treated by his physician. He explained. You can imagine my reaction when I heard I had angina. It wasn't the fact that I had angina. Doctor, why didn't he treat i t properly? . . . When I went to the doctor complaining about my arm, the minute I told him that I was doing extraordinary physical work, he says, that's what i t i s , i t ' s your muscles. But you take a good doctor I think at that time would have told me there's something wrong. Most of the subjects stated that they gained most of their knowledge related to their illness independently. One man explained, in a voice f i l l e d with emotion. When I got angina, I didn't even know what the word meant. I didn't have a clue. So I really had to learn myself because the doctor (in the hospital) didn't t e l l me anything and I went checking with everybody under the sun here and there and got a l l the bloody books. This same man further explained how he had wanted more information about his prognosis as well as the longterm effects of his i l l n e s s . Knowing such future implications seemed more important to this man at 42 years of age as compared to the more senior subjects. 47 This subject was especially upset when he received no warning or preparation for an angiogram which was scheduled for him while in hospital. The degradation when I had my angiogram done. I had a lady come to me to shave a l l my pubic hair off before I had the angiogram done. Now I've never had that happen to me in my l i f e . . . . This lady requested that I remove articles around my penis so that I could be shaved. I was totally humiliated because i t was a very spontaneous thing. Just walk in . Let me see your armband. Okay, I am here to shave you. Shave me for what? A major complaint from the subjects was that they did not receive sufficient specific information and guidance related to diet restrictions and menus, weight control and exercise regimes. One of the subjects described his concerns in this way. They never gave me a diet. They just assumed I knew what to do. . . . I never got anything in writing. They just said keep your weight down which is fine. It's hard to do when you've just given up smoking . . . and I don't know how far to go with exercise or when to do i t and when not to do i t . Which exercise is okay and which is not? If you are going to have a drink, what size drink do you have? This subject seemed to want more individualized diet counselling. For example, he wanted to know more about alternative diet plans which he could more easily follow. He explained. At this point, we know that i f you want to lose weight, you can have your boiled egg in the morning and with your melba toast and your cottage cheese, lettuce and tomatoes at lunch. This is fine but I mean I don't buy that and I think i t should have been something a l i t t l e better. 48 In their interactions with health professionals, i t seems that many of the subjects were dissatisfied with the treatment they received. The most common complaint seemed to be the lack of specific direction and written instructions related to certain types of l i f e - s t y l e changes, namely diet, exercise and weight control. Strauss et a l . (1984) refer to physicians and other health professionals acting as assisting or control agents when dealing with individuals with chronic i l l n e s s . Strauss and his colleagues further explain that health professionals often persuade or dissuade what they deem necessary for their clients' benefit. Although sane physicians may not always be viewed as being tactful, their use of threat and intimidation may sometimes bring results. This appeared to be the case with one of the subjects who was "scared into" making some important l i f e - s t y l e changes as already described. Family Interactions with family members mainly involved spouses. Three out of the five subjects who were married and li v i n g with their spouses appeared to depend on their wives a great deal for support and assistance in managing their illness. One of these subjects commented on his wife's involvement. She keeps a good eye on me. She is f u l l y aware of what I should and shouldn't do. She's the one that prompts me quite a b i t . 49 The spouses espec ia l l y played a major ro le in monitoring the i r husbands' d i e t s . One subject explained. Well the thing i s the wi fe, she i s the one that i s always watching my d i e t , watching the things I eat and watching what I do probably more than I do. She' s the one that prompts me quite a b i t . . . . She bugs the h e l l out of me but I 've got to l i s t e n to her because I know she's r i g h t . The 72 year o l d ' s spouse seemed much less involved with monitoring her husband's a c t i v i t i e s . She had recently undergone an operation and thus "had problems of her own" as her husband put i t . However, the fact that she did d i sp lay confidence related to her husband's a b i l i t y " t o come through i t a l l r i gh t " appeared to encourage him. Another part ic ipant who had been free from angina symptoms for several months explained how he thought his wife had "completely forgotton about what had happened." She had continued to make the same high c a l o r i c foods as before. Such behaviour exhibited by th i s spouse may be interpreted as a lack of knowledge in r e l a t i o n to her husbands' i l l n e s s . Although she was aware that her husband had angina, she may not have rea l i zed the s ign i f icance of making d iet changes as a means of r i s k modi f i cat ion. According bo Strauss et a l . (1984), persons who choose to adhere to prescribed regimens whi le managing the i r i l l n e s s require some personal and often f a m i l i a l organization of e f f o r t . Most of the spouses seemed to be playing a major ro le in managing the i r husbands' i l l n e s s . Strauss and h is colleagues might refer to such people as 50 control agents. The spouses especially assisted their husbands to adhere to their diet regimens by employing such tactics as reminding of diet restrictions and manipulating food menues. As mentioned, two of the subjects' spouses were less involved in this area. As a result, their husbands were finding i t more d i f f i c u l t to follow their diet and lose weight. It seemed that these latter subjects were relying mainly on their own efforts to make many of the l i f e - s t y l e changes related to their i l l n e s s . Others The subjects investigated had definite thoughts and feelings about whether they were comfortable discussing their illness with others. Half of the subjects had informed certain friends and collegues about their angina. They claimed that they were not treated any differently by those who were aware of their illness except perhaps that a l i t t l e more consideration had been shown Go them which they appreciated. One participant elaborated. We're in a very small company and there might be times when you are required to l i f t something, equipment or whatever. And so, they (his colleagues) are very good because they'll say 'cool i t , I ' l l do this.' Another subject, in explaining how he didn't hesitate bo t e l l others, commented. They a l l know at work, you know. They a l l make fun of me popping my p i l l s three times a day or whatever but i t doesn't bother me. 51 This 60 year o ld man had w i l l i n g l y r e t i r ed because of h i s angina and was i n the process of applying fo r a d i s a b i l i t y pension. Having others at work know about h i s angina therefore seemed appropriate. In contrast, another subject had to ld everybody except those at work. He explained how he had i nd i r e c t l y informed his colleagues of h i s condit ion. I t o l d them I go to the Y three times a week. I t o l d them I couldn ' t work 12 hours a day anymore. And I l e t them draw t h e i r own conclusions. In questioning the subject further, i t was discovered that he f e l t i f people at work d e f i n i t e l y knew about his angina, his job secur i ty might be jeopardized. The fact that th i s subject was attempting to keep h is i l l n e s s from his colleagues may be viewed as h i s way of adjusting to a major challenge, namely that of h i s job maintenance. This s i tua t i on may also be seen as one example where act ive measures are sought in response to the challenges and tasks posed by an i l l n e s s (Liposwski, 1970). The other ha l f of the subjects preferred that no one outside t he i r immediate family know about the i r angina. One was quite adamant about i t . He described h is angina as a "personal th ing , " saying: Talk ing w i th other people doesn't s a t i s f y me. I can ta l k wi th my w i fe . We can discuss i t . That gives me more s a t i s f a c t i on . In fact only one person besides h i s wife and daughter was aware of h i s condit ion and that was because he also had angina. Although the 52 two men never discussed their illnesses, the subject did pass on advice to his friend regarding risk modification and l i f e - s t y l e management. He explained. Our friends—only one person knows that I have angina. That's i t . We've asked him not to mention i t . We don't mention to anybody that he's taking the same p i l l as I do, and I try to find out what his problems are . . . and I give him advice. I just t e l l him with no explanation. This same subject explained his preference for keeping those at work from knowing about his angina. Nobody ever suspects that I have angina. I think they are the last ones I'd t e l l because their imagination really runs away with them. And so I just leave i t at that. Some of them wouldn't know what angina is anyway. He further j u s t i f i e d not t e l l i n g his colleagues by explaining: My angina hasn't affected my work. I'm s t i l l doing a l l the work I am supposed to. Maybe even more than I am supposed to do. . . . so thinking of work that j u s t i f i e s me not t e l l i n g anybody. Why should I? Another subject also insinuated that his angina was personal. He offered his rationale. "As a general rule I avoid mentioning i t . I'm not one to go and t e l l everything, a l l my private business to people." These latter two subjects explained how they generally tended to keep their personal affairs to themselves. It seemed that they were applying this same approach to their situation with angina. According to Lipowski (1970), such behavioural tendencies may be described as a person's coping style or his/her characteristic way of coping in various situations. 53 Two of the subjects explained that they hesitated to inform others of their angina because they were concerned that they might be treated differently as a result. They put i t this way. I'm not embarrassed because I got i t but I don't want the sympathetic shot. I don't want people saying how do you feel? I don't want somebody laying a trip on me. I wouldn't want other people to be influenced in their conduct towards me. I wouldn't want people to say, well we better give him the chair. He's got a bad heart. Both of these subjects, who happened to be the youngest and the eldest in the sample, seemed to indicate that having others show sympathy towards them because of their illness would cause them to feel uncomfortable. This appeared to be a major reason for keeping their illness to themselves. It is evident that the subjects under study generally varied in their preferred mode of interaction with others. Only two of the participants clearly appeared not to be bothered by having others know about their i l l n e s s . The remainder of the sample were found to have some reservations in this area. The efforts of these latter subjects to maintain a level of secrecy about their illness may be likened to a basic coping strategy called normalizing (Strauss et a l . , 1984). This beginning attempt to make their lives as normal as possible did not seem to be compatible with any knowledge that others might have concerning their illness. 54 Regimen Management A second key adjustment area encountered by a l l of the par t i c ipants i n the study was the management of ce r ta in regimens associated wi th the i r i l l n e s s and the modif icat ion of r i s k factors which could lead to an MI. Regimen management and r i s k modi f icat ion are so in ter re la ted that they w i l l be dealt with together. The subjects investigated discussed the i r management of three regimens i n pa r t i cu l a r : (1) d ie t ; (2) excercise; and (3) medications. Their continuous e f fo r t s to evaluate these regiments w i l l be discussed i n i t i a l l y . Evaluating Regimens Strauss et a l . (1984) expla in how regimens, usual ly suggested by physicians or other health personnel, are often evaluated by chron ica l l y i l l persons on the basis of legit imacy and/or e f f i c i ency . They further explain how regimens are also judged on a s oc i a l rather than medical bas i s . Such evaluations were noted to be made by one subject in pa r t i cu l a r i n the present study. He queried why he needed to be concerned with r i s k modi f icat ion, r a t i o n a l i z i n g : The damage i s done, i t ' s i r r e v e r s i b l e . I f I cut back on the f a t , i t might arrest i t (the angina), but I th ink, l i k e the doctor, that i t i s a disease. I f the disease i s there, there i s nothing on th i s earth that i s going to stop i t . The dammage i s done. . . . I think maybe you can slow the process down but w e l l , myself, I'm not going to because then you 55 become obsessed with i t and the obsession produces stress or whatever and that throws you into another category of frustration. He continued to rationalize about a need to alter his diet saying: If I am hungry, I w i l l eat. But I don't think I've ever had that much of a problem so I don't have to worry about i t . The other part is that the doctor, when I f i r s t went to him, said 'Well, I am going to set up a stress program for you.' And my wife says 'Oh no, what means diet.' He hasn't done anything about i t . So he's not concerned, why should I be? This person later admitted that being put on a diet would make him anxious. Maybe there would be some anxieties there. I wouldn't be able to eat the things we enjoy. Because we enjoy cooking and eating. Take that away from us? In judging the legitimacy of a diet change, he concluded that he could accept being overweight, attributing the excess weight to being middle-aged. When you start reaching a certain age you don't have any control over that. Nature takes over and i t produces fat. A person could say, I have to get r i d of that. I'm obsessed. I want to be thin again or muscular. I don't. I would prefer not to go on a diet. This same subject also objected to in i t i a t i n g a regular exercise program, rationalizing that he had done enough exercise when he was younger. I've done my exercise b i t I think from age whatever u n t i l 44 or 45. Besides, I get enough exercise at work. 56 Another subject i n evaluating the e f f i c i ency of h i s d iet regimen, was skept i ca l about the benef its of reducing cho lestero l intake. He commented. Quite f rank ly I think i t has become a f a l l a c y . I think your cholestero l i s b u i l t up i n your body and you can'd do much about i t . . . . Eight years ago I went to the doctor for a phys ica l and had my cholestero l checked out. I t was too high so he says, ' cu t out the f a t s ' , a l l of these things that I d i d . D idn ' t do any good at a l l . I s t i l l got i t (the angina). Obviously th i s man was not convinced that reducing h i s cho lestero l intake would be worthwhile. According to Strauss et a l . (1984), the lack of evidence that a regimen works to contro l a disease process represents a condit ion which i s not conducive to acceptance of that regimen. In evaluating the benefits of modifying cer ta in r i s k factors , two subjects admitted to being aware of the hazardous ef fects of smoking. They were not ready to give up the habit however, claiming they enjoyed i t too much. One of them expressed i t i n th i s way. Wel l , i t ' s j u s t that I keep that sort of a crutch, I guess. You know, you've taken away the booze from me and taken away some of my a c t i v i t y so I j u s t hang on to the c igaret tes . The other commented further, almost contradict ing himself. I t hasn ' t scared me enough. But I know a l l the p i t f a l l s and the black lungs and the rest of i t . But I 've smoked now for 40 years and a l l these super scans they have, they haven't detected anything so why worry. 