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Coping behaviours in myocardial infarction rehabilitation Dawson, Lynn Gail 1986

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COPING BEHAVIOURS IN MYOCARDIAL  INFARCTION  REHABILITATION  By LYNN G A I L DAWSON S c . N . , B.A., T h e U n i v e r s i t y o f W i n d s o r , 1 9 7 5  T H E S I S SUBMITTED IN P A R T I A L F U L F I L L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF S C I E N C E IN NURSING in THE FACULTY OF GRADUATE  STUDIES  (School o f Nursing) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g to t h e r e q u i r e d s t a n d a r d  THE U N I V E R S I T Y OF B R I T I S H COLUMBIA J U L Y 1986 ©  LYNN G A I L DAWSON,  1986  In p r e s e n t i n g requirements  this thesis f o r an  of  British  it  freely available  agree t h a t for  for reference  permission  understood  that  h i s or  be  her  copying or  f i n a n c i a l gain  (3/81)  Library  s h a l l make  and  study.  I  publication be  the  of  further this  Columbia  thesis  head o f  this  my  It is thesis  a l l o w e d w i t h o u t my  of  The U n i v e r s i t y o f B r i t i s h 1956 Main Mall V a n c o u v e r , Canada V6T 1Y3  DE-6  University  representatives.  s h a l l not  the  the  g r a n t e d by  permission.  Department  the  for extensive copying of  s c h o l a r l y p u r p o s e s may by  f u l f i l m e n t of  advanced degree a t  Columbia, I agree t h a t  department or for  in partial  written  ii ABSTRACT COPING  BEHAVIOURS IN MYOCARDIAL  INFARCTION  REHABILITATION T h i s s t u d y was d e s i g n e d t o d i s c o v e r t h e c o p i n g behaviours  u s e d by p a t i e n t s s i x t o t w e l v e  following a myocardial  months  i n f a r c t i o n (MI).  The c o n c e p t u a l i z a t i o n o f c o p i n g b e h a v i o u r s b a s e d on t h e UBC M o d e l f o r N u r s i n g w h i c h r e s e a r c h e r to examine coping behaviours t h e p a t i e n t s ' b a s i c human  was  d i r e c t e d the used t o meet  needs.  T h e s p e c i f i c r e s e a r c h q u e s t i o n was, "What new o r already established coping behaviours u t i l i z e d a f t e r an MI i n an a t t e m p t b a s i c human  have p a t i e n t s  to s a t i s f y  their  needs?"  S e v e n p a r t i c i p a n t s who h a d e x p e r i e n c e d an MI s i x to t w e l v e months p r e v i o u s l y , were r e c r u i t e d from cardiologists.  Data were c o l l e c t e d from t h e  participants during interviews using semi-structured open-ended q u e s t i o n i n g technique.  Data were coded  analyzed using the constant comparative developed Three  and  method  by G l a s e r a n d S t r a u s s . themes t h a t emerged from the data were:  1)  coping behaviours  r e l a t e d to r i s k r e d u c t i o n ,  2)  coping behaviours  r e l a t e d to r e t u r n i n g to  3)  coping behaviours  r e l a t e d t o r e a c h i n g a new  normal, normal.  i ii The f i n d i n g s s u p p o r t e d t h e n e e d f o r l i f e s t y l e changes i n v o l v i n g t h e use o f e x i s t i n g c o p i n g  behaviours  a n d / o r t h e d e v e l o p m e n t o f new c o p i n g b e h a v i o u r s s u b j e c t s ' b a s i c human n e e d s .  t o meet  C e r t a i n unmet b a s i c human  n e e d s w e r e i d e n t i f i e d f o l l o w i n g an MI w h i c h r e q u i r e d t h e d e v e l o p m e n t o f new c o p i n g b e h a v i o u r s  t o meet them.  N u r s e s a r e i n a u n i q u e p o s i t i o n t o a s s i s t MI patients i n developing coping behaviours b a s i c human n e e d s . of coping behaviours  t o meet  their  The d e s c r i p t i o n s and e x p l a n a t i o n s i d e n t i f i e d i n t h i s s t u d y may  serve  as a u s e f u l g u i d e f o r n u r s e s t o h e l p p a t i e n t s d e a l changes i n t h e i r l i v e s and d e v e l o p behaviours  necessary  t o m e e t t h e i r b a s i c human n e e d s .  coping  with  iv T A B L E OF CONTENTS ABSTRACT  i i  T A B L E OF CONTENTS L I S T OF T A B L E S  iv vii  ACKNOWLEDGEMENTS CHAPTER ONE:  Page  viii  INTRODUCTION  1  Background to the Study Problem Statement Purpose UBC M o d e l f o r N u r s i n g D e f i n i t i o n o f Terms Assumptions Limitations Summary  1 5 5 6 7 8 9 10  CHAPTER TWO:  REVIEW OF THE RELATED L I T E R A T U R E  Coping C a r d i a c D i s e a s e as a C r i t i c a l P e r i o d L e a d i n g to Loss Loss L e a d i n g t o t h e Change P r o c e s s C h a r a c t e r i s t i c s of Loss Loss Leading to the G r i e v i n g Process.... S p e c i f i c R e s p o n s e s t o L o s s I n c u r r e d by an MI Denial Anger Depression Reorganization Risk Factor Reduction D i e t a r y Changes Smoking C e s s a t i o n Stress Reduction O t h e r C h a n g e s P r e c i p i t a t e d by a M y o c a r d i a l Infarction R e t u r n t o Work Sexuality C o p i n g B e h a v i o u r s i n t h e UBC M o d e l f o r Nursing  11 12 15 15 16 16 17 17 18 19 20 22 22 23 23 26 26 29 31  V  CHAPTER T H R E E :  METHODOLOGY  Selection of Participants C h a r a c t e r i s t i c s of P a r t i c i p a n t s Ethical Considerations Data C o l l e c t i o n Data A n a y l s i s Summary CHAPTER FOUR:  36 38 40 41 42 44 45  F I N D I N G S OF THE STUDY  46  . Coping Behaviours Related to Risk Reduction. Dietary Modification Smoking C e s s a t i o n M e d i c a t i o n Regimen Exercise C o p i n g B e h a v i o u r s R e l a t e d t o G e t t i n g Back t o Normal R e a l i z a t i o n o f t h e Need f o r Change D e a l i n g w i t h C h e s t P a i n and O t h e r P h y s i c a l Symptoms O t h e r P h y s i c a l Symptoms G e t t i n g Others to Help R e t u r n t o Work Working P a r t i c i p a n t s Stigma Time O f f Retired Participants R e l a t i o n s h i p s and Role Changes C o p i n g B e h a v i o u r s R e l a t e d t o R e a c h i n g a New Normal  47 47 52 54 56  CHAPTER F I V E :  CHAPTER S I X : SUMMARY AND I M P L I C A T I O N S FOR NURSING....  BIBLIOGRAPHY  63 65 68 70 70 72 73 74 76 85  D I S C U S S I O N OF THE F I N D I N G S  Introduction Coping Behaviours Related to Risk Reduction. C o p i n g B e h a v i o u r s R e l a t e d t o G e t t i n g Back t o Normal Forces A f f e c t i n g Coping Behaviours C o p i n g B e h a v i o u r s R e l a t e d t o R e a c h i n g a New Normal  Implications Implications Summary  60 60  f o r Nursing Practice f o r Nursing Research  90 91 101 103 112  119 122 128 132 133  vi APPENDICES A p p e n d i x A: A p p e n d i x B: A p p e n d i x C: A p p e n d i x D: A p p e n d i x E:  S u b s y s t e m s , Needs and G o a l s I n f o r m a t i o n R e l a t e d to C a r d i a c Research Study C o n s e n t Form Sample Q u e s t i o n Data C o l l e c t i o n Tool  140 141 142 143 144  L I S T OF T a b l e 1:  TABLES  C h a r a c t e r i s t i c s of the  Participants.  vi i i ACKNOWLEDGEMENTS  I w o u l d l i k e t o e x p r e s s my t h a n k s t o t h e members o f my t h e s i s c o m m i t t e e , Gormick  Carol J i l l i n g s and J a n e t  f o r t h e i r encouragement,  p o s i t i v e s u p p o r t and  expert guidance throughout this research process. I would l i k e t o extend a s p e c i a l  thanks to the  p a r t i c i p a n t s who w e r e w i l l i n g t o s h a r e t h e i r p e r s o n a l experiences about c r i s e s i n t h e i r l i v e s . openness  Their  p r o v i d e d a f i r s t h a n d a c c o u n t o f t h e MI  experi ence. I w i s h t o t h a n k my c l a s s m a t e s who h a v e e n r i c h e d my l a s t two y e a r s , many s p e c i a l  f r i e n d s a n d my f a m i l y .  a l s o w o u l d l i k e t o t h a n k Bob who h a s n e v e r c e a s e d t o o f f e r h i s h e l p , i n s i g h t and p r a i s e t h r o u g h o u t research  this  project.  Finally,  I w o u l d l i k e t o t h a n k my L o r d J e s u s  C h r i s t f o r g i v i n g me H i s s t r e n g t h a n d j o y t o c o m p l e t e this  thesis.  I  1  CHAPTER  ONE  INTRODUCTION  C a r d i o v a s c u l a r d i s e a s e c o n t i n u e s t o be t h e l e a d i n g cause of death Acute  in Canadian  s o c i e t y (Canada,  and c h r o n i c h e a l t h p r o b l e m s  1983).  with r e l a t e d  d i s a b i l i t y and l i m i t a t i o n s r e s u l t i n g f r o m h e a r t d i s e a s e a r e on t h e i n c r e a s e i n o u r p o p u l a t i o n Anderson, (MI)  & Buergin, 1983).  A myocardial  infarction  r e s u l t i n g f r o m c o r o n a r y a r t e r y d i s e a s e i s an  event t h a t poses A f t e r the i n i t i a l  a s e r i o u s t h r e a t to  acute  individuals.  a c u t e e v e n t has p a s s e d ,  a r t e r y d i s e a s e i s viewed term  (Bauwens,  coronary  as a c h r o n i c i l l n e s s ,  i n n a t u r e , h a v i n g an u n c e r t a i n p r o g n o s i s ,  long without  a c u r e and n e c e s s i t a t i n g l i f e s t y l e c h a n g e s ( S t r a u s s , 1984). a new of  A s i t u a t i o n i s created r e q u i r i n g adjustment condition.  Whether t h i s i s the f i r s t or  to  latest  s e v e r a l e p i s o d e s , i n d i v i d u a l s must f a c e the  d i f f i c u l t task of resuming uncertainty  (Mullen,  l i f e w i t h some d e g r e e  1978).  Background  to the  H o m e c o m i n g f o r p a t i e n t s who acute myocardial  Study have e x p e r i e n c e d  i n f a r c t i o n c a n be a s t r e s s f u l  for p a t i e n t s , spouses  of  an  event  and f a m i l i e s as t h e y a d j u s t t o  2 necessary changes i n l i f e s t y l e  (Pinneo,  1984).  L i f e s t y l e c h a n g e i s r e f e r r e d t o i n t h e l i t e r a t u r e as a change i n a s p e c i f i c area or behaviour of one's f o r c e d by h i s i l l n e s s .  I t e n c o m p a s s e s key  life  problem  a r e a s t h a t r e q u i r e a t t e n t i o n a f t e r an MI.  Areas  of  l i f e s t y l e t h a t were p r e v i o u s l y t a k e n f o r g r a n t e d as c a r e e r g o a l s and a c h i e v e m e n t s , f a m i l y and s o c i a l i d e n t i t y may  financial  such  situations,  r e l a t i o n s h i p s , s e x u a l i t y and  personal  a l l be t h r e a t e n e d and r e q u i r e some c h a n g e .  U n l i k e o t h e r i l l n e s s e s t h a t have g r a d u a l b e g i n n i n g s , a myocardial  i n f a r c t i o n may  have a d r a m a t i c e n t r y i n t o  the p e r s o n a l world w i t h o u t p r e v i o u s warning.  Persons  are immediately  I live?'  and t h e n ,  'How  faced with the q u e s t i o n , 'Will well will  The m y o c a r d i a l  I live?'.  infarction rehabilitation period is  c h a r a c t e r i z e d by " c u t t i n g b a c k "  (Mullen,  P a t i e n t s are t o l d to e l i m i n a t e v a r i o u s c i g a r e t t e s , a c t i v i t i e s and s t r e s s f u l daily life.  1978).  foods,  s i t u a t i o n s from  T h i s i s in c o n t r a s t to i n d i v i d u a l s  s u f f e r i n g from o t h e r c h r o n i c i l l n e s s e s such  as  u l c e r a t i v e c o l i t i s or k i d n e y d i s e a s e t h a t have l e n g t h y procedures  to perform which  permanent reminder  of the i l l n e s s .  i n f a r c t i o n p a t i e n t may symptom-free. back because  leave a visible  He may  The  and  myocardial  h a v e c h e s t p a i n o r may  remain  n o t be p h y s i c a l l y f o r c e d t o c u t  o f symptoms.  P a t i e n t s who  are given  3 i n s t r u c t i o n to  'take i t easy' or  specific guidelines f r u s t r a t i n g and  their  Fear, anxiety  Patients  a r e on t h e i r  f e e l i n g s of l o s s  by i n d i v i d u a l s  follow  process.  R e a c t i o n s to the the  pattern  The  s e l f c o n c e p t and perceptions  has  loss  and  (Rizzuto,  1983,  successful  in dealing  an MI,  t h i s can  1971).  initial ability  changes in l i f e s t y l e , s e l f concept Changing a b e h a v i o u r or a c t i v i t y  l i t e r a t u r e the  with s i t u a t i o n s  as a c h a n g e i n one (Mullen, to  that present a threat  to  i n t e g r i t y so t h a t t h e  f e a r and  grief will  be r e s o l v e d  Lazarus, 1966).  f e e l i n g s of (Miller, As  area 1978).  term c o p i n g r e f e r s  personal  with threatening  the  with  affect their  consequences in other areas of l i f e  L i p o w s k i , 1970;  Parkes,  f e e l i n g s of l o s s i n the  isolation is rarely possible  dealing  o f ways by  individuals'  role behaviour.  In t h e  and  role behaviour r e f l e c t s  to cope w i t h f u r t h e r  in  grieving  lifestyle,  If i n d i v i d u a l s are  following  perceived  e x t e n t of the changes i n  of the  fear, anxiety,  MI  loss  of the  d e p r e s s i o n are e x p e r i e n c e d i n a v a r i e t y  period  an  Shock, d i s b e l i e f , anger, denial  individual.  own  characterize  responses of i n d i v i d u a l s e x p e r i e n c i n g 1982).  choice  lifestyle.  and  ( S c a l z i , 1973,  and  without  f i n d t h i s freedom of  confusing.  as t h e y r e d e s i g n  the  may  'relax'  anxiety, 1983;  individuals  s i t u a t i o n s , l i f e s t y l e changes  cope result.  4 L i f e s t y l e changes are i n c o r p o r a t e d i n t o d a i l y l i f e i n o r d e r t o s a t i s f y b a s i c human In w o r k i n g  needs.  with myocardial  this author observed coping behaviours  infarction patients,  t h a t i n d i v i d u a l s u s e a number o f  t o s a t i s f y t h e i r b a s i c human  T h e s e may be c o p i n g b e h a v i o u r s  needs.  t h a t a r e new o r a l r e a d y  e s t a b l i s h e d ones t h a t a r e u t i l i z e d as a r e s u l t o f t h e MI.  I t i s important t o i d e n t i f y and e v a l u a t e t h e  effectiveness of the coping behaviours in order to intervene a p p r o p r i a t e l y . learned, e f f e c t i v e coping behaviours b e i n g u s e d may n e e d  u s e d by p a t i e n t s Previously  not presently  t o be s t r e n g t h e n e d  or reinforced.  N u r s i n g h a s an i m p o r t a n t r o l e i n f o s t e r i n g c o p i n g behaviours  t h a t h e l p p a t i e n t s s a t i s f y t h e i r b a s i c human  n e e d s i n s u c h a way a s t o m i n i m i z e  the p o t e n t i a l l y  n e g a t i v e e f f e c t o f t h e MI. Numerous m e d i c a l  and n u r s i n g s t u d i e s have  described psychological, social  and f a m i l y problems  the e f f e c t s o f t e a c h i n g i n p a t i e n t s w i t h infarction  ( S c a l z i , 1973; Croog,  Doehrman, 1977).  and  myocardial  1966; M u l l e n , 1978;  However, t h e c o p i n g b e h a v i o u r s  o f MI  p a t i e n t s a s t h e y s a t i s f y t h e i r b a s i c human n e e d s h a v e not been w i d e l y e x p l o r e d i n n u r s i n g  literature.  5 Problem  To g a i n u n d e r s t a n d i n g w i t h an MI t h e s t u d y w i l l  Statement  of patient's experiences answer the f o l l o w i n g  question: What new o r a l r e a d y e s t a b l i s h e d c o p i n g b e h a v i o u r s p a t i e n t s u t i l i z e d a f t e r an MI i n an a t t e m p t  have  to satisfy  t h e i r b a s i c human n e e d s ?  Purpose  The  areas t h a t have been i d e n t i f i e d i n t h e  l i t e r a t u r e a r e d e a l t w i t h i n a v a r i e t y o f ways by individuals.  The purpose  o f t h i s s t u d y i s t o f o c u s on  i d e n t i f y i n g and d e s c r i b i n g t h e c o p i n g b e h a v i o u r s by i n d i v i d u a l s i n an a t t e m p t human n e e d s a f t e r an MI. will  used  to satisfy their basic  T h e UBC M o d e l f o r N u r s i n g  be u s e d t o c a t e g o r i z e t h e d a t a .  6 UBC M o d e l f o r N u r s i n g  A b e h a v i o u r a l system  approach  d e s c r i b e d i n t h e UBC  Model f o r N u r s i n g  (1980) w i l l  coping behaviours  t h a t i n d i v i d u a l s use t o s a t i s f y b a s i c  human n e e d s .  be u s e d i n e x a m i n i n g  the  I n t h e UBC M o d e l f o r N u r s i n g t h e  individual  i s viewed  subsystems  (see Appendix).  b a s i c human n e e d  as a b e h a v i o u r a l system w i t h Each  subsystem  and n e e d - r e l a t e d g o a l .  e f f e c t i v e n e s s of the coping behaviour  nine  represents a The  d e p e n d s on i t s  a b i l i t y t o s a t i s f y b a s i c human n e e d s a n d t h e r e b y decrease  tension.  Tension  i s a need-related sensation  t h a t i s c o n s t a n t l y e x p e r i e n c e d by a s u b s y s t e m i n varying i n t e n s i t y depending  on t h e d e g r e e  o f need  sati s f a c t i on. Patterns of coping behaviours  a r e used to s a t i s f y  c o n s t a n t l y r e c u r r i n g needs i n o r d e r t o a c h i e v e behavioural  system  balance.  Behavioural  system  balance  i s p r e s e n t when t h e n e e d s a n d g o a l s o f t h e n i n e subsystems  a r e met.  A critical  p e r i o d which  maturational or unpredictable event need  satisfaction.  coping behaviours necessary.  is a  ( e g , MI) t h r e a t e n s  The d e v e l o p m e n t and use o f s u i t a b l e to s a t i s f y t h e needs a f f e c t e d i s  Previous coping behaviours  i n one's  r e p e r t o i r e may be o r may become u n s u i t a b l e d u r i n g a  7 critical  p e r i o d a n d may f a i l  to permit s a t i s f a c t i o n of  one o r more o f t h e b a s i c human Coping behaviours w i l l s t u d y as t h o s e r e s p o n s e s  needs.  be r e f e r r e d t o i n t h i s  that attempt  to s a t i s f y basic  human n e e d s (UBC M o d e l f o r N u r s i n g , 1 9 8 0 ) . " l i f e s t y l e changes"  The terms  and " c o p i n g " i n the l i t e r a t u r e  encompass o n l y those r e s p o n s e s o r changes  that deal  with a t h r e a t to one's b o d i l y i n t e g r i t y whereas "coping behaviour" i n t h i s study i n c l u d e s a l l the behaviours u s e d t o s a t i s f y b a s i c human  needs.  Definition  1.  2.  B a s i c Human Need - a  fundamental  requirement  f o r survival  behavioural  system  Coping Behaviour  o f Terms  and growth  (UBC M o d e l f o r N u r s i n g , 1 9 8 0 )  - a response  i n d i c a t e s t h e way a s u b s y s t e m s a t i s f y a b a s i c human n e e d Model f o r N u r s i n g , 3.  of the  which i s attempting to  f o r the system  (UBC  1980).  L i f e s t y l e Change - a change o f a s p e c i f i c b e h a v i o u r o r a r e a o f one's l i f e as a r e s u l t o f a threat or i l l n e s s .  8 4.  Myocardial  Infarction - myocardial  ischemia  r e s u l t i n g from the o c c l u s i o n o f blood  flow  producing necrosis of the heart muscle. (Solack, 1982).  Assumptions  1.  The o n s e t and p r o g r e s s i o n o f c o r o n a r y  heart  disease causes changes i n the l i f e s i t u a t i o n s of i n d i v i d u a l s and t h e i r 2.  families.  I n d i v i d u a l s with a myocardial  i n f a r c t i o n are  v a l i d subjects to represent the coping used to deal with t h i s 3.  behaviours  illness.  Those i n d i v i d u a l s e x p e r i e n c i n g  myocardial  i n f a r c t i o n a r e a b l e and w i l l i n g t o i d e n t i f y and share the coping behaviours  they use t o s a t i s f y  t h e i r b a s i c human n e e d s . 4.  I n d i v i d u a l s with myocardial common c o p i n g b e h a v i o u r s  i n f a r c t i o n use  as they l i v e w i t h  their  illness. 5.  I n d i v i d u a l s use c o p i n g b e h a v i o u r s  i n an  attempt t o reduce t e n s i o n s and s a t i s f y t h e i r b a s i c human n e e d s (UBC M o d e l f o r N u r s i n g ,  1980).  9 L i mi t a t i o n s  T h i s s t u d y may  be l i m i t e d  in relying  from p h y s i c i a n s i n o r d e r to g a i n access participants.  The  e x p e r i e n c e s and c o p i n g Continual  validation  referrals  to  s t u d y i s d e p e n d e n t on  p a r t i c i p a n t ' s w i l l i n g n e s s and a b i l i t y  on  the  to express  his  behaviours.  and c l a r i f i c a t i o n  the data s h o u l d reduce the  limitation.  while  collecting  10  Summary In t h i s c h a p t e r t h e p r o b l e m  and p u r p o s e  s t u d y have been i n t r o d u c e d w i t h background s u p p o r t i n g the study. and p o s t MI b e h a v i o u r Chapter  The  of the information  l i t e r a t u r e r e l a t e d to c o p i n g  i s reviewed  in Chapter  2.  3 i s a d e s c r i p t i o n of the methodology used  implement the study.  to  The a n a l y s i s o f t h e d a t a w i l l  d e s c r i b e d and d i s c u s s e d i n C h a p t e r  4.  Chapter  s u m m a r i z e and draw c o n c l u s i o n s f r o m t h i s s t u d y .  be  5 will The  i m p l i c a t i o n s of the f i n d i n g s of the study f o r n u r s i n g will  be d i s c u s s e d .  11  CHAPTER  REVIEW OF THE  TWO  RELATED L I T E R A T U R E  A review of the l i t e r a t u r e r e l a t e d to c o p i n g r e v e a l e d a w i d e v a r i e t y o f d e f i n i t i o n s and u s e s o f t h e term.  For the purpose  of t h i s study i t i s important  to  review the l i t e r a t u r e i n o r d e r to d i f f e r e n t i a t e  the  meaning of c o p i n g w i d e l y used i n the l i t e r a t u r e  from  t h a t d e s c r i b e d i n t h e UBC behaviours.  M o d e l f o r N u r s i n g as  coping  I t i s the l a t t e r meaning t h a t w i l l  explored in this  be  study.  A d e s c r i p t i o n o f t h e common l i f e s t y l e  changes  used  by p a t i e n t s d u r i n g t h e p e r i o d o f m y o c a r d i a l  infarction  rehabilitation will  l e a d to a  be p r e s e n t e d .  An MI may  s e n s e o f l o s s , s u c h as l o s s o f h e a l t h . something  meaningful  emotional  responses  Specific anger,  responses  o r o f v a l u e may  The l o s s o f  precede  the  of g r i e v i n g ( S c a l z i & Burke, s u c h as s h o c k ,  a n x i e t y and d e p r e s s i o n  1982).  disbelief, denial,  are experienced  v a r i e t y o f ways and a t d i f f e r e n t t i m e s by  in a  the  i ndi v i d u a l . Areas where s i g n i f i c a n t l i f e s t y l e  changes can  be  made i n c l u d e a r e a s o f r i s k r e d u c t i o n s u c h as d i e t a r y changes, attempt  s m o k i n g c e s s a t i o n and s t r e s s r e d u c t i o n . t o r e t u r n to a normal  In an  lifestyle, additional  12  changes  r e l a t e d t o r e t u r n t o work and s e x u a l i t y may  a l s o be n o t e d f o l l o w i n g MI. A r e v i e w o f t h e s e will  provide a theoretical  background  areas  for this  study.  Coping  The c o n c e p t o f c o p i n g h a s r e c e n t l y r e c e i v e d much a t t e n t i o n i n the p s y c h o l o g i c a l l i t e r a t u r e and and n u r s i n g j o u r n a l s . the French  medical  The w o r d ' t o c o p e ' comes  from  'couper' meaning to s l a s h or to s t r i k e .  s u g g e s t s the a b i l i t y to f i g h t back  (Webster,  It  1983).  Richard Lazarus (1966), a p s y c h o l o g i s t , d e s c r i b e s c o p i n g as a p r o c e s s u s i n g s t r a t e g i e s t o d e a l w i t h t h r e a t or harm. Coping i s c o g n i t i v e a c t i v i t y appraisal  i n the form of c o g n i t i v e  o f e v e n t s and r e a c t i o n s f o l l o w e d by  d e t e r m i n a t i o n of a course of a c t i o n based reappraisal.  the  on  Coping r e f e r s to d e a l i n g with  situations  t h a t p r e s e n t a t h r e a t t o p e r s o n a l i n t e g r i t y so t h a t f e e l i n g s o f a n x i e t y , f e a r and g r i e f w i l l  be r e s o l v e d  ( M i l l e r , 1983;  1966).  Pearlin  L i p o w s k i , 1970; (1978,  1981)  Lazarus,  suggests three major  coping with d i f f e r e n t functions.  These  t h a t change the s i t u a t i o n out of which  are  types of  responses  a stressful  e x p e r i e n c e a r i s e s ; responses t h a t c o n t r o l the meaning of the s t r e s s f u l  e x p e r i e n c e a f t e r i t occurs but b e f o r e  13  t h e e m e r g e n c e o f s t r e s s and r e s p o n s e s  t h a t f u n c t i o n to  control  emerged.  emotional  s t r e s s a f t e r i t has  Weisman ( 1979, coping.  "Coping  p.27)  take a b r o a d e r view  combines p e r c e p t i o n ,  of  performance,  a p p r a i s a l , c o r r e c t i o n , f o l l o w e d by f u r t h e r a c t i v i t y problem  solving behaviour".  mastery,  and  The a i m o f c o p i n g i s  c o n t r o l or r e s o l u t i o n (Weisman & Worden,  1976-77). Coping  has b e e n f u r t h e r e x p l a i n e d u n d e r  the l a b e l s  c o p i n g t a s k s , c o p i n g s t y l e s , c o p i n g s t r a t e g i e s and coping behaviours. behaviours  A c c o r d i n g to Lazarus  a r e ways o f d e a l i n g w i t h c o n d i t i o n s o f  t h r e a t or harm.  The c o p i n g s t y l e and c o p i n g s t r a t e g i e s  used c h a r a c t e r i z e the c o p i n g b e h a v i o u r s 1970).  (1966) c o p i n g  Coping  (Lipowski,  t a s k s are the p a r t i c u l a r c h a l l e n g e s t h a t  m u s t be o v e r c o m e i n o r d e r t o p r e s e r v e  integrity,  r e s t o r e or m a i n t a i n a p o s i t i v e concept of s e l f  and  f u n c t i o n e f f e c t i v e l y i n r e l a t i o n s h i p s and l i f e r o l e s ( M i l l e r , 1983; behaviour  Hamburg & Adams, 1 9 6 7 ) .  i s e f f e c t i v e when t h e c o p i n g t a s k s m e e t t h e  challenges p r e v i o u s l y mentioned.  R o s k i e s and  (1980) s t a t e t h a t a c o p i n g b e h a v i o u r a task i s  A coping  Lazarus  i s e f f e c t i v e when  accomplished.  C a r o l y n C a r l s o n ( 1 9 8 1 ) i s a n u r s e who  has  d e s c r i b e d c o p i n g as t h e p r o c e s s o f m a n a g i n g d i f f i c u l t i e s by w o r k i n g  through  and a r o u n d  o b s t a c l e s to  14  reduce  tension.  everyday  I t i s sometimes used t o d e s c r i b e small  adjustments.  P e o p l e a c t t o meet needs and t o  a c h i e v e g o a l s and d e v e l o p behaviour.  relatively stable patterns of  A disruption of this pattern results in  i n c r e a s e d t e n s i o n s i n c e both needs and g o a l s a r e threatened.  Coping  whose p u r p o s e  i s a response  to increased tension  i s t o remove t h r e a t s t h a t h i n d e r t h e need  and g o a l b e i n g m e t . As o n e c a n s e e f r o m t h e r e v i e w o f l i t e r a t u r e , c o p i n g has been viewed  as c o p i n g t a s k s , c o p i n g  styles,  c o p i n g s t r a t e g i e s , c o p i n g p r o c e s s e s and c o p i n g behaviours.  It is difficult  t o come t o a c o n s e n s u s  a d e f i n i t i o n and d e s c r i p t i o n o f c o p i n g from l i t e r a t u r e i n order to provide u t i l i t y for  nursing practice.  on  this  and d i r e c t i o n  I t i s important to define coping  o p e r a t i o n a l l y w i t h i n a framework i n order t o p r o v i d e the u t i l i t y practice. for  and d i r e c t i o n n e c e s s a r y f o r n u r s i n g I t i s w i t h i n t h e f r a m e w o r k o f t h e UBC M o d e l  N u r s i n g t h a t t h e term c o p i n g b e h a v i o u r w i l l  in t h i s study.  Coping  Nursing i s a response  behaviour  i n t h e UBC M o d e l f o r  that attempts  human n e e d f o r t h e s y s t e m .  be u s e d  to satisfy a basic  15 C a r d i a c D i s e a s e as a C r i t i c a l  Following a myocardial  P e r i o d Leading to Loss  i n f a r c t i o n , an i n d i v i d u a l  experiences loss or threat of loss with c o - e x i s t i n g gain.  A c r i t i c a l p e r i o d s u c h a s an MI r e q u i r e s t h e  development and use o f s u i t a b l e c o p i n g b e h a v i o u r s t o s a t i s f y b a s i c human n e e d s (UBC M o d e l f o r N u r s i n g , 1980) .  Loss Leading  t o t h e Change  Process  L o s s may l e a d t o a p r o c e s s o f c h a n g e i n o n e ' s l i f e s t y l e r e q u i r i n g the use o f s u i t a b l e coping behaviours  i n o r d e r f o r o n e ' s b a s i c human n e e d s t o be  satisfied.  Lewin (1951) d e s c r i b e d t h r e e steps i n the  change p r o c e s s : refreezing. individual  u n f r e e z i n g , m o v i n g t o a new l e v e l a n d  During the u n f r e e z i n g phase, the r e c o g n i z e s t h e need f o r a change and s e l e c t s  a number o f a p p r o a c h e s . the a c t u a l b e h a v i o u r where t h e b e h a v i o u r  M o v i n g t o a new l e v e l  change.  involves  R e f r e e z i n g i s the phase  becomes p a r t o f one's  lifestyle.  Lewin (1951) a l s o i n t r o d u c e d the concepts o f d r i v i n g a n d r e s t r a i n i n g f o r c e s t h a t may h e l p o r h i n d e r t h e process o f change.  16  C h a r a c t e r i s t i c s of C h a n g e i s an i n h e r e n t f o l l o w i n g an MI. may  The  be e x p e r i e n c e d  p a r t of the l o s s e s  process  1970).  temporary, actual ( L a m b e r t , 1979; may  self-esteem  L o s s can  or t h r e a t e n e d ,  Peretz,  experience  loss  1970).  above  experienced.  w i t h o u t t h a t w h i c h has  m e a n i n g f o r t h e i n d i v i d u a l (UBC Peretz,  incurred  of change d e s c r i b e d  t h r o u g h e a c h new  Loss i s being  1980;  Loss  or c o u l d  Model f o r  Nursing,  be p e r m a n e n t o r sudden or Following  gradual an MI,  one  l o s s of health, job, family r o l e ,  which threatens  need s a t i s f a c t i o n .  p e r s o n ' s r e s p o n s e r e l a t e d to the l o s s w i l l the meaning a t t a c h e d  have  and The  depend  to the p a r t i c u l a r l o s s or  on  threat  of l o s s . Loss Leading The  to the G r i e v i n g  p e r s o n ' s r e s p o n s e r e l a t e d t o t h e l o s s may  to the g r i e v i n g p r o c e s s . which i s a chronic social  r o l e and  others  are three  process.  New  In c o r o n a r y  artery  lead  disease  i l l n e s s , l o s s of p h y s i c a l i n t e g r i t y ,  interdependency relationships areas  t h a t may  l o s s e s can  g r i e v i n g process has  Process  grieving  be e x p e c t e d t o r e a c t i v a t e  (Crate, 1965).  been c h a r a c t e r i z e d  l e a d to the  with  The  grieving  by a s e q u e n c e o f  b e h a v i o u r s t h a t are somewhat p r e d i c t a b l e .  the  process  subjective According  to  17 P a r k e s ( 1 9 7 1 ) and M a r r i s  (1974) f o u r stages  loss:  numbness; p i n i n g w i t h  g l o b a l d e n i a l and  f r u s t r a t e d search  f o r the l o s t o b j e c t ;  a p a t h y , g i v i n g up hope o f r e c o v e r i n g reorganization  accompany  depression,  t h e l o s s ; and  i n v o l v i n g t h e b u i l d i n g o f new  a s s u m p t i o n s about the world  a  and o n e s e l f .  a  plans  and  This could  i n t e r p r e t e d as w a y s t h a t i n d i v i d u a l s ' r e a c t t o and deal with  then  loss.  As a r e s u l t o f t h e l o s s i n c u r r e d a f t e r an MI, of the b e h a v i o u r a l anger, depression responses  be  will  responses and  reorganization.  be r e v i e w e d  o f t h e r e s p o n s e and  observed  with  include  some  denial,  Each of  these  r e s p e c t to a d e f i n i t i o n  an e x a m p l e o f how  i t r e l a t e s to  c e r t a i n b a s i c human n e e d s . S p e c i f i c Responses to Loss  Incurred  by an  MI  Denial Denial reducing Denial  i s a behaviour  the p e r c e p t i o n  used to a l l e v i a t e a n x i e t y  of the t h r e a t ( S c a l z i , 1973).  i s d e f i n e d as b e h a v i o u r  to a c c e p t  e i t h e r an o b v i o u s  fact in a situation.  that indicates a  Denial  Bartel , 1971).  (Hackett  The  person  failure  f a c t or the meaning of t h i s may  meet c e r t a i n b a s i c needs d u r i n g h o u r s a f t e r an MI  by  be u s e d e f f e c t i v e l y t o t h e f i r s t 24 t o  & C a s s e m , 1974; may  48  Soloff &  n o t be d e l i b e r a t e l y  18  r e f u s i n g t o b e l i e v e what has happened b u t r a t h e r i s unable to believe i t (Levine, denial  i s proportional  i l l n e s s threatens time serves 1982). and  1970).  to the extent  the s e l f .  The d e g r e e o f that the physical  The use o f d e n i a l  at this  a b e n e f i c i a l purpose ( S c a l z i , & Burke,  I t may a l l o w  depression  the person to avoid  associated  with  non-denial  the anxiety (Hackett  &  Cassem, 1974). Denial  may c o n t r i b u t e  t o m e e t i n g one's need f o r  s a f e t y and s e c u r i t y and s e l f - e s t e e m UBC M o d e l f o r N u r s i n g . have a n e g a t i v e  as d e s c r i b e d  However, prolonged  e f f e c t on o t h e r  i n the  denial  may  b a s i c human n e e d s , s u c h  as o n e ' s n e e d f o r a b a l a n c e o f a c t i v i t y a n d r e s t i f o n e d o e s n o t b e l i e v e t h a t he n e e d s t o make c h a n g e s i n t h i s area. Anger Anger, b i t t e r n e s s and a f r u s t r a t e d s e a r c h  f o rthe  lost object are c h a r a c t e r i s t i c behaviours i n the grieving process. influenced  Again,  t h i s response will  by t h e i n d i v i d u a l ' s p e r c e p t i o n  be  of the loss  or t h r e a t .  Anger i s a response to the anxiety  experienced  due t o a t h r e a t , w h i c h l e a v e s t h e  individual  powerless t o deal with  o b s e r v e d as a c o p i n g  i t . A n g e r may be  behaviour to s a t i s f y basic  human  19  needs f o r s e l f - e s t e e m ego-valuative  and s a f e t y and s e c u r i t y i n t h e  and p r o t e c t i v e subsystems.  i n d i v i d u a l ' s a n g e r may be o p e n l y  expressed,  i n s i d e o r may be i n d i r e c t l y e x p r e s s e d Fowkes, Zipes & Wallace, that physicians often fail  1983).  and nurses  The  (Andreoli,  I t has been  on t h e  Direct questioning' i s required to  discover the emotional during  patients  anger and f e a r i n  p a t i e n t s b e c a u s e o f an o u t w a r d c h e e r f u l n e s s  times  observed  caring f o r cardiac  to detect anxiety,  patients' part.  may be k e p t  state of patients at various  t h e i r i l l n e s s experience  (Granger,  1974).  Depression Depression found  h a s b e e n s t u d i e d i n MI p a t i e n t s a n d  t o be common a t v a r i o u s t i m e s  recovery  period (Wishnie,  Hackett  Kavanaugh, Shepard & Tuck, 1975). become d e p r e s s e d they  while  a r e home ( F r o e s e ,  Doehrman, 1977).  & Cassem, 1971; Many p a t i e n t s do n o t  in hospital but rather after Hackett  & Cassem, 1974;  I t has been found  p a t i e n t does n o t r e a l i z e t h e f u l l emotional  throughout the  that the cardiac  p h y s i c a l and  impact of h i s i l l n e s s u n t i l  he a t t e m p t s t o  r e t u r n to h i s former a c t i v i t i e s and f i n d s t h a t they a r e limited 1971).  (Granger,  1974; W i s h n i e , H a c k e t t ,  & Cassem,  20 As t h e i m p a c t  of the l o s s e s i s r e a l i z e d , d e s p a i r  s e t s i n and b e h a v i o u r (1980) suggests experienced  becomes d i s o r g a n i z e d .  that depression  by h e a l t h y  Bowlby  i s an a f f e c t  i n d i v i u d a l s c h a r a c t e r i z i n g the  s u b j e c t i v e a s p e c t of the s t a t e of d i s o r g a n i z a t i o n . Both the world and e m p t y .  and  the i n d i v i d u a l are c o n s i d e r e d  T h i s i s why  the l o s s of s e l f - e s t e e m  often c h a r a c t e r i s t i c of d e p r e s s i o n . helplessness, hopelessness  and  The  t h e l o s s e s r e a l i z e d a f t e r an MI may t o ' g i v e up'  Depression  may  (Scalzi  w i t h t h e MI,  of  are  immense i m p a c t cause  of  the  & Burke, 1982).  o c c u r when o n e ' s w e l l  l i f e u n d e r g o e s a b r u p t c h a n g e due  is  Feelings  dependency  c h a r a c t e r i s t i c of d e p r e s s i o n .  individual  poor  scheduled  to l o s s e s i n c u r r e d  t h r e a t e n i n g o n e ' s b a s i c human n e e d s . R e o r g a n i z a t i on  The  final  p h a s e o f r e o r g a n i z a t i o n o c c u r s when  p l a n s and a s s u m p t i o n s a b o u t t h e w o r l d b u i l t up and assumptive and  and t h e s e l f  i n t e g r a t e d i n t o one's world.  world  i s the world  The  The i n t e r p r e t a t i o n  o f t h e m e a n i n g and c a u s e o f o n e ' s i l l n e s s and and  change (Parkes,  p l a n s f o r t h e f u t u r e may 1971).  are  known t o e a c h i n d i v i d u a l  i n c l u d e s e v e r y t h i n g one k n o w s .  expectations  new  one's  require  21  The v i e w t h a t o n e h a s o f o n e s e l f , t h e r e v i s e d e x p e c t a t i o n s a n d t h e c h a n g e s made o r t o be made w i l l impact The  d i f f e r e n t l y on e a c h  individual will  individual  (Mullen,  e x p e r i e n c e d e n i a l , anger  1978).  depression  and r e o r g a n i z a t i o n a t d i f f e r e n t t i m e s t h r o u g h t o u t t h e recovery  process.  The g r i e v i n g p r o c e s s i s a s e q u e n c e s u s e d f o l l o w i n g an MI i n an a t t e m p t b a s i c human n e e d s .  to s a t i s f y  T h e l o s s due t o an MI may  one o r m o r e s u b s y s t e m s subsystem  of behaviours one's affect  a n d g a i n may be s e e n i n t h e same  as t h e l o s s o r i n o t h e r s .  The v a l u e o f t h e  loss to the person, the preparation f o r the loss, the age a n d h e a l t h o f t h e i n d i v i d u a l (Bowlby, initial  1980),  experiencing the loss  t h e number o f l o s s e s i n c u r r e d f r o m t h e  l o s s ( i m p a c t on o t h e r s u b s y s t e m s )  taken through  and t h e time  the g r i e v i n g process are forces that  i n f l u e n c e the development o f s u i t a b l e coping behaviours.  The c o g n i t i v e and e x e c u t i v e a b i l i t i e s o f  the i n d i v i d u a l  and p r e v i o u s c o p i n g b e h a v i o u r s a v a i l a b l e  to the i n d i v i d u a l  also a f f e c t the s u i t a b i l i t y of coping  behaviours  t o s a t i s f y b a s i c human n e e d s f o l l o w i n g a  myocardial  infarction.  As an i n d i v i d u a l  begins to reorganize h i s  l i f e s t y l e , c h a n g e s a r e made i n t h e a r e a s o f r i s k r e d u c t i o n such as d i e t , smoking and s t r e s s r e d u c t i o n .  22 Return  t o work and  s e x u a l i t y are other areas a f f e c t e d  by an MI w h i c h r e q u i r e c h a n g e and w i l l  Risk Factor  Dietary  be  discussed.  Reduction  Changes  A l t e r i n g e a t i n g h a b i t s may  be  extremely  f r u s t r a t i n g and d i f f i c u l t f o r t h e p a t i e n t and family (Pinneo,  1984;  W e i g h t r e d u c t i o n may and d i f f i c u l t . way  the  Newton & S i v a r a j a n , 1 9 8 2 ) . be n e c e s s a r y  Many p e o p l e  but prove  begin changing  t o be  slow  their entire  o f e a t i n g by c u t t i n g down on s a l t , c h o l e s t e r o l ,  s a t u r a t e d f a t s and c a l o r i e s .  T h i s i s something  t h e p a t i e n t c a n do t o h e l p h i m s e l f . still  Although  that this is  an a r e a o f c u t t i n g b a c k , t h e p a t i e n t may  more c h o i c e and control evidence  feel  good about  over the d i e t .  a c e r t a i n amount o f  Although  t h e r e i s no c o n c l u s i v e  a t t h i s t i m e , t h a t an i n d i v i d u a l c a n  the p r o c e s s of c o r o n a r y by m o d i f y i n g  have  reverse  a r t e r y d i s e a s e or prolong  the d i e t , c l i n i c a l  life  s t u d i e s have i n d i c a t e d  t h a t a l o w e r i n g o f b l o o d c h o l e s t e r o l l e v e l s and low-density  l i p o p r o t e i n (LDL)  r e s u l t s in a reduced ( S t a m l e r , 1978; about  Holub,  cholesterol levels  rate of coronary 1 9 8 6 ) . The  heart  p a t i e n t may  t h e e f f e c t s o f a l c o h o l on t h e h e a r t .  disease inquire While  23 alcohol  i s not a r i s k f a c t o r i n coronary a r t e r y  d i s e a s e , i n e x c e s s i v e a m o u n t s i t i n c r e a s e s t h e work o f t h e h e a r t by i n c r e a s i n g t h e h e a r t r a t e . which  a l c o h o l i s c o n s u m e d may  The  setting in  i n f l u e n c e i t s impact.  D r i n k i n g i n a r e l a x e d atmosphere  may  be q u i t e d i f f e r e n t  t h a n d r i n k i n g a f t e r a l a r g e meal i n a c r o w d e d , smoke f i l l e d room ( P i n n e o ,  1984).  Smoking C e s s a t i o n Smoking i s the r i s k f a c t o r which  i s well  d o c u m e n t e d as i n c r e a s i n g t h e r i s k o f MI.  The r i s k  MI d e c r e a s e s m a r k e d l y  smoking  f o r t h o s e who  (Mallaghan & Pemberton, 1977). smoking  quit  P a t i e n t s who  stop  b r e a t h e more e a s i l y and e n j o y t h e t a s t e o f f o o d  better (Pinneo,  1984).  Stress  Reduction  The p u b l i c i s b e i n g b o m b a r d e d w i t h b o o k s , and w o r k s h o p s a b o u t s t r e s s and r e l a x a t i o n . The l i t e r a t u r e a d d r e s s e s how  s t r e s s c a n be  articles popular  prevented,  m a n a g e d and e v e n e l i m i n a t e d ( L a z a r u s & F o l k m a n , Concepts  1984).  previously called anxiety, conflict,  f r u s t r a t i o n , emotional now  of  d i s t u r b a n c e and a l i e n a t i o n  beem r e n a m e d s t r e s s ( A p p l e y & T r u m b u l l ,  1967).  have  24 S t r e s s has been c i t e d i n t h e development o f coronary  artery disease.  The e x a c t  role that  p l a y s i s a s y e t unknown a n d u n d e r s t u d y .  stress  Presently,  t h e r e a r e no c a u s e a n d e f f e c t m o d e l s t o e x p l a i n t h e influence o fpsychological depression,  f a c t o r s such as a n x i e t y ,  sleep disturbance  on t h e c a r d i o v a s c u l a r  and emotional  system.  I t i s known  exhaustion that  patients face p o t e n t i a l l y s t r e s s f u l s i t u a t i o n s recovery  f r o m an MI.  Examples o f these  during  include  changes  in d a i l y r o u t i n e s , changes i n b o d i l y response t o activity, financial  concerns,  r o l e changes with the  f a m i l y and r e t u r n i n g t o work. stressful  The r e s p o n s e t o a  s i t u a t i o n v a r i e s from person  depends on the r e p e r t o i r e o f c o p i n g individual needs. coping  already  possesses  Thesuccess with  t o person  behaviours  that the  t o meet h i s b a s i c  o r f a i l u r e o fprevious  and human  attempts a t  s i m i l a r s t r e s s f u l s i t u a t i o n s i s o f major  importance. Stress responses categories:  have been d i v i d e d i n t o  Body symptoms s u c h  as f l u s h i n g ,  four sweating,  f a t i g u e , d r y m o u t h , s t u t t e r i n g , a n d an i n c r e a s e s o r decrease  in appetite, exercise o r sleep  habits,  p a l p i t a t i o n s , b a c k a c h e , c o n s t i p a t i o n and d i a r r h e a ; Cognitive  states t h a t  include d i s t r a c t i b i 1 i t y ,  worry,  f o r g e t f u l n e s s , d e n i a l and a t t e m p t s a t p r o b l e m - s o l v i n g ; Feeling states  such as shakiness,  agitation,  25 Motor  irritability,  a n x i e t y , a n g e r and d e p r e s s i o n ;  symptoms s u c h  as muscular t i g h t n e s s , increased  r e a c t i o n , i n c o o r d i n a t i o n (Appley S h a f f e r , 1982;  R i z z u t o , 1983;  & Trumbull,  Pelletier,  startle 1967;  1984).  P a l p i t a t i o n s and t a c h y c a r d i a a r e among t h e m o s t widely  recognized  stress.  physical effects o f psychological  S t u d i e s have d e m o n s t r a t e d t h a t  emotional  s t r e s s can p l a y a r o l e i n p r e m a t u r e v e n t r i c u l a r tachycardia in persons  with heart disease  (Wheeler &  Sheehan, 1978). Parkes  (1971) has s t a t e d t h a t change u s u a l l y  to s t r e s s .  leads  Change t h a t i s l a s t i n g , takes p l a c e i n a  s h o r t p e r i o d o f time o r a f f e c t s a l a r g e area o f one's assumptive  world  potential  ( l i f e s p a c e ) has t h e  t o produce s t r e s s .  Mullen  greatest (1978) found  c h a n g e made b y i n d i v i d u a l s u s u a l l y a f f e c t e d more one  that than  a r e a , w i t h t h e e f f e c t s and c o n s e q u e n c e s o f c h a n g e  having  an i m p a c t  Relaxation response Jacobson,  on v a r i o u s a r e a s o f l i f e s t y l e .  i s the prime s t r a t e g y a f f e c t i n g the s t r e s s  m e n t i o n e d i n t h e l i t e r a t u r e ( M i l sum, 1964).  meditation,  Techniques  biofeedback,  that are h e l p f u l a r e  progressive relaxation using  n e u r o m u s c u l a r c o n t r o l , and v a r i o u s h o l i s t i c Jacobson  ( 1 9 6 4 ) has d e s c r i b e d  relaxation techniques  1984;  aspects.  progressive  d i r e c t e d toward r e l a x a t i o n o f  m a j o r m u s c l e g r o u p s b y c o n t r a c t i o n and  relaxationof  26 various  muscles.  exercises  may  a f t e r an  MI.  The  isometric  n o t be a d v i s a b l e  Relaxation stress reduction  component of i n the e a r l y  techniques are only  n o t be p o s s i b l e  recovery  one  or s t r e s s management.  these  aspect  of  While i t  may  to change c e r t a i n s o u r c e s of s t r e s s  a p e r s o n ' s l i f e , one  can  change the  Recognition  of events t h a t are  recognition  o f o n e ' s own  stressful  physical  r e s p o n s e s to these s t r e s s e s  reaction  and  is a  to i t .  and  emotional  beginning.  Consciously  c h o o s i n g to r e a c t to the s i t u a t i o n s i n a  new  way  t h e n p r a c t i c i n g t h e s e new  way  of d e a l i n g with s t r e s s (Newton, S i v a r a j a n ,  and  in  responses i s a  O t h e r C h a n g e s P r e c i p i t a t e d By A M y o c a r d i a l  1982).  Infarction  R e t u r n t o Work Despite  t h e aim  an MI,  studies  return  t o work a r e  for early mobilization  show t h a t h a l f t h e  & Cassem, 1971).  and  permitted  r e l u c t a n t t o do so ( W i s h n i e , Many e x p r e s s a n x i e t i e s  t h e i r a b i l i t y t o work f u l l same d u t i e s  patients  following  f e a r of h a v i n g another heart  attack.  Hackett  concerning  or p a r t time, perform  a d e q u a t e l y , f e a r of r e c u r r i n g  to  chest Some  the pain patients  27 use  t h e i r heart  ( P i n n e o , 1984;  attack  as a r e a s o n t o r e t i r e f r o m work  W i s h n i e , H a c k e t t & Cassem, 1971).  In t h e l i f e o f an i n d i v i d u a l work i s more t h a n earning  a living.  associations, and  I t i s a key  d e t e r m i n e s the  one's l i f e s t y l e .  t h e i r work and  the  cardiac  interpersonal  position in  derive meaning  have s e r i o u s  e f f e c t s on  Commonly i n c a r d i a c  disability  significance.  their  r e h a b i l i t a t i o n l i t e r a t u r e has  to work.  physical  from  1968).  s u g g e s t e d f a c t o r s i n f l u e n c i n g the p a t i e n t ' s return  society  l o s s of or change i n employment  (Croog, Levine & Lurie, The  status  Individuals  b e c a u s e o f an MI may lives  element in  The  i s not of  disease  to  the  overwhelming  fear of heart  consequences reinforced  decision  disease  and  by t h e p a t i e n t and  i s the  i m p o r t a n t c a u s e o f d i s a b i l i t y and  return  t o work and  its  his  family  a lack  of  a c t i v i t y (Rosenbaum & B e l k n a p ,  1959). Anxiety obstacles  and  depression  attack  t o r e h a b i l i t a t i o n e f f o r t s and  It i s estimated patients  after a heart  t h a t b e t w e e n 20%  e i t h e r never return  t o 60%  pose  return of  t o work o r  to work.  post-MI  remain  underemployed f o r the r e m a i n d e r of t h e i r w o r k i n g l i v e s (Stern, Pascale,  & Ackerman, 1977).  A n o t h e r f a c t o r a f f e c t i n g the p a t i e n t ' s a b i l i t y to r e t u r n  t o work may  decision  d e p e n d on s u p p o r t  or  from  28 t h e s p o u s e , f a m i l y and support  Insufficient  o f p a t i e n t s f r o m t h e i r f r i e n d s and  p r o d u c e s s t r e s s and social  s o c i a l network.  and  takes  its toll  p h y s i c a l h e a l t h and  p a t i e n t s and  t h e i r spouses.  t h e f a m i l y may Studies  family  on t h e  emotional,  f u n c t i o n i n g of  A serious disruption in  ensue. on t h e r a t e o f r e t u r n t o work by  p a t i e n t s i n d i c a t e t h a t some o c c u p a t i o n s  and  s e t t i n g s a r e more c o n d u c i v e  to  than  others  r e h a b i l i t a t i o n process  (Durbin  Reeder (1965) r e p o r t e d  a d i f f e r e n c e i n the  and  p o l i c i e s o f w h i t e and  heart  work the  & Goldwater,  1956). attitudes  blue c o l l a r workers.  c o l l a r w o r k e r s a r e more e a s i l y a c c e p t a b l e p l a c e than  MI  White  i n t h e work  blue c o l l a r employees because of the  of t h e i r j o b s .  White c o l l a r workers often  nature  have  f l e x i b l e o f f i c e - t y p e j o b s where a d j u s t m e n t s  regarding  work s c h e d u l e s  c a n be made.  worker  f r e q u e n t l y has  a p h y s i c a l l y strenuous  a l t e r n a t i v e s and  The  f l e x i b i l i t y may  blue c o l l a r  job where  n o t be  considered.  Employees are r e l u c t a n t to have the c a r d i a c doing  these  experiencing  j o b s due  to the p o s s i b i l i t y of  patient his  a h e a r t a t t a c k a t work. Thus the  better  e d u c a t e d w h i t e c o l l a r w o r k e r more e a s i l y r e t u r n s adapts to reemployment than  the blue c o l l a r worker  i s m o r e l i k e l y t o r e t u r n more s l o w l y , c h a n g e j o b s retire  (Doehrman, 1977).  to  and who  or  29 R e t u r n t o work i s l i k e l y t o be i n f l u e n c e d a t t i t u d e s of employers toward the c a r d i a c p r o b l e m o f p a t i e n t s who  by  patient.  a r e f i t t o r e t u r n t o work  cannot f i n d s u i t a b l e employment i l l u s t r a t e s the attached Lerner,  the  to c a r d i a c d i s e a s e  ( G r o d e n , 1967;  The and  stigma  Burgess,  & Hartman, 1983).  Burgess, Lerner,  & Hartman (1983) note t h a t  r e h a b i l i t a t i o n programs have been d i r e c t e d at patients emotional,  to work. social  few  returning  W o r k i n g demands a r a n g e o f and  b e e n a l t e r e d by h e a r t  physical disease  s k i l l s t h a t may and  Coping b e h a v i o u r s to deal w i t h m u s t be d e v e l o p e d i n o r d e r r e h a b i l i t a t i o n and  have  the r e s u l t i n g l o s s e s .  the demands o f w o r k i n g  to promote a  successful  r e t u r n to work. S e x u a l i ty  One  of the l o s s e s p e r c e i v e d  the l o s s of p h y s i c a l  capacity.  individual's self-esteem or f e m i n i n i t y .  "The  and  by t h e MI T h i s may  patient is  threaten  the c o n c e p t of  the  masculinity  patient experiences  a general  fear  of being  impotent to face the c o n t i n u i n g  challenge  of  l i f e and  this anxiety  i s symbolized  i n the i n a b i l i t y  perform sexually"  ( W a g n e r , 1976,  r e l y on t h e i r own  k n o w l e d g e , m y t h , and  regarding  s e x u a l i t y a f t e r an MI.  p.119).  Many  patients  misconceptions  T h i s may  to  be due  to  30 the l a c k o f d i s c u s s i o n and e d u c a t i o n  regarding  s e x u a l i t y a f t e r an M I . All and  the studies reviewed  female  spouses.  r e f e r r e d to male p a t i e n t s  T h e e f f e c t o f an MI on t h e  s e x u a l i t y o f women a s p a t i e n t s h a s n o t b e e n s t u d i e d . S t u d i e s have d e s c r i b e d t h e l a c k o f e f f e c t i v e s e x u a l c o u n s e l l i n g and i t s consequences ( S t e r n , 1977; T u t t l e , Cook & F i t c h , 1 9 6 4 ) . about  their decrease  When p a t i e n t s w e r e i n the frequency  questioned  of sexual  a c t i v i t y , i t was a t t r i b u t e d t o c h a n g e s i n t h e p a t i e n t s ' sexual  d e s i r e , fear of having  of sudden death, spouse's  heart attack or  f e e l i n g s o f a n x i e t y and d e p r e s s i o n ,  f e a r a n d symptoms o f c o r o n a r y  ( H e l l e r s t e i n & Friedman, 1980).  another  disease  1970; McLane, Krop & Mehta,  An MI a f f e c t s t h e s e x u a l i t y o f b o t h  Reduced sexual  partners.  a c t i v i t y a f t e r a myocardial  i n f a r c t i o n may l e a d t o f r u s t r a t i o n f o r b o t h  partners  and m a r i t a l p r o b l e m s w h i c h may i m p e d e t h e r e c o v e r y process  ( S c a l z i , 1982; K o l l e r , Kennedy & B u t l e r , 1972).  T h e s e p s y c h o l o g i c a l e f f e c t s o f an MI a l s o h a v e a r o l e i n how t h e p a t i e n t v i e w s h i m s e l f . i m a g e may o c c u r .  Heart attacks occuring during  age  ( 5 0 - 6 0 ) may a u g m e n t t h e i m p a c t  and  sexual Before  Changes i n body middle  and f e a r o f aging  inadequacy. sexual  a c t i v i t y i s resumed, c o n s i d e r a t i o n  s h o u l d be g i v e n t o t h e p a t i e n t ' s g e n e r a l  h e a l t h and  31  t o l e r a n c e f o r p h y s i c a l a c t i v i t y p r i o r t o t h e MI; extent  of myocardial  arrhythmias  damage and  ( S c a l z i , 1982).  frequency  of angina  Stair climbing  has  shown t o be a h e m o d y n a m i c i n d i c a t o r o f h e a r t needed f o r sexual Mansfield  activity  (Green,  to climb  two  o f a f l i g h t o f s t a i r s and  activity.  been  work  Siewicki  and  oxygen  The d e f i n i t i o n  the r a t e of c l i m b i n g  the p a t i e n t d u r i n g  D o u g l a s and W i l k e s  and  f l i g h t s of s t a i r s i s s i m i l a r  to t h a t r e q u i r e d f o r sexual  be g i v e n  1975).  (1977) showed t h a t the m y o c a r d i a l  requirement  The  the c o u n s e l l i n g  (1975) concluded  that  should  period.  sexual  a c t i v i t y i s w e l l w i t h i n the c a p a c i t y of most c a r d i a c patients. A combination  of these  p h y s i c a l and  psychological  f a c t o r s f r e q u e n t l y d i s r u p t c o m m u n i c a t i o n and between the c o u p l e . behaviours  The  in tension  e f f e c t of unsuitable  i n t h e a r e a o f s e x u a l i t y may  n e g a t i v e l y on v a r i o u s  subsystems with  coping  impact a subsequent  rise  s i g n a l l i n g an unmet n e e d .  Coping Behaviours Following  a review  i n t h e UBC  Model f o r  of the responses  a f f e c t i n g t h e i n d i v i d u a l a f t e r an MI, i n t h e UBC  intimacy  Model f o r N u r s i n g  the responses  and  will  and  Nursing changes  coping  be e x a m i n e d .  behaviours Many o f  c h a n g e s made by an i n d i v i d u a l a r e  32 coping b e h a v i o u r s used i n a attempt to s a t i s f y b a s i c human  one's  needs.  The UBC M o d e l  f o r Nursing defines a coping  b e h a v i o u r a s a r e s p o n s e w h i c h i n d i c a t e s t h e way i n which a subsystem  i s attempting to s a t i s f y a basic  human n e e d f o r t h e s y s t e m .  B a s i c human n e e d s a r e a  fundamental  requirement f o r survival  behavioural  system.  and growth o f t h e  A coping behaviour i s suitable  when t h e r e s p o n s e s a t i s f i e s a b a s i c human n e e d a n d t h e response i s appropriate to s o c i e t a l e x p e c t a t i o n s . In t h e UBC M o d e l  f o r N u r s i n g an i n d i v i d u a l i s  v i e w e d a s a b e h a v i o u r a l s y s t e m made up o f n i n e i n t e r a c t i n g and i n t e r d e p e n d e n t s u b s y s t e m s . subsystem  Each  i s r e s p o n s i b l e f o r t h e s a t i s f a c t i o n o f one  b a s i c human n e e d ( A p p e n d i x A ) . N u r s i n g a u t h o r s have used a needs o r i e n t a t i o n i n g a t h e r i n g i n f o r m a t i o n , p l a n n i n g , implementing and evaluating nursing care.  T h e names o f t h e n e e d s may be  d i f f e r e n t f r o m t h o s e i n t h e UBC M o d e l  f o r Nursing but  n o n e t h e l e s s may mean t h e same t h i n g .  Cardiac  l i t e r a t u r e d i s c u s s e s t h e i n d i v i d u a l ' s need f o r m o b i l i t y , f o r s l e e p a n d f o r s e n s o r y s t i m u l a t i o n by o u t l i n i n g t h e d a n g e r s a n d c o m p l i c a t i o n s when t h e s e needs a r e l a c k i n g Homan, 1 9 8 3 ) .  ( U n d e r h i l l , 1982; S a n f o r d , 1983;  C o n c e r n s r e g a r d i n g body image and  self-concept, the role of the family, the importance of  33 the environment  a r e o t h e r needs t h a t a r e d i s c u s s e d i n  the c r i t i c a l  care l i t e r a t u r e  ( R o b e r t s , 1976; K i n n e y ,  Dear, Packa,  & Voorman, 1981).  Dietary  needs,  r e s p i r a t o r y needs r e l a t e d t o the e f f e c t s o f smoking and ways o f p r o t e c t i n g o n e s e l f f r o m f u r t h e r h e a r t a t t a c k s are presented i n n u r s i n g l i t e r a t u r e ( S i v a r a j a n , 1982). T h e s e n e e d s a r e c o n s i d e r e d when c a r i n g f o r a p a t i e n t who h a s e x p e r i e n c e d an MI.  A comparison  with the needs  and g o a l s o f t h e UBC M o d e l f o r N u r s i n g r e v e a l s some similarities. I t i s i n t e r e s t i n g t o n o t e t h a t some o f t h e n e e d s and g o a l s o f t h e s u b s y s t e m s as c r i t e r i a  f o r measuring  are s i m i l a r to those e f f e c t i v e coping  listed  behaviours  and f o r d e s c r i b i n g c o p i n g t a s k s . M a i n t a i n i n g a p o s i t i v e concept of s e l f , a d j u s t i n g to a l t e r e d social r e l a t i o n s h i p s and d e a l i n g w i t h l o s s and r o l e change a r e a few o f t h e c o p i n g t a s k s d e s c r i b e d ( M i l l e r , 1 9 8 3 ; Hamburg & Adams, 1 9 6 7 ) .  I n t e g r i t y of the i n d i v i d u a l ,  e f f e c t i v e f u n c t i o n i n g i n r e l a t i o n s h i p s and a p o s i t i v e s e l f concept  are other areas mentioned  i n the reviewed  l i t e r a t u r e and a r e a l s o g o a l s o f t h r e e subsystems  in  t h e UBC M o d e l f o r N u r s i n g . I d e a l l y the subsystems  are i n a balanced  r e l a t i o n s h i p with each o t h e r ( b e h a v i o u r a l balance).  A range o f coping behaviours  system i s u s e d i n an  34 attempt to reduce t e n s i o n , which i s c o n s t a n t l y e x p e r i e n c e d i n v a r y i n g i n t e n s i t y by a s u b s y s t e m . Coping b e h a v i o u r s which a r e both i n n a t e and acquired are organized into r e p e t i t i v e , p a t t e r n s t h a t become t h e i n d i v i d u a l ' s  predictable characteristic  way o f a t t e m p t i n g t o s a t i s f y b a s i c human  needs.  A c h a n g e i n o n e ' s d i e t may a f f e c t a number o f t h e needs of the i n d i v i d u a l . the  The need f o r n o u r i s h m e n t i n  i n g e s t i v e s u b s y s t e m , t h e need f o r s e n s o r y  s t i m u l a t i o n i n t h e s a t i a t i v e s u b s y s t e m and t h e need f o r s e l f - e s t e e m i n t h e e g o - v a l u a t i v e s u b s y s t e m may be a f f e c t e d p o s i t i v e l y o r n e g a t i v e l y by d i e t a r y  changes.  The l o s s o f o n e ' s h e a l t h may h a v e e v e n more g l o b a l e f f e c t s and the i n t e r a c t i n g and i n t e r d e p e n d e n t p r o p e r t i e s o f t h e subsystems a r e r e a l i z e d as one's need for  s a f e t y , s e c u r i t y , s e l f - e s t e e m , l o v e , a c t i v i t y and  r e s t , m a s t e r y a n d s e n s o r y s a t i s f a c t i o n may be a f f e c t e d by s u c h a l o s s . Each s u b s y s t e m i s viewed as a l i f e s p a c e .  This  c o n s i s t s o f an i n n e r p e r s o n a l r e g i o n r e p r e s e n t i n g a b a s i c human n e e d a n d a b i l i t i e s  ( c o g n i t i v e and  e x e c u t i v e ) to s a t i s f y t h e need. The p s y c h o l o g i c a l e n v i r o n m e n t r e p r e s e n t s t h e goal and f o r c e s t h a t a r e meaningful  to the subsystem.  