57 Both subjects were concerned about their weight and f e l t that stopping smoking would lead to excessive weight gain. One explained why curbing his smoking was the lesser of his p r i o r i t i e s . I took a look at myself to see what I was doing wrong, you know. Eating, I f e l t was my biggest downfall. . . . The cigarettes aspect, okay, that takes a lot of wind away from me, but the theory of cutting out the cigarettes and putting on weight. I'm big enough now. If I cut out the cigarettes I am going to be craving candy or I am going bo be going back bo food. As long as I can keep i t down to what I have been smoking then I feel comfortable with i t . The subject who had lived with his angina for almost three years was beginning to experience some benefits from modifying his diet and stress exposure. Oh I definitely see value in making some changes, particularly with the diet and the tension. You really have to moderate your diet. You feel better i f you do. This man was particularly motivated to monitor his diet because of a recent onset of diabetes. Strauss et a l . (1984) point out how often people suffer from more than one chronic il l n e s s . This means that they may be involved with managing two or more regimens simultaneously. Some of the regimens may be in competition with each other or may actually cause the symptoms of the other illness to occur. Fortunately this subject was not involved with competing regimens and thus did not have to be concerned with such conflicts. For example, the fat, cholesterol and calorie restrictions related to his heart disease also complemented his diabetic diet regimen. 58 In judging whether or not they would take up and adhere to prescribed and non-prescribed regimens, the subjects appeared to use ce r ta in evaluation c r i t e r i a . Diet regimens were assessed on the basis of t he i r e f f i c i ency and legit imacy. For example, one subject was not convinced that r e s t r i c t i n g cho lestero l intake could work to contro l angina. Professing a continuing t rust and confidence i n his phys ic ian, another par t i c ipant would not consider d ie t ing or exercis ing i f not s p e c i f i c a l l y prescribed fo r him. Sane of the subjects claimed that d ie t ing and cessation of smoking might be Goo much of a s a c r i f i c e . In add i t ion, the interrelatedness of eating and smoking habits could be problematic where stopping smoking could cause food intake to increase leading to weight ga in. These evaluations noted with regard to regimen management and r i s k factor modi f icat ion demonstrate how the l i v e s of the chron ica l l y i l l can be complicated w i th r e s t r i c t i on s and how each r e s t r i c t i o n i s therefore so read i l y put on t r i a l . Such evaluations which according to Strauss et a l . (1984) are made cont inual ly by chron ica l l y i l l persons, might also make one wonder how long regimens are ac tua l l y adhered to, even i n modified form. Diet Regimens A l l but one of the part ic ipants seemed Go recognize the importance of weight contro l as part of managing h i s i l l n e s s . This one exception, as discussed e a r l i e r , was convinced that los ing weight was not a 59 worthwhile endeavor. As also mentioned, attempts to c u r t a i l smoking a c t i v i t i e s made weight contro l a l l the more d i f f i c u l t . One of the subjects who rea l i zed he was overweight, wished to know his idea l weight so that h i s weight-loss regimen could be more goa l -d i rected. This i s the same subject who i den t i f i ed a need for more spec i f i c guidel ines re lated to h i s d ie t regimen. Strauss et a l . (1984) describe how a pat ient may wish to adhere to a regimen but the instruct ions concerning i t may leave him confused and unsure. I t appears that although th i s subject wished to fo l low a d iet i n order to lose weight, he f e l t f rust rated and uncertain about set t ing h i s own l i m i t s and goals. The way I f e e l , I don 't know what my weight should be. I j u s t f e e l that I'm about 15 pounds overweight than I am normally. I j u s t f e e l a l i t t l e uncomfortable. And those 15 pounds have been put on since I qu i t smoking. Two of the part ic ipants i n pa r t i cu l a r mentioned how they had l o s t weight i n i t i a l l y and were now becoming f rustrated as they were seeing only minimal resu l t s from the i r e f f o r t s . One of them put i t i n th i s way. I used to drink a l o t of coke and eat a chocolate bar i n the middle of the day. I don ' t do that anymore. When I stopped those two things, I started to lose a l o t , 10 pounds, by doing that. But then I stopped lo s ing . Other areas of d i f f i c u l t y were i d e n t i f i e d i n r e l a t i o n to the subjects ' management of the i r d iet regimens. One subject commented. 60 The portions are the main things. I'm always nibbling celery or carrots after supper. I'm always hungry. It's a l i t t l e d i f f i c u l t to get used to especially when people are eating a l l around you. Many found i t hard to resist their spouses' culinary expertise. One participant explained. My.wife w i l l put down a l l sorts of things I shouldn't eat in front of me. She is in there baking that stuff. How can I refuse? She puts cookies and squares when she packs me my lunch, sometimes I eat them, other times I ' l l give them away bo someone else. After analyzing these subjects' anecdotes, i t seems that the efficiency of their diet regimes could be questioned. For example, the participants' attempts to limit their favourite foods, in combination with their slow weight loss, could affect their perceptions of the effectiveness of their diet regimens. In general, the subjects' diet regimens did not appear to be d i f f i c u l t to follow. However, without specific guidelines and depending on the extent of changes to be made to their regular eating habits, continued adherence could be affected, particularly when the efficiency of the subjects' efforts was questionable. Exercise Regimens Half of the subjects in the study sample had begun bo exercise on a regular basis since being diagnosed. The types of exercises engaged 61 in included walking and swimming. One of the subjects had followed up on a suggestion made by his physician, enrolling in a local cardiac rehabilitation exercise program. He, along with the other exercising subjects, claimed a feeling of well-being for having participated. He expressed i t in this way. "Yes, I do feel better. I f e e l better about myself too, doing a l l this exercising and coming to classes." The subject who had taken up swimming commented. Oh no, I wouldn't miss i t now (the swimming). In fact I am getting that I'd like maybe to increase i t from twice a week to three times a week because I am finding such a joy out of i t . Those who were exercising regularly were either retired, unemployed or had flexible working hours as was the case with the subject who had joined the exercise class. As pointed out earlier, one of the subjects f e l t he had done enough exercise in his past and walked enough at work to compensate; however he later revealed some uncertainty as to what an exercise program would entail and how i t would affect him. He commented. I think in the last 10 years that we have lived here we (he and his wife) might have gone for two walks. That is about i t . Whereas around the neighbourhood, I see people go religiously. If I did, I don't know what would happen. What would the doctor say? Would he t e l l me to walk every day a l i t t l e b i t , slow down or what? Having not exercised regularly for a long time, this subject may actually have been afraid to resume regular fitness activity which 62 might exacerbate angina symptoms. Another participant emphasized the fact that he recognized the importance of regular exercise but pointed out that finding the time to engage in such activities was a major problem for him. Well, I 've heard of people going to cardiac classes at once or twice a week and they run around. It's like a l i t t l e club. But really, I'm not for that sort of thing because I am working. It's alright for people who've got lots of time off and can do these things. . . . If you are working a l l day, a l l week and then you come home at night and by the time you get home, digest your supper, watch the news, read the newspaper, i t ' s too late and I get tired. According bo Strauss et a l . (1984), the time and effort required to implement a regimen is a common characteristic evaluated by chronically i l l persons when deciding about taking up and adhering to a particular regimen. The authors further explain that interference with important daily activities is a major consideration when making this decision. The eldest subject, who was the most recently diagnosed in the sample, was s t i l l in the process of trying to establish a regular walking schedule. On the whole however, those who had the time to incorporate regular exercise into their daily schedules seemed to have taken up the habit more readily. They were found to continue to adhere to these regimens, perceiving good effects from their participation. Medication Regimens A l l of the subjects studied had been prescribed medications by their physicians, to be taken on a regular basis. Some of the 63 par t ic ipants were s t i l l having the i r dosages regulated and were experiencing increased fat igue as a major side e f f e c t . One described h i s react ion as fo l lows. They put me on various dosages. I found that I was on 10 mg and I should have been on 60 or whatever. But the more I went on, the more t i r e d or s leep ier I got. . . . I t took about a month out of my system to reset to the new drug. Another subject assessed h is react ion to h i s medications by making a comparison to previous energy l e ve l s . He stated. I f i nd that since I 've been taking the medications, I am a l o t more t i r ed now than when I wasn't taking them. One par t i c ipant experienced another type of s ide e f f ec t , inf luencing h i s response time bo d i f fe rent s t i m u l i . He explained. Being on the medication I 've noticed i t ' s r e a l l y put me into a state that I have to give a second thought before I react to what I was th ink ing. L ike i f I go to do something, i t almost stops you. I t causes you to go a l i t t l e slower. Although most of the subjects had experienced some adverse ef fects at one time or another from taking t he i r medications, these adverse e f fect s seemed to be eventually outweighed by symptom r e l i e f . One subject explained that since having h i s medications adjusted, he f e l t more energetic to do things. I look back on the l a s t s i x months and I think I have more energy. Even though I'm doing more work maybe but I would say I 've had more fee l i ng to do things i n a relaxed state than I d id before. . . . I seem to have a d i f fe rent type of more energy i f t ha t ' s an explanation. . . . Even at work, I'm not as t i r e d . 64 The medications were noted to curb the frequency of angina episodes according to another subject. He stated. I not iced when I was on my holidays I had to cut them short because of the recurrent pains. I would get them four or f i v e times every week. The medication I am on now seems to curb them bet ter . I s t i l l get them a b i t but nothing too severe. One man explained how he general ly f e l t better from taking h i s medications, commenting: "I am ac tua l l y much better now than a month ago when I was j u s t s ta r t ing the medication." Apart from some i n i t i a l increase i n fat igue i t appeared that the subjects experienced mostly pos i t i ve outcomes from maintaining t he i r medication regimens. This may be explained by some of the conditions which Strauss et a l . (1984) i den t i f y as being conducive to one's adherence to a regimen. For example, no r e a l l y d i s t ress ing side ef fects were apparent and i t seemed evident that the regimen was working to contro l symptoms. One subject also f e l t that taking his medications was also helping to contro l the disease process. Again th i s i s another cha rac te r i s t i c which chron ica l ly i l l persons use to evaluate regimens (Strauss et a l . , 1984). The subject s tated. I t (the medication) i s helping, i t i s t ry ing to arrest i t (the angina). I t can ' t cure i t though I know. Two of the part ic ipants mentioned some of the inconveniences re lated to taking cer ta in medications. They explained. 65 I don ' t know i f anybody has ever mentioned i t . This i s a l l very w e l l to say when you are gett ing into a s t r e s s fu l s i tua t i on where you get these chest pains, you take your n i t r o and s i t down and re lax . Have you ever t r i ed to s i t down in the middle of town? The Las ix p i l l s , they are j u s t a nuisance. You always have to be near a bathroom a l l the time. . . . Before you take i t you got to think, w e l l what am I going to do today. You know, i f I am going to have ready access to a bathroom, f i ne . I f I don 't then I don 't take the things. Now I am s ta r t ing to taper r i ght o f f . As pointed out with exercise regimens, interference with da i l y a c t i v i t i e s may not be conducive to maintaining a regimen (Strauss et a l . , 1984). I t appeared that because th i s l a t t e r subject ' s symptoms seemed to be under cont ro l , i t was reason enough for him to s t a r t " taper ing o f f " h i s medications. He explained his strategy i n th i s way. Wel l , I think i f I watch myself and pace myself I can do without them (the medications), I hope. But i f i t i s not working, i f I s ta r t to f e e l r ea l bad or the pains become r e a l l y frequent, I w i l l go back to i t . I ' l l take i t a l i t t l e . These attempts to discontinue medications may also stem from the fact that the effectiveness of the regimen may mean that i t i s now time to come o f f of i t (Strauss et a l . , 1984). Ac tua l l y th i s was not the f i r s t time that t h i s subject had attempted to discontinue h is medications. A few months a f te r he was diagnosed w i th angina, he had stopped taking h i s p i l l s abruptly. He commented. I took the medications regular ly up u n t i l about two or three months a f te r I got out of the ho sp i t a l . I would run out and I would f ee l a l i t t l e better so I j u s t wouldn't renew my presc r ip t ions . 66 Perhaps th i s i s another instance of minimization where the subject may be seen denying the seriousness of h i s i l l n e s s (Lipowski, 1970). Another subject had experimented with reducing h i s antihypertensive medication. Although no change was noted i n the way he f e l t or i n h i s blood pressure reading (taken at h i s exercise c lasses) , he decided to resume the f u l l dose, perhaps f e a r f u l of any harmful ef fects which might ensue. He described his r a t i ona le . Well I thought maybe I was gett ing better so I cut the p i l l s i n ha l f fo r awhile and came i n for my blood pressure reading and there was no d i f ference. There was a whole week with ha l f a p i l l and there wasn't any d i f ference but I went back to them. Both subjects did not inform the i r physicians of the i r attempts to modify the i r medication regimens Strauss et a l . (1984) explain that such concealment may be charac te r i s t i c of the chron ica l l y i l l . In learning t he i r medication regimens, these ind iv iduals may have been t r y i ng to maintain as much contro l of a normal l i f e and at the same time contro l the symptoms or disease i t s e l f . This may be seen as a further attempt at normalizing, a coping strategy which some of the subjects had previously used when they decided to keep others from knowing about the i r i l l n e s s . Strauss et a l . (1984) also state that i t depends on one's t ru s t i n h i s physic ian as to whether he w i l l consider the regimen binding or attempt to bargain with the physician fo r modi f icat ions. The three regimens discussed by the part ic ipants i n th i s study 67 revealed a substant ia l number of character i s t i c s which Strauss et a l . (1984) have i den t i f i ed as inf luencing adherence/compliance. In t a l k i ng w i th the subjects, learning to carry out a l l three regimens seemed to be a manageable task, en ta i l i n g e l iminat ion of s pec i f i c foods and addi t ion of cer ta in a c t i v i t i e s and drugs. As some of these subjects had pointed, however, more s pec i f i c guidel ines i n the area of d ie t and exercise might have made th i s learning process eas ier. Symptom Control Strauss et a l . (1984) suggest that the contro l of symptoms may be associated w i th adherence to e f fec t i ve regimens. This re lat ionsh ip became evident when some of the subjects revealed that by adhering to t he i r medication regimens, they could better contro l symptoms of fat igue and chest pain. Many of the part ic ipants commented on learning about t he i r symptoms and the i r consequences. Strauss and h is associates explain how chron ica l l y i l l people attempt bo learn the pattern of t he i r symptoms: when they occur; how long they pe r s i s t ; whether they can be prevented, shortened or reduced in in tens i ty . The subjects investigated seemed to fo l low a s im i la r learning process, indicated by the i r remarks concerning symptoms of fat igue and chest pa in. Fatigue The subjects spoke of fat igue as t he i r most common complaint. One 68 explained. I go for walks regularly now. I get tired very, very quickly. That is the thing that I really notice, that I get tired. If I go out and wash the car for instance, I am perspiring heavily by the time I'm finished. Another subject remembered how tired he used to be earlier cn in his illness. I was just tired, excessively tired at the end of every day. Sometimes I would go bo bed at seven or eight o'clock in the evening. So I could get myself in shape to get up the next morning. Other participants referred to previous energy levels as a means of measuring the extent of their fatigue. They commented. I don't go out as much as I used to, you know. I stay hone quite a bit because I've noticed that I get boo tired. You know, where I used to go to bed at midnight, now I'm in bed by ten or ten-thirty. Angina Pain Some of the subjects also spoke of their angina pain. One of the participants mentioned how he was learning to distinguish his angina pain from other types of discomfort. This is Tuesday and you know, I look at that and I can usually pretty well t e l l . If I've got aches and pains, I can say well that's from overdoing i t on the weekend shovelling snow and my muscles are sore. The angina pain is different. It stays. 