C o g n i t i v e and e x e c u t i v e a b i l i t i e s which a r e components of c o p i n g b e h a v i o u r s c o n s i s t o f the c a p a c i t y  35 t o know a n d m a n i p u l a t e t h e p s y c h o l o g i c a l e n v i r o n m e n t . S o c i o c u l t u r a l , i m p e r s o n a l and p e r s o n a l f o r c e s a f f e c t o r influence coping behaviours. facilitate subsystem  Coping  behaviours  o r i n h i b i t movement t o w a r d t h e g o a l o f t h e (UBC Model  f o r Nursing,  1980).  I t i s w i t h i n t h e f r a m e w o r k o f t h e UBC M o d e l f o r N u r s i n g t h a t the term c o p i n g b e h a v i o u r w i l l this study.  Coping behaviour w i t h i n t h i s  be u s e d i n framework  e n c o m p a s s e s more t h a n t h e p r e s e n t a t i o n o f a t h r e a t t o one's  integrity eliciting  a n x i e t y , f e a r and g r i e f .  i s more t h a n a r e s p o n s e t o s t r e s s o r c o n t r o l stressful change. lifestyle  experiences.  It  over  I t i s more t h a n a l i f e s t y l e  C o p i n g b e h a v i o u r s a r e r e s p o n s e s w h i c h may be changes  incorporated into daily l i f e  p u r p o s e o f s a t i s f y i n g o n e ' s b a s i c human  needs.  f o r the  36 CHAPTER THREE  METHODOLOGY  A d e s c r i p t i v e study c o n s t r u c t s a p i c t u r e or account  of events  as t h e y n a t u r a l l y o c c u r ( W a l t z ,  B a u s e l l , 1981).  &  D e s c r i p t i v e s t u d i e s l o o k f o r ways t o  c a t e g o r i z e , c l a s s i f y or c o n c e p t u a l i z e s i t u a t i o n s . o r d e r to d e s c r i b e the c o p i n g b e h a v i o u r s p a t i e n t s in meeting  MI  t h e i r b a s i c human n e e d s , d a t a o f a  q u a l i t a t i v e n a t u r e were The m e t h o d o l o g y u s e d t h e o r y , was  u s e d by  In  elicited. in t h i s study,  grounded  d e s c r i b e d by G l a s e r and S t r a u s s  (1967).  T h i s method i s a p r o c e s s of moving from the data to concept  and t h u s c o n c e p t u a l i z i n g t h e s i t u a t i o n .  the  Diers  ( 1 9 7 9 ) d e s c r i b e s t h i s m e t h o d as a p s y c h o l o g i c a l thinking process using d i s c r i m i n a t i o n , d e f i n i t i o n classification.  The  and  r e s e a r c h e r must t r e a t " a l l the  d a t a " a t some l e v e l . W h e t h e r t h e m a t e r i a l i s r e s e a r c h d a t a , o t h e r ' s i d e a s or from c o m p a r e d t o -the o n g o i n g  the l i t e r a t u r e , i t i s to  data f o r the purpose  g e n e r a t i n g t h e b e s t f i t t i n g and w o r k i n g  be  of  ideas  (Glaser,  1978) . Grounded theory views the development of theory an o n - g o i n g  conceptual  c a n s e e how  concepts  p r o c e s s w i t h s t e p s , so t h a t have been d e v e l o p e d .  The  as one  method  37 has f o u r s t a g e s : 2)  1)  comparing  data i n each  category,  i n t e g r a t i n g t h e c a t e g o r i e s a n d t h e i r p r o p e r t i e s , 3)  d e l i n e a t i n g t h e t h e o r y a n d 4) (Glaser & Strauss,  w r i t i n g the theory  1967).  G r o u n d e d t h e o r y was u s e d t o u n c o v e r t h e c h a r a c t e r i s t i c p a t t e r n s and changes i n t h e c o p i n g behaviours  o f MI p a t i e n t s .  s o r t i n g data under  D a t a w e r e c a t e g o r i z e d by  the subsystems  o f t h e UBC M o d e l f o r  N u r s i n g t o c a t e g o r i z e common t h e m e s r e l a t e d t o t h e s a t i s f a c t i o n o f b a s i c human n e e d s . behaviours  used to s a t i s f y needs o f t h e system  described. useful  The c o p i n g  The m e t h o d o l o g y o f grounded  were  t h e o r y was  f o r i d e n t i f y i n g the coping behaviours  p a t i e n t s t o s a t i s f y t h e i r b a s i c human n e e d s .  u s e d by MI The  c h a n g e s t h a t i n d i v i d u a l s made i n t h e i r l i v e s a n d t h e i r p e r c e p t i o n s and d e s c r i p t i o n s o f t h e e f f e c t o f t h e i r i l l n e s s on t h e i r l i f e s t y l e w e r e e l i c i t e d t h r o u g h perspective. impact  L o s s e s e x p e r i e n c e d and t h e i r n a t u r e and  on i n d i v i d u a l s w e r e a l s o d e s c r i b e d .  further understanding behaviours  this  I n t h i s way  was g a i n e d i n t h e a r e a o f c o p i n g  and t h e i n f l u e n c e s and f o r c e s a f f e c t i n g  them. Data  used f o r a n a l y s i s were t r a n s c r i p t i o n s o f  t a p e d , semi - s t r u c t u r e d i n t e r v i e w s w i t h MI p a t i e n t s . I n t e r v i e w s were c o n d u c t e d s u b j e c t s ' MI.  6-12 m o n t h s a f t e r t h e  One t o two i n t e r v i e w s , e a c h  38 a p p r o x i m a t e l y one hour i n l e n g t h each p a r t i c i p a n t .  and v a l i d a t e r e c u r r i n g  Selection  data  elements.  of Participants  selected  to meet t h e f o l l o w i n g 1)  with  A sample s i z e o f seven provided  necessary to discover  Participants  were c o n d u c t e d  f o r t h e s t u d y were  required  criteria:  The p a r t i c i p a n t s w i l l  be a d u l t s  35-69 y e a r s o f  age. 2)  The p a r t i c i p a n t s w i l l medical diagnosis  be a d u l t s who h a d a  o f an i n i t i a l  i n f a r c t i o n 6-12 m o n t h s 3)  4)  previous.  T h e p a r t i c i p a n t s m u s t be a b l e speak and read  passing  f o r interviews.  o f t h e head nurse i n  u n i t o f one V a n c o u v e r h o s p i t a l  access to the records  patients  greater  f o r t h i s study over a  month p e r i o d w i t h t h e h e l p  the c o r o n a r y c a r e had  i n the  t o be a c c e s s i b l e  P a r t i c i p a n t s were o b t a i n e d three  to understand,  English.  The p a r t i c i p a n t s must l i v e Vancouver area  myocardial  containing  t h e names o f  through the coronary care  unit.  who  39 P a t i e n t s w i t h i n a s i x t o t w e l v e month p e r i o d w i t h a diagnosis of myocardial  i n f a r c t i o n were c o n s i d e r e d .  The c a r d i o l o g i s t who i s t h e d i r e c t o r o f t h e u n i t was a p p r o a c h e d  f o r her consent  participants.  T h e c a r d i o l o g i s t was a b l e t o s u g g e s t t h e  persons  t h a t s h e was s t i l l  and h e l p i n r e c r u i t i n g  f o l l o w i n g and t h a t l i v e d i n  the g r e a t e r Vancouver a r e a .  H e r s e c r e t a r y was  willing  t o c o n t a c t t h e p a t i e n t s a n d r e a d t o them t h e i n f o r m a t i o n c o n t a i n e d i n INFORMATION RESEARCH STUDY ( A p p e n d i x  B).  RELATED TO CARDIAC  I f the person  was  i n t e r e s t e d i n p a r t i c i p a t i n g h i s name a n d p h o n e number were g i v e n t o t h e i n v e s t i g a t o r . The i n v e s t i g a t o r then c o n t a c t e d p o t e n t i a l p a r t i c i p a n t s by t e l e p h o n e t o d i s c u s s t h e study and t h e i r p o s s i b l e p a r t i c i p a t i o n i n the study. agreed  Each  of the seven  participants contacted  t o p a r t i c i p a t e and a c o n v e n i e n t  arranged  t o m e e t i n t h e i r homes.  was  One g e n t l e m a n was  v e r y b u s y a n d i t was more c o n v e n i e n t meeting  time  to arrange a  w i t h him a t h i s o f f i c e .  An e x p l a n a t i o n o f t h e s t u d y was g i v e n t o e a c h p a r t i c i p a n t at the beginning consent  of the interview.  was o b t a i n e d p r i o r t o t h e i n t e r v i e w .  Written  40 Characteristics of the Participants  Data were o b t a i n e d from a s t u d y sample o f s i x m a l e s age 45-69 and one f e m a l e age 60.  F i v e o f t h e men  w e r e m a r r i e d , o n e was w i d o w e d a n d t h e woman was widowed. one  T h r e e men w e r e e m p l o y e d , two w e r e r e t i r e d a n d  man a n d woman w e r e u n e m p l o y e d .  The i n t e r v i e w s were  c o n d u c t e d seven t o twelve months f o l l o w i n g t h e d i a g n o s i s and h o s p i t a l i z a t i o n f o r m y o c a r d i a l i n f a r c t i on.  Table 1  P a r t i c i pant  Sex  Age  1 2 3 4 5 6 7  M M F M M M M  45 63 60 69 58 54 66  M-married reti red  W-widowed  Mari t a l Status M M W M M M W E- employed  Work Recency o f S t a t u s MI(mos.) E R U R E E R  10 12 7 9 8 10 12  U-unemployed  R-  41  Ethical Considerations  P r i o r a p p r o v a l f o r t h i s s t u d y was UBC  E t h i c s Committee f o r Reasearch  obtained  Studies.  from  The  p a r t i c i p a n t ' s r i g h t s were p r o t e c t e d i n the f o l l o w i n g ways: A d e s c r i p t i o n o f t h e s t u d y and an e x p l a n a t i o n o f t h e p a r t i c i p a n t ' s r o l e was  a v a i l a b l e to  p r i o r to o b t a i n i n g consent (Appendix W r i t t e n c o n s e n t was  participants  B).  r e c e i v e d from the  p r i o r to the i n t e r v i e w (Appendix  participant  C).  P a r t i c i p a n t s were a s s u r e d t h a t t h e y were f r e e to withdraw  f r o m t h e s t u d y a t any t i m e o r r e f u s e t o a n s w e r  any o f t h e q u e s t i o n s w i t h o u t a d v e r s e a f f e c t t o f u r t h e r medical or nursing care. P a r t i c i p a n t s were a s s u r e d t h a t a l l i n f o r m a t i o n i n the taped i n t e r v i e w would t h e i r name w o u l d  and  n o t be u s e d i n any w r i t t e n o r  published material. completion of the  be k e p t c o n f i d e n t i a l  The t a p e s w o u l d  be e r a s e d u p o n  study.  P a r t i c i p a n t s w e r e i n f o r m e d t h a t t h e r e w e r e no risks associated with p a r t i c i p a t i o n in this study. potential  b e n e f i t s of the study would  be r e a l i z e d  The as  42 p a r t i c i p a n t s and n u r s i n g p r o f e s s i o n a l s g a i n from the e x p e r i e n c e s o f these  insight  people.  P a r t i c i p a n t s were i n f o r m e d t h a t they would have a c c e s s t o t h e r e s u l t s o f t h e s t u d y upon i t s c o m p l e t i o n .  Data  Collection  Data were g a t h e r e d o v e r a p e r i o d o f t h r e e months u s i n g a s e m i - s t r u c t u r e d i n t e r v i e w guide open-ended q u e s t i o n s (Appendix  D).  with  The q u e s t i o n s were  not s t a n d a r d i z e d b u t were used as a - g u i d e  to explore  the e x p e r i e n c e s and t h e c o p i n g b e h a v i o u r s  developed  by  t h e p a r t i c i p a n t s i n o r d e r t o m e e t t h e i r b a s i c human needs. verbal  O b s e r v a t i o n a l methods were a l s o used  with  ( i n t o n a t i o n , q u a l i t y o f s p e e c h , manner) and  non-verbal  ( e y e c o n t a c t , body l a n g u a g e , a p p e a r a n c e )  behaviours  noted.  Coping  behaviours  t h a t w e r e i d e n t i f i e d by t h e  p a r t i c i p a n t s were e x p l o r e d i n more d e t a i l . i n c l u d e d g a t h e r i n g i i n f o r m a t i o n about  This  t h e b a s i c human  n e e d t h a t was b e i n g s a t i s f i e d by t h e c o p i n g  behaviour,  the f o r c e s ( s o c i o c u l t u r a l , personal or impersonal) affected or influenced the coping behaviour abilities coping  that  and t h e  ( c o g n i t i v e and e x e c u t i v e ) t h a t determined the  behaviour.  43 The i n t e r v i e w s w e r e t a p e r e c o r d e d  and t r a n s c r i b e d .  Once t h e i n t e r v i e w h a d b e g u n , t a p i n g d i d n o t a p p e a r t o be a h i n d r a n c e  to easy c o n v e r s a t i o n .  e s t a b l i s h e d e a s i l y through conversation  a time o f s o c i a l  p r i o r to the i n t e r v i e w where  d a t a was g a t h e r e d expressed  R a p p o r t was  (Appendix  E).  demographic  Many p a r t i c i p a n t s  p l e a s u r e a t b e i n g g i v e n an o p p o r t u n i t y  c o n t r i b u t e to the researcher's  to  l e a r n i n g and t o n u r s i n g  knowledge. The i n t e r v i e w s ranged in l e n g t h . noted  Following  from  t h i r t y to s i x t y minutes  the i n t e r v i e w , the researcher  any p a r t i c u l a r v e r b a l o r n o n - v e r b a l  other observations or i n t e r e s t .  t h a t were o f p a r t i c u l a r s i g n i f i c a n c e  of the i n d i v i d u a l s .  O r i g i n a l l y two i n t e r v i e w s w e r e p l a n n e d  with  each  Second i n t e r v i e w s were c a r r i e d o u t w i t h  f o u r o f the seven  p a r t i c i p a n t s a s two r e f u s e d  further  q u e s t i o n i n g b e c a u s e they f e l t they had p r o v i d e d information  or  F i e l d n o t e s w e r e made o f c e r t a i n i d e a s o r  major concerns  participant.  behaviour  at the f i r s t interview.  interviews in q u a l i t a t i v e research  a l l the  Followup i s f o r the purpose  o f r e l i a b i l i t y w h e r e t h e f o c u s i s on i d e n t i f y i n g a n d documenting r e c u r r e n t , accurate, c o n s i s t e n t or i n c o n s i s t e n t f e a t u r e s as p a t t e r n s , themes, v a l u e s o r experiences  ( L e i n i n g e r , 1985).  44 T h e i n v e s t i g a t o r v a l i d a t e d t h e d a t a by a s k i n g t h e p a r t i c i p a n t s q u e s t i o n s t h a t a r o s e from the a n a l y s i s o f t h e i r d e s c r i p t i o n and from  interviews of other  parti c i pants.  Data A n a l y s i s  The t r a n s c r i b e d d a t a f r o m t h e i n t e r v i e w s a n d n o t e s were e x a m i n e d and a n a l y z e d t h r o u g h constant comparison. subsystems  Data were coded  a system  While  c a t e g o r i z i n g d a t a , t h e y were compared w i t h  previous  i n f o r m a t i o n i n t h e same o r d i f f e r e n t c a t e g o r i e s .  category. subsystem  generates  of  a c c o r d i n g to the  o f t h e UBC M o d e l f o r N u r s i n g .  constant comparison  field  This  p r o p e r t i e s of the  For example examining  data i n the a c h i e v i n g  r e v e a l e d a v a r i e t y o f f o r c e s and c o g n i t i v e  and e x e c u t i v e a b i l i t i e s a f f e c t i n g t h e n e e d  f o r mastery.  As t h i s p r o c e s s c o n t i n u e d , d i v e r s e p r o p e r t i e s b e c a m e apparent.  Coping  b e h a v i o u r s , f o r c e s and c o g n i t i v e and  e x e c u t i v e a b i l i t i e s were compared w i t h t h e d a t a throughout  the c a t e g o r i e s of the nine  subsystems.  Common t h e m e s a r i s i n g f r o m t h e d a t a a n d t h e i r r e l a t i o n s h i p w i t h i n v a r i o u s subsystems  were n o t e d .  c o p i n g b e h a v i o u r s and t h e i r d e t e r m i n a n t s a b i l i t i e s ) were r e v i e w e d c o u l d be c l e a r l y  repeatedly until  described.  (forces, the themes  The  45  Summary  T h i s c h a p t e r o u t l i n e d the p r o c e s s used to a p p l y the methodology of grounded identify  theory i n t h i s study  and d e s c r i b e t h e c o p i n g b e h a v i o u r s  to  u s e d by  p a t i e n t s as t h e y m e e t t h e i r b a s i c human n e e d s d u r i n g rehabilitation.  The  f i n d i n g s and a c c o u n t s  of the  p a r t i c i p a n t s ' p e r c e p t i o n s and e x p e r i e n c e s w i l l described in Chapter  4.  be  MI  46 CHAPTER FOUR  F I N D I N G S OF THE STUDY  This chapter o u t l i n e s the f i n d i n g s of the research study.  The c o p i n g b e h a v i o u r s  u s e d by MI p a t i e n t s t o  s a t i s f y t h e i r b a s i c human n e e d s a r e e x p l a i n e d a n d described through  the accounts  o f the p a r t i c i p a n t s and  the a n a l y s i s and i n t e r p r e t a t i o n o f t h e r e s e a r c h e r . In t h i s c h a p t e r t h e f i n d i n g s a r e p r e s e n t e d a c c o r d i n g t o t h r e e main themes d e p i c t i n g t h e experiences of the p a r t i c i p a n t s . "Risk Reduction" i s the f i r s t  t h e m e d e s c r i b i n g many o f t h e c o p i n g  behaviours  i n i t i a t e d i n an a t t e m p t  t o meet t h e i r  needs  and p r e v e n t f u r t h e r c o m p l i c a t i o n s a n d r e c u r r a n c e o f an MI.  " G e t t i n g B a c k t o N o r m a l " i s a theme d e s c r i b i n g t h e  initial  r e a l i z a t i o n o f t h e need  f o r change and t h e  a f f e c t o f t h i s on c e r t a i n a r e a s o f t h e l i f e s t y l e . final  theme " R e a c h i n g  personal  The  a New N o r m a l " o u t l i n e s t h e  a t t i t u d e s a n d p e r c e p t i o n s o f t h e MI p a t i e n t s  over time. behaviours  There  i s a d e s c r i p t i o n of the coping  u s e d t o m e e t t h e i r b a s i c human  needs.  Changes i n a t t i t u d e s and p e r c e p t i o n s were e x p l o r e d . Throughout  the d e s c r i p t i o n o f these themes, f o r c e s and  c o g n i t i v e and e x e c u t i v e a b i l i t i e s  that affect  need  s a t i s f a c t i o n and goal achievement  are addressed.  47 1.  Coping Behaviours Related to Risk  Reduction  Some o f t h e f i r s t c h a n g e s t h a t w e r e made by t h e p a r t i c i p a n t s f o l l o w i n g MI w e r e i n t h e a r e a o f d i e t a r y modification, cessation  consistent medication  a n d commencement  taking,  of exercise.  c o m p r i s e d t h e o v e r a l l theme o f r i s k  Dietary  All written  concerning MI.  from h e a l t h  t h e i r d i e t while  The i n f o r m a t i o n ,  reduction.  verbal  and/or  professionals their  a s u n d e r s t o o d by t h e Some c l a i m e d  that  they  a v o i d c e r t a i n foods such as  eggs, bacon, f a t t y foods,  and r e d meat w h i l e  others  were t o l d o n l y t o r e d u c e t h e i r s a l t i n t a k e . p u t on a s p e c i f i c d i e t a n d g i v e n i n s t r u c t i o n s while  areas  in hospital following  participants, varied greatly. were t o l d t o c o m p l e t e l y  These  Modification  of the participants received information  smoking  others  new  Some w e r e  cooking  w e r e g i v e n more  general  gui d e l i n e s . Four o f the p a r t i c i p a n t s changed t h e i r d i e t s i m m e d i a t e l y upon r e t u r n i n g household change with  home. T h i s i n v o l v e d a  d i f f e r e n t cooking  h a b i t s as well  as t h e i n g e s t i n g o f a new g r o u p o f f o o d s .  Anxiety  was  48 an i n i t i a l  force that influenced  the desire to e a t .  One man c o m m e n t e d . I'm s t i l l on t h e d i e t t h e y g a v e me - l o w cholesterol. . . . I was a n x i o u s , d i d n ' t f e e l e a t i ng. A n o t h e r man  like  stated.  I f o l l o w e d w h a t t h e y t o l d me t o d o . C h a n g e y o u r d i e t . We h a d t o q u i t u s i n g o i l s . . . I d i d n ' t c u t down c o m p l e t e l y , b u t I c u t down on e g g s . I o n l y a l l o w m y s e l f t h r e e e g g s a week. I c h a n g e d m a r g a r i n e s . I don't use high c h o l e s t e r o l s t u f f and c u t o u t s a u s a g e s a n d b a c o n a n d a l l t h e h e a v y f a t s t u f f . I t ' s a change. A n o t h e r man e x p l a i n e d  the change o f d i e t i n  r e l a t i o n t o h i s hope t h a t i t w i l l further  reduce h i s r i s k of  problems.  I t r y t o do g o o d t h i n g . I c h a n g e my d i e t . I d o n ' t know i f t h a t w i l l h e l p b u t I t r y . No r e d m e a t , no f r i e d f o o d s . I d o n ' t u s e s a l t i n my food. I c u t down on c o o k i e s a n d c a k e s . I l o s t 40 pounds s i n c e the h e a r t a t t a c k . One o f t h e p a r t i c i p a n t s c h a n g e d h i s d i e t b u t n o t as a r e s u l t o f i n f o r m a t i o n professionals while  received  in hospital.  f a t - f r e e , low sugar, high  from  health  He b e g a n t h e  f r u i t , vegetable  and g r a i n  d i e t known a s t h e P r i t i k i n D i e t ( P r i t i k i n , 1 9 7 9 ) . has  r e s u l t e d i n many c h a n g e s i n h i s d i e t a r y  Some a r e a s  habits.  w e r e l e s s o f a p r o b l e m a s he s t a t e d .  This  49 In a n y c a s e i t was e a s y b e c a u s e we w e r e a l r e a d y o f f t h e s a l t , we'd a l r e a d y r e d u c e d t h e m e a t e n d o f i t a n d w e ' r e b i g f i s h e a t e r s a n y w a y . So i t w a s n ' t t o o h a r d t o g e t on t o , n o t p u r e P r i t i k i n b u t d a r n close to i t . Two o f t h e p a r t i c i p a n t s s p e c i f i c a l l y t h a t they had n o t changed  their diet.  mentioned  However, one  woman f o u n d t h a t s h e no l o n g e r l i k e d c e r t a i n some o f w h i c h w e r e h i g h c h o l e s t e r o l  foods.  foods, She  explai ned. I h a v e n ' t c h a n g e d my d i e t w h i c h i s v e r y s t r a n g e but t h i n g s t h a t I used to e a t b e f o r e I don't l i k e . Now I u s e d t o l i k e b a c o n a n d e g g s a n d now I d o n ' t l i k e e g g s . . . I f i n d I h a v e n ' t p u t m y s e l f on a n y d i e t but there a r e foods I l i k e o r don't l i k e . I d o n ' t know why. I d o n ' t f e e l h u n g r y f o r t h o s e t h i n g s (eggs and b a c o n ) . I t ' s n o t j u s t from reading that i t ' s bad f o r your h e a r t . F o r t h i s woman, h e r n e e d f o r s a f e t y a n d s e c u r i t y was i n f l u e n c e d p o s i t i v e l y by h e r d i s t a s t e f o r c e t a i n f o o d s which she had been c o u n s e l l e d n o t t o e a t . Her needs were met b e c a u s e she d i d n o t l i k e c e r t a i n  foods  and d i d n o t e a t them, n o t b e c a u s e she c o n s c i o u s l y changed  her eating  habits.  A n o t h e r man s t r u g g l e d w i t h t h e d i e t he was g i v e n by t h e d i e t i c i a n .  He knew a n d u n d e r s t o o d t h e d i e t b u t  c o u l d n o t seem t o s t a y w i t h i t . He e x p l a i n e d t h a t he was i n v i t e d o u t t o o much o r was g o i n g t o v a r i o u s b a n q u e t s a n d was u n a b l e t o r e m a i n on a d i e t . also noteworthy  t h a t smoking  I t was  c e s s a t i o n was a n e g a t i v e  50 force in t h i s area. and  self-esteem  The needs f o r s e n s o r y  influenced  the coping  satisfaction  behaviour of this  man i n r e l a t i o n t o h i s n e e d f o r s a f e t y a n d s e c u r i t y . He  explained. I t h i n k t h a t ' s why i t ' s s o h a r d t o k e e p on t h e d i e t b e c a u s e I ' v e g o t t a h a v e s o m e t h i n ' t o f i l l me. F i v e o f the seven p a r t i c i p a n t s l o s t  p o u n d s f o l l o w i n g t h e i r MI. by h e a l t h  20-40  A l l o f them w e r e  counselled  p r o f e s s i o n a l s to reduce t h e i r weight.  One  s a i d s h e p u t on 3 o r 4 p o u n d s a n d a n o t h e r t h o u g h t h i s weight had not changed.  Four o f the p a r t i c i p a n t s  mentioned t h e i r previous  alcohol  that they  habits.  drank h e a v i l y and have s t o p p e d  I drank q u i t e a b i t before  Two  completely.  and I c u t t h a t o u t .  I used to drink a l o t . Scotch, now, no s c o t c h i n t h e h o u s e .  y o u know.  Two p a r t i c i p a n t s o f f e r e d t h e i n f o r m a t i o n are c o n t i n u i n g  admitted  Not  that  they  to drink a l c o h o l i c beverages.  I didn't quit d r i n k i n beer. y o u know, c o n s u m p t i o n . 1  J u s t c u t down on i t ,  * • • •  M i n d y o u , I d i d n ' t a s k D r . B. a b o u t d r i n k i n g . I f i g u r e d s h e may s a y n o . ( L a u g h ) Oh, I l i k e my c o u p l e 'a d r i n k s e v e r y a f t e r n o o n b e f o r e d i n n e r . I s a y I c o u l d n ' t e a t my own c o o k i n ' u n l e s s I h a v e a d r i n k o r two w h i l e I'm d o ' i n i t . ( L a u g h )  51 M o s t o f t h e p a r t i c i p a n t s had to understand  the c o g n i t i v e  t h e i r needs i n r e l a t i o n to the  i n f l u e n c i n g the g o a l .  a s s i s t e d them by c h a n g i n g ways and  families  habits of  who cooking.  f o r c e s i d e n t i f i e d were s o c i a l g a t h e r i n g s  the food served  d i d not comply with t h e i r d i e t .  mentioned t h a t they would r e a l l y enjoy then  forces  P o s i t i v e f o r c e s i d e n t i f i e d by  t h e p a r t i c i p a n t s w e r e t h e i r w i v e s and  Negative  ability  go b a c k t o t h e i r new  Most  t h e meal  and  eating habits l a t e r .  gentleman t r a v e l l e d e x t e n s i v e l y with  One  h i s j o b and  that eating out, p a r t i c u l a r l y eating a i r l i n e  where  found  food,  posed a problem. The  n e e d s t h a t w e r e m o s t a f f e c t e d by t h e  change t h a t these  dietary  p a r t i c i p a n t s m e n t i o n e d were the  f o r n o u r i s h m e n t , f o r s t i m u l a t i o n of the system's ( s m e l l , t a s t e ) and I t was and  t h e n e e d f o r s a f e t y and  senses  security.  the need of the p r o t e c t i v e subsystem f o r s a f e t y  security that provided  reduction changes. modifications  The  the impetus f o r r i s k  forces that influenced  i n a p o s i t i v e way  were f a m i l y  i n s t r u c t i o n s f r o m h e a l t h p r o f e s s i o n a l s and weight l o s s . had  need  negative  Smoking c e s s a t i o n , a n x i e t y  dietary  members, r e s u l t s with  and  depression  a f f e c t s on t h e a b i l i t y o f t h e i n d i v i d u a l s  to change t h e i r d i e t s .  52 Smoking  Cessation  S i x of the seven p a r t i c i p a n t s i n the study p r i o r t o t h e i r MI. smoking.  A l l b u t one  now  stopped  I t i s i n t e r e s t i n g to note t h a t the s i x  q u i t smoking c l a i m t h a t they explain  has  smoked  how  they  stopped abruptly.  who They  stopped.  I q u i t smoking. J u s t c u t 'er r i g h t o f f . g i v e you a dime f o r a t h o u s a n d of them.  Wouldn't  I h a v e n ' t t o u c h e d a c i g a r e t t e s i n c e my h e a r t attack. The d o c t o r s a i d , "No m o r e s m o k i n g " , so I h a v e n ' t t o u c h e d one. I t ' s b e e n god a w f u l h a r d , I ' l l t e l l you. I s t i l l miss i t with c o f f e e i n the m o r n i n g , but I h a v e n ' t done i t . I t ' s g e t t i n g e a s i e r . I t h i n k I f e e l b e t t e r . I wasn't a heavy s m o k e r a n y w a y . Maybe a p a c k w o u l d l a s t me two days. I f o l l o w e d what they t o l d d o i n g t h i s and d o i n g t h a t . day and I q u i t . I had no e i t h e r q u i t or d i e , r i g h t t e l l s me, " I f y o u w a n t me y o u d o n ' t s m o k e . So t h a t For these  me.  Quit smoking, q u i t I had smoked a p a c k a c h o i c e , d i d I? It's and my d o c t o r t o be y o u r c a r d i o l o g i s t was i t , I q u i t s m o k i n ' .  p a r t i c i p a n t s the need f o r s a f e t y  and  s e c u r i t y i n the p r o t e c t i v e subsystem i n f l u e n c e d  the  coping  For  behaviour of abruptly  most, t h e i r doctor insisting doctor.  t h a t they  was  a strong  stop  not  smoking.  positive  force  smoking or f i n d a n o t h e r  A n o t h e r f o r c e was  s m o k i n g was  stopping  permitted.  h o s p i t a l i z a t i o n where  53 Some s t a t e d t h a t t h e y breathing t h i s had The  f e l t b e t t e r and  e a s i e r as a r e s u l t o f t h e i r b e h a v i o u r n o t n e c e s s a r i l y p r o m p t e d them t o s t o p  i n t h a t way.  One  e a t i n g more; o t h e r s  man  by s m o k i n g was  smoking.  no  longer  m e n t i o n e d t h a t he had  f o u n d t h a t s m o k i n g and  a l c o h o l i c d r i n k went t o g e t h e r all  but  need f o r s t i m u l a t i o n of the system's s e n s e s i n  t h e s a t i a t i v e s u b s y s t e m , met met  were  and  these  been  coffee  or  substances  had  p a r t i c i p a n t stopped smoking j u s t p r i o r to  his  been s i g n i f i c a n t l y r e d u c e d . One  MI. noisy  He was  experiencing  snoring  doctor.  and was  He e x p l a i n e d  d i f f i c u l t y breathing,  pressured his  and  by h i s f a m i l y t o s e e  a  condition.  D r . C. s e n t me f o r a r e s p i r a t i o n c h e c k and I f o u n d o u t t h a t one p a r t was r e a l l y bad and I c o u l d n ' t b r e a t h e and e v e n now I h a v e a l i t t l e b i t o f p r o b l e m s . I'd get b r e a t h l e s s a l l of a sudden. B e f o r e I w o u l d w h e e z e . . . t h a t was b a d . So when I saw a l l t h a t , I s a i d , " W e l l t h e o n l y way t o g e t b a c k t o n o r m a l i s . . . t h a t c i g a r e t t e has t o go. I j u s t went ' c o l d t u r k e y ' a f t e r smoking f o r a l l those years. My f a m i l y w o u l d n ' t a c t u a l l y b e l i e v e that I q u i t smoking. My son u s e d t o smoke b u t when he saw he d o e s n ' t t o u c h i t a n y m o r e . The  coping  b e h a v i o u r u s e d by t h i s man  need f o r p h y s i c a l f a m i l y and  s a f e t y was  his doctor  me  quitting  to meet h i s  to q u i t smoking.  His  were a p o s i t i v e f o r c e i n  i n f l u e n c i n g and m a i n t a i n i n g  the c o p i n g  behaviour.  54 The and  o n l y woman i n t e r v i e w e d  smoked t h r o u g h o u t  hacking  c o u g h and  breathlessness.  had  not stopped  the i n t e r v i e w .  admittedly  had  She  had  smoking a loose,  some d i f f i c u l t i e s  with  However, o t h e r f o r c e s seemed to a f f e c t  h e r s m o k i n g s u c h as d e p r e s s i o n .  She  explained.  I d o n ' t know i f I ' l l e v e r be a b l e t o g i v e i t up. S o m e t i m e s I smoke a l o t . . . i t a l l d e p e n d s on my mood. I f I'm k i n d o f d e p r e s s e d , I ' l l s i t h e r e and I ' l l smoke. I f i n d I g e t d e p r e s s e d a l o t . I d o n ' t know why. S m o k i n g c e s s a t i o n was s a f e t y and  s e c u r i t y , oxygenation  one's senses attempts  an a r e a w h e r e t h e n e e d f o r and  s t i m u l a t i o n of  w e r e t h e p r i m e n e e d s a f f e c t e d by  the  of the i n d i v i d u a l s to stop smoking.  f o r c e s t h a t i n f l u e n c e d them p o s i t i v e l y o r  The  negatively  included t h e i r family, t h e i r doctor, t h e i r health needs, depression  and t h e s m o k i n g r e s t r i c t i o n s i m p o s e d  by h o s p i t a l i z a t i o n . Medication  Regimen  T h r e e o f t h e p a r t i c i p a n t s had taking prescribed medication o f them were s t i l l  Four  p r i o r t o t h e i r MI.  questioning  prescribed medication  not been used  t h e i r need to take  over a continued  period of  o f t h e p a r t i c i p a n t s had d o c u m e n t e d  f o r w h i c h t h e y had medication.  been p r e s e n t e d  an  to Most the time.  hypertension  anti-hypertensive  However, a l l s a i d t h a t they d i d not  take  55 the m e d i c a t i o n  r e g u l a r l y p r i o r t o t h e i r MI.  One man  p u t i t t h i s way. B e f o r e I have t o take t h e b l o o d p r e s s u r e p i l l s , I w o u l d s k i p some. I mean o n e t o d a y , t h e n m i s s two d a y s b u t a f t e r t h i s ( h e a r t a t t a c k ) my i n t a k e o f my m e d i c a t i o n i s r e g u l a r , r e l i g i o u s l y , i t h a s t o be taken. T h i s change i n t a k i n g m e d i c a t i o n echoed  religiously  was  by two o t h e r p a r t i c i p a n t s i n t h e i r s e a r c h f o r a  cure or c o n t r o l of t h e i r Another  disease.  man p r e v i o u s l y on v a r i o u s m e d i c a t i o n s f o r  h y p e r t e n s i o n commented. When I f i r s t s t a r t e d p e r s p i r e so much b u t I've always had h i g h s u r p r i s e d I'm n o t on one m e d i c a t i o n ) . One man e x p r e s s e d  on [ m e d i c a t i o n ] t h e y made me now i t d o e s n ' t b o t h e r me. blood pressure. I'm t o o much m e d i c a t i o n now ( o n l y  some d i f f i c u l t y  understanding  how m e d i c a t i o n w o u l d h e l p h i s c o n d i t i o n . H i s bewilderment  s p i l l e d over i n t o h i s view o f medicine  a v a g u e s c i e n c e s i n c e t h e r e w e r e no d e f i n i t e for  as  answers  many o f h i s q u e s t i o n s . One t h i n g t h a t b o t h e r s me a b o u t t h e w h o l e t h i n g i s , ah, I d o n ' t r e a l l y u n d e r s t a n d i t a l l and I don't t h i n k i t ' s anybody's f a u l t and I've almost come t o t h e c o n c l u s i o n t h a t i t ' s s t i l l n o t a v e r y p o s i t i v e s c i e n c e . . . m a n y a s p e c t s o f i t a r e , I'm s u r e , b u t w h a t ' s g o i n g on a t a n y g i v e n t i m e seems t o be v a g u e . . . s o I c a n o n l y t h i n k i t ' s t h e p i l l s I'm o n , b u t s i n c e my b l o o d p r e s s u r e i s h o l d i n g a t what t h e y t h i n k i s i d e a l . . . 1 4 0 o v e r 80. Ah, so I f i g u r e whatever d i s c o m f o r t I have o t h e r w i s e , i t  56 m u s t be w i t h i t . . . . I w o u l d h a v e t o s t a y on t h i s m e d i c a t i o n , I t h i n k t h e y s a i d , f o r e v e r and p r o m i s e d n e v e r t o go o f f i t . And so I ' v e b e e n r e l i g i o u s l y ( n a t u r a l l y i t h a s n ' t been t h a t l o n g ) , but I've been t a k i n g those f o u r times a day. According taken  to the p a r t i c i p a n t s , m e d i c a t i o n s  f o l l o w i n g an MI  in order  to p r o t e c t t h e i r h e a l t h  and m e e t t h e n e e d f o r s a f e t y and f o r c e s s u c h as u n d e r s t a n d i n g prescribed medication  security.  a f f e c t e d whether or not  One  man  the one  S i d e e f f e c t s were  f o r c e s i n f l u e n c i n g the needs i n  subsystems.  Certain  or misunderstanding  a d h e r e d to the p r e s c r i b e d r e g i m e n . negative  were  other  complained of the d i s t u r b i n g  e f f e c t s of Propranolol  decreasing  his sexual  F a m i l i e s were p o s i t i v e or n e g a t i v e to the p r e s c r i b e d m e d i c a t i o n  desire.  forces in  adherence  regimen which u l t i m a t e l y  a f f e c t e d the s a t i s f a c t i o n of the need f o r s a f e t y security. organize  One  man  r e l i e d t o t a l l y on h i s w i f e  his medication  and  side  g i v e him  and  to  his daily  pills.  E x e r c i se All physical  of the p a r t i c i p a n t s began to engage i n e x e r c i s e i n a new  m o s t , r e g u l a r e x e r c i s e had their lives. his stroke  One  man  six years  e n c o u r a g e m e n t and  way  a f t e r t h e i r Mi's.  not been a normal p a r t  had w a l k e d two previous.  For of  miles daily since  Some r e c e i v e d  guidance regarding  physical  activity  57 from  their doctor.  Some f e l t t h a t t h e y d i d n o t r e c e i v e  e n o u g h c o n c r e t e i n s t r u c t i o n and f o u n d "don't  overdo  All  i t " not s p e c i f i c  "take i t easy"  enough.  of the p a r t i c i p a n t s began a program of  f o l l o w i n g t h e i r MI a t t h e a d v i c e o f t h e i r They were u n c l e a r about paced  themselves  They  walking  doctor.  the g u i d e l i n e s of w a l k i n g  a c c o r d i n g t o t h e i r own  and  a b i l i t y and  f o r c e s o f f a t i g u e and c h e s t p a i n i m p i n g i n g activity.  or  on  the  their  explained.  I w a s n ' t a g r e a t e x e r c i s e r b e f o r e . I u s e d t o go f o r a walk, then t h a t wears o f f . I t h i n k i t does w h e t h e r y o u ' r e on a d i e t o r a h e a r t a t t a c k o r w h a t e v e r , a f t e r y o u do i t f o r so l o n g .  I d i d a b i t o f w a l k i n g and r e s t i n g and s l e e p i n g e v e r y day i n t h e a f t e r n o o n . To h e l p my h e a r t n o t to i n j u r e i t . Four of the p a r t i c i p a n t s thought previous sporadic walking  that their job  habits constituted exercise,  b u t a f t e r t h e i r MI t h e y d e c i d e d o t h e r w i s e . more c o n s c i o u s and d e l i b e r a t e a b o u t routine of d a i l y walking  or  engaging  They became in a  constituting exercise.  I u s e d t o go f o r a w a l k e v e r y d a y [ a f t e r M I ] . P r e v i o u s w a l k i n g — No! I was w h a t y o u c a l l l a z y . You s e e I d r o v e t r u c k so I f i g u r e d I g o t e n o u g h e x e r c i s e , but you don't get enough e x e r c i s e .  As t i m e w e n t a l o n g I s t a r t e d t h e w a l k i n g b i t . I had b e e n a d v i s e d t o w a l k a h , a t a f a i r l y b r i s k  58 p a c e and s t a r t e x t e n d i n g i t f r o m 15 m i n u t e s t o h a l f an h o u r o r s o . So I s t a r t e d d o i n g t h a t and s l o w l y b u i l d i n g up t h e t i m e and e f f o r t i n t h a t way. My w i f e and I d i d a f a i r b i t o f w a l k i n g on t h e w e e k e n d s b u t n o t as a d a i l y h a b i t . No, I d i d n ' t h a v e any e x e r c i s e p r o g r a m s , t h o u g h I o f t e n had a h a b i t o f w a l k i n g a t n o o n h o u r a t work j u s t to get out of the b u i l d i n g . T h i s ( d a i l y e x e r c i s e ) was new t o me as an o r g a n i z e d event. The  primary  p u r p o s e o f an e x e r c i s e  d i f f e r e d among t h e p a r t i c i p a n t s .  For four of  p a r t i c i p a n t s , p h y s i c a l e x e r c i s e was regular event,  was  program  described  as a  u n d e r t a k e n by them i n o r d e r  the need f o r a b a l a n c e  between the p r o d u c t i o n  u t i l i z a t i o n of energy.  However, f i v e of  e x e r c i s e program a g a i n s t f u t u r e Mi's This achieved  the goal  subsystem, i n t e g r i t y of the  to meet and  the  p a r t i c i p a n t s a l s o mentioned the p r e v e n t i v e  activity.  the  nature  of  as an i m p e t u s f o r  of the  protective  system.  As a r e s u l t o f t h e i n i t i a t i o n o f a r e g u l a r  exercise  program, f i v e of the p a r t i c i p a n t s found  added  in other  self-esteem,  areas.  The  i n t a k e o f o x y g e n and were enhanced through  need f o r m a s t e r y ,  One  man  benefits  s t i m u l a t i o n of the system's activity.  p o s i t i v e f o r c e i n the a c h i e v i n g , r e s p i r a t o r y and  an  T h u s a c t i v i t y was  senses a  ego-valuative,  s a t i a t i v e subsystems.  commented.  I g u e s s I g o t up t o t h a t p o i n t w h e r e I f e l t f a i r l y c o m f o r t a b l e and maybe I w o u l d m i s s t h e e v e n i n g w a l k f o r some r e a s o n and t h e n o f c o u r s e my j o b  59 w o u l d t a k e me away s o m e t i m e s . . . . M o s t t i m e s I f e l t f i n e a n d a s t i m e g o e s on I h a v e f e l t l e s s dizzy a t times than I d i d i n the e a r l y convalescent period. So now m o s t t i m e s I c a n do t h e a c t i v i t y t h a t I n o r m a l l y w o u l d d o , a n d t h e way I would n o r m a l l y walk w i t h o u t t h a t t i g h t n e s s f e e l i n g or breathlessness. Exercise following between  t h a t was u n d e r t a k e n by t h e p a r t i c i p a n t s  t h e i r MI a f f e c t e d t h e n e e d f o r a b a l a n c e  the production  and u t i l i z a t i o n o f e n e r g y and  the need f o r s a f e t y and s e c u r i t y . from the e x e r c i s e  positively influenced  mastery, self-esteem,  the e x e r c i s e were c h e s t  t h e need f o r  N e g a t i v e f o r c e s r e s u l t i n g from p a i n and f a t i g u e  which  t h e need f o r s a f e t y and s e c u r i t y and t h e  need f o r a b a l a n c e between u t i l i z a t i o n of energy. on r i s k r e d u c t i o n  the production  As d e s c r i b e d  medication-taking  and  i n the findings  c h a n g e s , a l l o f t h e p a r t i c i p a n t s made  some c h a n g e s i n t h e a r e a s o f d i e t , and e x e r c i s e .  smoking,  Many o f t h e c h a n g e s  made by t h e p a r t i c i p a n t t h u s f a r h a v e b e e n ones.  permanent  These were a r e a s o v e r which t h e p a r t i c i p a n t s had  some c o n t r o l  i n t h e c h a n g e s t h a t t h e y made.  a b i l i t y t o u n d e r s t a n d a n d make a l i f e s t y l e during  derived  i n t a k e o f oxygen and s t i m u l a t i o n  of the system's s e n s e s .  influenced  The r e s u l t s  a critical  The change  p e r i o d was p r o m p t e d p r i m a r i l y by t h e  need f o r s a f e t y and s e c u r i t y . precipitated risk reduction  Other needs  that  changes were t h e need f o r  60 oxygenation  and t h e need f o r a b a l a n c e  p r o d u c t i o n and u t i l i z a t i o n o f e n e r g y . to reduce first  2.  t h e i r r i s k o f a second  step i n g e t t i n g back t o  Coping  All  Behaviours  between Making changes  MI s e e m e d t o be t h e  normal.  R e l a t e d t o G e t t i n g Back t o Normal  o f the p a r t i c i p a n t s i n the study  eventually  t o l d t h e i n v e s t i g a t o r t h e i r s t o r y o f t h e i r MI experience. caused it.  Many s h a r e d  t h e i r MI a n d t h e e v e n t s  what  p r e c e d i n g and l e a d i n g t o  They seemed t o d e r i v e t h e r a p e u t i c b e n e f i t from  relating their personal The  t h e i r b e l i e f s about  story to a concerned  recounting of this personal  people  listener.  e x p e r i e n c e may  help  t o i n t e g r a t e t h e e v e n t o f an MI i n t o t h e i r  l i v e s , a n d h e l p them f o r m u l a t e themselves  a new i m a g e o f  w i t h new o r r e v i s e d g o a l s .  the e g o v a l u a t i v e subsystem  The needs i n  f o r s e l f r e s p e c t and r e s p e c t  from o t h e r s were a f f e c t e d as t h e p a r t i c i p a n t s a t t e m p t e d t o make m e a n i n g o u t o f t h e i r  experience.  R e a l i z a t i o n o f t h e Need f o r Change  Most o f t h e p a r t i c i p a n t s remarked t h a t a l i f e s t y l e c h a n g e was n e c e s s a r y . his coronary  One p a r t i c i p a n t u p o n f i n d i n g o u t  a r t e r y d i s e a s e was i n o p e r a b l e s t a t e d .  61  So i t was t h a t my l i f e s t y l e w o u l d p r o b a b l y h a v e t o c h a n g e and I d i d n ' t know r e a l l y w h a t t h a t m e a n t . A n o t h e r p a r t i c i p a n t who six  years  previously  had  suffered a mild  CVA  commented.  Yes o f c o u r s e I knew f r o m h a v i n g t h e s t r o k e y o u ' v e got to s t a r t l i v i n g a l i t t l e d i f f e r e n t l y , you know, b e h a v e y o u r s e l f i n o t h e r w o r d s . Previous stroke helped  coping  behaviours  t h i s man  developed  after a  to meet h i s needs a f t e r h i s  b e c a u s e he u s e d c o p i n g  behaviours  t h a t were  MI  already  part of his r e p e r t o i r e . " W e l l I w a s n ' t n o r m a l , " s t a t e d one E v e n b e i n g i n t h e h o s p i t a l f o r two a g r e e i n my own s e l f t h a t I had a d i d n ' t b e l i e v e i t . . . I wasn't even t h o u g h t h e y t o l d me, t h a t I had a w o u l d n ' t agree to i t .  participant. weeks, I d i d n ' t heart attack. I sure, even heart attack, I  • • • •  I f e l t m o r e p r o t e c t e d when I was i n t h e h o s p i t a l . I d i d n ' t know w h a t had h a p p e n e d . When y o u ' r e c o m i n ' o u t i t ' s t h e s u d d e n r e a l i z a t i o n y o u a r e on y o u r own and t h i s has h a p p e n e d t o y o u . Denial was  during  the i n i t i a l  w e e k s f o l l o w i n g an  a common r e s p o n s e o f t h e p a r t i c i p a n t s .  Denial  t h e a b o v e s i t u a t i o n c a n be v i e w e d as a c o p i n g used to s a t i s f y the need f o r s e l f r e s p e c t i n ego-valuative  s u b s y s t e m and  p r o t e c t i v e subsystem. important by d e n y i n g  During  s a f e t y and  f o r the i n d i v i d u a l s to m a i n t a i n that they  had  in  behaviour the  security in  the i n i t i a l  MI  the  p h a s e , i t was self  a serious illness.  respect  Thus  62 denial  as a c o p i n g  behaviour influenced the  s a t i s f a c t i o n o f t h e need f o r s e l f r e s p e c t .  The  p r o t e c t i v e environment of the hospital might denial  facilitate  and meet t h e need f o r s a f e t y and s e c u r i t y .  For h a l f o f the p a r t i c i p a n t s , the idea o f changing t h e i r l i f e s t y l e was  difficult.  You know, r e m o l d i n g t h e w h o l e s t r u c t u r e o f y o u r e n t i r e l i v i n g , i t ' s n o t e a s y . I t c a n ' t be d o n e i n an h o u r o r i n a d a y , i t h a s t o be g r a d u a l . For o t h e r s ,  change d i d n o t pose a l a r g e  problem.  T h i n g s a r e g r a d u a l l y c o m i n g b a c k t o way t h e y w e r e as f a r a s t h e l i f e o f t h e h o u s e i s c o n c e r n e d a n d e v e r y t h i n g e l s e . Ah, h a b i t s , y o u d o n ' t very o f t e n lose habits unless you're younger. Habits are h a r d t o c h a n g e a t my a g e . I t h i n k i t ' s g o n n a be all right. R e s p e c t o f s e l f by s e l f a n d o t h e r s  was a n e e d  a f f e c t e d by t h e l o s s e s e n c o u n t e r e d f o l l o w i n g an MI. One p a r t i c i p a n t made t h i s comment a b o u t t h e c h a n g e i n herself.  I t h i n k i t ' s made a d i f f e r e n c e i n me i n a l o t o f w a y s . I'm n o t a s c a r e f r e e a s I u s e d t o b e . I t ' s a f f e c t e d my p e r s o n a l i t y . I know I w o r r y a b o u t i t so u s u a l l y when I'm w i t h p e o p l e , I n e v e r t a l k about i t . As t h e p a r t i c i p a n t s r e a l i z e d t h e i r n e e d f o r c h a n g e in various  areas,  t h e i r sense o f s e l f r e s p e c t f o r  t h e m s e l v e s was a f f e c t e d . already  Suitable coping  d e v e l o p e d t o meet a c r i t i c a l  period  behaviours such as  63 t h i s h e l p e d one  t h i r d of the p a r t i c i p a n t s to meet  need f o r s e l f - e s t e e m . unable  One  their  o f t h e p a r t i c i p a n t s was  to deal with the s i t u a t i o n a l t h o u g h a p r e v i o u s  critical  p e r i o d had b e e n e x p e r i e n c e d .  i n c o p i n g b e h a v i o u r s may  The d i f f e r e n c e  have been i n r e l a t i o n to the  s u p p o r t and r e s p e c t f o r s e l f by o t h e r s p e r c e i v e d by individual  d u r i n g the c r i t i c a l  the  period.  D e a l i n g w i t h C h e s t P a i n and O t h e r P h y s i c a l Symptoms  Angina  p e c t o r i s i s a syndrome of c o r o n a r y a r t e r y  disease with t r a n s i e n t myocardial  ischemia  c h a r a c t e r i z e d by c h e s t d i s c o m f o r t .  It is usually  p r e c i p i t a t e d by a c t i v i t i e s o r e v e n t s t h a t i n c r e a s e t h e m e t a b o l i c demand f o r o x y g e n ( H i n d l e & W a l l a c e , The "angina"  1983).  p a r t i c i p a n t s used the terms " c h e s t p a i n " interchangeably in their accounts.  A l l of the  p a r t i c i p a n t s i n t e r v i e w e d h a v e had a n g i n a symptoms t h e i r MI.  The  p h y s i c a l d i s c o m f o r t from angina  p a r t o f t h e i r e v e r y day l i f e . t h e i r symptoms and one was evidenced  Suitable coping behaviours  to handle  and s o c i a l  became  them as  met. to deal with  i n c l u d e d the a b i l i t y of the i n d i v i d u a l p h y s i c a l , emotional  after  S i x o f them d e a l t w i t h  unable  by t h e i r n e e d s b e i n g  and  to  limitations.  i n v o l v e d the i n d i v i d u a l ' s c o g n i t i v e a b i l i t y  angina  realize This to  64 determine  the r e s t r i c t i o n s or changes i n a c t i v i t y  were n e c e s s a r y . individual  The  executive  often determined  r e s u l t e d d i r e c t l y from the coping  behaviour  a b i l i t y of  For  following a  because of  i n a b i l i t y of the i n d i v i d u a l to execute The  continue  a f o r c e i n f l u e n c i n g need s a t i s f a c t i o n .  Even though the f o r c e i n f l u e n c i n g i n a c t i v i t y s t r o n g , t h e y l e a r n e d how  the p a r t i c i p a n t s , the f o r c e of angina d e a l w i t h a t home and  themselves  was  For three  of  too s t r o n g  to  required readmission  to h o s p i t a l .  o f the p a r t i c i p a n t s spoke o f the need to pace and  t h e i r a c t i v i t i e s i n o r d e r to  c h e s t p a i n and o t h e r p h y s i c a l s y m p t o m s . various techniques formed the important their  was  t o d e a l w i t h t h e i r symptoms by  a p p r o p r i a t e l e v e l s o f a c t i v i t y and r e s t .  All  the  a c t i v i t y at that  i n a b i l i t y of the i n d i v i d u a l to  a c t i v i t y , was  which  example,  o f r e s t i n g d u r i n g and  bout of c h e s t p a i n or f a t i g u e developed  time.  the  the coping behaviours  the c h e s t p a i n .  that  minimize  They  to c o n t r o l t h e i r symptoms. coping  behaviours  used  used These  to meet  needs. I had a n g i n a down t h e a r m s and a c r o s s t h e c h e s t . I d i d n ' t o v e r d o i t . . . w h i c h i s my p a r t . I c o u l d t e l l how f a r I c o u l d w a l k . . . I c o u l d f e e l i t . U s u a l l y when I h a v e p a i n , b e f o r e I t a k e n i t r o , I u s u s a l l y go t o bed f i r s t . I t h i n k t h a t ' s the b e s t way t o f i n d o u t . . . . I ' l l go and l a y down and i f i t ' s n o t g o n e , I t a k e n i t r o , g e t a h e a d a c h e and maybe I ' l l go t o s l e e p w i t h i t .  65  One  man  e x p l a i n e d t h a t i t became h a r d e r  to w a l k w i t h o u t  chest pain.  n e c e s s i t a t e d another medication  adjustment  artery bypass g r a f t .  and  His overwhelming  admission  harder  symptoms  to h o s p i t a l f o r  and c o n s i d e r a t i o n o f a He d e s c r i b e d i t t h i s  coronary way.  I t j u s t g o t f u r t h e r and f u r t h e r t o go u n t i l I c o u l d n ' t go a n y m o r e . I t ' s j u s t t h e way I f e l t . was h a v i n g more p a i n when I w a l k e d . Not too, severe at f i r s t , but then i t g r a d u a l l y s t a r t e d g e t t i n g w o r s e and w o r s e and w o r s e . I t was a c o u p l e o f w e e k s , t h e n I had t o go b a c k i n t o t h e hospi t a l . A n o t h e r man  explained  I  h i s management of h i s p a i n .  Now I go o u t f o r a w a l k and I ' l l g e t a p a i n a c r o s s t h e t o p o f my c h e s t o r my l e f t e l b o w . I s t o p and r e s t f o r a m i n u t e o r two and c a r r y o n . I t ' s not l i k e b e f o r e , y o u d o n ' t know w h a t i t was a l l a b o u t b e f o r e , w h e r e now y o u f i g u r e , w e l l I g o t t a s t o p and h a v e a r e s t f o r a m i n u t e o r two. He w e n t on t o e x p l a i n . I've g o t t a take i t easy. I was o u t w i t h my l a d y f r i e n d t o c u t and r a k e h e r l a w n on S u n d a y . A f t e r a w h i l e I s a i d , " W e l l I'm g l a d t o s i t down f o r awhile...my elbow s t a r t s a c h i n ' . Other  Physical The  Symptoms  p a r t i c i p a n t s mentioned other  symptoms b e s i d e s c h e s t p a i n .  bothersome  F a t i g u e was  one o f  the  symptom m e n t i o n e d by a l l o f t h e p a r t i c i p a n t s e s p e c i a l l y in the i n i t i a l  few w e e k s f o l l o w i n g t h e i r h o m e c o m i n g .  66  I h a v e b a d d a y s when I'm t i r e d b u t I know m y s e l f t h a t t h e n I'm n o t o v e r d o i n g i t . I f I d o n ' t f e e l g o o d , I s t a y home. W e l l , I ' v e n o t i c e d t h a t i t h a s made a d i f f e r e n c e i n m y s e l f . I h a d a p r o b l e m w i t h my l e g . My l e g was j u s t numb. I t was t o o h o t a n d t h e n t o o c o l d . I t h i n k I was r e a l t i r e d . I t h i n k t h a t was j u s t f r o m being t i r e d . I had t o take i t e a s y . I d i d a b i t o f w a l k i n ' and r e s t i n ' and s l e e p i n ' every day i n t h e a f t e r n o o n . One man d e s c r i b e d  h i s symptoms a s an i l l - a t - e a s e  s t a t e c h a r a c t e r i z e d by b r e a t h l e s s n e s s tightness.  He a l s o e x p e r i e n c e d  convalescent  period.  and c h e s t  dizziness i n the early  He c o m m e n t e d t h a t t h e s e  symptoms  w e r e p r e s e n t when he f i r s t came home f r o m h o s p i t a l . described  h i s progress  He  toward f e e l i n g normal.  Now m o s t t i m e s I c a n do t h e a c t i v i t y t h a t I n o r m a l l y w o u l d do a n d t h e way I w o u l d n o r m a l l y walk without t h a t t i g h t n e s s f e e l i n g o r breathlessness. I d o n ' t w o r r y a b o u t i t , e x c e p t when t h a t f e e l i n g comes o n , t h e n i t r e m i n d s me t h a t I c a n o n l y do so much a t o n e t i m e . He d e s c r i b e d  his continuing  symptoms.  T h i s f e e l i n g o f d i s - e a s e I g e t , I d o n ' t know w h e t h e r some p e o p l e w o u l d e v e n c l a s s t h a t a s a n g i n a , l i k e some p e o p l e t h a t I ' v e t a l k e d t o w h i l e I was i n h o s p i t a l s a i d t h a t t h e y d i d g e t a r a t h e r d e f i n i t e sharp p a i n . I d o n ' t r e a d m i n e t h a t way, I r e a d i t a s a s o r t o f t i g h t n e s s l i k e when I u s e d to p l a y l a c r o s s e , you'd run a l l day, p r e t t y w e l l and e v e n t u a l l y be g a s p i n g f o r b r e a t h a n d h a v e d i f f i c u l t y g e t t i n g i n enough a i r .  67 F i v e o f the p a r t i c i p a n t s s t a t e d t h a t they  were  more i n t o u c h w i t h t h e i r body e s p e c i a l l y i n t e r m s o f physical  symptoms.  T h i s has helped  them t o r e s p o n d  appropriately or inappropriately to their One  symptoms.  man d e s c r i b e d i t t h i s way.  T h i s f e e l i n g w i l l come on a n d I'm r e a l l y f o r c e d t o s t o p a n d I u n d e r s t a n d t h a t a n d I l i s t e n now. I g u e s s t h a t ' s o n e o f t h e b i g c h a n g e s . . . . I'm much more a t u n e d t o w h a t my b o d y i s d o i n g a t a n y g i v e n time. I might not understand i t , though. One  woman f o u n d  t h a t s h e t o o was i n t o u c h w i t h h e r  b o d y symptoms b u t t h a t t h i s c a u s e d to t h e t h r e a t o f a n o t h e r  MI.  f e a r and a n x i e t y due  She a l s o e x p r e s s e d  a lack  o f k n o w l e d g e a b o u t t h e p a i n a n d how t o d e a l w i t h i t . I t ' s r e a l l y , I t h i n k more f r i g h t e n i n g b e c a u s e t h e y don't t e l l y o u , l i k e they don't g i v e y o u enough i n f o r m a t i o n . You g e t t h i s a w f u l p a i n , y o u t h i n k i t ' s r e l a t e d t o y o u r h e a r t a t t a c k . You t a k e a p i l l a n d t h e p a i n h a s n ' t g o n e away so y o u t a k e a n o t h e r o n e a n d t h e n t h e r e ' s more p a i n a n d maybe t h a t p a i n h a s n o t h i n g t o do w i t h y o u r h e a r t a t t a c k at a l l . I don't t h i n k y o u have enough i n f o r m a t i o n on w h a t i s a h e a r t p a i n o r w h a t o t h e r p a i n s a r e . F o r t h i s woman p r e v i o u s  aches and pains a l s o posed  a t h r e a t a n d a p o t e n t i a l r e l a t i o n s h i p t o MI p a i n .  She  e x p l a i ned. I f y o u h a v e i n d i g e s t i o n y o u b e g i n t o t h i n k , "Oh I c a n ' t remember", 'cause i f they were t h a t b a d , I would have seen about i t . You p r o b a b l y had a l l these t h i n g s going through y o u b e f o r e and y o u d i d n ' t know i t . A n d y o u f e e l f o o l i s h g o i n g t o t h e  68 d o c t o r a n d s a y i n g , "Oh, I h a d t h e s e p a i n s on S a t u r d a y a n d t h e y l a s t e d f o r s o many h o u r s a n d I h a v e n ' t h a d them s i n c e . " P r i o r t o h i s MI, o n e man t r i e d t o d i s c e r n t h e d i f f e r e n c e between p a i n from from  a heart attack.  a h i a t u s h e r n i a and t h a t  This information  h e l p e d him  i d e n t i f y t h e s i t u a t i o n when he h a d h i s MI. T h e y s a i d warm t e a w i l l r e l i e v e . . . m a k e t h e s t o m a c h m u s c l e s r e l a x a n d h e l p y o u r h i a t u s h e r n i a . So t h i s S u n d a y m o r n i n g I g o t up a t 7:00 am w i t h t e r r i b l e p a i n s a n d I h a d a c u p o f warm t e a a n d I t o o k some M a a l o x a n d f i n a l l y a f t e r 2 h o u r s I was down on t h e f l o o r w i t h p a i n a c r o s s h e r e a n d down t h e r e [he i n d i c a t e s c h e s t and arms]. I finally p h o n e d my b o y a n d s a i d I t h i n k we b e t t e r go t o t h e h o s p i t a l . B e f o r e t h i s , a l l a l o n g I had thought i t was a h i a t u s h e r n i a . I t was t h e same p a i n a s b e f o r e . Now, w h e n e v e r I g e t t h e s e p a i n s , I ' l l take one o f t h e s e l i t t l e d y n a m i t e p i l l s . I don't t h i n k t h e y h u r t y o u a t a l l , do t h e y ? Getting Others  to Help  A n o t h e r way t h a t t h e p a r t i c i p a n t s m a n a g e d t h e i r physical  symptoms and t h e r e s t r i c t i o n s c a u s e d  was t o o b t a i n h e l p w i t h normally  some o f t h e h o u s e h o l d  c a r r i e d o u t by t h e p a r t i c i p a n t .  by t h e s e jobs  One man  explained.  A l o t o f t h e p h y s i c a l t h i n g s I might have done, now my s o n t a k e s i t on o r we g e t i t d o n e by somebody e l s e . A window washer once o r t w i c e a y e a r i n s t e a d o f my d o i n g i t a l l .  69 One his  man  d i d not f i n d i t too d i f f i c u l t  to a d j u s t to  l i m i t a t i o n s a f t e r an MI b e c a u s e he had a d j u s t e d  and  made many c h a n g e s 6 y e a r s p r e v i o u s a f t e r h i s s t r o k e . He had d o n e a l l t h e g a r d e n i n g  f o r the townhouse complex  w h e r e he l i v e s b u t had g i v e n t h a t up a f t e r h i s s t r o k e and  n e v e r w e n t b a c k t o i t . I n s t e a d , he c u l t i v a t e d a  small patch of tomatoes in h i s backyard  for  gardening  enj oyment. The woman i n t e r v i e w e d had a d i f f i c u l t r e l i n q u i s h i n g household some h o u s e h o l d  tasks.  She  time  d i d not t h i n k t h a t  t a s k s r e q u i r e d much e f f o r t and c o u l d  not  visualize asking for help. I c o u l d n ' t p i c t u r e s o m e b o d y c o m i n g i n t o my h o u s e , d o i n g my l a u n d r y . I d o n ' t t h i n k t h a t ' s h a r d work to l i f t t h e l i d o f f t h e w a s h e r and t h r o w y o u r c l o t h e s i n . And I d o n ' t t h i n k i t ' s h a r d when y o u h a v e a v a c u u m c l e a n e r t h a t g o e s by i t s e l f . A l l y o u h a v e t o do i s p u s h t h e h a n d l e . They were s a y i n g , "Don't vacuum!" W e l l , i f y o u ' v e g o t t a vacuum, where you s t a n d t h e r e pushing the h a n d l e . . . i f y o u c a n ' t do t h a t y o u ' v e g o t t o be r e a l l y bad i f y o u c a n ' t v a c u u m o r i f y o u c a n ' t p u t your d i s h e s i n the dishwasher. You're not l i f t i n g a n y t h i n g when y o u t a k e t h e c u p s and s a u c e r s and p u t them i n t h e d i s h w a s h e r . The  p a r t i c i p a n t s d e a l t with t h e i r chest pain  o t h e r p h y s i c a l symptoms i n a v a r i e t y o f w a y s . needs t h a t arose because of these n e e d f o r s a f e t y and  b e t w e e n r e s t and t h e u t i l i z a t i o n o f e n e r g y , for  mastery  and s e l f - e s t e e m .  The  symptoms w e r e  s e c u r i t y , the need f o r a  C h e s t p a i n and  and  the  balance the  need  other  70 physical  symptoms w e r e n e g a t i v e  forces impinging  s a t i s f a c t i o n o f t h e a b o v e b a s i c human n e e d s .  The  c o g n i t i v e a b i l i t y of the i n d i v i d u a l to develop coping  b e h a v i o u r s t o m e e t t h e n e e d s was an  on t h e  suitable  important  factor.  