69 Another subject was often unable to attribute his chest pain to anything. He explained. Oh they occur three or four times a week but nothing heavy. It just happens anytime at a l l . It can even happen when I am laying in bed. Having had angina for almost three years, this subject did not appear too concerned about these episodes of chest pain. Perhaps this relaxed attitude was related to a tendency to continue to downplay the seriousness of his il l n e s s . Discovering Limitations The subjects were also involved with learning their physical limitations in relation to symptom control. One subject explained how he had to "learn the signs." There is a message there some place within your body t e l l i n g you something. . . . I know my l i m i t . I might have pushed myself before but I can pace myself now and adjust to i t . Another participant put i t this way. I more or less just realize my limitations. When I get overly tired, I stop and go at a slower pace. Some of the subjects had curtailed certain strenuous activities in order to prevent the onset of angina symptoms. One man explained. I don't do any strenuous exercise or aerobics or anything of that nature. May be I should but I don't want to fool around with i t in case something goes wrong. 70 Another par t ic ipant commented on how he had eliminated many of h i s previous recreat iona l per su i t s . I used to play s o f t b a l l with the younger members of the s t a f f and I don 't do that now. I used to do a b i t of s k i i ng , I 've stopped that a couple of years ago. I was too t i r e d when I got through with i t . That was i t fo r a couple of days. I t j u s t drained me completely so I more or less stopped. The l a t t e r subject further explained how he had learned to accept h i s l im i t a t i on s . You get to l e a m to do th i s automatical ly. I f I become over fatigued before i t used to bother me quite a b i t . Now i t doesn 't. I say, okay, I 've reached my l i m i t so back o f f fo r a wh i le . I 've more or less learned to accept i t that way. I don ' t get upset about i t . A l l of the subjects seemed to be involved with what Strauss et a l . (1984) claim i s part of learning about symptom cont ro l . These authors expla in that the s ick person must discover h i s l i m i t s , that i s , how far he can carry on despite symptoms. Some of the part ic ipants had learned to do things i n d i f fe rent ways. One subject explained how he had to readjust h i s way of performing one household chore. I don 't have to t e l l myself or force myself. Commonsense t e l l s me. I f i t i s going to snow and i t i s going to snow a l l day, I don 't wait u n t i l there i s s i x inches of snow out there. I shovel i t away at two inches. I t ' s a l o t eas ier. Such readjustments seem to be a re su l t of discovering one's l im i ta t i on s and are s im i l a r to what Strauss et a l . (1984) r e fe r to as redesigning l i f e - s t y l e s i n order to contro l i l l n e s s symptoms. Avoiding 71 cer ta in strenuous a c t i v i t i e s as pointed out with the other subjects, may also be viewed in th i s way. One man in par t i cu la r was often test ing his l im i ta t i ons in order to determine the extent of h is c a p a b i l i t i e s . He remarked. Yes I'm a person that I don ' t learn unless I get b i t t e n , unless I get burned. Not that I know i t a l l . I t ' s j u s t that I have been a very s e l f independent male chauvinist a l l my l i f e and you've r e a l l y got to lead me to the water and on the r i gh t path before I w i l l s tar t dr ink ing. These comments might suggest that perhaps th i s man usual ly confronted most s i tuat ions in th i s manner. It may represent his s t y le of coping or in other words his cha rac te r i s t i c way of problem-solving in response to harm or threat (Lipowski, 1970). This subject commented further, suggesting d i f f i c u l t y accepting h i s i l l n e s s . And maybe that i s j u s t a mental t r i p t ry ing to see what my l im i ta t i on s are. I keep doing that every day. I keep going to the end of the l i n e u n t i l I get t o t a l l y exhausted or I get pret ty severe pain. . . . That 's the biggest thing because I fought i t . I'm s t i l l f i gh t ing i t to some extent, and tha t ' s why I stress the fact that I keep t ry ing to push myself, my l im i t a t i on s , hoping that I can get back to my previous phys ical c a p a b i l i t i e s . By always attempting to test h i s l im i t a t i on s , th i s subject may ac tua l l y be denying the seriousness of h i s i l l n e s s . This sort of behaviour may represent an attempt to minimize the threatening aspects of h i s i l l n e s s , stemming from his f a i l u r e to accept i t s s ign i f icance to h i s way of l i f e (Lipowski, 1970). S ca l z i (1973) explains that although denia l i s common for the f i r s t 24 to 48 hours post M I , - i t may extend 72 w e l l into convalescence espec ia l l y wi th younger pat ients under 40 years of age. This 42 year o ld subject had suddenly been confronted with a new i l l n e s s impacting on h i s way of l i f e . His response then may be seen as s im i la r to the denia l exhibited by younger MI pat ient s . I t seems that most of the subjects investigated used much of the i r own wisdom, judgement and ingenuity to learn about symptom cont ro l . They became aware of some of the factors which tr iggered the i r symptoms and began to r ea l i z e the i r phys ica l l i m i t a t i o n s . Working through the s ign i f icance of the i r i l l n e s s to the i r way of l i f e resulted in many of the par t i c ipants having to redesign or a l t e r ce r ta in aspects of the i r l i f e - s t y l e . Job-Related Concerns A l l of the subjects who were working commented on how the i r angina affected t he i r job performance as w e l l as t he i r a b i l i t y to to le rate stress on the job and deal wi th f i n anc i a l and retirement concerns. E f f e c t on Job Performance Many of the subjects described how the i r angina affected job a c t i v i t i e s . Two of the par t ic ipants conmented i n the fo l lowing way: My job i s one which demands a f a i r l y high degree of concentration and you got to know what you ' re about. Otherwise you miss things which I have been doing to a greater or lesser degree. I get these recurrent chest pains 73 on the job. I f e e l not too bad and then I get a couple of these sharp chest pains again so that j o l t s me right up again. It's a funny thing. Sometimes the courier work I do requires me to go somewhere and pick up maybe a ton of goods and would you believe i t , on my way to picking this up I would have a l i t t l e pain just thinking about doing myself damage, picking up a l l these boxes. When I get there I would load the boxes on with no pain. Dealing with Stress A l l subjects admitted to being exposed to stress on the job and realized that i t could be harmful in terms of their heart disease. One participant f e l t stress was a major factor contributing to the onset of his angina. He commented. This (stress) is probably what brought i t on because i t was just at that time I had tax returns and a l l these things to worry about. He further explained how d i f f i c u l t i t was to avoid stress. Work is stressful. They say, keep away from stress but i f you're going to work, especially these times, you've got stress. It's too d i f f i c u l t to eliminate i t because in my business, bad debts are awful these days and i t is stressful. Retirement/Financial Concerns The subject who was experiencing recurrent chest pains on the job, affecting his concentration, had decided to take early retirement at 74 age 60. He explained. I would s t i c k r i ght through to 65 i f I could but i t i s a b i t of anxiety which has led to a loss of concentration on my job . I'm not performing my job as we l l as I should. I'm not as sharp as I used to be and I th ink i t has to do with my angina. . . . Although I r e a l i z e there i s a b i t of stress on the job, there must be and I am going to pack i t up for that reason. I t seemed that th i s subject had come to terms wi th the impl icat ions of h i s angina i n r e l a t i on to his job performance. This appeared to be an area i n which his l im i ta t i ons had been rea l i zed . He had decided to apply for a d i s a b i l i t y pension and appeared w i l l i n g to l i v e on a reduced income so that he could keep h is angina i n check. So I thought I might as w e l l leave the whole thing and cut i t (the work) r i g h t out and see how I can do on my own. I f I am going to get pains, I might as we l l get them at heme i n my time. I t means I w i l l be on a reduced income and I ' l l have to change my accommodation to su i t my income. I t ' s a factor but i t s no r ea l concern. The other three subjects who were working were also close to retirement age. Only one spoke of wanting bo r e t i r e ear ly because of h i s angina; however, due to f i n a n c i a l reasons and family r e s p o n s i b i l i t i e s , he f e l t committed to continue working. He explained. Wel l , I'm 60 now and I 've no pension so I am in the pos i t i on that I 've got enough to sort of go along and l i v e more or less the l i f e - s t y l e . Nobody knows these days. . . . I 've got two boys. I 'd l i k e to see them sort of get the i r niche. I 'd l i k e to see them get set t led before I s e t t l e down myself. Hopefully i n f l a t i o n won't keep on, I might r e t i r e shorter than I th ink. 75 The 42 year old subject who was presently managing financially on government assistance had to adjust to the fact that he was unable to function in his previous occupation. He remarked. As for as my work is concerned, okay I realize that I probably can't go back and do the things I did for the last few years because of the mental pressure that i t took and the physical length of time that I was on my feet working. I'm slowly losing my life-long occupation which I could have gone with to my early seventies. And then my financial loss which I was making over ^ a year. And now I'm si t t i n g here fighting—well, I hope my cheque comes in the mail. What i f i t doesn't come in the mail? What do I do the next day? It appeared to have been a major adjustment for this man to deal with the loss of financial security and become forced to depend on government assistance. Loss, when associated with il l n e s s , may refer to deprivation of significant needs and values such as self-esteem, security and satisfaction with body parts and functions (Lipowski, 1969). This subject's response to his loss of occupational identity and financial security may be similar to the grief reaction of physically i l l patients described by Lindemann (1944). This subject had to work through his losses, redesigning his way of l i f e to be compatible with his transition from the role of a paid worker to one of dependency on others. Most of the subjects who were employed appeared to have taken steps to evaluate their angina in terms of i t s effect cn job performance. Their illness seemed to have developed at a time in their lives when they were also being confronted with planning for their 76 retirement. For two of the participants, angina made retirement more of a p r i o r i t y . These subjects seemed to indicate that their illness could threaten their enjoyment of a stage in their l i f e which they had always looked forward to. In contrast, two other subjects appeared content to continue to work at their occupation inspite of their angina. Attendant Psychological Concerns Many of the subjects revealed certain psychological concerns which evolved during the process of coping with angina. These concerns were related to various frustrations and the acceptance and future implications of their illness. Frustration Most of the participants experienced varying amounts of frustration due to the limitations imposed by their illness on many of their daily a c t i v i t i e s . Some of the subjects expressed frustration in relation to certain routine a c t i v i t i e s . They commented. Frustrating, oh! I'd take the garbage cans out to the street, a matter of about 60 feet. That's just one garbage can. By the time I came back I was fagged. To me i t s frustrating because I am always used to doing what I wanted to do whether I wanted to go out and mow the lawn, I'd do i t , no restrictions. But now I have to go out and do part of i t and then I s i t down and wait and then go out and do some more. 77 This l a t t e r subject seemed p a r t i c u l a r l y annoyed, r e a l i z i n g the e f f e c t h i s p h y s i c a l l i m i t a t i o n s had on many of the a c t i v i t i e s he used to do and enjoy. He remarked. A l l i t does i s j u s t make you f r u s t r a t e d because you can't do the things you used t o . I used to go hunting. I can't do that anymore. I used to go f i s h i n g where you l i f t the boat i n t o the water. Can't do that any more. And so these are the t h i n g s . You get f r u s t r a t e d because i t ' s your l i f e - s t y l e and you have to compensate. This p a r t i c i p a n t a l s o appeared angry, having had to e l i m i n a t e c e r t a i n h a b i t s which could place him at r i s k f o r f u r t h e r development o f CAD. I was f r u s t r a t e d because I couldn't have a smoke. F r u s t r a t e d because they t o l d me to keep my weight down. As t h i s subject approached retirement age, he r e a l i z e d he would be r e s t r i c t e d i n many of the a c t i v i t i e s which he had so looked forward to enjoying. I mean at my age you s t a r t to t h i n k about r e t i r e m e n t . And the only t h i n g i s , I f e e l that i n your l i f e you t h i n k , oh geez, I would l i k e to do t h i s and I would l i k e to do t h a t . I t means th a t you can't do i t . You know, I enjoyed g e t t i n g out on the d i v i n g board there and d i v i n g and swimming and going great guns but I can't s o r t o f go out there. I f l o a t and do whatever but you can't do the things that you used to do. I t ' s f r u s t r a t i n g . I t seemed th a t most o f the s u b j e c t s ' f r u s t r a t i o n s stemmed from t h e i r p h y s i c a l l i m i t a t i o n s . One su b j e c t s p e c i f i c a l l y i d e n t i f i e d f r u s t r a t i o n r e l a t e d to h i s diminished sexual performance. 78 And a guy, espec ia l l y when you are only 42 l i k e I am, then a l l of a sudden you can ' t perform. I think of a l l the things that—okay, the work i s n ' t going to bother me and the walking i s n ' t going to bother me but when my sexual appetite diminishes or I can ' t even perform a sexual act! Scalzi(1973) describes how aggressive sexual behaviour among post MI male patients attempts to counteract anxiety that re su l t s from a threat to self-image and fears of sexual inadequacy or impotence. Although th i s subject was not noted to exh ib i t any aggressive or inappropriate sexual behaviour, the fact that he was extremely concerned about his sexual performance may be re lated to the type of anxiety expressed above. He described h i s decreased sexual a b i l i t i e s as " a r ea l ego j o l t espec ia l ly at my age" (42 years ) . In add i t ion, his sense of mascul in ity seemed threatened. Other things could be much of a problem to me such as keeping my male mascul in i ty. Just the da i l y encounters of say, w e l l , I ' l l give you a hand. Now I can ' t give you a hand a l l of the time. Having to depend cn others also made this subject uncomfortable, again affecting his self-image and sense of masculinity. He explained: "I don't allow people to try to assist me any more than I need." Having to depend on the government for financial assistance was also d i f f i c u l t for him to accept. He expressed i t this way. By now becoming a permanent handicapped di s a b i l i t y pension on the government—sane thing that comes totall y to handicapped people—as these things come to me, I have to come to grips with acceptance of these things. It seems a l l of a sudden I'm becoming a total burden to society. 