R e t u r n t o Work  Four o f the p a r t i c i p a n t s were s t e a d i l y employed p r i o r t o t h e i r MI a n d t h r e e o f them r e t u r n e d The  to work.  f o u r t h d i d n o t r e t u r n t o work f o l l o w i n g t h e MI f o r  a variety of  Working  reasons.  Participants  One g e n t l e m a n h a d a j o b r e q u i r i n g h e a v y l i f t i n g and  found r e t u r n i n g  t o work d i f f i c u l t .  He  explained.  I'm b a c k t o w o r k . I'm n o t d o i n g t h e same j o b . I'm i n s i d e t h e w a r e h o u s e . My o l d j o b h a d t o o much s t r a i n i n i t . I w e n t b a c k t o work S e p t e m b e r 3 0 , 1985 (5 m o n t h s a f t e r MI) f u l l t i m e . I s h o u l d n ' t h a v e d o n e t h a t . I made a w r o n g move t h e r e . I f i n d t h a t t h i s work i s j u s t t o o much f o r me. I g e t home a n d I d o n ' t f e e l l i k e d o i n g n o t h i n g e x c e p t s l e e p i n g and I d o n ' t t h i n k t h a t ' s r i g h t . He h a s made some c h a n g e s i n h i s j o b a n d h i s work habits  i n order  to meet h i s need f o r s a f e t y and  71  s e c u r i t y and h i s need f o r b a l a n c e between  production  and u t i l i z a t i o n o f e n e r g y . I t ' s a l l d e m a n d i n g , p h y s i c a l work t h a t r e q u i r e s lifting. I w a t c h w h a t a n d how I l i f t . I have t o b e c a u s e I'm j u s t n o t g o n n a t a k e t h e c h a n c e . No job i s worth h u r t i n g y o u r s e l f and going through that stuff again. I t was s u g g e s t e d  t o o n e man t h a t he t a k e  months o f f b e f o r e r e t u r n i n g t o work. t h i s a d v i c e and found idea.  five  He c o m p l i e d  with  i n r e t r o s p e c t t h a t i t was a g o o d  He w o r k s a t a G o v e r n m e n t o f f i c e j o b w i t h a g r e a t  deal of r e s p o n s i b i l i t i e s , t r a v e l l i n g , o u t s i d e and c o u r s e s .  He was a b l e t o work h a l f  f i r s t r e t u r n e d t o work.  Although  reading  d a y s when he  t h i s j o b was n o t o n e  r e q u i r i n g h e a v y p h y s i c a l l a b o u r , i t d i d i n v o l v e much mental  labour.  D e s p i t e t h i s h o w e v e r , he e n j o y e d h i s  job and d i d n o t f i n d i t d i f f i c u l t , s t r e n u o u s stressful  to return.  or very  He s t a t e d .  I w o u l d n ' t h a v e c o n s i d e r e d my j o b a n y w h e r e n e a r a s s t r e s s f u l a s some p e o p l e ' s . A n d t h e r e was a l o t of s a t i s f a c t i o n that I think would compensate f o r any s t r e s s t h e r e w a s . T h i s man made c h a n g e s w h e r e he no l o n g e r work home a t n i g h t .  brought  T h i s was a m a j o r c h a n g e f o r a man  who h a d a l w a y s p l a c e d s u c h a h i g h p r i o r i t y on w o r k . made t h i s s t a t e m e n t  about  the changes.  He  72 W e l l , i f i t d o e s n ' t g e t done a t t h e o f f i c e , i t d o e s n ' t g e t done. I guess I never o p e r a t e d t h a t way. Now I d o . Work h a d f u l f i l l e d h i s n e e d f o r m a s t e r y a n d sensory stimulation i n the past. e x p r e s s s a t i s f a c t i o n and enjoyment met t h e s e  from h i s j o b which  needs.  Another change f o r work.  He c o n t i n u e d t o  he made was h i s p r e p a r a t i o n t i m e  He w e n t t o b e d e a r l y i n t h e e v e n i n g  hours) and a r o s e e a r l y i n t h e morning  (21:00  (05:00 h o u r s ) .  T h i s a l l o w e d h i m two e x t r a h o u r s i n t h e m o r n i n g t o r e l a x by s i t t i n g q u i e t l y a n d e a t i n g a n d watching  sometimes  television.  S t i gma One man d e s c r i b e d t h e s t i g m a a t t a c h e d t o h e a r t p a t i e n t s a n d t h e r e s p o n s e he h a d r e c e i v e d a t work by his employer  a n d f e l l o w w o r k e r s when t h e y h e a r d he h a d  an MI. I c o u l d n ' t s h i f t around i n here (change j o b s w i t h i n the company). I ' d have t o f i n d s o m e t h i n g e l s e a n d who's g o n n a h i r e a 46 y e a r o l d guy who's had a h e a r t a t t a c k ? As s o o n a s t h e y h e a r t h e w o r d H E A R T . . . h o o ho man, i t ' s l i k e t h e r e ' s s o m e t h i n g wrong w i t h y o u . A n o t h e r p a r t i c i p a n t who h a s n o t r e t u r n e d t o work d e s c r i b e d i t t h i s way.  73 When y o u do go l o o k f o r a j o b and y o u s a y , " L o o k , I ' v e had a h e a r t a t t a c k , " t h e y d o n ' t w a n t y o u . I t ' s k i n d o f d i f f i c u l t t o l o o k f o r a j o b . D r . B. s a y s , "You c a n do s e d e n t a r y w o r k . " And I l o o k e d t h a t up and i t means y o u s i t down and do n o t h i n g m u c h . Who's g o n n a h i r e y o u t o do much s i t t i n g ? The  response  e m p l o y e r s and  t h a t the p a r t i c i p a n t s r e c e i v e d  f e l l o w w o r k e r s as t h e y a t t e m p t e d  r e t u r n t o work and  from  to  get back to normal, a f f e c t e d t h e i r  n e e d f o r r e s p e c t o f s e l f by o t h e r s w h i c h i n t u r n affected their respect for  self.  Time O f f One  p a r t i c i p a n t who  returned  business  t o work w i t h i n two m o n t h s , b u t on a  " p a r t - t i m e " b a s i s and was  owned h i s own  no l o n g e r d i d h e a v y l a b o u r .  a m e c h a n i c and w o r k e d w i t h h i s s o n and t h e y  a b l e to h i r e another  worker to f i l l  He  were  i n f o r him.  He  was  a b l e t o go t o work l a t e i n t h e m o r n i n g a f t e r h i s e x e r c i s e c l a s s and  do some l i g h t work and m o s t o f  p a p e r work i n v o l v e d w i t h t h e b u s i n e s s . allowed  him  the  This situation  t o m e e t h i s n e e d f o r m a s t e r y and  sensory  s t i m u l a t i on. One  of the p a r t i c i p a n t s w i t h a heavy l i f t i n g  job  has t a k e n  a great deal of h i s s i c k time s i n c e r e t u r n i n g  to work.  He has b e e n q u e s t i o n e d  employer.  a b o u t t h i s by  his  74 "How come y o u ' r e s i c k a l l t h e t i m e and o f f a l l t h e time?" What do y o u s a y , " W e l l I was s i c k ! " I am u s i n g a l o t o f time but I f i g u r e t h a t ' s what i t ' s t h e r e f o r . S o m e t i m e s , i t ' s v e r y h a r d f o r me t o w o r k f o u r h o u r s and t h e n I h a v e t o come home and l a y down. Retired Participants Three of the p a r t i c i p a n t s were r e t i r e d , each a minimum o f f o u r y e a r s  p r i o r to t h e i r h e a r t  E a c h o f them s a i d t h a t t h e y had retirement. Forces,  and  One two  V a n c o u v e r and  w e r e r e t i r e d bus  one  in  to t h e i r  d r i v e r s , one  here in  Fiji.  p a r t i c i p a n t s a r e now  involved  in  a c t i v i t i e s t h a t g i v e them s a t i s f a c t i o n and  sense of achievement. bowling, car.  well  had w o r k e d f o r t h e C a n a d i a n A r m e d  Each of these other  adjusted  attack.  g o l f i n g , gardening,  F o r one man,  church  Physical activities c a m p i n g and  a  included  driving  the  h i s r e t u r n to the p o s i t i o n of a  l e a d e r s i g n i f i e d a r e t u r n to former normal  a c t i v i t i e s f o r him.  After t h e i r heart attacks,  p a r t i c i p a n t s have been a b l e to resume the t h a t they p r e v i o u s l y engaged.  these  activities  They d e s c r i b e  i t in this  manner. I go b o w l i n g , I d r i v e my c a r ; do a l i t t l e I'm n o t c r i p p l e d y o u know.  work.  I w e n t b a c k t o b o w l i n g a l m o s t r i g h t away and a h , g o l f w e l l , I s u p p o s e I w a i t e d a m o n t h o r two before I started g o l f i n g again. I bounced back fairly quickly.  75  Regarding participant  the matter  of d r i v i n g h i s car,  one  confessed.  I w a s n ' t s u p p o s e d t o d r i v e my c a r b u t I d i d (he l a u g h s ) . A f t e r 34 y e a r s o f d r i v i n g , I f i g u r e d t h e r e was g o n n a be no s t r a i n on me t h a t way a n y m o r e . When I t a l k e d t o D r . B. she s a i d , "No d r i v i n g y o u r c a r ! " But I t h i n k I o n l y d i d t h a t f o r a day o r two. I f s h e o n l y knew t h a t I d r o v e a l l t h e way up t h e r e t o s e e h e r , s h e ' d h a v e had a fi t. Returning  t o work was  to the p a r t i c i p a n t s .  and who  that t h e i r doctors  at d i f f e r i n g times.  f l e x i b l e schedules  importance  M o s t o f them d i d n o t w a n t t o  out the p r e s c r i b e d time and r e t u r n e d  an a r e a o f g r e a t  without  suggested  T h o s e who  had  demanding, p h y s i c a l  c o u l d work p a r t t i m e as t h e y e a s e d  wait  labour  back i n t o  t h e i r normal r o u t i n e s , were a b l e to deal w i t h t h e i r r e t u r n t o work m o r e e a s i l y . physical  T h o s e who  had  heavy  l a b o u r j o b s w h i c h w e r e i n f l e x i b l e and who  received a negative h e a r t d i s e a s e from  response  to t h e i r d i a g n o s i s  t h e i r e m p l o y e r s and  also  of  fellow workers  had a m o r e d i f f i c u l t t i m e r e t u r n i n g t o w o r k .  The  r e t i r e d p a r t i c i p a n t s were a b l e to r e t u r n to  previous  a c t i v i t i e s w i t h i n three to s i x months a f t e r t h e i r Their adjustment any  to t h e i r former  p a r t i c u l a r problems.  s i t u a t i o n d i d not  MI. pose  76  R e l a t i o n s h i p s and R o l e  All  Changes  o f t h e p a r t i c i p a n t s s p o k e o f t h e i r MI  subsequent  and  r e c o v e r y p e r i o d as a t i m e o f c h a n g e n o t  for themselves  but a l s o f o r t h e i r f a m i l i e s .  Five of  t h e p a r t i c i p a n t s d e s c r i b e d t h e e f f e c t o f t h e MI t h e i r s p o u s e and c l o s e f a m i l y m e m b e r s . p a r t i c i p a n t s w e r e w i d o w e d and f a m i l y and how The  s i x men  Two  spoke of t h e i r  t h e i r r e l a t i o n s h i p was  of  on the  immediate  affected.  i n the study spoke of t h e i r wives'  in s p e c i f i c areas of r i s k r e d u c t i o n .  only  help  D i e t changes  which p o t e n t i a l l y a f f e c t the e n t i r e f a m i l y were o r g a n i z e d by t h e f e m a l e She l o o k e d a f t e r me, general.  spouse. f o o d and e v e r y t h i n g i n  My w i f e , she l o o k a f t e r me a f t e r my h e a r t a t t a c k . She h e l p me g e t b e t t e r . Man n e e d g o o d w i f e . She i s g o o d w i f e . She c o o k g o o d m e a l s . She g i v e s me my p i l l s . My w i f e s t o p p e d c o o k i n g w i t h s p i c e s and g r e a s e s . We d o n ' t u s e b u t t e r i n t h e h o u s e . She c h a n g e d t o s u n f l o w e r o i l and t h e s a l t i n t a k e i s n o t h i n g . We d o n ' t e a t r e d m e a t , more f i s h , more w h i t e m e a t , c h i c k e n and t u r k e y . The  p a r t i c i p a n t s who  s a i d they changed t h e i r  also acknowledged t h e i r wives' d i e t c h a n g e d as w e l l .  h e l p and  s u p p o r t as  diet her  77 I have i n f a c t reduced the s a l t f o r sometime b e c a u s e my w i f e had r e a d t h a t i t w a s n ' t g o o d f o r e i t h e r of us. She has a s l i g h t b l o o d p r e s s u r e problem. One running  man  described  g i v i n g h i s wife the task  the f a m i l y f i n a n c e s .  The  role of  of  finance  manager changed i n t h i s f a m i l y . So I c o u n t t h a t as a g o o d t h i n g t h a t she now i s t o t a l l y i n v o l v e d i n t h a t [ f i n a n c e s ] and I'm t h e one who g e t s an a l l o w a n c e (he l a u g h s ) w h i c h I d o n ' t m i n d b e c a u s e now t h e r e ' s no w o r r y t o i t . I s t i l l g e t i n t o any b i g d e c i s i o n s w h e t h e r w e ' r e going to purchase something or not. But I d o n ' t h a v e t o w o r r y a b o u t o r t h i n k a b o u t w h e t h e r I'm doing the r i g h t t h i n g or not. Four of the p a r t i c i p a n t s spoke of the p o s i t i v e t h i n g s t h a t have r e s u l t e d i n t h e i r f a m i l y l i f e  and  roles since t h e i r Mi's.  his  b e n e f i t e d from t h i s  One  man  explained  how  son  experience.  I t h i n k i t s o r t o f s t a r t l e d him ( h i s f a t h e r h a v i n g an MI) b u t I t h i n k a g a i n t h a t h e ' s e n j o y e d t h e f a c t t h a t h e ' s now d e p e n d e d upon t o do l i t t l e t h i n g s l i k e mowing t h e l a w n and s h o v e l l i n g snow, n o t t h a t we g e t much h e r e . A l o t of the p h y s i c a l t h i n g s I m i g h t h a v e d o n e , now my son t a k e s i t on o r we g e t i t d o n e by s o m e b o d y e l s e . B u t I t h i n k p r o b a b l y t h a t ' s b e e n b e t t e r f o r him t o o . So I t h i n k g o o d t h i n g s h a v e come o u t o f i t and may be g o o d f o r me t o o . • • • •  L o t s o f c h a n g e s . I c o u l d n ' t have done i t f o r l o n g 'cause I have a good f a m i l y . They are a supportive family. When a s k e d how f a m i l y , he r e p l i e d .  his heart attack affected his  very very  78 T h e y a r e w i t h me a n d i t ' s so e a s y ' c a u s e t h e y t r y to u n d e r s t a n d . Y o u r t e m p e r g e t b a d and t h e y s e e i t r i g h t on y o u r f a c e . T h e y know i f y o u ' r e l y i n g . They've been v e r y u n d e r s t a n d i n g . A n o t h e r man  spoke o f h i s sons' c o n c e r n f o r  him.  Oh, t h e y ' r e s t i l l a f t e r me t o s e l l t h i s p l a c e b u t I k e e p t e l l i n g t h e m , "What am I g o n n a do w i t h a l l t h e s t u f f I g o t h e r e ? " T h e y w a n t me t o s e l l i t and move o u t t h a t way. So I ' d be c l o s e r t o t h e m . A n o t h e r man  spoke o f h i s c l o s e k n i t f a m i l y .  and h i s w i f e l i v e d w i t h one d a u g h t e r  He  and h e r f a m i l y .  He d e s c r i b e d h i s f a m i l y r e l a t i o n s h i p s . I h a v e t h r e e s o n s , two d a u g h t e r s , e i g h t g r a n d c h i l d r e n . They are a l l here ( i n V a n c o u v e r ) . T h e y a r e v e r y g o o d t o me a n d my w i f e . T h e y come and t a k e me o u t . D r i v e me p l a c e s . I s e l l my c a r a f t e r I h a v e h e a r t a t t a c k . I go t o t h e i r h o u s e s , one o f them e a c h w e e k . We h a v e d i n n e r , we v i s i t , we h a v e p r a y e r s . He w e n t on t o d e s c r i b e h i s i n v o l v e m e n t i n t h e Muslim  faith.  He d e r i v e d a s t r o n g s e n s e o f l o v e a n d  b e l o n g i n g from h i s f a i t h . My f a i t h pray. I pray f i v e life. My  He d e s c r i b e d i t t h i s  way.  has h e l p e d me s i n c e my h e a r t a t t a c k . I b e l i e v e God h e a l s me. I f e e l good. I times a day. I go t o m o s q u e . I t i s my f a m i l y and my r e l i g i o n .  He c o n t i n u e d t o e x p l a i n w i t h a n i m a t i o n h i s r o l e o r l e a d e r i n the mosque.  He t r a v e l l e d t o t h e homes o f  o t h e r s i n the community t o p r a y w i t h the p e o p l e as w e l l as a t t e n d e d m e e t i n g  times i n the mosque.  T h i s man's  79 r e l a t i o n s h i p w i t h God a n d h i s f a m i l y h a d a s i g n i f i c a n t i m p a c t on m e e t i n g h i s n e e d f o r l o v e a n d b e l o n g i n g . also contributed  It  t o meeting h i s need f o r r e s p e c t o f  s e l f by s e l f a n d o t h e r s . Two o f t h e p a r t i c i p a n t s r e m a r k e d t h a t f a m i l i e s were o v e r p r o t e c t i v e o f them. explained  their  One man  that the overprotective behaviour  of his  f a m i l y o n l y l a s t e d f o r a s h o r t t i m e when he f i r s t came home.  T h e y w e r e w a t c h i n g me a l l t h e t i m e f o r a b o u t t h e f i r s t month. They d i d n ' t a f t e r t h a t . They d e c i d e d , " A h , h e ' s a l r i g h t . L e t 'im g o . " He e x p l a i n e d  t h a t t h e f a m i l y had d e a l t w i t h a  previous  critical  cancer.  They had p u l l e d t o g e t h e r  support  p e r i o d when h i s w i f e  had s u r g e r y f o r  as a f a m i l y t o  h e r a n d he f e l t t h e y w e r e d o i n g  t h e same f o r  him. The  s e c o n d p a r t i c i p a n t was a d a m a n t a s s h e  complained about her family pampering h e r . I g e t t i r e d o f my f a m i l y s a y i n g t h a t I l o o k t i r e d when I'm n o t t i r e d . T h e y ' l l s a y , " I d i d n ' t c a l l b e c a u s e we d o n ' t w a n t t o d i s t u r b y o u . " W e l l I t h o u g h t , "How c o u l d y o u d i s t u r b me, I'm w a t c h i n g T.V.. B u t t h e y t h i n k ' c a u s e y o u ' v e h a d a h e a r t attack, you're t i r e d a l l the time. They're always t e l l i n g y o u , "Oh, y o u c a n ' t do t h i s a n d y o u c a n ' t do t h a t . " I t seems l i k e t h e y w a n t t o s t a y away f r o m me f o r some r e a s o n a s i f s o m e t h i n g ' s g o n n a h a p p e n t o me.  80  She her  w e n t on t o s p e a k a b o u t t h e a f f e c t o f h e r MI on  son and d a u g h t e r i n d i v i d u a l l y . My s o n s t a r t e d b u i l d i n g a h o u s e a b o u t f o u r o r f i v e m o n t h s a g o a n d I ' v e n e v e r s e e n i t . He k e e p s s a y i n g , "We d o n ' t w a n t y o u c l i m b i n g a r o u n d ' t i l we g e t t h i s o r t h a t i n . " A n d t h a t r e a l l y u p s e t s me. My d a u g h t e r h a s b e e n v e r y s t r a n g e a n d d i f f e r e n t . We w e r e v e r y c l o s e u n t i l t h i s h a p p e n e d a n d w e ' r e n o t now. I t h i n k i t ' s b e c a u s e o f h e r f a t h e r . She s p e n t a l o t o f t i m e w i t h h i m . He d i e d a b o u t a month b e f o r e I had t h e h e a r t a t t a c k a f t e r a t r u c k a c c i d e n t a n d was i n h o s p i t a l f o r t h r e e m o n t h s . I t t o o k h i m t h r e e m o n t h s t o d i e . One d a y s h e s a i d , "I'm s i c k o f t h i s - - m y p a r e n t s d y i n g on me." So I s a i d , "Go home t h e n , I d o n ' t w a n t t o be u p s e t . " I u n d e r s t a n d a l i t t l e ' c a u s e I knew w h a t t h e y w e n t through. She  t a l k e d about her i n a b i l i t y to share her  f e e l i n g s with  h e r f a m i l y and i n s t e a d o f  another  critical  period bringing the family together,  a rift.  She  i t caused  explained.  My h e a r t a t t a c k h a s a f f e c t e d o u r r e l a t i o n s h i p v e r y badly. So I k i n d o f s h u t m y s e l f o f f f r o m t h e m . I t d o e s make a b i g d i f f e r e n c e i n t h e f a m i l y . They t h i n k t h a t t h e same t h i n g t h a t h a p p e n e d t o t h e i r f a t h e r i s g o n n a h a p p e n t o me. I t r e a l l y d e s t r o y s the f a m i l y . The  need f o r i n d e p e n d e n c e and a r e t u r n to f o r m e r  way o f l i f e w i t h  her family i s expressed  by t h i s  parti c i pant. I t h i n k y o u r f a m i l y p l a y s t o o much i n t h i s . I f they c a r e about you and t h a t you've g o t a bad h e a r t t h e n t h e y s h o u l d be c o m i n g h e r e . I s h o u l d n ' t h a v e t o be c o n v i n c i n g them t h a t t h e r e ' s n o t h i n g w r o n g w i t h me. I t h i n k i t ' s ' c a u s e I ' v e  81 a l w a y s b e e n an i n d e p e n d e n t p e r s o n . I t was q u i t e a s h o c k ' c a u s e I ' v e n e v e r b e e n s i c k a day i n my life. I ' v e n e v e r had t o h a v e a n y b o d y do a n y t h i n g f o r me. I t b o t h e r e d me when I was home a f t e r a b o u t a m o n t h and I c o u l d n ' t d r i v e y e t . I just c o u l d n ' t be i n d e p e n d e n t and g e t i n my c a r , b u t t h e r e ' s no way I ' l l ask s o m e b o d y t o do s o m e t h i n g . I ' d r a t h e r l e t them know t h a t I n e e d s o m e t h i n g . Maybe t h a t ' s my f a u l t , b u t I d o n ' t t h i n k y o u c a n c h a n g e y o u r w h o l e l i f e and how y o u w e r e . I c o u l d n e v e r go o u t and ask s o m e b o d y f o r h e l p . I'd s o o n e r l e a v e i t ' t i l I c o u l d do i t m y s e l f . The  needs of t h i s p a r t i c i p a n t f o r l o v e ,  belongingness  and  dependence, f o r self-esteem  m a s t e r y w e r e a f f e c t e d as she former l i f e s t y l e .  Her  fought  and  to r e t u r n to  need f o r s e l f - e s t e e m  her l i f e .  Her  f a m i l y and  by h e r as a n e g a t i v e satisfaction  her  was  i n f l u e n c e d by h e r s t r u g g l e f o r i n d e p e n d e n c e and over  for  f r i e n d s were  control  perceived  f o r c e i n her l i f e a f f e c t i n g need  i n t h e a f f e c t i v e and  ego-valuative  subsystems. In c o n t r a s t , t h e p a r t i c i p a n t who family's support experience Two  and  a t t h i s t i m e had perception  described  a very d i f f e r e n t  of the s i t u a t i o n .  of the p a r t i c i p a n t s s p e c i f i c a l l y  commented  a b o u t t h e a f f e c t t h a t t h e h e a r t a t t a c k has had r e l a t i o n s h i p and  friends.  n o t h a v e a s p o u s e and found  his  on t h e i r  T h e y w e r e t h e o n e s who  lived alone.  One  did  participant  t h a t h e r f r i e n d s w a n t e d t o t a l k f o r h e r and  were  o v e r - p r o t e c t i v e when she a t t e m p t e d t o g e t i n v o l v e d i n the s o c i a l committee of the condominium complex i n  82 w h i c h she l i v e d .  She became q u i t e u p s e t when h e r  f r i e n d s i n s i s t e d t h a t she l e t them d r i v e h e r c a r .  She  complai ned. You know, t h e y t r e a t y o u l i k e y o u ' r e h a n d i c a p p e d or a r e a l i n v a l i d . I f i n d t h a t real hard to deal w i t h . Maybe I'm w r o n g , b u t t h e y make y o u f e e l handicapped. I g e t i n t h e c a r and d r i v e a l l t h e t i m e . And i f t h e y ' r e a f r a i d t o d r i v e w i t h me, t h e y s h o u l d n ' t come i n my c a r . She  spoke of b e i n g depressed because of the  t r e a t m e n t she r e c e i v e d f r o m h e r  friends.  You know y o u c a n do t h e s e t h i n g s b u t I t h i n k b e c a u s e t h e way y o u r f r i e n d s t r e a t y o u , y o u f e e l y o u a r e b e i n g p u s h e d i n t o t h e b a c k g r o u n d and y o u d o n ' t do t h e t h i n g s y o u a l w a y s u s e d t o do and I t h i n k t h a t d e p r e s s e s me. So i t ' s a l o t t o do w i t h people. Having a heart attack a l s o helped t h i s  participant  t o m e e t p e o p l e i n h e r c o - o p c o m p l e x and she b e c o m e i n v o l v e d on t h e c o u n c i l .  She d e s c r i b e d i t t h i s  way.  S o c i a l l y i t ' s d o n e a few t h i n g s . I l o s t my o t h e r s o c i a l l i f e , so I h a v e t o l o o k f o r a n o t h e r o n e . Some f r i e n d s w e r e v e r y s u p p o r t i v e and t o o k on a c a r e g i v e r (almost spousal) r o l e of cooking f o r her, m a k i n g s u r e she had e n o u g h e x e r c i s e and r e s t .  The  p a r t i c i p a n t r e c e i v e d t h i s type of care very f a v o u r a b l y and e n j o y e d t h e e x t r a a t t e n t i o n .  83 The  other  p a r t i c i p a n t who  was  widowed, spoke  h i g h l y o f h i s " l a d y f r i e n d " who  had  quite frequently.  support  She  c o m p a n i o n s h i p f o r him  provided during  t h e f a c t t h a t he was  the  and  not p h y s i c a l l y a b l e and  drank  p a r t i c i p a n t s expressed f a m i l y r o l e s and The  r e l a t i o n s h i p s and  f a m i l y was  important  their and  were a f f e c t e d  force in  s u c h as d i e t a r y c h a n g e s , s m o k i n g and  in their  d e p e n d i n g on t h e s i t u a t i o n .  a p o s i t i v e or negative  medication-taking  the  also with  the need f o r s e l f - e s t e e m  p o s i t i v e l y or n e g a t i v e l y  areas  coffee  changes t h a t took p l a c e  need f o r l o v e , b e l o n g i n g n e s s  d e p e n d e n c e and  The  to  men.  In g e t t i n g t h e i r l i v e s b a c k t o n o r m a l ,  friends.  This  h i s male f r i e n d s .  g o l f , he w e n t o u t t o t h e g o l f c o u r s e with  over f o r meals  t h i s time of change.  p a r t i c i p a n t also kept in touch with Despite  him  e x e r c i s e and  r o l e i n a s s i s t i n g the  other  cessation,  t h u s had  an  i n d i v i d u a l to "get  back  t o n o r m a l ." All  of the p a r t i c i p a n t s v o i c e d  c h a n g e was MI.  Dealing  s y m p t o m s was The  necessary with  a r e a l i z a t i o n that  in their l i f e s t y l e following  various  physical  and  a common o c c u r e n c e f o r t h e  a f f e c t o f c h a n g e and  of the p h y s i c a l  emotional participants. and  emotional  symptoms w e r e s e e n as p a r t i c i p a n t s a t t e m p t e d t o to t h e i r former j o b s .  T h o s e who  their  were r e t i r e d  return  84 experienced  t h i s gradual  h o b b i e s and r e g u l a r Relationships a noticeable  activities. i n t h e f a m i l y and w i t h  area of perceived  by t h e p a r t i c i p a n t s . struggled  r e t u r n t o normal i n t h e i r  support  friends  or lack  T h i s was o b s e r v e d a s  to deal with  thereof  they  the changes a f f e c t i n g t h e i r  f o r m e r r o l e s i n the f a m i l y and i n t h e i r s o c i a l The n e e d s m o s t a f f e c t e d i n t h i s a r e a need f o r l o v e , b e l o n g i n g n e s s ,  production  perception  the  dependence, the need f o r  the need f o r a b a l a n c e  o f s e l f by between  and u t i l i z a t i o n o f e n e r g y and t h e need f o r  s t i m u l a t i o n of the systems Forces  circle.  involved  s a f e t y and s e c u r i t y , t h e need f o r r e s p e c t s e l f and o t h e r s ,  were  that influenced  senses. n e e d s a t i s f a c t i o n were  the  o f the need f o r change, the a t t i t u d e toward  i t and s e v e r i t y o f p h y s i c a l  symptoms.  The t y p e o f j o b  the p e r s o n had, t h e f a m i l y s t r u c t u r e and i n t e r a c t i o n a n d t h e e f f e c t o f any r o l e c h a n g e s w e r e o t h e r i n f l u e n c i n g need s a t i s f a c t i o n . p o s i t i v e and n e g a t i v e attitude perception coping  T h e s e were  forces  both  f o r c e s , o f t e n d e p e n d i n g on t h e and o n e ' s a b i l i t y t o u s e  b e h a v i o u r s to meet t h e i r n e e d s .  suitable  85 3.  C o p i n g B e h a v i o u r s R e l a t e d t o R e a c h i n g a New  Normal  After r e l a t i n g the findings of coping behaviours r e l a t e d t o " R i s k R e d u c t i o n " and " G e t t i n g Back t o N o r m a l " t h o s e c o n c e r n e d w i t h " R e a c h i n g a New will  Normal"  be p r e s e n t e d . T h i s new n o r m a l i s m o s t l y e m b o d i e d i n a c h a n g e i n  one's a t t i t u d e s and p e r c e p t i o n s .  Many o f t h e c h a n g e s  made h a v e b e e n c o n t i n u e d by t h e p a r t i c i p a n t s who i n c o r p o r a t e d a new v i e w o f t h e m s e l v e s .  have  T h i s has g i v e n ,  m e a n i n g t o t h e c h a n g e s t h a t h a v e o c c u r r e d by d e l i b e r a t e c h o i c e and t h o s e o v e r w h i c h t h e y have had l i t t l e control.  Behavioural  System B a l a n c e , where t h e needs  o f each o f t h e n i n e s u b s y s t e m s a r e met,  i s the outcome  o f a new n o r m a l . One o f t h e s u b j e c t s i l l u s t r a t e d h i s a t t i t u d e  nine  m o n t h s a f t e r h i s MI. E v e r y t h i n g y o u c a n d o , I c a n d o . As f a r a s I'm concerned, t h i n g s a r e g r a d u a l l y coming back. I t h i n k i t ' s g o n n a be a l l r i g h t . Another described her perception of her current s t a t u s seven months. Maybe my k i d s a r e r i g h t a n d maybe I do l o o k h o r r i b l e and t i r e d , b u t I t h i n k t h e y say i t 'cause I was a l w a y s on t h e go b e f o r e . Maybe t h e r e ' s b e e n a c h a n g e a n d maybe I do l o o k t i r e d . I d o n ' t know.  86 She c o n t i n u e d t o e x p r e s s h e r n e e d f o r l o v e , b e l o n g i n g n e s s and  dependence.  ( P r e t e n d i n g t h a t she i s t a l k i n g t o h e r d a u g h t e r . ) I t ' s h a r d t o say I want a t t e n t i o n b u t I want y o u t o g i v e i t t o me, I'm n o t g o i n g t o a s k y o u . . . w h o c a r e s a b o u t w h a t ' s h a p p e n i n g t o me? I d o n ' t know how t o o v e r c o m e t h a t . T h i s i s t h e biggest stress. I s i t and t h i n k about i t t o o much, w h i c h i s b a d . I d o n ' t know how t o s o l v e t h i s problem. I t ' s a p e r s o n a l problem and n o t h i n g t o do w i t h y o u r c o n d i t i o n , b u t i t ' s y o u r c o n d i t i o n t h a t c a u s e d i t . As f a r a s I'm c o n c e r n e d , my h e a r t a t t a c k j u s t happened a t a bad time (one month a f t e r the death of her husband). She t r i e d t o a n a l y z e h e r f e e l i n g s a n d u s e h e r c o g n i t i v e a b i l i t y t o change  h e r f e e l i n g s o f anger and  j e a l o u s y t o w a r d h e r d a u g h t e r ' s f a t h e r - i n - l a w who h a s a l s o h a d an MI a n d a c c o r d i n g t o t h i s s u b j e c t r e c e i v e d f a r more a t t e n t i o n t h a n s h e . I d o n ' t t h i n k i t ' s j e a l o u s y o r I d o n ' t h a t e them but I d o n ' t want t o hear a l l about h i s c o n d i t i o n 'cause I t h i n k he's b e i n g well taken c a r e o f . T h i s s u b j e c t c o n t i n u e d t o h a v e many unmet n e e d s i n her a f f e c t i v e , e g o - v a l u a t i v e , p r o t e c t i v e and r e p a r a t i v e subsystems interview. feelings.  a month l a t e r a t t h e time o f t h e s e c o n d She was u n a b l e t o r e s o l v e h e r p r o b l e m s a n d She v o i c e d t h e n e e d t o c h a n g e  t h a t i t was n o t p o s s i b l e .  but admitted  She s t a t e d .  You c a n ' t c h a n g e y o u r w h o l e l i f e a n d how y o u w e r e . I d o n ' t know. I t seems l i k e y o u ' r e w a i t i n g f o r  87 something to happen a l l the time. I d o n ' t know w h a t I'm w a i t i n g f o r . I t c o u l d be b e c a u s e I l i v e by m y s e l f . One  man  a f t e r h i s MI. needs.  d e s c r i b e d h i s a p p r o a c h t o l i f e one  year  He has b e e n m e e t i n g h i s b a s i c human  His approach i s very matter  o f f a c t and  to  poi n t . I w a s n ' t a f r a i d t o come home h e r e a l o n e . I f you l e t i t b o t h e r y o u t h a t way, I d o n ' t t h i n k t h a t ' s t h e r i g h t a t t i t u d e t o t a k e a t a l l . You c a r r y on as i f n o t h i n g had e v e r h a p p e n e d . One his  p a r t i c i p a n t , reviewing  t h e a f f e c t o f t h e MI  on  l i f e over the past ten months r e l a t e d h i s  perceptions  and a t t i t u d e s t h a t have c h a n g e d .  I g u e s s I was a b i t f u z z y o v e r t h i n g s , way m o r e t h a n I am now, b e c a u s e I g u e s s I p u t i t i n a d i f f e r e n t p e r s p e c t i v e ; t h a t t h i n g s don't have to be n e a t and o r d e r l y a l w a y s . I d o n ' t mean t h a t I am n e a t and o r d e r l y i n a l l t h i n g s , p r o b a b l y n o t i n my t h i n k i n g f o r i n s t a n c e b u t I u s e d t o f u s s o v e r g a r d e n s , l i k e t h e e d g e had t o be d o n e , e v e r y t h i n g had t o be f i n i s h e d o f f b e c a u s e i f i t w a s n ' t , i t b u g g e d me. He s p o k e o f a c o n s c i o u s  d e c i s i o n to change c e r t a i n  t h i n g s and o t h e r a r e a s w h e r e he had  no c o n t r o l .  C e r t a i n t h i n g s I d e c i d e d t o l e t go o f . . . o t h e r s a r e permanent or not but are p h y s i c a l l i m i t a t i o n s (he c a n no l o n g e r do g a r d e n i n g , wash w i n d o w , wash car). But I've d e c i d e d t h a t t h e s e o t h e r t h i n g s j u s t a r e n ' t as i m p o r t a n t and I p o s s i b l y t h o u g h t t h a t t h e y w e r e and o t h e r t h i n g s t h a t I had n o t t h o u g h t t o o much a b o u t . I'm s t a r t i n g t o t h i n k a b o u t more. I t h i n k I've got a b i t b e t t e r  88 o r g a n i z e d a n d I ' v e l e a r n e d t o r e l a x more o r w o r k e d at r e l a x i n g . He e x p r e s s e d be  hope t h a t t h e s e l i m i t a t i o n s w i l l n o t  permanent. No, maybe I c a n g e t b a c k t o some o f t h e s e t h i n g s i f i t ' s a matter of stamina. T h a t ' s w h a t I mean when I s a y I d o n ' t q u i t e u n d e r s t a n d e x a c t l y w h e r e t h a t w i l l go a s f a r a s my p h y s i c a l c a p a b i l i t i e s and I s u r e d o n ' t wanna do a n y t h i n g I'm n o t s u p p o s e d t o be d o i n g . T h a t seems a b i t v a g u e i n i m p o r t a n t m a t t e r s , b u t t h e r e ' s a l o t o f vague t h i n g s i n my m i n d . He a d m i t t e d  that part of h i s determination to  c o n t i n u e w i t h t h e c h a n g e s he i n i t i a l l y made w e r e b e c a u s e o f t h e h o p e he h a d f o r a c u r e . told that h i s coronary  He h a d b e e n  a r t e r y d i s e a s e was i n o p e r a b l e  and t h a t he i s n o t a c a n d i d a t e  for angioplasty.  H i s h o p e was r e l a t e d t o t h e c l a i m s o f t h e P r i t i k i n Diet ( P r i t i k i n ,  1979).  He e x p l a i n e d .  S i n c e P r i t i k i n c l a i m s some r a t h e r d r a m a t i c r e v e r s a l s i n c o n d i t i o n s , I keep hoping t h a t (he laughs) i f I stay with t h i s d i e t , i f they don't b e f o r e come t o an e a s y way t o c l e a r o u t t h e a r t e r i e s o r s p r e a d them o r w h a t e v e r t h i s n a r r o w i n g i s . . . i f t h e y come up w i t h s o m e t h i n g t h a t ' l l do t h a t , p e r h a p s by t h a t t i m e I ' l l h a v e s e m i - s o l v e d the problem o f those t h a t a r e n ' t a l r e a d y determi nated. Another coronary  p a r t i c i p a n t who a l s o h a d i n o p e r a b l e  a r t e r y d i s e a s e a n d h a d an u n s u c c e s s f u l  89 a n g i o p l a s t y d e s c r i b e d h i s hope f o r h e a l i n g i n r e l a t i o n to h i s f a i t h i n God. The M u s i em r e l i g i o n i s my l i f e . I pray. b e l i e v e God h e a l s me. I f e e l g o o d .  I  S i x o f t h e p a r t i c i p a n t s were a b l e t o v e r b a l i z e a r e a s w h e r e c h a n g e s h a d b e e n made i n o r d e r t o m e e t t h e i r needs.  T h e i r needs were n o t a l l met a t t h i s  time,  t h e y were d e v e l o p i n g  however  behaviours  suitable coping  t o f a c i l i t a t e need s a t i s f a c t i o n .  A new i m a g e o f o n e s e l f was n e e d e d i n o r d e r t o a d j u s t t o t h e c h a n g e s i m p o s e d by t h e MI a n d t h e s u b s e q u e n t l o s s e s o r t h e c h a n g e s d e l i b e r a t e l y made by t h e i n d i v i d u a l . T h e n e e d f o r r e s p e c t o f s e l f by s e l f a n d o t h e r s a n d t h e n e e d f o r m a s t e r y were t h e two m a j o r needs a f f e c t e d as t h e s u b j e c t s s t r u g g l e d t o r e s t o r e balance  to t h e i r system.  In C h a p t e r 4, t h e f i n d i n g s o f t h i s s t u d y r e p o r t e d u s i n g t h r e e main themes experiences Reduction,  were  to describe the  o f i n d i v i d u a l s a f t e r t h e i r f i r s t MI. G e t t i n g Back t o N o r m a l  Normal  were t h e themes  coping  behaviours  a n d R e a c h i n g a New  used to d i s c u s s the v a r i o u s  u s e d by t h e i n d i v i d u a l s . A  d i s c u s s i o n and i n t e r p r e t a t i o n o f t h e f i n d i n g s w i l l f o l l o w i n C h a p t e r 5.  Risk  90 CHAPTER  FIVE  D I S C U S S I O N OF THE F I N D I N G S  I n t r o d u c t i on This chapter will  discuss the findings of the  study a c c o r d i n g t o t h e t h r e e themes o u t l i n e d i n C h a p t e r 4:  Coping Behaviours Related to Risk Reduction,  Coping  B e h a v i o u r s R e l a t e d t o G e t t i n g Back t o Normal and C o p i n g Behaviours Related to Reaching  a New N o r m a l .  The  l i t e r a t u r e p r e s e n t e d i n C h a p t e r 2 was r e v i e w e d f o r t h e purpose will  o f p r o v i d i n g a background  f o r the study and  be r e f e r r e d t o a s i t a p p l i e s t o t h e f i n d i n g s .  This chapter will  p r o v i d e f u r t h e r e x p l o r a t i o n and  i n t e r p r e t a t i o n of the reports related to the categories developed during the data  analysis.  I t was t h e i n t e n t o f t h i s s t u d y t o i d e n t i f y a n d e x p l o r e t h e c o p i n g b e h a v i o u r s u s e d by i n d i v i d u a l s f o l l o w i n g an MI i n an a t t e m p t  to satisfy their basic  human n e e d s .  nursing research  There  is little  l i t e r a t u r e d i r e c t e d toward  the study of coping  b e h a v i o u r s d e s i g n e d t o m e e t b a s i c human n e e d s . i n t e r p r e t a t i o n o f data from t h i s study w i l l  The  form t h e  b a s i s f o r t h i s d i s c u s s i o n with l i t e r a t u r e used to  91  e x p l a i n some o f t h e f i n d i n g s i n t h i s s t u d y other  authors'  work.  Coping Behaviours Related  to Risk  The p a r t i c i p a n t s i n t h i s s t u d y share t h e i r experiences infarction.  i n l i g h t of  following  Reduction  were w i l l i n g t o myocardial  They t o l d o f the p e r s o n a l  outcomes  r e s u l t i n g f r o m t h e MI a n d t h e c h a n g e s t h a t t h e y w i l l i n g l y a n d t h o s e t h a t w e r e f o r c e d upon During  the f i r s t  made  them.  few w e e k s a f t e r t h e MI, t h e  i n d i v i d u a l s r e a l i z e d t h a t c e r t a i n c h a n g e s were necessary. what t h e s e  Many w e r e n o t a b l e t o c l e a r l y a r t i c u l a t e c h a n g e s w e r e b u t had a s e n s e t h a t  w o u l d be d i f f e r e n t f r o m now  on.  In t h e e a r l y p h a s e o f r e c o v e r y , in the study strong these  experienced  the p a r t i c i p a n t s  certain forces that  e n o u g h t o i m p o s e c h a n g e on t h e m . forces included  things  smoking c e s s a t i o n  were  Examples of while  h o s p i t a l i z e d a s s m o k i n g was n o t p e r m i t t e d ,  t h e f e a r and  t h r e a t o f d e a t h f r o m a n o t h e r MI, a c a r d i o l o g i s t who i n s i s t e d that the p a t i e n t s stop doctor  a n d r e s t r i c t i o n s i m p o s e d by h e a l t h  in the area of p h y s i c a l d i e t a r y change. previous  smoking or f i n d another professionals  a c t i v i t y , r e t u r n t o work  The p h y s i c a l  and  i n a b i l i t y to perform  a c t i v i t i e s because of chest  pain, fatigue or  92 other  physical  symptoms was a n o t h e r f o r c e  bringing  about change i n b e h a v i o u r . Forced  change through h o s p i t a l i z a t i o n or  r e s t r i c t i v e i n s t r u c t i o n s from h e a l t h p r o f e s s i o n a l s i n the i n i t i a l  p o s t MI p e r i o d may be a l o n g  term  benefit  b e c a u s e many p e o p l e a r e u n a b l e t o make i m m e d i a t e changes necessary  t o meet t h e need f o r s a f e t y and  s e c u r i t y and t h e need f o r s e l f - e s t e e m .  An e x a m p l e o f  t h i s was o n e p a r t i c i p a n t who h a d k e p t l o n g work h o u r s and was f o r c e d t o l e a v e  h i s work f o r a t i m e by  h o s p i t a l i z a t i o n and a c t i v i t y r e s t r i c t i o n .  An  initial  i n a b i l i t y t o make d e c i s i o n s may be d u e t o s h o c k , d i s b e l i e f and d e n i a l Denial  i n t h e e a r l y d a y s f o l l o w i n g an MI.  i s an a t t e m p t t o a l l e v i a t e a n x i e t y a n d  depression  by r e d u c i n g  ( S c a l z i , 1973).  Denial  the perception  of the threat  may be c a l l e d a  b e h a v i o u r as i t i s a t t e m p t i n g  coping  t o meet t h e need f o r  s a f e t y and s e c u r i t y and p r e s e r v e  self-esteem.  C h a n g e s w e r e made b e c a u s e o f t h e l o s s e s f o l l o w i n g an MI.  incurred  The p a r t i c i p a n t s ' r e s p o n s e t o t h e  l o s s o f t e n d e p e n d e d on t h e m e a n i n g a n d v a l u e to t h e p a r t i c u l a r l o s s .  One  attached  response to the threat of  an MI was t h e r e s p o n s e o f a n g e r .  T h i s was a i m e d m a i n l y  toward t h e i r f a m i l i e s , employees, f r i e n d s and h e a l t h p r o f e s s i o n a l s b u t seldom v e r b a l i z e d t o anyone e x c e p t t h o s e c l o s e s t t o them.  A n g e r was o f t e n  expressed  93 b e c a u s e o f t h e t h r e a t o f t h e MI on t h e n e e d f o r self-esteem.  A n g e r may be c a l l e d a c o p i n g  t h a t was u s e d  to deal with the t h r e a t to  The  behaviour self-esteem..  p a r t i c i p a n t s ' s e l f - e s t e e m was a f f e c t e d due t o t h e  l o s s o f a b i l i t y t o work, l o s s o f i n d e p e n d e n c e and l o s s of c e r t a i n household of s e l f - i d e n t i t y .  r o l e s which impacted  on t h e  A n g e r was n o t t h e e x p e r i e n c e  sense of a l l  or the p a r t i c i p a n t s mentioned t h a t they c o u l d not remember h a v i n g  f e e l i n g s of anger.  Feelings of depression the p a r t i c i p a n t s .  were a r e a l i t y f o r most o f  C o m i n g home f r o m  t h e h o s p i t a l and  f i n d i n g t h a t l i f e was n o t t h e same a n d t h a t t h e y d i d not f e e l  l i k e t h e i r former  of d e p r e s s i o n .  selves, resulted in feelings  None o f t h e p a r t i c i p a n t s  feelings of despair, helplessness or They d i d not sense  need t o f e e l  hopelessness.  t h e n e e d t o ' g i v e up' as d e s c r i b e d  by S c a l z i a n d B u r k e ( 1 9 8 2 ) . self-esteem  expressed  and sense  However, the l o s s o f  of mastery i n r e l a t i o n to  productive  Perhaps the i n i t i a l  the  again d i d occur. phases o f d e n i a l , anger and  d e p r e s s i o n , w h i c h may be v i e w e d a s c o p i n g  behaviours,  a r e more v i v i d l y d e s c r i b e d a n d r e m e m b e r e d w h i l e t h e participant i s experiencing The  them o r s h o r t l y t h e r e a f t e r .  intense f e e l i n g s generated  i n the i n i t i a l  recovery  94 p h a s e may  become b l u r r e d w i t h  the p a r t i c u l a r concerns  the p a s s i n g  at that  of time  time.  For the p a r t i c i p a n t s i n t h i s study, experienced behaviours  t h e MI  seven to twelve  associated with  and  who  had  months ago,  reorganization  the  as  described  by P a r k e s ( 1 9 7 1 ) w e r e t h e m o s t v i v i d and e a s i l y remembered d u r i n g  the i n t e r v i e w s .  T h i s was  b e c a u s e they were a l l c u r r e n t l y r e o r g a n i z i n g world,  experiencing  expectations  and  c h a n g e and  process  where they  phase (Lewin, recognized  process  i s very  T h e y had  1951)  i n the  change.  The  a l s o the types  f o r c e s a v a i l a b l e in one's l i f e . i d e n t i f i e d as t h r e a t e n e d  The  For and  of p o s i t i v e  O t h e r needs t h a t were  a t t h i s time were the need f o r  stimulation, for mastery, for love,  belongingness, balance  into  l o n g e r d e p e n d i n g on t h e number  o f t h e l o s s e s and  sensory  i t would  behaviours  o n e ' s l i f e s t y l e d o e s t a k e a number o f m o n t h s .  extent  level  timing of t h i s  i n d i v i d u a l but from the data  take  change  m o v i n g t o a new  a p p e a r t h a t t h e i n c o r p o r a t i n g o f new  some, i t may  moved  the need f o r change,  s e l e c t e d an a p p r o a c h and w e r e now involving behavioural  their  the r e v i s i n g of t h e i r  view of t h e m s e l v e s .  from the u n f r e e z i n g  probably  and  d e p e n d e n c e and  b e t w e e n a c t i v i t y and areas  the need f o r a  rest.  of d i e t a r y m o d i f i c a t i o n , a r e g u l a r  e x e r c i s e p r o g r a m , s m o k i n g c e s s a t i o n and  consistent  95  medication-taking conscious  were a r e a s  o f change that  required  e f f o r t on t h e p a r t o f t h e p a r t i c i p a n t s .  Having received only minimal  i n s t r u c t i o n and  g u i d a n c e from h e a l t h p r o f e s s i o n a l s c o n c e r n i n g  these  a r e a s , t h e p a r t i c i p a n t s w e r e on t h e i r own t o c a r r y o u t these had  changes.  T h e r e were a r e a s where t h e i n d i v i d u a l s  c h o i c e and c o n t r o l l e d t h e e x t e n t  a change r a t h e r than  having  to which they  made  i t f o r c e d upon them.  example, d i e t a r y m o d i f i c a t i o n s were a d j u s t e d individuals ate out i n a restaurant.  when  Positive forces  t h a t i n f l u e n c e d change were s u p p o r t i v e f a m i l y who e n c o u r a g e d a n d h e l p e d  For  f r i e n d s and  the i n d i v i d u a l s ,  p a r t i c u l a r l y i n t h e area o f d i e t , e x e r c i s e and increasing self-esteem. be n e g a t i v e their  T h e s e same f o r c e s c o u l d  also  forces a f f e c t i n g the e f f o r t s to adhere to  regimen. Medication-taking  was a c o p i n g  behaviour  r e p o r t e d l y c a r r i e d o u t on a r e g u l a r b a s i s t o m e e t t h e need f o r s a f e t y and s e c u r i t y .  So f a r , t h e p a r t i c i p a n t s  were f a i t h f u l l y t a k i n g t h e i r m e d i c a t i o n . were q u e s t i o n i n g  i t s use s i n c e they  H o w e v e r , some  f e l t well or  because o f s i d e e f f e c t s t h a t were n e g a t i v e l y a f f e c t i n g t h e i r need f o r s a f e t y and s e c u r i t y , s e n s o r y and  t h e need f o r a b a l a n c e All  while  between a c t i v i t y and r e s t .  o f t h e p a r t i c i p a n t s r e c e i v e d some  i n the h o s p i t a l with  stimulation  regard  information  t o d i e t , e x e r c i s e and  96  activity  r e s t r i c t i o n s , t h e i r medications  cessation.  and smoking  Some o f t h e i n f o r m a t i o n was r e c e i v e d f r o m a  d i e t i c i a n , a f e w m e n t i o n e d i n f o r m a t i o n g i v e n by but t h e m a j o r i t y o f t h e i r i n s t r u c t i o n s were as c o m i n g f r o m All  nurses  perceived  their doctor.  b u t o n e p a r t i c i p a n t i n t h i s s t u d y h a d t h e same  cardiologist.  After the i n i t i a l  followup  v i s i t s , the  frequency  of v i s i t s to the c a r d i o l o g i s t varied  according  to t h e i r i n d i v i d u a l needs.  The f a m i l y  p h y s i c i a n was now t h e m a i n h e a l t h p r o f e s s i o n a l g i v i n g i n f o r m a t i o n and r e s p o n d i n g questions.  to medical  concerns  The p a r t i c i p a n t s had q u e s t i o n s  aspects o f change or experiences r e l u c t a n t to "bother Some f o u n d  regarding  b u t were o f t e n  the doctor" with t h e i r questions.  t h e i r answers through  literature.  and  the reading ofl a y  One p a r t i c i p a n t a t t e n d e d  a cardiac  r e h a b i l i t a t i o n e x e r c i s e p r o g r a m w h e r e t h e r e was a variety of information-giving sessions. also received information experienced The  an MI t h e m s e l v e s  information  contained  from  The m a j o r i t y  f r i e n d s who h a d  o r knew s o m e o n e who h a d .  r e c e i v e d was n o t a l w a y s a c c u r a t e b u t  the perceptions  and b e l i e f s o f  concerned  individuals. Many o f t h e c h a n g e s made by i n d i v i d u a l s w e r e made "on  t h e i r own" a n d w e r e n o t m o n i t o r e d  professionals.  Personal  adjustments  by h e a l t h w e r e made i n t h e  97 i n s t r u c t i o n g i v e n them by t h e i r d o c t o r s .  Some  discussing c e r t a i n topics with t h e i r doctor  avoided  because  they were a f r a i d o f what t h e a n s w e r s m i g h t b e . E v e n among t h o s e who h a d t h e same c a r d i o l o g i s t a n d h o s p i t a l , t h e i n s t r u c t i o n s and i n f o r m a t i o n varied greatly.  reviewed  T h i s may h a v e b e e n due t o t h e  individuals' perceptions  and i n t e r p r e t a t i o n s o f what  they were t o l d and t h e i r a p p l i c a t i o n o f i t . W h i l e t h e p a r t i c i p a n t s w e r e i n h o s p i t a l , no f o r m a l teaching with  s e s s i o n s were h e l d .  P a m p h l e t s were g i v e n o u t  i n f o r m a t i o n on g u i d e l i n e s f o r a c t i v i t y a n d r i s k  reduction suggestions. as a r e i n f o r c e m e n t presented.  W r i t t e n m a t e r i a l may be h e l p f u l  to i n f o r m a t i o n which i s f i r s t  This allows the i n d i v i d u a l s opportunity to  t a k e t h e i n f o r m a t i o n w i t h them a n d r e a d i t a t a l a t e r t i m e when t h e y may be m o r e a p t t o a b s o r b , review  or question  the content  understand  and i m p l i c a t i o n s f o r  them. There i s great controversy regarding  the optimal  time  f o r t e a c h i n g and l e a r n i n g  especially during a c r i t i c a l best time individual  i n the l i t e r a t u r e  p e r i o d s u c h a s an MI.  f o r l e a r n i n g may v a r y f r o m and thus t h e nurse  individual to  requires skill in  a s s e s s i n g when p a t i e n t s a r e r e a d y regarding  f o r information  t h e i r immediate and f u t u r e s i t u a t i o n s .  fact, the patient's level  The  of psychological anxiety  In may  98 be t h e c r i t i c a l time p e r i o d . study  variable in teaching,  (Guzzetta,  1979).  The  r a t h e r than  the  individuals in this  w e r e i n t e r e s t e d i n l e a r n i n g more a b o u t t h e i r  condition.  I t i s beyond the scope of t h i s study  c o n c l u d e as G u z z e t t a s u c h as an MI may  (1979) does, t h a t a c r i t i c a l  be t h e t u r n i n g  p o s i t i v e change i n t h e i r Cardiac  point to b r i n g  recovering  n e e d and  from a myocardial  process  b e l i e f that  i n f a r c t i o n need  (Gerard  &  Owens, McCann & H u t e l m y e r , 1 9 7 8 ) .  empirical  Peterson, However,  e v i d e n c e r e l a t e d to the t e a c h i n g  has  not been f u l l y e v a l u a t e d  e f f e c t i v e n e s s of p a t i e n t education  learning  in terms of  the  p r o g r a m s n o r has i t  been used to d e v e l o p p a t i e n t e d u c a t i o n (Guzzetta,  about  r e h a b i l i t a t i o n programs have been based i n  knowledge about t h e i r c o n d i t i o n 1984;  event  lives.  h o s p i t a l s because of a recognized patients  to  techniques  1979).  T e a c h i n g t h a t i s b e g u n a t t h e w r o n g t i m e may totally ineffective.  W i l l the i d e n t i f i c a t i o n of  o f a b a s i c human n e e d b e i n g  met  reveal  learning  be lack needs?  T h i s c o u l d be u s e d t o d e t e r m i n e t h e l e a r n i n g n e e d s o f the  i n d i v i d u a l to begin  instance,  i f an i n d i v i d u a l i s e x p e r i e n c i n g  when w a l k i n g coping  giving information.  i t w o u l d be u s e f u l  b e h a v i o u r s to deal with  b a l a n c e a c t i v i t y and  rest.  to begin chest  For chest  teaching  p a i n and  An e x p l a n a t i o n  of  how  pain about to  basic  99 a n a t o m y and p h y s i o l o g y w h i c h  i s often presented  d u r i n g a t e a c h i n g p r o g r a m , may a f t e r the i n d i v i d u a l symptoms.  o r may  l e a r n s how  first  n o t be u s e f u l  to deal with h i s  I t i s i m p o r t a n t t o d e v e l o p ways t o m a i n t a i n ,  p r o m o t e and e n h a n c e c o p i n g b e h a v i o u r s r e l a t e d t o r e d u c t i o n i n the i n i t i a l  p e r i o d f o l l o w i n g an  risk  MI.  A s t u d y by G e r a r d & P e t e r s o n ( 1 9 8 4 ) r e v e a l e d a d i s c r e p a n c y i n p a t i e n t s and n u r s e s v i e w s o f teaching items. "how  P a t i e n t s were more i n t e r e s t e d i n t h e  t o " a s p e c t s s u c h as "how  a n o t h e r MI",  important  "how  to decrease chances  of  t o f e e l when t o i n c r e a s e a c t i v i t y "  and "what a c t i v i t y r e s t r i c t i o n s " a p p l i e d t o t h e m . N u r s e s w e r e more c o n c e r n e d w i t h t h e "whys" r a n k e d "why was  p a t i e n t s had c h e s t p a i n s " , "why  l i m i t e d " and "why  as m o s t i m p o r t a n t . people understand  e a c h m e d i c a t i o n was Perhaps  t h e "why"  and  activity being  taken"  nurse b e l i e v e that i f they w i l l  comply.  Risk  f a c t o r s s u c h as t h e f a c t o r s c o n t r i b u t i n g t o t h e of  h e a r t d i s e a s e , how  a t t a c k a n d how  onset  to reduce r e c u r r e n c e of heart  r i s k f a c t o r s a f f e c t the h e a r t were o f  primary concern to p a t i e n t s . The  p a r t i c i p a n t s i n t h i s r e s e a r c h s t u d y had  the i n i t i a l  phase  o f t h e i r i l l n e s s and had  r e l a t e d t o t h e r e a s o n s "why"  passed  concerns  with regard to t h e i r  p r e s e n t c o n d i t i o n and f u t u r e o u t c o m e .  Perhaps  s u g g e s t s t h a t i n i t i a l l y t h e p a t i e n t s do n e e d  this specific  100  guidance  about  " w h a t " t o do a n d f u r t h e r e x p l a n a t i o n s o f  t h e r a t i o n a l e w o u l d be b e t t e r r e c e i v e d Beginning  later.  to teach people while i n h o s p i t a l  about  the areas o f r i s k r e d u c t i o n and a c t i v i t y r e s t r i c t i o n i s necessary  f o r t h e i r own s a f e t y p r o v i d e d t h a t p e o p l e a r e  w i l l i n g and a b l e t o l e a r n .  I f n o t , the nurse  must  p r o v i d e f o r t h e need o f s a f e t y and s e c u r i t y f o r t h e patient. Helping i n d i v i d u a l s return to their  former  j o b s , f a m i l y l i f e and place i n s o c i e t y i s a goal  that  has f a r r e a c h i n g demands a n d a t i m e f r a m e n o t c o n f i n e d to t h e hospi t a l . The  data from  t h i s study r e v e a l s a need f o r  t e a c h i n g a n d c o u n s e l l i n g o f MI p a t i e n t s a t t h e community l e v e l .  One o f t h e p a r t i c i p a n t s s u g g e s t e d  t h a t i t w o u l d be h e l p f u l f o r h e r t o h a v e s o m e o n e the i n v e s t i g a t o r t o c a l l and q u e s t i o n s .  Another  a f t e r g o i n g home f r o m unanswered. one  and d i s c u s s c o n c e r n s , s a i d he h a d many  h o s p i t a l which  like  problems  questions  remained  P r e s e n t l y , i n t h e c o m m u n i t y t h e r e i s no  f o r people  to call  e s p e c i a l l y seven  to discuss their  concerns,  t o t w e l v e m o n t h s a f t e r an MI.  Initial  f o l l o w u p may be d o n e by p u b l i c h e a l t h o r home c a r e nurses  b u t r e f e r r a l s t o n u r s i n g s e r v i c e s f o r MI  patients i s not a regular occurrance.  There  be a g a p b e t w e e n t h e a c u t e c a r e a g e n c i e s community  agencies.  seems t o  and t h e  101  A discussion of the coping behaviours  r e l a t e d to  risk reduction explained the i n d i v i d u a l s response to loss through  d e n i a l , anger,  reorganization.  d e p r e s s i o n and  Most o f t h e i n d i v i d u a l s were c u r r e n t l y  r e o r g a n i z i n g t h e i r l i f e s t y l e a s t h e y made c h a n g e s i n t h e i r d i e t , smoking h a b i t s , e x e r c i s e and medication-taking. coping behaviours  Reducing  r i s k f a c t o r s were t h e  i n the i n i t i a l  phase used  t o meet  t h e i r b a s i c human n e e d s f o r s a f e t y a n d s e c u r i t y , s e l f - e s t e e m and a b a l a n c e  between r e s t and a c t i v i t y .  discussion o f these coping behaviours  A  l e d to a  d i s c u s s i o n o f the g i v i n g o f i n f o r m a t i o n t o enhance and promote these c o p i n g  Coping  Behaviours  behaviours.  R e l a t e d t o G e t t i n g Back t o Normal  E x p e r i e n c i n g symptoms s u c h a s c h e s t p a i n , f a t i g u e , and b r e a t h l e s s n e s s made t h e p a r t i c i p a n t s i n t h e s t u d y more a w a r e o f t h e i r b o d i e s a n d o f t h e f a c t t h a t were n o t normal. task to master.  D e a l i n g w i t h t h e i r symptoms b e c a m e a Some d e v i s e d t h e i r own d a i l y  w h i c h b e c a m e t h e i r own p e r s o n a l  treatment  I n c l u d e d i n t h i s were c o p i n g b e h a v i o u r s e x e r c i s e and m e d i c a t i o n - t a k i n g . conclude the l e v e l  from  they schedule  regimen. such as r e g u l a r  I t i s d i f f i c u l t to  t h i s s t u d y e x a c t l y what a r o l e change and  o f knowledge o r the l a c k t h e r e o f played i n  102 developing  suitable coping  m e n t i o n was perceived disease  behaviours.  Specific  made by t h e p a r t i c i p a n t s a b o u t  lack of s u f f i c i e n t knowledge about and  how  t o manage i t .  a c q u i s i t i o n and  that  the  a p p l i c a t i o n o f k n o w l e d g e o n c e i t has  imparted. A f t e r t h e a c u t e p a r t o f t h e i l l n e s s has  they  cardiac  I t w o u l d seem  cognitive a b i l i t i e s play a large role in  been  the  have s u r v i v e d  the t h r e a t of d e a t h , the goal  i n d i v i d u a l s i s t o l i v e as n o r m a l l y t h e i r s y m p t o m s and t h a t how  passed  illness.  as p o s s i b l e  Strauss  and  of despite  (1984) comments  n o r m a l t h e y make t h e i r l i v e s and  their  f a m i l i e s l i v e s d e p e n d s on t h e i r s y m p t o m s , t h e  regimens  t h e y m u s t f o l l o w and  disease.  t h e i r knowledge of t h e i r  When r e g i m e n , symptoms o r k n o w l e d g e o f d i s e a s e  turns  o u t t o be i n t r u s i v e , t h e n s i c k p e r s o n s h a v e t o work very  hard  a t c r e a t i n g some s e m b l a n c e o f n o r m a l l i f e  themselves.  C e r t a i n l y these  f a c t o r s are important  f o r c e s t h a t i n f l u e n c e the c o p i n g t o m e e t t h e i r b a s i c human n e e d s .  behaviours persons  for as use  103  Forces A f f e c t i n g Coping  Behaviours  In a t t e m p t i n g t o g e t b a c k t o n o r m a l , c e r t a i n forces  a f f e c t e d t h e needs and a b i l i t i e s o f t h e  participants.  A l l o f t h e p a r t i c i p a n t s had a n g i n a  symptoms a f t e r MI.  The i m p e r s o n a l  force of chest  pain  affected the coping  behaviours of the individuals.  p a r t i c i p a n t h a d s t a i r s i n h e r home l e a d i n g  to her  bathroom and found i t t i r i n g and sometimes  developed  chest  pain  g o i n g up a n d down t h e s t a i r s .  One  The p h y s i c a l  e n v i r o n m e n t a n d l o c a t i o n o f t h e home was a n o t h e r impersonal one  force.  Financial  c o n c e r n s w e r e m e n t i o n e d by  o f t h e y o u n g e r p a r t i c i p a n t s who was h a v i n g  difficulty returning anxiety The  and worry about p r o v i d i n g  negative  This  caused  f o r h i s family.  w o r k i n g e n v i r o n m e n t o f t h e i n d i v i d u a l was  another strong study.  to h i s former job.  f o r c e m e n t i o n e d by p a r t i c i p a n t s  A job requiring  heavy p h y s i c a l  labour  i n the was a  f o r c e a s i t i m p i n g e d on t h e n e e d f o r s a f e t y  and  s e c u r i t y and t h e need f o r a b a l a n c e between  rest  and  a c t i v i t y as t h e i d i v i d u a l  chest  pain  and f a t i g u e  jobs  allowing  often  experienced  due t o t h e n a t u r e o f w o r k .  