79 These l a t t e r responses appear to demonstrate one way that angina, as a chronic i l l n e s s , i s d i f fe rent from other i l l ne s se s of an acute nature (Dimond & Jones, 1983; M i l l e r , 1983). Because acute i l l n e s s i s usua l ly temporary, dependency on family and others to re l i eve cer ta in r e spon s i b i l i t i e s i s often accepted. Chronical ly i l l persons however, are faced with a permanent i r r e ve r s i b l e i l l n e s s where dependency over a long period of time i s not apt to be accepted by the i nd i v idua l . Acceptance Despite the f rust rat ions described above, most of the subjects claimed that they were begining to accept t he i r i l l n e s s . The same subject who had ra t i ona l i zed h i s way out of taking up d iet and exercise regimens appeared to have a po s i t i ve at t i tude re lated to l i v i n g w i th h i s i l l n e s s . I can l i v e with i t . I don 't f i nd i t a r e a l shocker type of change of habits I mean j u s t phys i ca l l y and psychological ly at my age I should be i n the area of changing my l i f e - s t y l e . He claimed that i t d i dn ' t bother him that he couldn ' t engage i n many of the a c t i v i t i e s he used to do, implying that at h i s age (56), these changes were to be expected. Oh i t doesn't bother me that I can ' t do some of the things I used to. I mean, l i k e I s t i l l am able to enjoy watching basketbal l or f o o t b a l l . I r e f l e c t back on what I used to do. Not that I wish I want to but there i s no way and I t r y to t e l l other people the same age that you know, don 't think you are that young. 80 Another subject also appeared to f ind i t easier to accept his i l l n e s s because of h is age. He commented. I'm not suf fer ing from i t (angina). I know that I w i l l never go out and win any wrest l ing match or boxing but who would at 63? The eldest of the subjects e x p l i c i t l y denied being f rus t rated about h i s i l l n e s s , claiming that he could adjust h i s l i f e - s t y l e accordingly. I don 't f e e l any sense of f r u s t ra t i on that I should be able to do things. I f I can ' t do i t , I can ' t do i t . In other words I can l i v e with i t . . . . I'm quite ready to face r e a l i t y and i f I have angina then I ' l l have to govern my actions accordingly. The youngest subject, on the other hand, s t i l l appeared to be i n the process of working through the impact of h i s i l l n e s s on h i s way of l i f e . He commented. I'm only 42, you know, l i k e I had and always have had a very good d i spos i t i on I could accept things, understand things. But I j u s t couldn ' t cone to gr ips wi th i t (the angina). . . . Not being able to do the things I used t o . That ' s probably the biggest f r u s t r a t i on . When you are accustomed to being an act ive person. L ike I get up ear ly i n the morning and I do things but I found when a l l of a sudden when I had to slow r ight down to a crawl and at my age, that i s probably the most f ru s t ra t i ng th ing. Accepting the fact that I can ' t walk from here downtown which I normally used to do. . . . S o the acceptance of what i s happening to me as far as the heart i s concerned i s s t i l l taking time. His d i f f i c u l t y accepting h i s i l l n e s s , when "only 42", may have been compounded by h i s f i n a n c i a l l y dependent s i t ua t i on . 81 During the second interview, this subject revealed that despite the restrictions imposed on his way of l i f e , he was begining to understand his angina and accept i t s permanency. He explained. The mental part I'm getting over that—the acceptance part. Having looked at the total medical aspect of i t and getting to understand exactly what I got I realize i t can't be beaten, you've got i t . He also implied that he realized he had to adjust his ac t i v i t i e s according to his limitations in order to control the disease process. My limitations bother me but what can I do? . . . It's the monitoring i t and keeping i t in retrospect and i f you can hold i t back. From getting to where you start protecting yourself. So I have accepted that fact. This was the same participant who had earlier explained how he often tested his limitations. Such behaviour was previously likened to a form of denial. As this subject came closer to accepting his illness i t seemed easier for him to acknowledge his limitations. Perhaps as Gorman and Anderson (1982) explain, this use of denial may have helped the subject adjust to the impact of diagnosis by allowing him time to deal with many complex emotional feelings and incorporate his chronic illness into his way of l i f e . Having done this, he seemed more able to accept his illness and i t s l i f e - s t y l e implications. Another participant also referred to the permanency of angina as being d i f f i c u l t to accept. He explained. It is d i f f i c u l t to accept because i t is so new. To get a broken arm or something, you put i t in a cast and that is i t . It is an everyday occurrence. But this business isn't an everyday occurrence. It is here to stay with you. . . . The hardest thing to accept is that i t is a long term thing. 82 The man who seemed to express the most f ru s t ra t i on related to the r e s t r i c t i on s imposed by h i s i l l n e s s spoke of h i s i n a b i l i t y to accept h i s angina. I 've always been very act ive and I j u s t don ' t—haven ' t been able to accept i t r e a l l y . I 'd l i k e to do more than I am r ight now. Before I could do whatever I wanted to do. Now I c an ' t and you know, i t i s hard to accept. Although th i s subject seemed to have rea l i zed h i s l im i t a t i on s re lated to angina he s t i l l appeared unable to accept the i r impact on h i s way of l i f e . For many of the subjects, age seemed to be an important factor inf luencing t he i r a b i l i t y to accept t he i r i l l n e s s . Seme of the subjects who were nearing or into the i r retirement appeared to be more accepting of t he i r aging process and i t s concomitant phys ica l changes. Coping w i th angina seemed easier for them. On the other hand, two other part ic ipants who were nearing retirement age hadn't been able to adjust to the phys ica l l im i ta t i on s imposed by the i r i l l n e s s . I t appeared that they were s t i l l working through th i s loss of a l tered body function (Chodoff, 1962; Crate & Edwards, 1983) and thus were not ready to face the long term impl icat ions of the i r i l l n e s s . Again age seemed to be a major factor for the youngest subject, a f fec t i ng h i s a b i l i t y to accept h i s i l l n e s s . I t seemed that he was j u s t beginning to show signs of coming to terms with the permanent and i r r eve r s i b l e nature of h is i l l n e s s . 83 Future Implications As angina pector is i s a chronic i l l n e s s , i t i s long term by nature and thus car r ie s with i t future impl icat ions many of which are uncertain i n a va r ie ty of ways (Strauss et a l . , 1984). Often prognosis i s uncertain where one may be unsure of what i s going happen and when. One subject expressed h is uncerta int ies i n th i s way. I'm not sure how fa r I can go with i t . Ba s i ca l l y , I don ' t know how far I can go, i f i t i s going to get any better or get worse. The eldest subject also had some uncerta int ies regarding his prognosis yet did not appear overly concerned. He stated. I'm not worried about i t at the present time except that i t could poss ib ly get worse. The youngest subject appeared the most concerned with regard to h i s future. Although he wanted to return to some form of employment and "normal" l i f e - s t y l e , he was unsure of h is future capab i l i t i e s as a f u l l time worker. He expressed h is concerns i n th i s way. My at t i tude r i gh t now, as we are s i t t i n g here i s I am l o s t . You know, f i r s t I am deal ing with my heart. Deal wi th the medical problem f i r s t . I have accepted psycholog ical ly that I have to r e f r a i n from things but as fa r as the future i s concerned, I am s t i l l at a t o t a l loss u n t i l I know my l im i ta t i on s and u n t i l I know that I am protected and that I can put in a good eight or twelve hour day which I normally have a l l my l i f e . Again th i s seems to be another example where angina, as an i l l n e s s , implies the loss of po tent ia l for ce r ta in a c t i v i t i e s and ro le 84 functions (Lindemann, 1944; Lipowski, 1969). This subject seemed to view h i s i l l n e s s as a loss of phys ica l functioning and ro le as a wage earner. Being unsure of h i s future capab i l i t i e s may have actua l l y i n ten s i f i ed h i s response to th i s lo s s . In discussing the i r thoughts and feel ings concerning the i r prognosis, many of the subjects a lso expressed doubts about the benef i ts of coronary bypass surgery. They seemed inc l ined to avoid surgery fear ing that the disease process might reoccur regardless of such an intervent ion. They explained. I know i n some people i t works and seme people i t doesn ' t . I do know that bypass surgery i s not bene f i c i a l i n each case. People who have, i t hasn ' t been the end of t he i r angina. They s t i l l get the pains. I presume a l o t of people who have i t r e a l l y need i t desperately but I wouldn't have any surgery, any bypass surgery, unless i t was r e a l l y strongly recommended. The only thing I am concerned about i s a f te r they have i t , where they are going to have the same thing come back at them and they have to go through the whole thing again. I j u s t don 't want my chest cut up and do these things and then say, Oh, now I f e e l f i ne , that so many years down the p ike—you 've got the same problem again, you got to go back again. One par t i c ipant referred to open heart surgery as a l a s t resort . I always had the impression that once you started having operations on the heart you were f i n i shed. I 'd be very happy i f the doctor could t reat i t (angina) w i th the medication. In general, the par t ic ipants did not appear to have much f a i t h i n bypass surgery. However, because the i r symptoms were not severe enough 85 that the i r physicians had prescribed such surg ica l intervent ion, they may not have considered i t ser ious ly . Most of the subjects did not appear to view the i r i l l n e s s i n a l i f e - th rea ten ing context. In f a c t , many were not concerned about the p o s s i b i l i t y of a f a t a l heart attack, be l i ev ing that such an event was out of the i r con t ro l . They explained. There i s nothing I can do. You don 't even know i f you are going to l i v e tomorrow. . . . A l l of a sudden something could happen. Nobody knows. So we (he and h i s wife) j u s t look at that. There i s always some s ign, I don 't know, unless there i s a heart attack, there i s no s ign. I t i s instant. My father had died at 54 with a coronary. Just l i k e that. So I f e e l you e i ther go one way or the other. The eldest subject i n pa r t i cu l a r seemed accepting of a po ten t i a l f a t a l course of h is i l l n e s s . He w i l l i n g l y commented on the top ic . My philosophy i s when you ' re done, you 're done. See i f I k i l l that f l y there, t ha t ' s the end of him. That ' s the end of you. We're only another form of l i f e , same as that. . Having had three score years and ten, as a s a t i s f a c t i on , w e l l , I haven't been short changed. Everything from now on i s gravy on top. I have been able to accept that i f the time has come, okay. I 've had a good time while i t la s ted. At the same time th i s subject also seemed opt im i s t i c about h i s future. So what I am leading up to now i s the fact that surgery doesn't scare me and termination of l i f e doesn't scare me except that there are cer ta in things I want to get done f i r s t . . . . I am looking forward to seeing my great grandchildren grow up and I don 't think fo r a minute that the problem I have with the heart i s going to prevent me from gett ing at least another 20 years. 86 Another par t i c ipant , i n explaining some of the reasons why he had decided to r e t i r e ear ly , may have actua l l y been concealing a concern that h i s angina could cause h i s l i f e to be cut short. He stated. Well I'm going to quit my j ob . L i f e i s too short. I mean, I'm not concerned that I ' l l die or get s ick or something l i k e that but I'm j u s t fed up with the hass le. These previous two ancedotes could suggest that both subjects may have been minimizing the s ign i f i cance of the i r i l l n e s s by ignoring i t s po tent i a l f a t a l consequences (Hamburg, 1967; Lipowski, 1970). Another par t ic ipant appeared to have devoted l i t t l e thought to the p o s s i b i l i t y of incurr ing an ML. He commented. Wel l , I f i nd a l i t t l e pain doesn't worry me at a l l . . . . I s t i l l get those chest pains once i n awhile and then I s t a r t to think, i s th i s i t ? But normally I don 't think about i t . This man did not appear threatened by his i l l n e s s , perhaps because he had never experienced symptoms severe enough to cause him to ant ic ipate any form of personal danger. Generally speaking, most of the subjects appeared to minimize any l e t h a l impl ications that the i r i l l n e s s may have had. At th i s stage i n t he i r response to angina, they did not appear to perceive t he i r i l l n e s s as a po tent i a l threat to t he i r l i v e s . Weisman (1972) discusses adapting to a threatening i l l n e s s i n terms of four stages: (1) recognit ion of the r e a l i t y of the i l l n e s s ; (2) denia l of the i l l n e s s as a threat; (3) replacement wi th a more acceptable meaning; (4) 87 reor ientat ion to the changes. Many of the subjects i n th i s study may be fo l lowing a s im i l a r pattern of response. Confronted with the numerous adjustment areas already i den t i f i e d , they may not have been ready to incorporate a l l of the threatening aspects of the i r i l l n e s s into the i r da i l y l i v e s . I I I . Secondary Coping Response In order to cope with the adjustment areas i d e n t i f i e d , the subjects appeared to have developed various basic s t rateg ies . Some of these strategies seemed to be i n response bo the subjects ' i l l n e s s i n general. Others were more i n response to s pec i f i c areas of adjustment. Basic Strategies f o r I l l nes s i n General As already noted i n r e l a t i on to the adjustment areas i d e n t i f i e d , some of the subjects responded with the i r own characte r i s t i c ways of perceiv ing, problem solv ing and act ing when the i r angina developed. Lipowski (1970) describes such responses as an i nd i v i dua l ' s coping s t y le which i n combination wi th the s i t ua t i ona l var iab les form coping s t rateg ies . Previously established strategies successfu l ly used in e a r l i e r s t re s s fu l s i tuat ions are often used f i r s t before new strategies are developed. The development and use of e f f ec t i ve strategies help broaden one's problem-solving c apab i l i t i e s (Hamburg, 1967). For example, one subject appeared to adapt h i s usual s ty le of 88 problem-solving when confronted with h i s new i l l n e s s . He explained. I 've always had the at t i tude that, i f you see a problem and i t might look unsurmountable, you j u s t study i t u n t i l you f i nd there i s a way around i t . Therefore, i f I have trouble wi th the heart I ' l l j u s t adapt to the s i tua t i on and cope with i t one way or another. And so I j u s t appl ied that a t t i tude, that approach, that there must be a way to solve i t and look fo r a so lu t ion . The subjects were noted to use various basic coping strategies as responses to to the i r i l l n e s s i n general. These strategies included: (1) taking contro l ; (2) "normal iz ing" way of l i f e (Straus et a l . , 1984); (3) downplaying; and (4) information seeking. Taking Control Some of the subjects appeared to f e e l strongly about the importance of taking contro l over the i r i l l n e s s as a way of coping w i th i t e f f e c t i v e l y and perhaps even overcoming seme of i t s l im i t a t i on s . One of the part ic ipants implied that with concentrated e f f o r t s , he might even be able to overcome h is angina or at least achieve maximum recovery. He commented. I intend to bu i l d myself up and I am going to increase my a c t i v i t y more and more i f I can without br inging on any problems. By the end of the summer I should be i n r ea l good shape because I intend to i f I can. . . . This thing i s not going to beat me. I t may have slowed me down but i t i s not going to beat me. This predominant act ion tendency i n response to i l l n e s s may be 89 associated w i th a basic s ty le of coping behaviourly whereby the subject seeks act ive measures i n response to the tasks and challenges of h i s i l l n e s s (Lipowski, 1969). At th i s stage i n h i s recovery, the subject appeared to be challenged to overcome the phys ica l l im i t a t i on s imposed by h i s angina. The concentration of h i s e f fo r t s i n th i s area seemed to be a c r u c i a l part of combating h i s i l l n e s s . Another part ic ipant who also seemed confident i n h i s a b i l i t y to contro l h i s i l l n e s s demonstrated a s im i la r coping strategy. He expressed h is confidence i n th i s way. Discovering t h i s problem of the heart hasn' t shaken