i n d i v i d u a l s a gradual  re-entry  work f o r c e w e r e p o s i t i v e f o r c e s a f f e c t i n g t h e satisfaction of basic  human n e e d s .  Flexible into the  104  The  response of i n d i v i d u a l s to p o s i t i v e or  n e g a t i v e f o r c e s w i t h r e g a r d t o r e t u r n i n g t o work i n f l u e n c e d the c o p i n g b e h a v i o u r s used to attempt t o m e e t t h e i r b a s i c human n e e d s .  Working  half  time,  c h a n g i n g j o b s , t a k i n g s i c k time and a d j u s t i n g working hours were methods t h a t were  used.  T h o s e who w e r e r e t i r e d r e s p o n d e d in t h e i r environment  to other forces  such as the p h y s i c a l a c t i v i t i e s o f  g o l f , b o w l i n g , g a r d e n i n g , camping  and d r i v i n g the c a r .  These were t h e a r e a s o f change as t h e y a t t e m p t e d t o r e t u r n t o former hobbies and a c t i v i t i e s . F a m i l i e s w e r e an i m p o r t a n t p a r t o f t h e r e h a b i l i t a t i o n p e r i o d f o l l o w i n g an MI f o r t h e p a r t i c i p a n t s of this study.  Supportive, understanding  f a m i l i e s were seen as a p o s i t v i e f o r c e i n f l u e n c i n g a v a r i e t y o f needs.  The s a t i s f a c t i o n o f t h e need f o r  l o v e , b e l o n g i n g n e s s a n d d e p e n d e n c e was e v i d e n t when m e t by a s u p p o r t i v e s p o u s e  and c h i l d r e n .  In c o n t r a s t , when t h e i n d i v i d u a l ' s n e e d  for love,  b e l o n g i n g n e s s a n d d e p e n d e n c y was n o t m e t , o t h e r unmet needs a r o s e as w e l l .  T h e f a m i l y was t h e n v i e w e d  negative f o r c e impeding  need  satisfaction.  as a  The need  f o r r e s p e c t o f s e l f by s e l f a n d o t h e r s was i n t e r d e p e n d e n t w i t h t h e need and d e p e n d e n c e .  f o r love, belongingness  I f the individual  d i d not experience  105 i n t i m a c y with t h e i r f a m i l i e s during t h i s time of l o s s , f e e l i n g good a b o u t o n e s e l f a l s o s u f f e r e d . Feelings of love, belongingness  and  dependence  are  i n t e r r e l a t e d and e a c h m u s t be p r e s e n t f o r n e e d s a t i s f a c t i o n to occur  i n the a f f e c t i v e s u b s y s t e m .  n e e d f o r d e p e n d e n c e i n c l o s e r e l a t i o n s h i p s may r i s e to q u e s t i o n s independence.  regarding  dependence  The  give  versus  Many o f t h e p a r t i c i p a n t s i n t e r v i e w e d  d i f f i c u l t y r e l i n q u i s h i n g c e r t a i n areas of and a l l o w i n g t h e m s e l v e s S i t u a t i o n s with both  t o d e p e n d on  f a m i l y and  had  independence  others.  f r i e n d s were a f f e c t e d  by t h i s c o n f l i c t . Dependence i n v o l v e s e x p e c t i n g help from  others  ( S t r y k e r , 1977).  r e s i s t a n c e to seek out help from f e e l i n g s of love, belongingness a critical  p e r i o d s u c h as an MI,  f o r c e s a f f e c t t h e p e r c e p t i o n and for love, belongingness  or a c t i v e l y seeking Refusal  or  others will and  a f f e c t the  dependence.  various types expression  and d e p e n d e n c e .  During of  of the  need  Sociocultural  f o r c e s i n f l u e n c i n g t h i s need are the s o c i e t a l b e l i e f s and  v a l u e s o f s e l f and  f a m i l y members.  Impersonal  f o r c e s i n c l u d e the p r o x i m i t y o f f a m i l y members,  the  c l o s e n e s s o f r e l a t i o n s h i p s w i t h i n t h e f a m i l y and  the  a v a i l a b i l i t y of other f r i e n d s h i p s . Coping  behaviours  t h a t i n f l u e n c e need s a t i s f a c t i o n  in the a f f e c t i v e subsystem i n c l u d e the a b i l i t y to  give  106 and r e c e i v e l o v e and a s s i s t a n c e , t o e s t a b l i s h s a t i s f a c t o r y r e l a t i o n s h i p s and c o m m u n i c a t e t h e n e e d f o r l o v e , b e l o n g i n g n e s s and d e p e n d e n c e .  As  individuals  s t r u g g l e to meet t h e i r need f o r m a s t e r y , t h i s i n t e r f e r e w i t h t h e i r need to ask f o r h e l p .  may  If  i n d i v i d u a l s do n o t a c h i e v e s e l f - e s t e e m , i t i s u n l i k e l y t h a t t h e i r needs will  be  f o r l o v e , b e l o n g i n g n e s s and  dependence  met.  Roles w i t h i n the f a m i l y u n i t s of the underwent  some c h a n g e s .  The r o l e c h a n g e s  participants d i s c u s s e d by  the p a r t i c i p a n t s were t h o s e o f p e r f o r m a n c e  such as the  g a r d e n e r , f i n a n c e m a n a g e r , c a r w a s h e r and  breadwinner.  Murray  and Z e n t n e r ( 1 9 8 5 )  describe emotional roles  as l e a d e r , n u r t u r e r , s u s t a i n e r and p r o t e c t o r .  such  They  m a i n t a i n t h a t the emotional response of a person to the r o l e he f u l f i l l s may  s h o u l d be c o n s i d e r e d b e c a u s e  someone  perform a job competently but hate doing i t . Data from the s t u d y showed t h a t e m o t i o n a l  changes  o c c u r r e d as a s p o u s e o r a f a m i l y member t o o k o v e r t h e d u t i e s of the o t h e r .  The i m p a c t o f t h e r o l e  change  m i g h t be b e t t e r e v a l u a t e d i n a n o t h e r s i x m o n t h s t o a y e a r a s m o s t o f t h e i n d i v i d u a l s had r e c e n t l y made t h e r o l e change impact.  a n d i t may  The n e e d s  be t o o s o o n t h e j u d g e t h e  f o r s e l f - e s t e e m and m a s t e r y may  t h r e a t e n e d when r o l e s a r e c h a n g e d .  total be  The d a t a r e v e a l e d  t h a t t h e h e l p and s u p p o r t t h a t t h e p e r s o n w i t h h e a r t  107  d i s e a s e r e c e i v e d from one's spouse and/or a f f e c t e d the l i f e s t y l e m a r r i e d men  family  c h a n g e s t h a t w e r e made.  A l l the  c o m m e n t e d t h a t t h e i r w i v e s had h e l p e d them  make some o f t h e n e c e s s a r y c h a n g e s i n t h e i r  lifestyle.  The w i v e s made d i e t a r y c h a n g e s , p a r t i c i p a t e d w i t h  them  in e x e r c i s e programs, were k n o w l e d g e a b l e r e g a r d i n g m e d i c a t i o n s and o f t e n t o o k o v e r h o u s e h o l d t a s k s f o r m e r l y a s s i g n e d to the  husband.  T h o s e p a r t i c i p a n t s who  d i d not have a spouse  c o m m e n t e d a b o u t l o n e l i n e s s , b e i n g on t h e i r own h e l p and w a n t i n g e x t r a a t t e n t i o n .  without  They l o o k e d f o r w a r d  t o f r i e n d s and f a m i l y i n v i t i n g them o u t o r c o m i n g to c a r e f o r t h e m . for  They t e n d e d to e x c e e d t h e i r  over  capacity  a c t i v i t y with their quest f o r independence.  R e a c t i o n s w e r e s t r o n g l y n e g a t i v e when t h e y f e l t they were b e i n g o v e r p r o t e c t e d o r t r e a t e d l i k e  that  an  i n v a l i d by f a m i l y o r f r i e n d s . The l i t e r a t u r e r e v e a l e d t h a t t h e t y p e o f s o c i a l e n v i r o n m e n t i n w h i c h an i n d i v i d u a l will  d e t e r m i n e t o some e x t e n t how  l i v e s and  learns  problems are solved  and how c r i t i c a l p e r i o d s a r e h a n d l e d ( K e a n e , Religious beliefs will meaning  of l i f e  individual  1981).  a f f e c t the o v e r a l l  i n f l u e n c i n g t h e ways i n w h i c h  deals with situations.  Cultural  p r o v i d e s u p p o r t and h e l p d u r i n g c r i t i c a l  view and an  groups  periods.  may  108 Community r e s o u r c e s t h a t a r e a v a i l a b l e can a l s o i n f l u e n c e the development  of coping  behaviours.  The a v a i l a b i l i t y o f f a m i l y a n d f r i e n d s a n d t h e i r response to the c r i t i c a l behaviours. ongoing  period will  influence  coping  A stable family structure i s important to  development  (Keane,  1981).  Murray  and Z e n t n e r  (1985) s t a t e d t h a t the l e s s r e a d i l y a v a i l a b l e the person's environmental  or emotional  support systems are  t o d e c r e a s e s t r e s s o r b u i l d c o p i n g r e s p o n s e s , t h e more hazardous  he w i l l  define the event.  Whether o r not the  f a m i l y m e e t s t h e demands o f a p o t e n t i a l l y s t r e s s f u l situation, i t i s important that role r e s p o n s i b i l i t i e s are  initially  s h i f t e d away f r o m t h e p a t i e n t .  Since  many n e e d s a r e met t h r o u g h t h e a s s u m p t i o n  of roles, i t  i s i m p o r t a n t t o r e a l i z e t h a t an i n i t i a l l y  protective  a c t i o n by t h e f a m i l y may l e n d t o an unmet n e e d i n another  area.  The 69.  seven p a r t i c i p a n t s ranged  i n age f r o m 45 t o  Four o f the p a r t i c i p a n t s were working  w e r e r e t i r e d a t t h e t i m e o f t h e MI. working  p a r t i c i p a n t s has r e t u r n e d  many i n f l u e n c e s  that determine  and  A l l b u t one o f t h e  to work.  the coping  There are behaviours  t h a t i n d i v i d u a l s u s e t o m e e t t h e i r b a s i c human Cognitive the c o p i n g  three  needs.  a b i l i t i e s a r e one such i n f l u e n c e t h a t a f f e c t behaviour.  109  It i s not p o s s i b l e to determine intellectual based who  the l e v e l  or c o g n i t i v e development of the  on t h e i r c u r r e n t o r f o r m e r j o b .  had j o b s r e q u i r i n g p o s t s e c o n d a r y  of individual  However,  those  education or  who  had b u i l t up a b u s i n e s s s e e m e d t o h a v e more i n s i g h t knowledge about effectively.  t h e i r c o n d i t i o n and how  T h e r e was  and  t o manage i t  also a noticeable difference in  t h e i r a t t i t u d e s and t h e m e a n i n g o f t h e i l l n e s s f o r them.  Because t h i s study d i d not measure c o g n i t i v e  development i t i s not p o s s i b l e to r e l a t e behaviours  coping  to the c o g n i t i v e a b i l i t y of each  H o w e v e r , some o f t h e p a r t i c i p a n t s w i t h l e s s  individual. education  and l e s s f a m i l y s u p p o r t f o u n d i t d i f f i c u l t t o suitable coping behaviours  to meet t h e i r needs.  p a r t i c i p a n t s p e n t a g r e a t d e a l o f t i m e and attempting family.  to r e s o l v e c e r t a i n problems  n o t e v i d e n t i n t h i s p a r t i c i p a n t . I t was  brought  about  energy the  ability  were  not p o s s i b l e  a change from p r e v i o u s  abilities  as a r e s u l t o f t h e MI o r w h e t h e r p a s t  j u d g m e n t and d e c i s i o n - m a k i n g  were  poor.  Keane (1981) s t a t e s the the l e v e l  of  intellectual  o r c o g n i t i v e d e v e l o p m e n t o f an i n d i v i d u a l w i l l m a j o r i n f l u e n c e i n d e t e r m i n i n g how d e f i n e s h i s i l l n e s s and w i l l with i t .  One  regarding  Good j u d g m e n t and d e c i s i o n - m a k i n g  t o know i f t h i s was  develop  the  be a  individual  a f f e c t h i s a b i l i t y to deal  110  One  p a r t i c i p a n t had e x p e r i e n c e d a c o n s i d e r a b l e  number o f p e r s o n a l l o s s e s o v e r t h e p a s t y e a r .  The  e f f e c t s from p r e v i o u s l o s s e s were never r e s o l v e d . p a r t i c i p a n t had a d i f f i c u l t t i m e d e a l i n g w i t h p r e s e n t l o s s and t h i s new  t h r e a t of death.  The  the  Resorting  to p r e v i o u s h a b i t s were not p a r t i c u l a r l y a p p r o p r i a t e i n this situation.  The p a r t i c i p a n t d i d n o t r e t u r n t o work  and t h e r e f o r e had t o d e a l w i t h b e i n g u n e m p l o y e d  or  r e t i r e d and t h e e f f e c t s on h e r s e l f - e s t e e m and s e n s e  of  mastery. A n o t h e r p a r t i c i p a n t who of p e r s o n a l l o s s e s used meet h i s n e e d s .  a l s o e x p e r i e n c e d a number  suitable coping behaviours  P a s t e x p e r i e n c e w i t h a CVA  and  d e a t h o f h i s w i f e h e l p e d p r e p a r e him f o r t h e new he i n c u r r e d d u r i n g t h e p e r i o d o f r e h a b i l i t a t i o n MI.  Previous coping behaviours  u s e d i n t h e new  stressful  P e r h a p s one who throughout  coping behavours.  utilize  appropriately.  The way affect  in which  present  number o f u n p r e d i c t a b l e  o r m a t u r a t i o n a l e v e n t s t h a t one given time w i l l  and  the r e p e r t o i r e of  dealt with will The  after  h i s b a s i c human n e e d s  already developed.  p r e v i o u s c h a n g e was  losses  i n h i s r e p e r t o i r e were  various maturational events  coping behaviours  the  situation.  has met  unpredictable events will  to  events  i s dealing with at  a l s o a f f e c t the a b i l i t y  to  respond  any  Ill  The event  p a r t i c i p a n t ' s perception of the unpredictable  (MI) i n f l u e n c e d t h e c o p i n g b e h a v i o u r .  The  meaning of t h e event i n terms o f the impact losses a f f e c t e d the response loss.  This response  as i t a t t e m p t s  of the  used t o deal w i t h t h e  may be c a l l e d a c o p i n g  to reduce  behaviour  t e n s i o n i n one o r more  s u b s y s t e m s a n d m e e t a b a s i c human n e e d . i n d i v i d u a l s i n t h e s t u d y a s s u m e d more  Certain  responsibility  f o r t h e i r i l l n e s s s i t u a t i o n a n d made c h a n g e s t o m o d i f y i t b u t o t h e r s l e f t i t up t o t h e i r s p o u s e o r d o c t o r t o control  t h e change p r o c e s s f o r them.  to d e t e r m i n e individual feel  I t i s important  t h e r e a l i t y o f t h e s i t u a t i o n f o r each r a t h e r t h a n how o t h e r s t h i n k s o m e o n e s h o u l d  o r behave i n a s i t u a t i o n .  Determining  of the event f o r the i n d i v i d u a l w i l l  help  the meaning nurses  e f f e c t i v e l y i n t e r v e n e by m a n i p u l a t i n g f o r c e s a n d strengthening coping  behaviours.  The e x e c u t i v e a b i l i t y o f t h e i n d i v i d u a l determines execute  the coping behaviours.  also  The a b i l i t y t o  a t a s k may d e p e n d on p r e v i o u s a c q u i r e d  a b i l i t i e s n o t r e l a t e d t o t h e MI o r on t h e l i m i t a t i o n s i m p o s e d by t h e l o s s e s i n c u r r e d w i t h t h e MI. P a r t i c i p a n t s i n t h i s study described t h e i r  experience  w i t h t h e p e r s o n a l f o r c e o f t h e i r c h e s t p a i n and o t h e r r e l a t e d symptoms r e l a t i n g i t s e f f e c t on t h e i r  need  s a t i s f a t i o n i n the p r o t e c t i v e , r e p a r a t i v e , r e s p i r a t o r y  112 and e g o - v a l u a t i v e s u b s y s t e m s .  The i n a b i l i t y  h o u s e h o l d t a s k s a n d r o l e s r e q u i r e d new  to perform  coping  b e h a v i o u r s s u c h as g e t t i n g someone e l s e t o h e l p w i t h the  tasks or r e l i n q u i s h i n g r o l e s .  unmet n e e d s i n o t h e r s u b s y s t e m s i n a d e q u a c y and  T h i s may  lead to  generating f e e l i n g s of  boredom.  The age o f a p e r s o n a t t h e o n s e t o f any or e m o t i o n a l  impairment  i s an i m p o r t a n t  a f f e c t i n g a person's a b i l i t y to cope Maturational  one man  factor  ( S t r y k e r , 1977).  e v e n t s o c c u r r i n g a t t h e same t i m e as an  u n p r e d i c t a b l e e v e n t s u c h as an MI may satisfaction  physical  affect  i n one o r m o r e s u b s y s t e m s .  i n the study i n the h e i g h t of a  need  For example, fulfilling  c a r e e r f o u n d t h e f o r c e o f an MI t o be a g r e a t o b s t a c l e impeding  h i s a b i l i t y t o c o n t i n u e w o r k i n g a t t h e same  pace. T h i s r e q u i r e d a change. had  Another p a r t i c i p a n t  who  many p l a n s f o r h i s r e t i r e m e n t r e f u s e d t o a l l o w h i s  illness  t o a f f e c t h i s p l a n s by d e v e l o p i n g s u i t a b l e  coping behaviours.  C o p i n g B e h a v i o u r s R e l a t e d t o R e a c h i n g a New  Normal  In t h e p a r t i c i p a n t s ' a c c o u n t s o f t h e i r e x p e r i e n c e , d e s c r i p t i o n s w e r e s h a r e d o f how themselves. changes  T h e r e was  a f f e c t i n g them.  t h e y were f e e l i n g  often a refusal  to r e c o n c i l e  about the  The n e e d s a f f e c t e d d u r i n g t h i s  113 time were the need f o r l o v e , b e l o n g i n g n e s s d e p e n d e n c e and The  and  t h e n e e d f o r r e s p e c t by s e l f and  changes in self-esteem  (the i n d i v i d u a l ' s  judgment of h i s worth) t h a t r e s u l t e d from in s e l f concept study.  as " I d o n ' t  observed  in t h e i r perception of t h e i r  i n c o m m e n t s made a b o u t t h e m s e l v e s ,  feel  n o r m a l " , and  get back to work."  "I don't  r e l a t i o n s h i p s and  adequacies  and  such  think I ' l l ever  Role performance i n the changes  l o s s i m p o s e d by t h e m a l s o t h r e a t e n e d Social  an a l t e r a t i o n  a f f e c t e d the p a r t i c i p a n t s i n t h i s  T h i s was  s i t u a t i o n and  others.  their  self-esteem.  interactions revealed  inadequacies  r e l a t e d to the r e s u l t a n t  effect in their self-esteem.  A negative  toward s e l f , r e s e n t f u l f e e l i n g s toward  attitude others,  h e s i t a t i o n s t o ask f o r h e l p and l a c k o f c o n f i d e n c e one  t o one o r g r o u p i n t e r a c t i o n s ( M i l l e r , 1983)  e v i d e n t i n d i c a t i o n s of the need f o r observed  behaviours  b a s i c human n e e d s .  were d e v e l o p e d  The c o p i n g  in  were  self-esteem  i n the i n t e r v i e w s d u r i n g t h i s  Coping  and  study. i n o r d e r to meet  behaviours  underwent  some r e v i s o n s i n o r d e r t o m e e t t h e i r n e e d s w h i c h do  not  change.  of  In some c a s e s  t h e way  of reaching  the goal  the s u b s y s t e m underwent r e v i s i o n i n o r d e r to meet need.  F o r i n s t a n c e , a man  who  the  f o r m e r l y d i d a l l the  y a r d work and m a i n t e n a n c e a r o u n d h i s home f o r a c t i v i t y and  f o r enjoyment found  he was  unable  t o do t h i s .  His  114 p e r s p e c t i v e c h a n g e d and he was  a b l e to d e l e g a t e  t a s k s to o t h e r f a m i l y members.  His energy  these  was  expended  by r e t u r n i n g t o work and c o m m e n c i n g a r e g u l a r w a l k i n g program.  He f o u n d t h a t he had t o r e s t  activities.  H i s need  f o r a c t i v i t y and r e s t was  b u t i n a v e r y d i f f e r e n t way. s t i m u l a t i o n was  n o t met  H i s need  i n t e r e s t s and new  needs.  be an o n g o i n g  ways t o s a t i s f y  p r o c e s s a s he  used  i d e n t i t y c a n be p r o f o u n d l y a f f e c t e d .  t h a t a f f e c t s the s e l f - i m a g e . remain  unaltered.  the i l l n e s s , the person's  social  His views  sense of i d e n t i t y A f t e r an MI,  change  It  may  situation  of himself  e f f o r t s to even  disabilities will (Strauss,  maintain  ones  necessary  f o s t e r a changed  1984).  the p a r t i c i p a n t s i n t h i s study  experienced physical d i s a b i l i t y limiting their to which  of  Regardless of the s e v e r i t y of  r e l a t i o n s h i p s and b u i l d t h e new  t o d e a l w i t h new  life"  to  l o s s e x p e r i e n c e s , one's sense  be t h e i n s t a b i l i t y o f t h e p e r s o n ' s  social  his  continues  view o f h i s i l l n e s s undergoes  due t o t h e s u b s e q u e n t  cannot  was  needs.  As a p e r s o n ' s  personal  met  for sensory  t o r e v i s e h i s g o a l s and t h e c o p i n g b e h a v i o u r s meet h i s  now  a t t h i s t i m e b u t t h i s man  s e a r c h i n g f o r new This will  between  they were p r e v i o u s l y  each "normal  accustomed.  Although  c a r d i a c disease i s not o f t e n v i s i b l e ,  the  physical  c h a n g e t h a t has o c c u r r e d n e c e s s i t a t e s a  115 d r a s t i c and of s e l f .  p a i n f u l r e v i s i on o f t h e i n d i v i d u a l s  T h i s r e v i s i o n may  the i l l n e s s p r o g r e s s e s changes.  be a c o n t i n u o u s  and  concept  process  as t h e p e r s o n ' s  as  disability  A r e v i s i o n o f s e l f - c o n c e p t i s demanded f o r a  p a t i e n t t o become p o s i t i v e l y m o t i v a t e d Mullen  (1978) d e s c r i b e s  (Martin,  an e q u a t i o n  for  1970).  clarifying  self-esteem. Self-esteem  =  success pretentions  When s u c c e s s  i n t h e f o r m o f a b i l i t y , and  physical  capacity i s changed, maintenance of self-esteem  depends  upon d e c r e a s i n g  that  the d e n o m i n a t o r .  t h e h o u s e n e e d n o t be k e p t p r e c i s e l y cared now  T h i s may  so c l e a n o r t h a t t h e y a r d  for personally.  one  can  one  t h i n k s n e e d s t o be d o n e .  do c a n be o f f s e t by c u t t i n g b a c k on Self-esteem,  P a r t i c i p a n t s r e l a t e d how perspectives  had  He w a n t e d t o p u t s u c h as s p e n d i n g on  system balance  a new  more  t h a t were  normal  included  his  time  Coping behaviours  u s e d by t h e p a r t i c i p a n t s t o r e a c h behavioural  and  One  l e s s t i m e a t work and  consuming household t a s k s . achieve  depends  t h a t t h e t h i n g s he u s e d t o w o r r y  energy i n t o other areas f a m i l y and  then  their attitudes  about were not worth the e n e r g y . time with  what  self".  c h a n g e d a f t e r t h e MI.  participant explained  so  C u t t i n g back i n what  on t h e a l t e r a t i o n o f o n e ' s " i d e a l  reduced  mean  an  and  116 attitudinal  c h a n g e , a new  p e r s p e c t i v e on l i f e and  c a p a c i t i e s and a c o n s c i o u s d e c i s i o n t o c h a n g e things.  T h i s was  one's  certain  i n c o n t r a s t to the b e g i n n i n g  stages  of change where i n d i v i d u a l s o f t e n f e l t f o r c e d to change r a t h e r t h a n c h o o s i n g t o do s o . r e s i s t e d or were u n a b l e  T h o s e who  to view themselves  c o n t i n u e d to e x p e r i e n c e d e n i a l , anger different times. also unable  Perhaps  t h o s e who  to view themselves  of one's s e l f concept  which  system  and d e p r e s s i o n a t  used d e n i a l were  differently.  t o be  balance  by c o p i n g  i s in a balanced  i t s environment  Model f o r N u r s i n g ,  a new  behaviour  normal  system  normal  for  behaviours  r e l a t i o n s h i p with 1980).  i s embodied i n the concept  b a l a n c e as i n d i v i d u a l s a r e  tensions using s u i t a b l e coping behaviours. a new  revision  developed.  such t h a t the system  Reaching  A  i s a dynamic s t a t e i n  t e n s i o n s are being reduced  (UBC  differently  d i d seem t o be n e c e s s a r y  suitable coping behaviours Behavioural  consciously  of  reducing The  idea of  r e f e r s to the change i n a t t i t u d e or  p e r s p e c t i v e t h a t has r e s u l t e d w i t h i n one o r more subsystems  w i t h the r e s u l t t h a t the needs of the  individual  a r e met  but perhaps  i n a new  way.  As t h e i n d i v i d u a l s r e s u m e d some o f t h e i r  former  a c t i v i t i e s and e x p e r i e n c e d i m p r o v e m e n t i n t h e i r physical  and e m o t i o n a l  c o n d i t i o n they expressed  for continued successes.  Some h o p e d t h a t t h e i r  hope  117 l i m i t a t i o n s w o u l d n o t be p e r m a n e n t and t h a t t h e y continue to improve. had c o r o n a r y  One  man  on h i s f a i t h i n One  powerful  hoped f o r a cure i f they  a r t e r y bypass surgery or followed a  certain diet. based  Others  would  spoke o f h i s hope f o r h e a l i n g God.  o f a human b e i n g ' s m o s t v a l u e d , p r i v a t e and r e s o u r c e s i s hope.  a c c o m p a n i e s and  i s based  Hope i s t h e a f f e c t  upon f a i t h  (Miller,  that  1983).  Hope t h a t i s c o n s t r u c t i v e i s more t h a n a s u p e r f i c i a l wish.  Personal  goal s e t t i n g , m o d i f i c a t i o n of goals  a r e a l i s t i c v i e w o f t h e p a s t , p r e s e n t and plans to reach g o a l s i s i m p o r t a n t hope.  Peace o f mind through  and  future with  i n moving  toward  the f u l f i l l m e n t of  goals  and h o p e s w i l l  meet needs the e g o - v a l u a t i v e , a c h i e v i n g  and a f f e c t i v e  subsystems.  Mullen prominent,  (1978) found  t h a t " w h i l e t h e MI i s s t i l l  patients reassess their l i f e goals  r e f e r e n c e to t h e i r p e r s o n a l of 1 i f e " (p.  with  d e f i n i t i o n s of the q u a l i t y  229).  P a t i e n t s interviewed i n t h i s study  described  c h a n g e s i n t h e i r v a l u e s , g o a l s and p r i o r i t i e s . any l o s s , may  With  come a g a i n w h i c h i s t h a t w h i c h c a n be  v a l u e t o t h e i n d i v i d u a l (UBC  Model f o r N u r s i n g ,  A d e e m p h a s i s on work and an e m p h a s i s on r e l a t i o n s h i p s was  1980).  family  m e n t i o n e d as a g a i n r e s u l t i n g f r o m  t h e i r l o s s of physical c a p a c i t i e s .  One  man  felt  of  that  118 h i s i l l n e s s was new  a b e n e f i t to h i s f a m i l y because  of  r e s p o n s i b i l i t i e s t h a t i t gave to h i s w i f e and As i n d i v i d u a l s made c h a n g e s t o r e d u c e  the son.  their  risk  o f a f u t u r e MI and n o r m a l i z e t h e i r l i v e s , t h e y m o v e d b e t w e e n t h e t h r e e theme a r e a s .  F l u c t u a t i o n s between  a r e a s o c c u r r e d as b a s i c human n e e d s w e r e a f f e c t e d by v a r i o u s f o r c e s and a b i l i t i e s a t v a r i o u s t i m e s  during  t h e p e r i o d f r o m t h e i r MI t o t h e t i m e o f t h e i n t e r v i e w s . Because the needs of the subsystems  are i n t e r a c t i n g  i n t e r d e p e n d e n t , the e f f e c t s of change w i l l be s e e n t h r o u g h o u t  the system.  With  time however  with the r e p e a t e d r i s e of e f f e c t i v e c o p i n g the i n d i v i d u a l s w i l l and  s t a b i 1 i ty .  continue  achieve behavioural  and to and  behaviours,  system  balance  119 CHAPTER  SUMMARY AND  T h i s s t u d y was  SIX  I M P L I C A T I O N S FOR  NURSING  designed to gain u n d e r s t a n d i n g  p a t i e n t s e x p e r i e n c e s w i t h an MI by d e s c r i b i n g new already established coping behaviours p a t i e n t s a f t e r an MI i n an a t t e m p t b a s i c human n e e d s . coping behaviours  utilized  to s a t i s f y  L i t t l e has b e e n w r i t t e n  of or  by their  about  i n r e l a t i o n to the s a t i s f a c t i o n  of  b a s i c human n e e d s f r o m t h e p a t i e n t ' s p e r s p e c t i v e . T h e r e f o r e t h i s s t u d y a d d s a d i f f e r e n t p e r s p e c t i v e by viewing b e h a v i o u r change i n r e l a t i o n to meeting human  needs. T h i s v i e w p o i n t was  f o u n d i n t h e UBC  based  upon a s y s t e m  Model f o r N u r s i n g .  From  framework this  p e r s p e c t i v e , the i l l n e s s e x p e r i e n c e of the was  basic  described through  examination  goals of a b e h a v i o u r a l system. in the b e h a v i o u r a l system  individual  of the needs  Because the  and  subsystems  are a l l i n t e r r e l a t e d  and  i n t e r d e p e n d e n t t h e e f f e c t s o f unmet n e e d s a r e s e e n i n various  subsystems.  A q u a l i t a t i v e methodology using grounded was  theory  u s e d t o e l i c i t t h e MI p a t i e n t s ' v i e w p o i n t s o f  experience.  Seven p a r t i c i p a n t s ,  f e m a l e , r a n g i n g i n age  s i x m a l e and  their  one  f r o m 45 y e a r s t o 69 y e a r s o f  age  120  were i n t e r v i e w e d seven initial  t o twelve months a f t e r  MI u s i n g a s e m i - s t r u c t u r a l i n t e r v i e w g u i d e  open-ended Three  with  questions. i n t e r r e l a t e d themes were d e v e l o p e d  research findings:  coping behaviours  r e d u c t i o n , g e t t i n g back t o normal normal.  their  The f i r s t  Some c h a n g e s w e r e i m p o s e d  related to risk  a n d r e a c h i n g a new  theme a d d r e s s e d  i n d i v i d u a l s made t o r e d u c e  from t h e  changes that  t h e i r r i s k o f a second  MI.  by s t r o n g f o r c e s a n d o t h e r  c h a n g e s w e r e made by c h o i c e .  Nurses  in t h i s p r o c e s s o f change perhaps  were n o t mentioned  because  they d i dnot  a s s i s t i n change o r were n o t v i s i b l e as p a t i e n t t e a c h e r s w h i l e t h e s e changes were  happening.  I t was e v i d e n t t h a t p r e v i o u s c o p i n g  behaviours  w e r e u t i l i z e d a n d new o n e s w e r e d e v e l p e d needs t h a t a r o s e . spouses  t o meet t h e  The p a r t i c i p a n t s r e f e r r e d t o t h e i r  as b e i n g h e l p f u l and s u p p o r t i v e .  The s h a r e d  r e s p o n s i b i l i t y f o r m a n a g i n g c e r t a i n c h a n g e s was a positive force i n f l u e n c i n g suitable coping  behaviours.  These t h r e e themes a r e n o t n e c e s s a r i l y e x p e r i e n c e d by p a r t i c i p a n t s i n t h e o r d e r p r e s e n t e d .  