my conv ict ion. I am qui te confident that I can adjust my l i f e . Improvement noted i n recent blood pressure readings seemed to boost th i s subject ' s morale even more. He commented. "Wel l , that shows that the o ld torso i s redeemable. You can get be t t e r . " In a s im i l a r context, another par t i c ipant appeared to demonstrate h i s idea of contro l over h i s i l l n e s s by accepting r e spon s i b i l i t y fo r i t s development and management. He explained. I can contribute a l o t of the angina to myself. Yes, I l e t myself get into th i s po s i t i on . I should never be th i s overweight. I shouldn 't have done a l o t of things that I d id . . . The only thing I can do now i s to monitor myself, you know, medical ly speaking they did what they can do. Now i t i s up to me to do what I can do. This man's subjective in terpretat ion of h i s i l l n e s s may be perceived i n terms of what Bainerman (1985) reported concerning a pos i t i ve co r re la t ion between heart attack v i c t ims ' frame of mind and 90 the speed of recovery. The evaluation made by th i s par t i c ipant about the part previous behaviour might have played i n development of h i s angina could indicate better chances for a more rapid recovery i n the form of adaptive coping behaviours (Lazarus, 1966, 1968; Lipowski, 1969). Normalizing Some of the subjects attempted to make the i r way of l i f e as normal as poss ible despite t he i r angina. Their coping strategies may not only be seen as measures for symptom contro l and regimen management but also as attempts to maintain as normal an existence as poss ib le (Strauss et a l . , 1984). The beginning of these normalizing t a c t i c s was f i r s t noted i n r e l a t i on to those subjects who preferred not to discuss t he i r i l l n e s s with others when i t i n i t i a l l y presented i t s e l f . Such e f fo r t s seemed to continue with some of these subjects. Strauss et a l . (1984) discuss normalizing t a c t i c s in r e l a t i on bo the s o c i a l impl icat ions of l i v i n g wi th chronic i l l n e s s . They describe s i ck people "passing" or interact ing as i f everything were normal when the i r symptons are i n v i s i b l e or others are unaware of t he i r i l l n e s s . A response s im i l a r to passing was i den t i f i ed i n r e l a t i on to one of the subjects. He commented on the strategies he used to engage i n "normal" interact ions while attending an out of town business convention. While I was there I t r i ed to contro l my symptoms without l e t t i n g others know there was something wrong. I was with 91 the guy who i s the manager o f t h i s one p r o j e c t , f o r two days. He was a f a s t walker, and I thought, how am I going t o do t h i s ? We walked f o r m i l e s i n tunnels underneath the p l a n t from one area to another and then up some s t a i r s . I t h i n k he was g e t t i n g more t i r e d than I was. What I would do was I'd enter i n t o c onversation and th a t would a u t o m a t i c a l l y slow him down. I'd ask him a question about some p a r t I was working on but the a c t u a l i d e a behind i t was t h a t I was t r y i n g t o balance my movements during the day. The youngest o f the subjects took t h i s s t r a t e g y even f u r t h e r , c o n c e a l i n g the f a c t t h a t he was t a k i n g medication w h i l e i n p u b l i c . He s t a t e d . When you go somewhere you take those bloody p i l l s w i t h you. So I took an empty p i l l b o t t l e and put them i n s i d e so you can't see. You can't t e l l . So I w a i t u n t i l I go to the bathroom and I take them so people don't know I'm popping p i l l s . That would bother me to take p i l l s i n f r o n t of people. T h i s man appeared to be attempting to maintain some semblance of normalcy as a means o f d e a l i n g w i t h f e e l i n g o f dependency. I t seemed t h a t many of the s u b j e c t s , i n the process o f coming to terms w i t h a new l e v e l o f n o r m a l i t y , s t i l l p r e f e r r e d not to be regarded as i l l by ot h e r s . C o n t i n u a t i o n o f Downplaying Two of the subjects appeared to continue downplaying t h e i r i l l n e s s as a means o f coping. I n f a c t , one o f these subjects who had l i v e d w i t h h i s i l l n e s s the longest (approximately three years) seemed to e x h i b i t t h i s s t r a t e g y most v i s i b l y . He expl a i n e d why he p r e f e r r e d to 92 ignore h i s angina. I don't l i k e to t h i n k about i t . To be honest w i t h you, I j u s t ignore i t . . . . I want to do anything I can which w i l l g i v e me my energy back and i f th a t means d i s r e g a r d i n g or downplaying p s y c h o l o g i c a l concerns, t h a t i s what I do. I j u s t don't l e t anything bother me i f I can help i t . He r a t i o n a l i z e d h i s downplaying i n t h i s way. " I f I can get i t out o f my head maybe I can shake i t a l l together. I t h i n k maybe i t i s psychosomatic, who knows? Although t h i s subject denied being d i s t r e s s e d about h i s i l l n e s s , i t became c l e a r t h a t he a c t u a l l y d i d have concerns e s p e c i a l l y w i t h regard to h i s p h y s i c a l c a p a b i l i t i e s . O c c a s i o n a l l y d u r i n g the i n t e r v i e w , he a c t u a l l y appeared to c o n t r a d i c t that he was downplaying h i s i l l n e s s . He commented. W e l l , I can't ignore i t but l e t ' s say I am t r y i n g to downplay i t . . . . F o r t u n a t e l y , i t hasn't bothered me em o t i o n a l l y . I'm not r e a l l y concerned about i t now. As a matter o f f a c t , a l l I want i s to get my st r e n g t h back. . . . There i s no r e a l p ersonal concern other than a concern about my p h y s i c a l a b i l i t y to perform or do t h i n g s . This p a r t i c i p a n t continued to c o n t r a d i c t h i m s e l f . He d i d not seem to want to acknowledge h i s i l l n e s s as a major t h r e a t to h i s l e v e l o f p h y s i c a l endurance. This i n t e r p r e t a t i o n o f h i s response was based on the f o l l o w i n g : As an i l l n e s s , i t i s no r e a l concern to me. I am not worried about dying or anything l i k e t h a t . The o n l y r e a l concern i s I don't want to be r e a l l y i n c a p a c i t a t e d to a degree than I am. In other words, I want to be completely mobile. 93 I t seemed that re l y i ng on medication served as a reminder that th i s subject had an i l l n e s s . Therefore the sooner he was able to discontinue these medications, the easier i t would be for him to ignore h i s angina. He put i t i n t h i s way. I have no r ea l anxiety about the angina at a l l p a r t i c u l a r l y when I see I ease o f f on the p i l l s , the anxiety lessens a l l the time. The further I get away from these the better I f e e l . This response may be explained by Strauss et a l . (1984) and the i r comments about management of regimens. Strauss and h is associates account for a person's re fusa l to submit to a regimen or at least minimally carry i t out, i n terms of denia l that the i l l n e s s r e a l l y ex i s t s . Another subject also appeared to interpret the seriousness of h i s i l l n e s s l i g h t l y , e spec ia l l y with regard to i t s l i f e - th rea ten ing impl icat ions. He r a t i ona l i z ed . The more rest I have, the longer I'm going to l a s t i n the long run. Again the downplaying exhibited by both subjects may be understood as minimization, representing a form of cognit ive coping s ty le i n response to phys ica l i l l n e s s (Lipowski, 1970). Minimization has also been associated s p e c i f i c a l l y wi th chronic i l l n e s s where such defense mechanisms as den ia l , repression and project ion are often used to downplay i l l n e s s symptoms and the i r consequences (Craig & Edwards, 1983; M i l l e r , 1983). 94 Information Seeking A l l o f the subjects seemed to use i n f o r m a t i o n seeking s t r a t e g i e s as a way o f l e a r n i n g how to cope w i t h t h e i r angina. Many sought out i n f o r m a t i o n about t h e i r i l l n e s s , comparing t h e i r own symptoms to what they read i n books or saw on t e l e v i s i o n . Being exposed to these forms of media seemed to help them undertand and accept t h e i r angina more e a s i l y . One s u b j e c t commented. I read a l i t t l e b i t about i t , heard a l i t t l e about i t and what I've seen on T.V. and now I can r e l a t e to i t . . . . A f t e r reading t h i s book t h a t confirms i t . The book t e l l s me a f t e r reading about the experiences o f other people, I compared myself. Many of the p a r t i c i p a n t s compared themselves to f r i e n d s , f a m i l y and r e l a t i v e s who a l s o had heart c o n d i t i o n s . Comments were made as f o l l o w s . You know, you are running i n t o more and more people my age that are r e t i r e d and a l o t o f them have e i t h e r my complaint or other complaints. And so I compared notes w i t h these f r i e n d s who have i t , and they j u s t t o l d me, you're not a c t i v e enough. So I s t a r t e d going i n t h a t p o o l and now when Monday or Thursday comes around I go downstairs h a l f an hour ahead of time w a i t i n g f o r them to come. And then to ray amazement I found t h a t my other b r o t h e r who l i v e s i n Quebec has i t too and he i s e i g h t years my j u n i o r . He went i n t o the h o s p i t a l and had the o p e r a t i o n and now he i s s k i i n g and doing e v e r y t h i n g again. These comments seem to r e f l e c t a f e e l i n g o f encouragement to 95 c a r r y on, w i t h the awareness t h a t others were a d j u s t i n g to a s i m i l a r p l i g h t . While being i n t e r v i e w e d , one subject made frequent i n q u i r i e s as t o how other people w i t h angina were coping. He commented. I j u s t wondered what everybody e l s e i s doing? . . . How do other people go about t h i s thing? Do they have a regime i n t h a t they do c e r t a i n things? I t seemed th a t t h i s subject wanted to make c e r t a i n t h a t he was doing everything p o s s i b l e to a d j u s t to h i s i l l n e s s . Perhaps comparing h i m s e l f t o others served as a means of s e t t i n g r e l e v a n t standards to f o l l o w . Many o f the p a r t i c i p a n t s asked numerous questions about pathophysiology, l i f e - s t y l e and prognosis. For example: Now the angina, could you s p e c i f i c a l l y i n d i c a t e what the term r e f e r s to? Those pains are down here and I haven't f e l t any p a i n around the h e a r t . The heart i s i n here, i s n ' t i t ? What's the d i f f e r e n c e between angina pains and a heart attack? Nobody has t o l d me t h a t . Do you t h i n k you can reverse what has happened by d i e t and e x e r c i s e ? I've never been t o l d whether t h i s t h i n g , once you've got i t under c o n t r o l , whether you can do the things you want to do or does i t get worse? One s u b j e c t seemed i n t e r e s t e d i n l e a r n i n g more about the p a r t blood pressure played i n h i s i l l n e s s . He i n q u i r e d . 96 I don't know anything about blood pressure. What i s th a t bottom number? What i s the top number? . . . Do you t h i n k I got t h a t t i g h t n e s s because o f h i g h blood pressure on top of the angina? Another p a r t i c i p a n t was curio u s about h i s s t r e s s t e s t . He remarked. What should I expect? How long should I be on t h a t t r e a d m i l l ? I'd l i k e to know a l i t t l e more about those s t r e s s t e s t s . I n q u i r i e s were a l s o made w i t h regard to regimen management. Questions regarding d i e t and e x e r c i s e were f r e q u e n t l y asked. For instance: I understood once you went on a d i e t you were f i g h t i n g c h o l e s t e r o l too? Is th a t so? Is there no d i e t t h a t would cause my body t o use up th a t f a t ? I was j u s t wondering whether e x e r c i s e would b r i n g a r e a l good blow on or would i t strengthen things? I don't know much about i t r e a l l y . Questions regarding medications and t h e i r management were a l s o g i v e n a focus. The f o l l o w i n g represent sane o f the subjects' v o i c e d concerns. Do you ever t h i n k I ' l l get o f f o f the medication? When I f e e l sleepy a l l day, I wonder how good i t would be t o l i e down? Now I don't know whether t h a t ' s because I'm t a k i n g these p i l l s or because I'm s i c k or what. A few o f the p a r t i c i p a n t s d i d not appear w e l l informed about the 97 use of n i t rog l ycer ine . One commented. And I d i dn ' t know about i t u n t i l I went to the hosp i ta l because Dr. d i d n ' t t e l l me how frequently you should take n i t rog lycer ine or what the signs are. He j u s t to ld me to take i t i f I ever f e l t a pain coming on. So he must have thought i t wouldn't be r e p e t i t i v e . In general, many of the information-seeking strategies used by the part ic ipants appeared s imi la r to some of the coping behaviours which have been associated with chronic i l l n e s s (Craig & Edwards, 1983; M i l l e r , 1983). For example, the subj ects ' use of extra-personal resources may represent an e f f ec t i ve means of seeking relevant information to re l i eve anxiety and restore a sense of contro l (Craig & Edwards, 1983). Learning about the i r i l l n e s s and i t s management in th i s way may also prove to be more meaningful and may enhance the subjects ' sense of confidence and self-esteem. Basic Strategies For Spec i f i c Adjustment Areas Basic strategies in a general sense have been discussed as a form of secondary coping response to angina. During the process of adjust ing to the i r i l l n e s s , many of the subjects also developed basic strategies to deal with spec i f i c areas of concern. The strategies which were i den t i f i ed in th i s study seemed bo be related to: (1) coping with fat igue; (2) managing angina pain; and (3) e l iminat ing stress at work. 98 Coping wi th Fatigue Many of the subjects had devised various strategies to cope with the increased fat igue they experienced i n r e l a t i on to the i r angina. One subject shared the approaches he used to combat fat igue. When I'm t i r e d , I l ay down and rest fo r a wh i le . I also t r y to do exercises so I can get my strength back, so I won't become so t i r e d . Another par t ic ipant dealt with fatigue i n th i s way. On weekends, I ' l l go home a f te r doing a b i t of shopping and I s t re tch out on the bed and have a nap. S t i l l another subject claimed he was able to cope with h i s fat igue by "catching up on h i s r e s t . " For example, i f he stayed up l a te one night, he would r e t i r e ear ly the next evening in compensation. These strategies used to cope with fat igue seemed to have developed as a re su l t of learning i n d e t a i l about the symptom and i t s consequences (Strauss et a l . , 1984). Knowing that fat igue could indicate that they had overtaxed the i r resources, the subjects attempted to acquire s u f f i c i e n t rest i n order to prevent the occurence of angina symtoms. Managing Chest Pain Many of the strategies used to cope with fatigue also appeared bo contribute to curbing chest pa in. More spec i f i c strategies geared to 99 managing chest pain seemed to involve taking nitroglycerine and/or re s t i n g . For example, one man explained the protocol he followed when self-administering nitrogylcerine. Well, now I get to the point that i f I get a l i t t l e exhausted then I slow r i g h t down to a crawl and naturally as I get myself more exhausted, my heart starts pumping, I get pains i n my chest, the angina starts to f l a r e up and so I have to take a n i t r o and slow myself r i g h t back down and take inventory as to what I'm doing and correct i t . He further explained how sometimes j u s t "slowing down" enabled him to control his angina pains. When I have to meet a deadline and I'm walking out to my car and I notice myself walking a l i t t l e faster and the faster I walk I notice t h i s heaviness so I slow down and take a deep breath. Relax. And so with that I f e e l I am c o n t r o l l i n g . Another subject remarked how he tended to avoid taking nitroglycerine, preferring to control his pain on his own. He explained. " I t r y not to take n i t r o unless the pain i s r e a l l y strong. I usually t r y to j u s t s i t there quietly and relax." Perhaps a major part of fe e l i n g i n control of his i l l n e s s stemmed from being able to control his chest pain independently. Many of the participants' strategies related to managing t h e i r angina pain seemed preventive i n nature, involving use of medications. For example, taking nitroglycerine as a precautionary measure p r i o r to p h y s i c a l l y or mentally s t r e s s f u l a c t i v i t i e s was a common practice. Some of the participants commented. 100 I f I know I am going to cb something strenuous, I stop, take a p i l l and go cn and do i t . I f I am going to cut the grass, I might get t i r e d so I take the n i t rog l ycer ine . Now I can cut the grass i n 30 minutes instead of 40 minutes. I sometimes might take a n i t r o when I have to walk a distance and I 've j u s t f in i shed lunch. I ' l l take one j u s t as a precaution. I ts not that I have chest pa in. I j u s t take one and walk that three or four blocks. I f my mother-in-law walked i n unexpectedly, I would get a l l excited and worked up and the adrenal in would be moving. That ' s when I would pop a couple of n i t r o because I know I would get the pa in. I guess what I do i s t r y to contro l my excitement. One par ic ipant explained that as he was s t i l l i n the process of discovering his l im i t a t i on s , he would always take h i s medications along as a back up. He put i t th i s way. I ' l l push myself but I ' l l always be cn guard by having my medication with me, using that as an ace i n the hole. Another man explained how he was prepared to deal with angina symptoms should they become progress ively worse. He commented. My wife would phone the doctor r i gh t away i f I was experiencing a l o t of chest pa in. Fortunately I haven't reached that stage yet. Such family arrangements represent another way of coping w i th symptom contro l where a supportive person from the family un i t serves as a "p rotect ive agent" fo r the chron ica l l y i l l person (Strauss et a l . , 1984). This nonmedical organization of e f f o r t may be usefu l i n preventing a medical c r i s e s . I t must involve danger s ignals being read co r rec t l y and appropriate actions being taken by the person himself and 101 s i gn i f i c an t others. Even the other precautionary measures i d en t i f i ed e a r l i e r i n r e l a t i o n to managing fatigue and chest pain may be seen as i nd i rect forms of organizing fo r po ten t i a l c r i s i s . In a d i rec t sense however, none of the part ic ipants appeared to have made spec i f i c arrangements against the p o s s i b i l i t y of c r i s i s occurence. For example, emergency telephone numbers were not made read i l y ava i lab le nor were family members prepared to perform l i f e - s a v i n g measures. Perhaps the subjects f e l t i n enough contro l of the i r symptoms that the experience of an actua l c r i s i s seemed f a r enough away that they could re lax t he i r guard. This avoidance to organize behaviour more i n accordance with a c r i s i s -prone condit ion may represent a mode of coping attempting to ignore or withdraw attent ion from a po ten t i a l l y f a t a l threat of MI (Lazarus, 1966; Lipowski, 1970). At th i s stage, the coping e f fo r t s exhibited by the part ic ipants seemed to be directed more towards contro l of such symptoms as fat igue and chest pa in. i El iminat ing Stress at Work A l l of the subjects who were employed seemed to have made attempts to a l l e v i a t e ex i s t ing stress leve l s at the workplace. Many of these stress-reducing strategies consisted of adjust ing the amount and i n tens i t y of cer ta in a c t i v i t i e s . One par t ic ipant explained how he coped with stress on the j ob . 102 I don ' t want to stress myself on the job a l l morning long working on the computer terminal so I pace myself. I 'd say about every 30 or 40 minutes, I e i ther go for coffee i f i t ' s about time I have a coffee or I go up into Engineering and j u s t walk around and maybe I schedule items I want to research and that gives me a break. I change what I am doing but I don ' t actua l l y stop working. Another par t i c ipant who worked as an accountant stopped taking extra projects home in the evenings. The subject who did courier work not only cut back on h i s hours but also slowed down h i s pace. He explained. Work i s n ' t as hect ic as i t used to be. I j u s t slow down and don ' t get any more speeding t i c k e t s . I f the l i g h t i s red, I stop and don 't go through. . . . I used to stew about s i t t i n g wait ing for a c a l l and not making any money. Now I may s i t fo r ha l f an hour occass ional ly and I say to myself, ' I 'm gett ing a r e s t . ' These e f fo r t s to adjust to job- re la ted stresses may be seen as another form of symptom contro l where cer ta in a c t i v i t i e s are avoided that are known to br ing on symptoms (Dimond & Jones, 1983). Having an awareness of some of the factors which contribute Go the occurence of angina symptoms, these subjects seemed to be able to make appropriate decisions re lated to adjusting the i r a c t i v i t y l e ve l s . Such decisions may exemplify how chron ica l l y i l l persons need s u f f i c i en t knowledge to funct ion as managers of the i r own care i n the i r da i l y l i v e s (Dimond & Jones, 1983). 103 IV. Awareness of Resulting Changes After implementing basic strategies directed towards angina in general as well as towards specific areas of symptom control, many of the subjects indicated an awareness of resulting changes which they had incorporated into their daily li v e s . They commented on the concrete changes they had made as well as those they had experienced both physically and psychologically. Concrete Changes Made Most of the l i f e - s t y l e changes admitted to by the participants were related to regimen management and symptom control. For instance, one subject remarked on the changes he had made to his diet. Now I watch what I consume and I exercise a l i t t l e more. Although I was pretty active before, i t seemed as soon as I burned up the energy I might stop and have a doughnut. I don't do that now. I f I get hungry, I stay hungry for awhile u n t i l my mealtime comes. I eat nothing after supper when I used to munch away. Yes i t has changed everything. Another participant admitted to implementing a regular walking schedule. "I used to go out walking but not to the degree I'm doing now. Now I make a point of going out everyday i f I can." Two of the subjects commented that they had reduced their consumption of alcohol. One of them explained. Well I used to drink pretty heavily because of economic times but that has totally changed from a bottle a day, to a bottle a week, down to a bottle a month. Now i t is even longer than that. 104 One subject had stopped smoking while two others were s t i l l holding on to the habit. Change in a general sense was described by another subject. He remarked. "I would say there has been a change in my habits or what I am doing a l i t t l e b i t changes whatever i t i s . " The fact that many of the subjects actually admitted to making certain changes to their way of l i f e may be significant. It may serve as an indicator that these subjects were beginning to accept the permanency of their illness and i t s concommitant need for risk modification in terms of l i f e - s t y l e changes. It may also show that a direct attempt had been made Go redesign activities in keeping with recognized limitations. Changes Experienced Many of the subjects experienced changes in the way they f e l t physically. They also commented cn psychological change since the onset of their i l l n e s s . Physical Change Two of the subjects remarked on the change they noted concerning their energy levels. One man explained. I don't t i r e as badly as I used to. For instance I can wash a whole car now and I won't be huffing and puffing. 105 In adjusting some of his day to day activities in keeping with his limitations, this subject was becoming more adept at symptom control. The subjects commented further on the physical changes they noted within themselves. It seems that my angina has stabilized. It's not getting worse and i f anything i t is getting better because a year ago I couldn't do certain things whereas now I can. I can walk further without any signs or feel that I have symptoms of angina pain. • • • • • I'm not getting as tired and not getting chest pains as often. I get them the odd time about three or four times a week, but nothing that heavy. And only in my chest. Before i t used to be in my shoulder. Just as these subjects had reflected back to their previous capabilities when f i r s t diagnosed with angina, they were again reflecting back. This time they referred back to their previous level of physical a b i l i t y at diagnosis, using i t as a yardstick to measure the progression of their i l l n e s s . Psychological Change One subject regretfully indicated that his l i f e had generally changed since developing angina. He explained. My wife and I go down to the sea-wall and walk but I don't do as much walking as I should. But there again we are on a h i l l . I've got a workshop at the back there and I putter around in that and in the summer time I vacuum the pool or swim or whatever but i t just isn't the same. 106 I t appeared that he was having d i f f i c u l t y coming to terms with some of the r e s t r i c t i on s imposed on h i s way of l i f e . This d i f f i c u l t y may resemble a psychological react ion s im i la r bo g r i e f described by Lindemann (1944). This subject may s t i l l be i n the process of working through the loss of cer ta in a c t i v i t i e s i n coping w i th the l i f e - s t y l e a l te rat ions re lated to h i s i l l n e s s . Two of the part ic ipants maintained that they hadn't experienced any psychological change fo l lowing the onset of the i r i l l n e s s . One of these men i n pa r t i cu l a r repeatedly denied any form of psychological react ion, admitting only to experiencing phys ica l changes since the onset of h i s i l l n e s s . He put i t i n th i s way. I don 't think there was any psychological react ion when I heard I had angina. . . . L ike I sa id psychological ly I haven't changed but the phys ica l aspect I would say yes. . . Now I f e e l that I can s t i l l cope with i t but I c an ' t say that i t has changed my way of th ink ing. This subject may be using denia l as a defense mechanism to minimize any psychological impact re lated to h i s angina (Lipowski, 1970; Craig & Edwards, 1983; S c a l z i , 1973). On the other hand, because he had been suf fer ing from angina symptoms fo r approximately the past ten years p r i o r to being diagnosed, the r e l i e f he experienced from knowing that these symptoms could be at t r ibuted to a concrete i l l n e s s may have overshadowed h is acknowledgement of other emotional responses. I t i s also poss ib le that he had already resolved any psychological concerns which occured whi le coping w i th h i s i l l n e s s . 107 In general, many of the subjects investigated seemed to acknowledge various changes that they had made to the i r way of l i f e since the onset of the i r angina. To admit to such changes may indicate a form of acceptance of t he i r i l l n e s s and i t s integrat ion into t he i r d a i l y l i v e s . I t may also be viewed as evidence of e f f ec t i ve coping. In the i r discussion of adaptation to the continual changes associated with chronic i l l n e s s , Craig and Edwards (1983) claim that when coping strategies are e f f e c t i v e , ind iv iduals bel ieve that t he i r actions have been successful w i th regard to the outcome of the s i t ua t i on . Therefore they f e e l a sense of contro l w i th in themselves. This f ee l i ng of pos i t i ve e f fect may have been encountered by some of the subjects i n th i s study, providing them with a sense of psychological i n teg r i t y and a t t r i bu t i n g to the i r a b i l i t y to cope. 108 CHAPTER FIVE « SUMMARY, CONCLUSIONS AND IMPLICATIONS FOR NURSING Summary and Conclusions The purpose of the study was to determine how angina patients experience and cope with the i r chronic i l l n e s s fo l lowing diagnosis. By e l i c i t i n g these pat ients ' viewpoints on the i r i l l n e s s , ins ight was gained into some of the adjustment areas they encountered as we l l as the coping strategies they used. The conceptual framework for th i s study was adapted from Strauss et a l . (1984) (Appendix I ) . Their framework, focusing on the soc i a l and psychological aspects of l i v i n g with chronic i l l n e s s , was found to be a usefu l guide for i dent i f y ing some of the adjustment areas encountered and coping strategies u t i l i z e d by the angina patients invest igated. Qua l i tat ive methodology, using phenomenological theory, was used to determine the angina patients viewpoints of t he i r i l l n e s s experience. The study was conducted with a convenience sample of s i x male subjects, ranging in age from 42 to 72 years, with recency of diagnosis of angina pector is from two to t h i r t y - f ou r months. None of these subjects were known to have suffered an MI. Using a semi-structured interview guide w i th open-ended questions, the 109 invest igator interviewed each subject at home, on two occasions. The in ter - subject ive nature of the interviews allowed the researcher to understand how the subjects were experiencing the i r i l l n e s s and how they were coping with i t . Data coding and analys is were approached using the constant comparative method developed by Glaser and Strauss (1967). Although the subjects attached d i f fe rent meanings to cer ta in aspects of the i r i l l n e s s , they commonly described s im i l a r reference points which highl ighted the i r experiences i n coping w i th angina. These reference points provided the invest igator wi th a means to analyse and understand the data. The re su l t i ng phases which emerged from the common reference points formed a pattern through time. The common reference points as i d e n t i f i e d by the subjects guided how the phases were both understood and organized. As a r e su l t , the f indings of the study revealed four phases of coping experience where each phase was associated wi th s pec i f i c common reference points (Appendix V I I I ) . Phase I, l abe l l ed " I n i t i a l Coping Response," followed the onset of the subjects ' angina symptoms. A l l of the subjects i n i t i a l l y downplayed the i r angina symptoms p r i o r to diagnosis. They did th i s as long as severe or pers i s tant chest pain d id not occur to in ter fere w i th t he i r everyday a c t i v i t i e s . When symptoms became r e s t r i c t i v e , they sought medical at tent ion leading to the i r diagonosis of angina pecto r i s . Most of the subjects were able to remember many of the v i v i d de ta i l s surrounding the i r diagnosis. They also re f lec ted back to the i r previous c apab i l i t i e s p r i o r to diagnosis as a means of measuring the 110 changes i n body functioning which had developed since the onset of t he i r i l l n e s s . Phase II followed diagnosis and involved the subjects ' confrontation with s pec i f i c adjustment areas re lated to l i v i n g w i th angina. In th i s study f i v e major adjustment areas were i d e n t i f i e d : (1) in teract ion wi th others; (2) regimen management; (3) symptom contro l ; (4) job- re lated concerns; and (5) attendant psychological concerns. Part of the subjects ' i n i t i a l adjustment to the i r i l l n e s s involved interact ing with health profess ionals and family members as we l l as dealing w i th others knowing about the i r i l l n e s s . Most of the subjects ' interact ions with health professionals appeared to be with physicians. The comments made by the subjects general ly re f lec ted a lack of s u f f i c i e n t guidance from the i r physicians re lated to managing cer ta in l i f e - s t y l e changes, namely d i e t , exercise and weight contro l (e.g. s p e c i f i c a l l y wr i t ten in s t ruc t ions ) . The fact that nurses were not mentioned i n these interact ions could indicate that nurses are e i ther not v i s i b l e or ava i lab le as pat ient teachers for th i s c l i e n t group. The subjects referred to the i r spouses as being supportive. In many of the accounts, i t was evident that the subjects d id not cope alone, but shared the r e spon s i b i l i t y for managing t he i r i l l n e s s with t he i r spouses. This sharing was a valuable coping strategy for the pa r t i c ipant s . Having others know about the i r i l l n e s s appeared to be a sens i t ive issue for the subjects i n th i s study. In a beginning attempt to make 111 their l ives as normal as possible, many of the subjects preferred that others outside the family unit were not informed that they had angina. The subjects' use of this coping strategy termed normalizing by Strauss et a l . (1984) did not appear compatible with any knowledge that others outside the family unit might have concerning their i l lnes s . The participants discussed management of three regimens in particular during the course of the interviews: (1) diet ; (2) exercise; and (3) medications. Before learning how to implement these regimens, the subjects f i r s t became involved with judging whether or not they would actually take up and adhere to them. They appeared to evaluate certain regimen characteristics based on the legitimacy and efficiency of each regimen. Symptom control, another adjustment area, appeared to be strongly associated with adherence to effective regimens. For example, adhering to medication regimens meant that the subjects could better control symptoms of fatigue and chest pain. When symptoms appeared under control , this seemed reason enough for a few of the subjects to start tapering off their medications. The subjects' efforts to decrease dependence cn medications were viewed as another attempt at normalizing as well as an attempt to gain control over their i l lnes s . While learning about symptom control the subjects had to become familiar with the pattern of their symptoms and their consequences. In discovering their limitations many of the participants had to redesign everyday ac t iv i t ie s and sacri f ice certain recreational pursuits in order to control their symptoms. 112 Those subjects who were employed seemed to be i n v o l v e d w i t h making c e r t a i n adjustments at work. Job performance i n most cases was not a f f e c t e d by angina. C o n t r o l l i n g exposure to s t r e s s on the j o b on the other hand, seemed to depend on the type o f employment i n which the s u b j e c t s were engaged. For some o f the s u b j e c t s , angina made reti r e m e n t more of a p r i o r i t y . These subjects seemed to i n d i c a t e that t h e i r i l l n e s s could threaten enjoyment o f a stage of t h e i r l i f e which they had always looked forward t o . For the other s u b j e c t s , c o n t i n u i n g to work i n s p i t e of t h e i r angina was not questioned. F i n a n c i a l concerns may have been a f a c t o r w i t h these p a r t i c i p a n t s . A f i n a l adjustment area was r e l a t e d to c e r t a i n p s y c h o l o g i c a l concerns which evolved as the s u b j e c t s coped w i t h t h e i r i l l n e s s . Despite f r u s t r a t i o n s r e l a t e d to v a r i o u s p h y s i c a l l i m i t a t i o n s , many of the subjects were be g i n i n g to acknowledge the permanancy of t h e i r angina. Some o f the p a r t i c i p a n t s appeared to be more accepting of t h e i r i l l n e s s and i t s concomitant need f o r r i s k m o d i f i c a t i o n . Others were s t i l l having d i f f i c u l t y working through t h e i r l o s s o f body f u n c t i o n i n g r e l a t e d bo angina. Many o f the s u b j e c t s tended to ignore the p o t e n t i a l f a t a l consequences of t h e i r angina. I t was f e l t t h a t they d i d not p e r c e i v e t h e i r i l l n e s s i n a l i f e - t h r e a t e n i n g c o n t e x t . Instead they appeared t o be c o n c e n t r a t i n g t h e i r e f f o r t s on the v a r i o u s adjustment areas as i d e n t i f i e d . At t h i s stage i n coping w i t h t h e i r i l l n e s s these subjects may not have been ready to s e r i o u s l y consider i t s f u t u r e i m p l i c a t i o n s . 113 In order to cope w i t h t h e i r i l l n e s s i n general as w e l l as s p e c i f i c adjustment areas, the subjects appeared to develop v a r i o u s b a s i c s t r a t e g i e s . These coping s t r a t e g i e s were viewed as a secondary form o f coping response, comprising Phase I I I of the f i n d i n g s . Some of the p a r t i c i p a n t s appeared to s t r i v e to take c o n t r o l over t h e i r i l l n e s s as an attempt t o overcome c e r t a i n l i m i t a t i o n s . N o r m alizing t a c t i c s a l s o served as a general coping s t r a t e g y where many o f the subjects attempted to conceal t h e i r angina from o t h e r s . T h i s preference to maint a i n some semblance o f normalcy may have served as a way o f m i n i m i z i n g the s u b j e c t s ' i l l n e s s by withdrawing a t t e n t i o n from i t . C ontinuing to downplay the seriousness o f t h e i r i l l n e s s and i t s p h y s i c a l l i m i t a t i o n s served as a b a s i c coping s t r a t e g y f o r some o f the p a r t i c i p a n t s . These e f f o r t s t o minimize the impact o f t h e i r i l l n e s s on t h e i r d a i l y l i v e s may have c o n t r i b u t e d to the e f f e c t i v e n e s s of other s t r a t e g i e s , such as t a k i n g c o n t r o l and n o r m a l i z i n g . Information-seeking e f f o r t s appeared to serve as u s e f u l coping s t r a t e g i e s f o r many o f the p a r t i c i p a n t s . R e f e r r i n g to v a r i o u s forms o f media and comparing themselves to others w i t h heart disease served to answer many o f the su b j e c t s ' questions as w e l l as help them understand and accept t h e i r i l l n e s s more e a s i l y . Despite these e f f o r t s , many of the p a r t i c i p a n t s s t i l l had u n c e r t a i n t i e s regarding the nature o f t h e i r i l l n e s s and i t s i m p l i c a t i o n s f o r everyday l i v i n g . Although the subjects had developed s t r a t e g i e s s p e c i f i c a l l y to cope w i t h such symptoms as f a t i g u e and chest p a i n , they had not made 114 d e f i n i t e arrangements to organize f o r p o t e n t i a l c r i s i s should one occur. T h i s l a c k o f o r g a n i z a t i o n a g a i n s t the p o s s i b i l i t y o f c r i s i s occurence was seen as another o f the subjects' attemts to downplay the seriousness o f t h e i r i l l n e s s . The subjects' acknowledgement o f the changes t h a t had r e s u l t e d from t h e i r coping e f f o r t s comprised Phase IV o f the f i n d i n g s . Most o f the subjects admitted to p h y s i c a l changes as opposed to p s y c h o l o g i c a l ones. Many o f these p h y s i c a l changes i n v o l v e d p o s i t i v e outcomes r e l a t e d to symptom c o n t r o l and regimen management. To admit to such changes o f p o s i t i v e e f f e c t was viewed as evidence of e f f e c t i v e coping. The subjects' r e c o g n i t i o n o f t h e i r s u c c e s s f u l coping e f f o r t s l e a d to a sense o f c o n t r o l w i t h i n themselves. These e f f o r t s could then be b u i l t on, f u r t h e r c o n t r i b u t i n g to the subjects' a b i l i t y to cope. This study revealed t h a t the subjects were coping w i t h a number o f adjustment areas r e l a t e d to t h e i r i l l n e s s . Because the subjects i d e n t i f i e d c e r t a i n d i f f i c u l t i e s f a c i n g them and a d e s i r e to overcome these d i f f i c u l t i e s u s i n g concrete behaviours, the study's f i n d i n g s have i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e , education and research. I m p l i c a t i o n s f o r Nursing P r a c t i c e Understanding the viewpoints o f angina p a t i e n t s concerning t h e i r experiences i n coping w i t h angina provides d i r e c t i o n f o r e f f e c t i v e n u r s i n g p r a c t i c e . The r e s u l t s o f t h i s study s t r o n g l y suggest the importance o f as s e s s i n g coping i n response to the impact of angina on 115 d a i l y l i f e as w e l l as i n response to s p e c i f i c areas of adjustment. Armed w i t h t h i s knowledge, nurses are b e t t e r able to pr o v i d e the necessary guidance and support so that i n d i v i d u a l s w i t h angina are more able to understand and manage t h e i r i l l n e s s . Although the phases i n d e n t i f i e d i n t h i s study described a common p a t t e r n o f coping response, i t must not be overlooked t h a t each subject was unique i n how he perceived and responded to h i s i l l n e s s . For example, age was a predominant f a c t o r a f f e c t i n g the s u b j e c t s ' focus on c e r t a i n adjustment areas. For t h i s reason, nurses cannot assume th a t the i l l n e s s experience o f angina p a t i e n t s i s a g e n e r a l i z a b l e one. Nursing care must be i n d i v i d u a l i z e d to deal w i t h the uniqueness of the experience o f each p a t i e n t . The f i n d i n g s o f t h i s study then have major i m p l i c a t i o n s f o r i n d i v i d u a l i z e d assesment o f angina p a t i e n t s . The phases o f coping response i d e n t i f i e d i n the study can be used as a guide f o r asses s i n g problems and concerns r e l a t e d bo v a r i o u s adjustment areas and f o r working towards e f f e c t i v e coping. The r e a c t i o n s experienced by angina p a t i e n t s must be examined over a c o n s i d e r a b l e l e n g t h o f time. I t i s not enough to intervene w h i l e i n h o s p i t a l or i n the p h y s i c i a n ' s o f f i c e . Nurses must meet p e r i o d i c a l l y w i t h these p a t i e n t s through home v i s i t s or groups i n the community t o f a c i l i t a t e e f f e c t i v e use of coping a b i l i t i e s and resources i n the management of angina. I n many h o s p i t a l s , education programs are o f f e r e d to c a r d i a c p a t i e n t s and t h e i r f a m i l i e s f o r enhancing development o f r e a l i s t i c e x p ectations concerning long-term p h y s i c a l and p s y c h o l o g i c a l 116 adjustment. R a r e l y are these programs followed up a f t e r discharge. Some angina p a t i e n t s may have been diagnosed i n t h e i r doctor's o f f i c e . As a r e s u l t , these p a t i e n t s may never have been in v o l v e d i n c a r d i a c teaching programs. T h i s study revealed t h a t i n f o r m a t i o n which some angina p a t i e n t s r e c e i v e from h e a l t h p r o f e s s i o n a l s o f t e n leaves them w i t h many u n c e r t a i n t i e s r e l a t e d to l i v i n g w i t h t h e i r i l l n e s s . For t h i s reason, community-based education programs to promote improved coping a b i l i t i e s to de a l w i t h necessary l i f e - s t y l e changes f o l l o w i n g d i a g n o s i s o f angina can e a s i l y be j u s t i f i e d . In both h o s p i t a l and community p a t i e n t education programs, h e a l t h p r o f e s s i o n a l s must develop content around the c l i e n t s ' problems and concerns. Because angina p a t i e n t s r e f l e c t on past experience to make sense o f t h e i r i l l n e s s , t e a c h i n g - l e a r n i n g s i t u a t i o n s should make use of t h i s p r i o r knowledge. Nurses must c a p i t a l i z e on how p a t i e n t s understand t h e i r i l l n e s s and manage i t . I f t h i s i s done, c l i e n t s may be b e t t e r able t o adhere to medical regimens because they understood them and can i n t e g r a t e them i n t o t h e i r d a i l y l i v e s . Teaching must be c a r r i e d out i n response to c l i e n t l e a r n i n g needs. Although c l i e n t s may r e q u i r e a b a s i c understanding o f pathophysiology, other aspects o f i l l n e s s should be presented i n concrete ways, r e l a t i v e to i d e n t i f i e d areas o f concern. For example, i n f o r m a t i o n on e x e r c i s e regimens should be learned i n terms of when t o e x e r c i s e , how o f t e n , how lo n g , how f a r and what s a f e t y measures should be taken when o v e r - e x e r t i o n occurs. Information concerning d i e t should be i n the form o f w r i t t e n i n s t r u c t i o n s and should i n c l u d e , among other 117 t h i n g s , s p e c i f i c food menus i n c l u d i n g a l t e r n a t i v e meal p l a n s . Information g i v i n g , however, i s not s u f f i c i e n t i n p a t i e n t education programs. Because i l l n e s s i n v o l v e s p h y s i c a l as w e l l as p s y c h o l o g i c a l responses, nurses must d e a l w i t h c l i e n t s ' f e e l i n g s . F a c i l i t a t i n g group d i s c u s s i o n s so t h a t c l i e n t s can a r t i c u l a t e and compare t h e i r emotional r e a c t i o n s to others i s a key component of any educative s t r a t e g y . Informing c l i e n t s o f t h e i r progress i n coping w i t h v a r i o u s adjustment areas should a l s o be incorporated i n t o these group d i s c u s s i o n s . Since the s u b j e c t s i n t h i s study coped by i d e n t i f y i n g progress w i t h c e r t a i n reference p o i n t s , feedback from nurses r e l a t e d to these reference p o i n t s could be b e n e f i c i a l . I n g e n e r a l , i n - h o s p i t a l and ccmmunity-based education may be seen as important areas of n u r s i n g p r a c t i c e where nurses can make themselves more v i s i b l e to angina p a t i e n t s , c o n t r i b u t i n g to the ongoing management o f t h e i r i l l n e s s . T h is study has major i m p l i c a t i o n s f o r both content and focus of h o s p i t a l and community education f o r angina p a t i e n t s . While i n h o s p i t a l , angina p a t i e n t s should be encouraged to attend p a t i e n t education sesions along w i t h the MI p a t i e n t s . Adequate e x p l a n a t i o n o f procedures such as angiograms and s t r e s s t e s t s should a l s o be o f f e r e d so t h a t p a t i e n t s can f e e l b e t t e r prepared and more i n c o n t r o l of t h e i r s i t u a t i o n . Discharge planning i s a l s o c r u c i a l to a s s i s t angina p a t i e n t s i n a d j u s t i n g to a l e s s secure environment at heme. A f t e r discharge from h o s p i t a l , home v i s i t ( s ) should be arranged to assess coping a b i l i t i e s and concerns and provide support and guidance 118 t o the angina p a t i e n t s as necessary. When ap p r o p r i a t e , r e f e r r a l s can be made to community-based c a r d i a c education and r e h a b i l i t a t i o n programs when a v a i l a b l e . Atttendance o f spouses should be encouraged i n a l l types o f programs as i n t h i s study, many o f the wives were found to p l a y a v i t a l r o l e i n both supporting and a s s i s t i n g t h e i r husbands i n the management o f t h e i r angina. I m p l i c a t i o n s f o r Nursing Education A l l l e v e l s o f n u r s i n g education should i n c l u d e a p p r o p r i a t e knowledge and s k i l l s to help students understand the impact o f c h r o n i c i l l n e s s on d a i l y l i f e . Nursing education must prepare the nurse to assess p a t i e n t s r e a c t i o n s i n response to t h e i r i l l n e s s and to a s s i s t p a t i e n t s i n coping w i t h these r e a c t i o n s so that they are able bo deal w i t h necessary l i f e - s t y l e adjustments. Nursing programs should i n c l u d e the concept o f chr o n i c i l l n e s s i n t h e i r core c u r r i c u l a . Included a l s o should be content r e l a t e d to coping, l o s s and change theory and i n t e r - p e r s o n a l and communication theory. When addressing CAD, i n s t r u c t i o n a l content should not overlook p a t i e n t teaching i m p l i c a t i o n s f o r angina p a t i e n t s . A l l of t h i s knowledge and s k i l l w i l l provide students w i t h a general guide to a s s i s t c h r o n i c a l l y i l l persons i n coping w i t h t h e i r i l l n e s s and i n t e g r a t i n g i t i n t o t h e i r way of l i f e . 119 I m p l i c a t i o n s f o r Nursing Research Although much research has been done on i n d i v i d u a l s w i t h CAD and MI, few s t u d i e s have focused s p e c i f i c a l l y on p a t i e n t s diagnosed w i t h angina p e c t o r i s . T h i s study represents a beginning attempt to provide knowledge o f common p a t t e r n s o f r e a c t i o n s t h a t angina p a t i e n t s experience i n response to t h e i r i l l n e s s . To what extent are these phases o f coping response present i n the gene r a l p o p u l a t i o n o f angina p a t i e n t s ? I t i s necessary f o r these responses to be examined to a gr e a t e r extent w i t h a random s e l e c t i o n o f angina p a t i e n t s . Further study i s a l s o r e q u i r e d to i d e n t i f y the commonalities and d i f f e r e n c e s between v a r i o u s age groups and sexes. While t h i s study has added bo the body o f coping l i t e r a t u r e i n r e l a t i o n to angina p a t i e n t s , i t has a l s o r a i s e d questions about the phenomenon o f coping. For example, how does one de f i n e and measure e f f e c t i v e coping? I s e f f e c t i v e coping d i r e c t l y a s s o c i a t e d w i t h compliance/adherence bo p r e s c r i b e d and nonprescribed regimens? Questions may a l s o be brought up i n r e l a t i o n to p a t i e n t t e a c h i n g . F i r s t o f a l l , does p a t i e n t teaching r e a l l y make a d i f f e r e n c e ? Does i t enhance the angina p a t i e n t s a b i l i t y to cope w i t h h i s i l l n e s s ? When i s the most e f f e c t i v e time to teach? Nursing researchers must begin to study the e f f e c t s o f s e l e c t e d planned n u r s i n g i n t e r v e n t i o n s such as p a t i e n t teaching on angina p a t i e n t s as they cope w i t h l i v i n g i n the face o f t h e i r c h r o n i c i l l n e s s . T his r e s e a r c h would u l t i m a t e l y l e a d bo more e f f i c i e n t and e f f e c t i v e n u r s i n g care. 120 Summary Thi s study was designed to examine the experiences of i n d i v i d u a l s w i t h angina as they cope w i t h t h e i r i l l n e s s . The f i n d i n g s o f the study r e v e a l e d angina p a t i e n t s p r o g r e s s i n g through f o u r phases of coping experience as they adjusted to t h e i r i l l n e s s and i t s concomitant need f o r r i s k m o d i f i c a t i o n . Nurses are i n a c r i t i c a l p o s i t i o n to a s s i s t angina p a t i e n t s i n coping w i t h t h e i r i l l n e s s . The phases of coping experience i d e n t i f i e d i n t h i s study may serve as a u s e f u l guide to help nurses assess problems and concerns r e l a t e d to coping w i t h angina so t h a t b e t t e r adjustment i n d a i l y l i f e w i l l ensue. 121 BIBLIOGRAPHY American Psychological Association. (1983). Publication manual of the  American Psychological Association (3rd ed.). Washington, D.C.: APA. Bainerman, J . (Feb., 1985). Patient attitude affects heart attack recovery. The Medical Post, 48. Beisser, A. (1979). Denial and affirmation in illness and health. American Journal of Psychiatry, 136, 1026-1030. Bogdan, R., & Taylor, S. (1975). Introduction to qualitative  research methods. Toronto: John Wiley & Sons. Busse, E. (1962). Some emotional complications of chronic il l n e s s . Gerontologist, 2, 153-156. Canada. (1983). Causes of death (Catalogue 84-203). Ottawa: Minister of Supply and Services Canada. Cay, E. (1982). Psychological problems in patients after a myocardial infarction. Advances in Cardiology, 29, 108-112. Chodoff, P. (1962). Understanding and management of the chronically i l l patient. American Practitioner, 13 (2), 136-144. Cleveland, S. & Johnson, D. (1962). Personality patterns in young males with coronary disease. Psychosomatic Medicine, 24, 600-610. Cook, R. (1979). Psychosocial responses to myocardial infarction. Heart and Lung, 8, 130-135. Craig, H. & Edwards, J. (1983). Adaptation in chronic illness: an eclectic model for nurses. Journal of Advanced Nursing, 8, 397-405. Crate, M. (1965). Nursing functions in adaptation to chronic i l l n e s s . American Journal of Nursing, 74(10), 72-76. Davis, A. (1978). The phenomenological approach in nursing research. In N. Ghaska (Ed.). The nursing profession: views through the mist (pp. 186-197). Scarborough, Ontario: McGraw-Hill Ryerson. Diers, D. (1979). Research in nursing practice. Philadelphia: J.B. Lippincott Co. Dimond, M. & Jones, S. (1983). Chronic illness across the l i f e span. Norwalk, Connecticut: Appleton-Century-Crofts. 122 Dovenmuehle, R. & Verwoerdt, A. (1962). Physical illness and depressive symptomatology. Incidence of depressive symptoms in hospitalized cardiac patients. Journal of American Geriatrics, 10, 932-947. Engel, G. (Sept., 1964). Grief and grieving. American Journal of  Nursing, 9, 93-98. Fardy, P., Bennett, J., Reitz, N., & Williams, M. (1980). Cardiac  rehabilitation implications for the nurse and other professionals. St. Louis: C.V. Mosby Co. Gazes, P. (1983). C l i n i c a l cardiology a beside approach (2nd ed.). Chicago: Medical Publishers Inc. Glaser, B. & Strauss, A. (1967). The discovery of grounded theory:  strategies for qualitative researcTu Chicago: Aidine Publishing Co. Gorman, D. & Anderson, J. (1982). I n i t i a l shock: impact of a l i f e threatening disease and ways to deal with i t . Social Work in Health  Care, 8, 37-46. Granger, J. (1974). Full recovery from myocardial infarction: psychosocial factors. Heart and Lung, 4 (3), 600-610. Graydon, J. (1984). Measuring patient coping. Nursing Papers, 2 (16), 3-11. Gruen, W. (1975). Effects of brief psychotherapy during the hospitalization period on the recovery process in heart attacks. Journal of Consulting and C l i n i c a l Psychology, 43, 232-233. Hackett, T. & Cassem, N. (1973). Psychological adaptation to convalescence in myocardial infarction patients. In J. Naughton, H. Hellerstein & I. Mohler (Eds.), Exercise testing and exercise  training in coronary heart disease (pp. 253-262)7 New York: Academic Press. Hackett, T. & Cassem, N. (1974). Development of a quantitative rating scale to assess denial. Journal of Psychosomatic Research, 18, 93-100. Hackett, T. & Cassem, N. (1982). Coping with cardiac disease. Advances in Cardiology, 31_, 212-217. Hamburg, D. & Adams, J. (1967). Perspectives on coping behaviour. Archives of General Psychiatry, 17, 276-284. Kannel, W., McGee, D., & Gordon, T. (1976). A general cardiovascular ri s k p r o f i l e : the framingham study. American Journal of Cardiology, 38, 41-46. 123 Kannel, W. (1979). Risk factors for atherosclerotic cardiovascular disease. In P. Conn (Ed.), Diagnosis and therapy of coronary artery  disease (pp. 11-33). Boston: L i t t l e Brown and Co. Kasl, S. & Cobb, S. (1966). Health behaviour, illness behaviour, and sick role behaviour. Archives of Environmental Health, 12, 246-266, 531-540. Kasl, S. (1974). The health belief model and behavior related to chronic i l l n e s s . M. Becker (Ed.), Health Education Monographs, 2, 433-453. Kubler-Ross, E. (1969). On death and dying. New York: MacMillan and Co. Lazarus, R. (1966). Psychological stress and the coping process. New York: McGraw H i l l Co. Lazarus, R. (1968). Emotions and adaptation: conceptual and empirical relations. In W. Arnold (Ed.), Nebraska symposium on motivation (pp. 175-270). Lincoln: University of Nebraska Press. Lazarus, R. (1974). Cognitive and coping process in emotion. In B. Weiner (Ed.), Cognitive views of human motivation (pp. 21-32). New York: Academic Press. Lazarus, R. & Launier, R. (1978). Stress-related transactions between person and environment. In L. Pervin & M. Lewis (Eds.), Perspectives in international psychology (pp. 287-327). New York: Plenum Press. Levenson, R., Montef errante, J., & Herman, M. (1984). Denial predicts favorable outcome in unstable angina pectoris. Psychosomatic  Medicine, 46, 25-31. Lindemann, E. (1944). Symtomatology and management of acute grief. The American Journal of Psychiatry, 101, 141-148. Lindemann, E. (1961). Recent studies on preventive intervention in social and emotional c r i s i s . In R. Ojemann (Ed.), Proceedings of  the third institute on preventive psychiatry (pp. 13-41). State University of Iowa. Lipowski, Z. (1969). Psychosocial aspects of disease. Annals of  Internal Medicine, 6, 1197-1207. Lipowski, Z. (1970). Physical illness, the individual and the coping process. Psychiatry In Medicine, 93, 91-101. McCorkle, R. & Quint-Benoliel, J. (1983). Symptom distress, current concerns and mood disturbance after diagnosis of l i f e threatening disease. Social Science and Medicine, 17, 431-438. 124 Mil l e r , J . (1983). Coping with chronic il l n e s s , overcoming  powerlessness. Philadelphia: F.A. Davis Co. Monat, A. & Lazarus, R. (1977). Stress and coping. New York: Columbia University Press. Murphy, L. (1962). The widening world of childhood: paths toward  mastery. New York: Basic Books Inc. Publishers. Niven, R. (1976). Psychologic adjustment to coronary artery disease. Postgraduate Medicine, 60, 152-157. Oiler, C. (1982). The phenomenological approach in nursing research. Nursing Research, 3 (31), 178-181. Olin, H. & Hackett, T. (1964). The denial of chest pain in 32 patients with acute myocardial infarction. Journal of the American  Medical Association, 190, 103-107. Ornery, A. (1983). Phenomenology: a method for nursing research. Advances in Nursing Science, _5, 49-63. Pattison, E. (1977). The experience of dying. Englewood C l i f f s , N.J.: Prentice-Hall Inc. Reiser, M. (1951). Emotional aspects of cardiac disease. American  Journal of Psychiatry, 107, 781-785. Reiser, M. & Biakst, H. (1959). Psychophysiologic cardiovascular disorders. In A r i e t i , S. (Ed.), American Handbook of Psychiatry, J_ (pp. 659-673). New York: Basic Books Inc. Rist, R. (Summer, 1979). On the means of knowing: qualitative research in education. New York University Education Quarterly, 17-21. Rosen, I., & Bibring, G. (1966). Psychological reactions of hospitalized male patients to a heart attack. Psychosomat ic Medicine, 28, 804-810. Scalzi, C. (1973). Nursing management of behavioural responses following an acute myocardial infarction. Heart and Lung, 2, 62-69. Schoenberg, B., Carr, A., Peretz, D., & Kutscher, A. (Eds.). (1970). Loss and grief—psychological management in medical practice. New York: Columbia University Press. Schwartz, H. & Jacobs, J . (1979). Qualitative sociology. A method to the madness. London: Collier MacMillan Publishers. 125 Sheehan, D. & Hackett, T. (1978). Psychosomatic disorders. In A. Nicholi (Ed.), The harrard guide to modern psychiatry (pp. 319-356). Cambridge: MA Belknap Press. Soloff, P. & Bartel, A. (1979). Effects of denial on mood and performance in cardovascular rehabilitation. Journal of Chronic  Disease, 32, 307-313. Stern, P. (1980). Grounded theory methodology: i t s uses and processes. Image, 12, 20-23. Strauss, A., Corbin, J., Fagerhaugh, S., Glaser, B., Maines, D., Suczek, B., & Wiener, C. (1984). Chronic illness and the quality  of l i f e . (2nd ed.). St. Louis: C.V. Mosby. Thomas, S., Sappington, H., Gross, H., Noctor, M., Freidman, E., & Lynch, J . (1983). Denial in coronary care patients - an objective reassessment. Heart and Lung, 12, 74-80. Weisman, A. (1972). On death and denying. New York: Behavioral Publications. Wenger, N. (1973). Early ambulation after myocardial infarction. In J. Naughton, H. Hellerstein & I. Mohler (Eds.), Exercise testing and  exercise training in coronary heart disease (pp. 324-328). New York: Academic Press. 126 APPENDICES '127 APPENDIX I A Framework for Understanding the Experiences of Chronically 111 Persons DIAGNOSIS OF ANGINA PECTORIS I 1 Key Problems/Adjustment Areas Basic Strategies I I I ! Family Organizational Units Consequences of Family and Organizational Units Key: i — — mm mm potentially cause c a l l for a M M B a M H lead to consisting of Adapted from Strauss et a l . , 1984, p. 16, 17. 128 APPENDIX II P h y s i c i a n Consent Form I , the undersigned, g i v e permission to Anne Kent, RN, BN (MSN student) t o contact consenting angina p a t i e n t s whom I s e l e c t from my p r a c t i c e f o r the purpose o f e x p l a i n i n g her research study e n t i t l e d "Coping With Angina P e c t o r i s F o l l o w i n g Diagnosis." P h y s i c i a n ' s Signature Researcher's Signature Dated at , t h i s day of , 1984. 129 APPENDIX III Coping w i t h Angina P e c t o r i s F o l l o w i n g Diagnosis P a r t i c i p a n t Information L e t t e r ( D i s t r i b u t e d i n Doctor's O f f i c e ) Dear Mr./Mrs./Miss/Ms.: My name i s Anne Kent. I am a student e n r o l l e d i n the Master o f Science i n Nursing Program at the U n i v e r s i t y o f B r i t i s h Columbia. As a pa r t o f my Master's program, I am conducting a rese a r c h study to l e a r n more about the concerns and experiences o f i n d i v i d u a l s diagnosed w i t h angina. I b e l i e v e t h a t i f nurses are aware o f the f e e l i n g s and concerns of i n d i v i d u a l s w i t h angina, they can o f f e r b e t t e r guidance, e s p e c i a l l y i n the community s e t t i n g , to prepare i n d i v i d u a l s f o r coping w i t h the problems r e l a t e d to t h e i r i l l n e s s . This study i s an attempt to b e t t e r understand how i n d i v i d u a l s cope w i t h angina and how they wish to be helped, i n order to adj u s t to t h e i r i l l n e s s . The purpose o f t h i s l e t t e r i s to i n q u i r e as to whether you are w i l l i n g to p a r t i c i p a t e i n my study. Should you agree to p a r t i c i p a t e , the study w i l l i n v o l v e the f o l l o w i n g : 1. My i n t e r v i e w i n g you i n your home on one or two occasions to dis c u s s your f e e l i n g s and concerns regarding your angina. 2. Tape r e c o r d i n g our d i s c u s s i o n s which w i l l l a s t approximately one to two hours per i n t e r v i e w . Other than the time r e q u i r e d f o r i n t e r v i e w i n g , you w i l l not be caused any inconvenience o r p o t e n t i a l harm should you decide to p a r t i c i p a t e i n the study. The b e n e f i t s of your involvement i n the study may be viewed as an o p p o r t u n i t y to d i s c u s s some of your f e e l i n g s and concerns r e l a t e d to your adjustment to your i l l n e s s . A l l i n f o r m a t i o n r e c e i v e d w i l l be t r e a t e d as c o n f i d e n t i a l and w i l l be analyzed along w i t h the data obtained from other angina p a t i e n t s . Your name and any i d e n t i f y i n g i nformation w i l l not be included i n my notes. My notes w i l l be i d e n t i f i e d by a code o n l y . I alone w i l l know your i d e n t i t y . YOUR REFUSAL TO PARTICIPATE IN THIS STUDY WILL IN NO WAY JEOPARDIZE YOUR FUTURE MEDICAL CARE. IF YOU DECIDE TO PARTICIPATE IN THIS STUDY AND THEN CHANGE YOUR MIND, YOU MAY WITHDRAW WITHOUT EFFECT ON YOUR MEDICAL CARE. YOU MAY ALSO REFUSE TO ANSWER ANY QUESTIONS AT ANY TIME. 131 APPENDIX IV Coping w i t h Angina P e c t o r i s F o l l o w i n g Diagnosis P a r t i c i p a n t Consent Form I , the undersigned, understand the nature o f Anne Kent's r e s e a r c h study e n t i t l e d "Coping With Angina P e c t o r i s F o l l o w i n g Diagnosis" and g i v e my consent to p a r t i c i p a t e . P a r t i c i p a n t ' s Signature Researcher's Signature Dated a t , t h i s day o f , 1984. 132 APPENDIX V Coping w i t h Angina P e c t o r i s F o l l o w i n g Diagnosis P a r t i c i p a n t Information L e t t e r (Mailed to p o t e n t i a l subj ects) Dear Mr./Mrs./Miss/Ms.: My name i s Anne Kent. I am a student e n r o l l e d i n the Master of Science i n Nursing Program at the U n i v e r s i t y o f B r i t i s h Columbia. As a p a r t o f ray Master's program, I am conducting a research study to l e a m more about the concerns and experiences o f i n d i v i d u a l s diagnosed w i t h angina. I b e l i e v e that i f nurses are aware o f the f e e l i n g s and concerns of i n d i v i d u a l s w i t h angina, they can o f f e r b e t t e r guidance, e s p e c i a l l y i n the community s e t t i n g , to prepare i n d i v i d u a l s f o r coping w i t h the problems r e l a t e d to t h e i r i l l n e s s . This study i s an attempt to b e t t e r understand how i n d i v i d u a l s cope w i t h angina and how they wish to be helped, i n order to adjust to t h e i r i l l n e s s . The purpose o f t h i s l e t t e r i s to i n q u i r e as to whether you are w i l l i n g to p a r t i c i p a t e i n my study. Should you agree to p a r t i c i p a t e , the study w i l l i n v o l v e the f o l l o w i n g : 1. My i n t e r v i e w i n g you i n your home on one or two occasions to di s c u s s your f e e l i n g s and concerns regarding your angina. 2. Tape re c o r d i n g our d i s c u s s i o n s which w i l l l a s t approximately one hour per i n t e r v i e w . Other than the time r e q u i r e d f o r i n t e r v i e w i n g , you w i l l not be caused any inconvenience o r p o t e n t i a l harm should you decide to p a r t i c i p a t e i n the study. The b e n e f i t s o f your involvement i n the study may be viewed as an o p p o r t u n i t y to d i s c u s s seme of your f e e l i n g s and concerns r e l a t e d to your adjustment do your i l l n e s s . A l l i n f o r m a t i o n r e c e i v e d w i l l be t r e a t e d as c o n f i d e n t i a l and w i l l be analyzed along w i t h the data obtained from other angina p a t i e n t s . Your name and any i d e n t i f y i n g i n f o r m a t i o n w i l l not be included i n my notes. My notes w i l l be i d e n t i f i e d by a code o n l y . I alone w i l l know your i d e n t i t y . YOUR REFUSAL TO PARTICIPATE IN THIS STUDY WILL IN NO WAY JEOPARDIZE YOUR FUTURE MEDICAL CARE. IF YOU DECIDE TO PARTICIPATE IN THIS STUDY AND THEN CHANGE YOUR MIND, YOU MAY WITHDRAW WITHOUT EFFECT ON YOUR MEDICAL CARE. YOU MAY ALSO REFUSE TO ANSWER ANY QUESTIONS AT ANY TIME. 134 APPENDIX VI Data C o l l e c t i o n Tool Demographic Data Date Name o f Subject ( i n i t i a l s ) Subject's Age M a r i t a l Status Occupation Date o f Angina Diagnosis A d d i t i o n a l Medical Problems C a r d i o l o g i s t / G e n e r a l P r a c t i o n e r I n t e r v i e w Data Observable Behaviours: 135 APPENDIX VII Sample In t e r v i e w Guide T e l l me about your i l l n e s s . How d i d you f e e l a f t e r l e a r n i n g of your diagnosis? How do you f e e l about your i l l n e s s now? What have you been doing to cope w i t h your i l l n e s s ? 136 APPENDIX VIII Relationship of Findings to Phases and Common Reference Points Following Onset of Angina Pectoris I. I n i t i a l Coping Response 1. Downplaying 2. Reflecting back 3. Responses unique to specific individuals - Surprise - Relief - Regret II. Managing Specific Adjustment Areas 1. Interactions with others a) heal til professionals b) family c) others 2. Regimen management a) evaluating regimens b) diet regimens c) exercise regimens d) medication regimens 3. Symptom control a) fatigue b) chest pain c) discovering limitations 4. Job-related concerns a) effect on job performance b) dealing with stress c) financial/retirement concerns 5. Attendant psychological concerns a) frustration b) acceptance c) future implications - bypass surgery - life-threatening impact 137 I I I . Secondary Coping Response 1. Basic s t r a t e g i e s f o r i l l n e s s i n general a) t a k i n g c o n t r o l b) n o r m a l i z i n g c) c o n t i n u a t i o n o f downplaying d) information seeking 2. Basic s t r a t e g i e s f o r s p e c i f i c adjustment areas a) coping w i t h f a t i g u e b) managing chest pain c) e l i m i n a t i n g s t r e s s at work IV. Awareness o f R e s u l t i n g Changes 1. Concrete changes made 2. Changes experienced a) p h y s i c a l change b) p s y c h o l o g i c a l change 

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