Because o f the  i n t e r r e l a t i n g , interdependent nature o f the in t h e b e h a v i o u r a l system  subsystems  e v e n t s a n d f o r c e s may  the needs o f v a r i o u s subsystems. f o l l o w i n g an MI d o e s n o t a l w a y s  Loss  affect  experienced  follow a particular  121  pattern or response  b u t h a s many d i m e n s i o n s  experienced  in v a r i o u s ways. Areas o f change which  w e r e made i n t h e i n i t i a l  few  w e e k s f o l l o w i n g t h e i r MI w e r e d i e t a r y m o d i f i c a t i o n s , smoking c e s s a t i o n , m e d i c a t i o n - t a k i n g and e x e r c i s e . Most o f t h e p a r t i c i p a n t s had d e v e l o p e d  a pattern f o r  d e a l i n g w i t h t h e s e r i s k f a c t o r s i n o r d e r t o meet needs.  I t w o u l d be i n t e r e s t i n g t o i n t e r v i e w t h e s e  people i n another compare The  their  s i x t o twelve months i n o r d e r t o  results. second  theme a l s o i n v o l v e d c h a n g e s made i n  their search f o r normality.  The p a r t i c i p a n t s mentioned  the a r e a s o f r e t u r n i n g t o t h e i r work, changes i n t h e i r r e l a t i o n s h i p w i t h t h e i r f a m i l y and f r i e n d s and t h e physical  l i m i t a t i o n s imposed  by c h e s t p a i n a n d o t h e r  symptoms w h e r e c o p i n g b e h a v i o u r s w e r e r e q u i r e d t o m e e t t h e i r needs.  L o s s e s e x p e r i e n c e d a s a r e s u l t o f t h e MI  w e r e r e a l i z e d a n d h a d an i m p a c t on f o r m e r  roles i n the  f a m i l y and s o c i e t y . The  participants' descriptions of their  attitudinal  and p e r s p e c t i v e changes were d e v e l o p e d i n  the theme, Coping Normal.  Behaviours  Related to Reaching  a New  Coming to g r i p s w i t h t h e meaning o f t h e i r  i l l n e s s and s e t t i n g r e a l i s t i c g o a l s and e x p e c t a t i o n s for themselves  embodied t h i s theme.  To a l a r g e e x t e n t  t h i s a r e a was f o u n d t o r e f l e c t t h e i r s e l f - c o n c e p t by  122  the presence  o f low o r high s e l f - e s t e e m .  Due t o t h e  u n c e r t a i n t y o f t h e i r f u t u r e , h o p e was a c o n c e p t emerged from t h e d a t a .  that  E x p r e s s i o n s o f hope i n v o l v e d  hope f o r a c u r e , hope f o r h e l p f r o m s u r g e r y o r o t h e r treatments  a n d hope a n d f a i t h i n G o d .  Studying the changes experienced  by i n d i v i d u a l s  a f t e r an MI f r o m t h e i r p e r s p e c t i v e l e a d s t o t h e f o l l o w i n g i m p l i c a t i o n s f o r n u r s i n g p r a c t i c e and n u r s i n g research.  Implications f o r Nursing Practice  The  UBC M o d e l f o r N u r s i n g  (1980) s t a t e s t h a t  nursing nurtures i n d i v i d u a l s during c r i t i c a l  p e r i o d s so  t h a t t h e y may d e v e l o p a n d u s e a r a n g e o f c o p i n g behaviours  t o s a t i s f y t h e i r b a s i c human n e e d s .  r e s u l t s o f t h i s study suggest  The  t h a t n u r s i n g does n o t  c u r r e n t l y h a v e an a c t i v e r o l e i n t h e p o s t h o s p i t a l p h a s e o f r e h a b i l i t a t i o n a f t e r an MI. that the r e h a b i l i t a t i o n period i s s t i l l p e r i o d because need  I t w o u l d seem a critical  i t i s a t t h i s t i m e when p a t i e n t s  still  assistance in developing s u i t a b l e coping  behaviours  t o m e e t t h e i r b a s i c human n e e d s .  Many  f o r c e s as w e l l as c o g n i t i v e and e x e c u t i v e  abilities  r e q u i r e m a n i p u l a t i o n i n o r d e r t o make s u r e  coping  behaviours  are suitable.  N u r s i n g n e e d s t o be a w a r e o f  123  the problems and concerns  that confront patients  during  t h e i r r e h a b i l i t a t i o n so t h a t t h e y a r e a b l e t o i n t e r v e n e when a p p r o p r i a t e human  t o h e l p p a t i e n t s meet t h e i r  basic  needs. The  f i n d i n g s o f the study  suggest  r i s k r e d u c t i o n has y e t t o e x p e r i e n c e  that the area of the c o n t r i b u t i o n  that the n u r s i n g p r o f e s s i o n s has to o f f e r . model o f d i s e a s e a n d t r e a t m e n t thus f a r .  The m e d i c a l  has been t h e main  focus  A f o c u s on t h e h e a l t h o f t h e i n d i v i d u a l a n d  how t o m e e t h i s b a s i c human n e e d s w o u l d a s s i s t t h e individual  t o make a p p r o p r i a t e l i f e s t y l e c h a n g e s  and a f t e r t h e e v e n t The  before  o f an MI.  findings provide  nursing practice i n  specific implications for  developing  p a t i e n t and f a m i l y c o p i n g  and  behaviours  strengthening directed at  m e e t i n g t h e b a s i c n e e d s o f t h e p a t i e n t f o l l o w i n g an MI. Nurses s h o u l d p r o v i d e o p p o r t u n i t i e s f o r t h e p a t i e n t and members w i t h i n t h e f a m i l y t o s h a r e the e x p e r i e n c e expressions  t h e i r f e e l i n q s about  a n d l i s t e n t o t h e f a m i l y members  and responses  members w e r e f o u n d  t o l o s s and g r i e f .  t o be a v e r y i m p o r t a n t  As f a m i l y  source of  support,  n u r s i n g i n t e r v e n t i o n s toward s u p p o r t i n g and  teaching  them w i l l  the i n d i v i d u a l  a s s i s t i n meeting both the needs o f  and f a m i l y .  P a t i e n t t e a c h i n g h a s b e e n an i d e n t i f i e d a r e a o f the n u r s i n g p r o f e s s i o n b u t has o f t e n c o n c e n t r a t e d  on  124  imparting medical on how  i n f o r m a t i o n r a t h e r than  to s t r e n g t h e n  and d e v e l o p  information  coping behaviours  w i l l m e e t i n d i v i d u a l and f a m i l y n e e d s .  Nursing  that  should  p r o v i d e i n f o r m a t i o n t o f a m i l y and p a t i e n t r e g a r d i n g s p e c i f i c p r o b l e m s t h a t may deal with  be e n c o u n t e r e d  and ways t o  them.  From t h i s s t u d y , i t i s i m p o r t a n t  to see  that  p a t i e n t s s h o u l d be r e c o g n i z e d as i m p o r t a n t p a r t i c i p a n t s i n t h e i r c a r e s i n c e t h e y manage and c o n t r o l l i f e s t y l e s once they are out of h o s p i t a l .  their This  should  be b e g u n i n h o s p i t a l u s i n g s t r a t e g i e s t o e n c o u r a g e development of coping behaviours t r a n s f e r r e d o n c e t h e y go home.  t h a t can  the  be  An e x a m p l e o f t h i s i s a  s e l f - m e d i c a t i o n program while i n h o s p i t a l i n preparation for discharge.  P a t i e n t s s h o u l d be  given  p r e p a r a t i o n and k n o w l e d g e t o a n t i c i p a t e c e r t a i n b o d i l y symptoms and  side effects.  This will  h e l p them a v o i d  the undue a n x i e t y t h a t a r i s e s from l a c k o f understanding.  As t h e p a t i e n t i s u l t i m a t e l y t h e  prime  manager of the e f f e c t s of h i s i l l n e s s , h e l p i s r e q u i r e d t o a c c u r a t e l y i n t e r p r e t and g u i d e t h e a c t i o n s  decided  upon. The  study i l l u s t r a t e d  some o f t h e n e e d s o f  p a t i e n t s s e v e n t o t w e l v e m o n t h s p o s t MI. f r a m e w o r k o f t h e UBC  Model f o r N u r s i n g  Using  MI the  the needs most  a f f e c t e d at various stages during r e h a b i l i t a t i o n  were  125 identified.  I t i s d i f f i c u l t t o s e t up r o u t i n e c a r d i a c  t e a c h i n g programs with i n d i v i d u a l s having v a r y i n g needs at d i f f e r e n t times.  T h i s d o e s n o t mean t h a t t e a c h i n g  s h o u l d be n e g l e c t e d b u t r a t h e r t h a t a g o o d  assessment  of the l e a r n e r should take place with a program s u i t e d to t h e needs o f t h e i n d i v i d u a l .  P e r h a p s t h i s i s a good  t i m e t o i n t r o d u c e a n u r s i n g model s u c h a s t h e UBC M o d e l f o r N u r s i n g on w h i c h t o b a s e c a r d i a c t e a c h i n g to p r o v i d e i n d i v i d u a l i z e d c a r e . p r o v i d e a way o f v i e w i n g  programs  A n u r s i n g model  would  n u r s i n g and t h e p a t i e n t so  t h a t i n d i v i d u a l ' s n e e d s w o u l d n o t be n e g l e c t e d . As s e e n f r o m t h e p a r t i c i p a n t s i n t h i s i n d i v i d u a l s h a v i n g an MI a t a b o u t  study,  t h e same t i m e a r e a t  very d i f f e r e n t p o i n t s i n t h e i r p r o c e s s o f change and the d e v e l o p i n g o f b e h a v i o u r s .  G r o u p l e a r n i n g may  p r o v i d e on way t o g i v e p a r t i c i p a n t s an o p p o r t u n i t y t o hear about  the problems of others that are s i m i l a r to  t h e i r own a n d a b o u t not coped The  with  how o t h e r s h a v e s u i t a b l y c o p e d o r  them.  p a r t i c i p a n t s i n t h i s study r e c e i v e d l i t t l e or  no t e a c h i n g on an o n g o i n g d i s c h a r g e from  formative basis after  the h o s p i t a l .  The major s o u r c e o f  i n f o r m a t i o n when t h e y w e n t home was t h e i r p h y s i c i a n . The  p a r t i c i p a n t s d i d n o t seem a v e r s e t o n u r s i n g  but had n o t e x p e r i e n c e d nurses  counselling or teaching  input, from  f o l l o w i n g d i s c h a r g e from h o s p i t a l . P a r t i c i p a n t s  126 were not always c o m f o r t a b l e  "bothering  the d o c t o r  their questions".  Reducing t h e i r risk f a c t o r s  somewhat c o n f u s i n g  or vague f o r those  reading  h e a r i n g c o n f l i c t i n g r e p o r t s on t h e m e d i c a l c e r t a i n areas  s u c h as d i e t and  It i s necessary  with  was and  research  exercise.  to examine the r e a c t i o n s  and  behaviours  o f i n d i v i d u a l s o v e r a p e r i o d o f t i m e and  just while  i n h o s p i t a l or i n the p h y s i c i a n ' s  Community n u r s i n g f o l l o w u p i n d i v i d u a l s who  and t e a c h i n g  not  office.  i s needed f o r  h a v e had an MI and a r e now  to r e v i s e t h e i r former  of  attempting A  nursing  l i a s o n b e t w e e n t h e h o s p i t a l and t h e c o m m u n i t y  nursing  agencies  patterns of l i v i n g .  might p r o v i d e c o n t i n u i t y f o r the p a t i e n t s  t h e i r needs.  Clinical  h o s p i t a l s and  have the n e c e s s a r y  research  s p e c i a l i s t s who theory,  s k i l l s c o u l d be i n s t r u m e n t a l  l i a i s o n from research  nurse  work i n  p r a c t i c e and  i n s e t t i n g up a  h o s p i t a l t o t h e c o m m u n i t y , s e t t i n g up  s t u d i e s and p r o v i d i n g i n f o r m a t i o n  c o u n s e l l i n n t o p a t i e n t s d u r i n g and hospital  and  and  following their  experience.  L i t t l e a t t e n t i o n has b e e n g i v e n by n u r s i n g other h e a l t h p r o f e s s i o n a l s to the personal  growth  experienced  by t h o s e w i t h  illnesses.  W i t h an e m p h a s i s on c a r e r e g i m e n s and d a i l y  t a s k s t o be a c c o m p l i s h e d , overlooked  by n u r s i n g .  s e r i o u s and  and  personal Nursing  may  chronic  g r o w t h may  be  learn a great  deal  127  overlooked from  by n u r s i n g .  N u r s i n g may  l e a r n a g r e a t deal  those l i v i n g with i l l n e s s e s . Changes i n v a l u e s  b e l i e f s may  be s u p p o r t e d  and c l a r i f i e d by  s e n s i t i v e to the needs of the  and  those  individual.  T h i s r e s e a r c h study of the coping behaviours d u r i n g MI r e h a b i l i t a t i o n c o n t r i b u t e s t o t h e  used  knowledge  base t h a t n u r s e s can use to i m p r o v e the c a r e g i v e n these p a t i e n t s .  By u s i n g a s y s t e m  m o d e l and  to  studying  b a s i c human n e e d s , t h e i n d i v i d u a l i s v i e w e d  as a w h o l e  w i t h i n t e r a c t i n g and  Further  interdependent  needs.  s t u d y by n u r s i n g i s r e q u i r e d t o a s s e s s t h e u t i l i t y o f a n u r s i n g model i n p r a c t i c e . based  S t u d i e s s h o u l d be  devised  on a n u r s i n g m o d e l i n o r d e r t o e x a m i n e f u r t h e r  the unique  a s p e c t t h a t n u r s i n g c o n t r i b u t e s to the  care  of the i ndi v i dual . The  UBC  Model f o r N u r s i n g  s t a t e s t h a t n u r s i n g ' s unique  (1980) used  in this  f u n c t i o n i s to  individuals experiencing critical  periods.  i s t o f o s t e r , p r o t e c t , s u s t a i n and t e a c h .  study  nurture To  nurture  Further  study i n t o these areas of n u r s i n g i n t e r v e n t i o n would h e l p n u r s e s more s p e c i f i c a l l y a s s i s t p a t i e n t s to develop  and u s e s u i t a b l e c o p i n g  behaviours.  I n t e r v e n t i o n s t r a t e g i e s to help i n the development of a range  of coping behaviours  w o u l d be u s e f u l t o p r o m o t e  n e e d s a t i s f a c t i o n f o r t h e MI  patient.  128  Implications f o r Nursing  Although  Research  n u r s i n g r e s e a r c h has been done  with  i n d i v i d u a l s w i t h c o r o n a r y a r t e r y d i s e a s e and s p e c i f i c a l l y t h o s e w i t h an MI, few s t u d i e s h a v e on t h e c o p i n g b e h a v i o u r s  focused  t h a t p a t i e n t s have used to  m e e t t h e i r b a s i c human n e e d s .  This study i s only a  beginning p o i n t to the study of coping  behaviours  w i t h i n t h e f r a m e w o r k o f t h e UBC M o d e l f o r N u r s i n g (1980).  F u r t h e r r e s e a r c h i s needed to study  n e e d s a n d how t o d e v e l o p a n d s t r e n g t h e n behaviours  t o meet c e r t a i n  specific  coping  needs.  The s t u d y h a s r a i s e d some q u e s t i o n s a b o u t c o p i n g behaviours. behaviours  How  d o e s one d e v e l o p a n d s t r e n g t h e n  so t h a t t h e y w i l l  coping  e f f e c t i v e l y meet the b a s i c  human n e e d s o f t h e i n d i v i d u a l ? T h e r e has been l i t t l e a t t e n t i o n g i v e n t o the i n t e r v e n t i o n s and s t r a t e g i e s t h a t e f f e c t i v e l y c l i e n t behaviour.  change  F u r t h e r s t u d i e s are needed to  r e s e a r c h human b e h a v i o u r  a s s o c i a t e d with  coronary  a r t e r y d i s e a s e a n d how t o e f f e c t a b e h a v i o u r p e o p l e p r i o r t o an MI a n d a f t e r an MI.  change i n  In t h i s  study,  t h e e x t e n t o f c o r o n a r y a r t e r y d i s e a s e was unknown t o t h e i n v e s t i g a t o r . Some p a r t i c i p a n t s s h a r e d a b o u t t h e i r c o n d i t i o n as t h e y p e r c e i v e d i t . study might attempt  to answer the q u e s t i o n s :  information Further Does t h e  129 e x t e n t of d i s e a s e a f f e c t the development u t i l i z a t i o n of coping behaviours needs?  and  t o m e e t b a s i c human  A r e t h o s e w i t h m o r e s e v e r e d i s e a s e more o r l e s s  motivated  t o make c h a n g e s i n t h e i r l i f e s t y l e ?  the most i m p o r t a n t  What a r e  factors i n f l u e n c i n g behaviour  change? S p e c i f i c n e e d s s u c h as s e l f - e s t e e m w e r e h i g h l i g h t e d by t h e p a r t i c i p a n t s o f t h e s t u d y .  The  s t u d y s h o w e d t h a t as p a t i e n t s r e v i s e d t h e i r g o a l s i n o r d e r t o m e e t t h e i r n e e d s , s e l f - e s t e e m e m e r g e d as important  need a f f e c t e d d u r i n g t h i s p r o c e s s .  an  It is  d i f f i c u l t t o a t t r i b u t e low s e l f - e s t e e m e n t i r e l y t o MI and  the  i t s e f f e c t s because a p r e v i o u s measure or  d e s c r i p t i o n of. t h e p e r s o n ' s s e l f - e s t e e m p r i o r t o i l l n e s s was  not a v a i l a b l e .  the  I t w o u l d be i n t e r e s t i n g t o  study the e f f e c t of the i l l n e s s with the v a r i o u s change and l o s s on s e l f - e s t e e m w i t h an a c c o u n t  of  the  i n d i v i d u a l ' s p r i o r r e s p e c t f o r s e l f and  their  p e r c e p t i o n o f a l t e r a t i o n t h a t had t a k e n  place.  It i s  the thought of t h i s r e s e a r c h e r t h a t those with high p o s i t i v e s e l f - e s t e e m p r i o r t o t h e i l l n e s s , as by t h e n e e d s and  g o a l s met  previous coping behaviours  period.  and  determining  w i l l meet t h e i r need f o r  self-esteem using s u i t a b l e coping behaviours critical  evidenced  i n other subsystems  t h e i r c o g n i t i v e and e x e c u t i v e a b i l i t i e s  or  after a  130  Although  t h i s study  d i d not deal  directly  with  f a m i l y members a n d f a m i l y f u n c t i o n i n g i n f o r m a t i o n  about  this important  part of the r e h a b i l i t a t i v e process  was  gained  the account  through  of the i n d i v i d u a l s .  F a m i l i e s were p o s i t i v e o r n e g a t i v e  forces playing  large  r o l e s i n t h e c h a n g e s made by i n d i v i d u a l s t o m e e t t h e i r b a s i c human n e e d s .  A study o f family coping  behaviours  as a r e s u l t o f t h e i l l n e s s o f o n e member m i g h t  give  v a l u a b l e i n s i g h t s i n t o t h e a f f e c t o f i l l n e s s on a family unit.  Interviewing  f a m i l y members w o u l d  provide  the p e r s p e c t i v e o f those  c l o s e l y involved with the  i l l n e s s of a loved one.  A question  f o r future  m i g h t a s k : What a r e t h e e x p e r i e n c e s p a t i e n t w i t h an MI? developed  and used  of families of a  What a r e t h e c o p i n g  behaviours  by f a m i l i e s t o m e e t t h e i r b a s i c  human n e e d s when o n e member h a s an MI? with  research  A model  dealing  f a m i l y f u n c t i o n i n g a n d n e e d s w o u l d be h e l p f u l i n  c a t e g o r i z i n g and a n a l y z i n g t h e d a t a . In t h e f i n d i n g s o f t h i s s t u d y  t h e r e was m e n t i o n  made o f t h e l a c k o f t e a c h i n g o r o t h e r n u r s i n g once t h e p a t i e n t l e f t t h e h o s p i t a l . MI p a t i e n t s a n d t h e c o p i n g  behaviours  input  The e x p e r i e n c e  of  t h e y u s e m u s t 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 n t e r v e n t i o n s i n h o s p i t a l and i n t h e p h y s i c i a n ' s  office  are not enough.  N u r s e s n e e d t o be i n v o l v e d w i t h  these  p a t i e n t s through  community f o l l o w u p  groups  o r community  131  to f a c i l i t a t e  the use o f s u i t a b l e c o p i n g  S t u d i e s n e e d t o be c o n d u c t e d  utilizing  behaviours.  community  followup f o r these p a t i e n t s to determine  how t o a s s i s t  p a t i e n t s t o meet t h e i r needs and t o d e t e r m i n e i f f o l l o w u p a f f e c t s a p o s i t i v e b e h a v i o u r c h a n g e t o meet b a s i c human n e e d s . Q u e s t i o n s a l s o a r i s e from t h i s study r e g a r d i n g patient teaching.  Does p a t i e n t t e a c h i n g d e v e l o p  b e h a v i o u r s t o m e e t b a s i c human n e e d s ? e f f e c t i v e time f o r teaching?  coping  When i s t h e m o s t  What s h o u l d be t a u g h t ?  Rather than o n l y p r o v i d i n g i n f o r m a t i o n - g i v i n g s e s s i o n s , p e r h a p s t e a c h i n g s h o u l d c o n c e n t r a t e on t h e d e v e l o p m e n t of c o p i n g b e h a v i o u r s p r o v i d i n g the n e c e s s a r y i n f o r m a t i o n f o r p a t i e n t s t o m e e t t h e i r b a s i c human needs through the use o f s u i t a b l e c o p i n g  behaviours.  132  Summary  This study behaviours  was  designed  t h a t i n d i v i d u a l s use  human n e e d s d u r i n g  behaviours  emerging themes.  coping  to meet t h e i r b a s i c  r e h a b i l i t a t i o n f o l l o w i n g an MI.  f i n d i n g s of the study coping  to examine the  revealed  t h a t MI  patients  t h a t were c a t e g o r i z e d Coping behaviours  using  used three  r e l a t e d to r i s k  r e d u c t i o n , g e t t i n g b a c k t o n o r m a l and  reaching  normal were d e s c r i b e d  and  The  be h e l p f u l f o r n u r s e s  t o i d e n t i f y ways t o a s s i s t  individuals in developing behaviours  discussed.  and  using  a  new  findings  suitable  may  coping  t o m e e t t h e i r b a s i c human n e e d s d u r i n g  r e h a b i 1 i t a t i on.  The  MI  133  BIBLIOGRAPHY American P s y c h o l o g i c a l A s s o c i a t i o n . (1983). Manual of the American P s y c h o l o g i c a l A s s o c i a t i o n . ( 3 r d . ed.). A n d r e o l i , K., F o w k e s , V., Z i p e s , D., W a l l a c e , A . ( E d s . ) . (1983). Comprehensive c a r d i a c care. (5th ed.). S t . L o u i s i C. V. M o s b y Company. A p p l e y , M & T r u m b u l l , R. (1967). P s y c h o l o g i c a l s t r e s s . New Y o r k : A p p l e t o n - C e n t u r y - C r o f t s . B a u w e n s , E . , A n d e r s o n , S.V., & B u e r g i n , P.( 1 9 8 3 ) . Chronic i l l n e s s . In P. P h i pp, B. L o n g , & A. Woods. M e d i c a l - s u r g i c a l n u r s i n g , c o n c e p t s and c l i n i c a l practice. Toronto: C. V. M o s b y Company. B o w l b y , J . ( 1 9 8 0 ) . A t t a c h m e n t and l o s s : Loss. ( V o l . 3 ) . New Y o F F i B a s i c Books Inc. B u r g e s s , A., L e r n e r , D., & H a r t m a n , C. (1983). P o l i c y i s s u e s f o r c a r d i a c r e h a b i l i t a t i o n programs. Image: The J o u r n a l o f N u r s i n g S c h o l a r s h i p , 15 , 3 , 75-79 . Canada. (1983). Causes of death (Catalogue 84-203). O t t a w a : M i n i s t e r o f S u p p l y and S e r v i c e s C a n a d a . C a r l s o n , C a r o l y n . (1981). Methods of c o p i n g . In N. M a r t i n , N. H o l t , D. H i c k s ( E d s . ) , C o m p r e h e n s i ve r e h a b i l i t a t i o n n u r s i n g . New Y o r k : McGraw-Hi11. Crate, M a r j o r i e . (1965). Nursing f u n c t i o n s in a d a p t a t i o n to c h r o n i c i l l n e s s . AJN, 65, 10, 7 2 - 7 6 . C r o o g , S.H., L e v i n e , S.S., & L u r i e , B. (1968). The h e a r t p a t i e n t and t h e r e c o v e r y p r o c e s s . S o c i a l S c i e n c e and M e d i c i n e , 2, 1 1 1 - 1 6 4 . D i e r s , Donna. (1979). P h i l a d e l p h i a : J.B.  Research in nursing p r a c t i c e . L i p p i n c o t t Company.  D o e h r m a n , S.R. (1977). Psychosocial aspects of r e c o v e r y from c o r o n a r y h e a r t d i s e a s e : A review. S o c i a l S c i e n c e and M e d i c i n e , 11, 1 9 9 - 2 1 9 . D o u g l a s , J . E . , W i l k e s , T. (1975). Reconditioning c a r d i a c p a t i e n t s . Am. F a m i l y P h y s . , 11, 1 2 3 - 1 2 9 .  134  D u r b i n , E . , & G o l d u a t e r , L. of the c a r d i a c p a t i e n t . Eyer, J . (1980). Social disease. Psychother.  (1956). R e h a b i l i t a t i o n C i r c u l a t i o n , 13, 4 1 0 .  causes of coronary heart P s y c h o s o m . , 3_4, 75.  F o s t e r , S., & A r d r e o l i , K. (1970). f o l l o w i n g i n f a r c t i o n . AJN, 70, F r i e d m a n , M., & R o s e n m a n , R.H. b e h a v i o u r and y o u r h e a r t . Fawcett P u b l i c a t i o n s . F r o e s e , A., H a c k e t t , T r a j e c t o r i e s of and now d e n y i n g patients during R e s . , JL8, 4 3 .  Behaviour 2344.  (1974). Type A Greenwich:  T., & C a s s e n , N. (1974). a n x i e t y and d e p r e s s i o n i s d e n y i n g acute myocardial i n f a r c t i o n h o s p i t a l i z a t i o n . J . Psychosom.  G e r a r d , Peggy & P e t e r s o n , Leona. (1984). Learning needs of c a r d i a c p a t i e n t s . C a r d i o v a s c u l a r N u r s i n g , 20_, 2, 7-11. G l a s e r , B.G. (1978). T h e o r e t i c a l s e n s i t i v i t y . Advances i n the methodology of grounded t h e o r y . Mill Val1ey: The S o c i o l o g y P r e s s . G l a s e r , B.G., & S t r a u s s , A . L . ( 1 9 6 7 ) . The d i s c o v e r y of grounded t h e o r y : S t r a t e g i e s f o r q u a l i t a t i v e r e s e a r c h . New Y o r k : A l d i n e P u b l i s h i n g Company. Granger, J . (1974). F u l l r e c o v e r y from m y o c a r d i a l infarction: P s y c h o s o c i a l f a c t o r s . Heart & Lung, 3, 4, 6 0 0 - 6 0 9 . G r e e n , A. (1975). S e x u a l a c t i v i t y and p o s t m y o c a r d i a l i n f a r c t i o n p a t i e n t s . Am. H e a r t J o u r n a l . 8 9 , 246. G r o d e n , B. M. (1967). R e t u r n t o work a f t e r i n f a r c t i o n . S c o t t i s h Medical J o u r n a l , 12, ,9, 2 9 7 - 3 0 1 .  myocardial  G u z z e t t a , C a t h i e E. ( 1 9 7 9 ) . R e l a t i o n s h i p between s t r e s s and l e a r n i n g . ANS, 1, 4, 3 5 - 4 9 . H a c k e t t , T., & C a s s e n , N. (1974). Development of a q u a n t i t a t i v e r a t i n g s c a l e to a s s e s s d e n i a l . J . P s y c h o s o m . R e s . , 18, 9 3 .  135 H a m b u r g , D., & Adams, J . ( 1 9 6 7 ) . A p e r s p e c t i v e on coping behaviour. Archives of General P s y c h i a t r y , 1_7 . 2 7 7 - 2 8 4 . H e l l e r s t e i n , H.K., & F r i e d m a n , E.H. (1970). Sexual a c t i v i t y and t h e p o s t c o r o n a r y p a t i e n t . A r c h i v e s o f I n t e r n a l M e d i c i n e , 125, 992. Hindle., P a u l a , W a l l a c e , Andrew. ( 1983). C o m p l i c a t i o n s o f c o r o n a r y a r t e r y d i s e a s e . In K. A n d r e o l i , V. F o w k e s , D. Z i p e s , & A. W a l l a c e ( E d s . ) , Comprehensive c a r d i a c care. (5th ed.). ( p p . 1 3 6 - 1 6 6 ) . S t L o u i s : C. V. M o s b y C o m p a n y . H o l u b , B. (1986). Assessment of the d i e t a r y c h o l e s t e r o l - b l o o d r e l a t i o n s h i p . R a p p o r t , l_,  2.  J a c o b s e n , E. ( 1 9 6 4 ) . A n x i e t y and t e n s i o n c o n t r o l . P h i l a d e l p h i a : J . B. L i p p i n c o t t . J e n k i n s , C. D. ( 1 9 7 8 ) . Behavioural risk factors in c o r o n a r y a r t e r y d i s e a s e . A n n a l s Rev. Med., 29, 543 . K a v a n a u g h , T., S h e p h a r d , R . J . , & T u c k , J . A . Depression after myocardial i n f a r c t i o n . C a n a d i a n M e d i c a l A s s o c i a t i o n , 113, 25.  (1975). Journal of  Keane, Anne. (1981). Developmental i s s u e s i n c a r d i a c d i s e a s e . In W. M c G u i n ( E d . ) . P e o p l e w i t h c a r d i a c problems: Nursing concepts. (pp. 401-423 ). P h i l a d e l p h i a: J . B. L i p p i n c o t t . K i n n e y , M., D e a r , C , P a c k a , D., V o o r m a n , D. ( E d s . ) . ( 1 9 8 1 ) . AACN's c l i n i c a l r e f e r e n c e f o r c r i t i c a l - c a r e n u r s i n g ^ New Y o r k : M c G r a w - H i l l Book Company. K o l l e r , R, K e n n e d y , J . W., B u t l e r , J . (1972). C o u n s e l l i n g t h e c o r o n a r y p a t i e n t on s e x u a l activity. P o s t g r a d . Med., 5 1 , 134. L a m b e r t , V. Clinton:  (1979). The i m p a c t Prentice-Hall.  of p h y s i c a l  illness.  L a z a r u s , R. ( 1 9 6 6 ) . P s y c h o l o g i c a l s t r e s s and t h e c o p i n g p r o c e s s . New Y o r k : McGraw-Hi11. L a z a r u s , R., & F o l k m a n , S. and c o p i n g . New Y o r k : Company.  ( 1984). S t r e s s , apprai sal Springer Publishing  136  L e i n i n g e r , M. ( E d . ) . ( 1 9 8 5 ) . Q u a l i t a t i v e r e s e a r c h methods i n n u r s i n g . O r l a n d o ! Grune & S t r a t t o n . L e v i n , K. (1951). F i e l d theory in social s c i e n c e . New Y o r k : H a r p e r & Row P u b l i s h e r s . L e v i n e , M. ( 1 9 7 0 ) . The i n t r a n s i g e n t p a t i e n t . A m e r i c a n J o u r n a l o f N u r s i n g , 70, 2 1 0 6 - 2 1 1 1 . L i p o w s k i , Z.J. (1970). P h y s i c a l i l l n e s s , the i n d i v i d u a l and t h e c o p i n g p r o c e s s . P s y c h i a t r y i n m e d i c i n e , j , 91. L  M c L a n e , M., K r o p , H., & M e n t a , J . ( 1 9 8 0 ) . P s y c h o s e x u a l a d j u s t m e n t and c o u n s e l l i n g a f t e r m y o c a r d i a l infarction. A n n a l s o f I n t e r n a l Med. 92, 5 1 4 - 5 1 9 . M a l l a g h a n , M., & P e m b e r t o n , J . ( 1 9 7 7 ) . Some b e h a v i o u r a l c h a n g e s i n 493 p a t i e n t s a f t e r an a c u t e myocardial i n f a r c t i o n . B r i t i s h Journal of P r e v e n t a t i v e and S o c i a l M e d i c i n e , 3 1 , 8 6 - 9 0 . M a r r i s , P e t e r . ( 1 9 7 4 ) . L o s s and c h a n g e . R a u t l e d g e and D e g a n P a u l .  London:  M a r t i n , N. ( 1 9 7 0 ) . N u r s i n g i n r e h a b i l i t a t i o n . In I. Beland (ed.) C l i n i c a l n u r s i n g : P a t h o p h y s i o l o g i c a l and p s y c h o s o c i a l a p p r o a c h e s . ( 2 n d . e d . ) . L o n d o n : Trie M a c M i l l a n Company Col 1 i e r - M a c M i 1 1 an L i m i t e d . M i l l e r , J.F. (1983). Coping with c h r o n i c i l l n e s s : O v e r c o m i n g p o w e r l e s s n e s s . P h i l a d e l p h i a: F.A. D a v i s Company. M i l s u m , J . H. ( 1 9 8 4 ) . H e a l t h , s t r e s s and i l l n e s s . A s y s t e m s a p p r o a c h . New Y o r k : P r a e g e r P u b l i s h e r s . Mullen, Patricia. ( 1 9 7 8 ) . C u t t i n g back a f t e r a h e a r t a t t a c k : An o v e r v i e w . H e a l t h E d u c a t i o n M o n o g r a p h s , 6, 3, 2 9 5 - 3 1 1 . M u r r a y , R., & Z e n t n e r , J . for health promotion. P r e n t i ce-Ha11 I n c .  (1985). 3rd ed.  Nursing concepts Englewood C l i f f s :  N e w t o n , K.M., & S i v a r a j a n , E.S. (1982). Cardiac rehabilitation: L i f e s t y l e adjustments. In S. U n d e r b i l l , S. Woods, E. S i v a r a j a n , & C. H a l p e n n y (Eds.), C a r d i a c N u r s i n g . (pp. 562-571). P h i l a d e l p h i a : J . B . L i p p i n c o t t Company.  137  Owens, J . , M c C a n n , C , & H u t e l m y e r , C. (1978). Cardiac r e h a b i l i t a t i o n : A patient education p r o g r a m . N u r s i n g R e s e a r c h , 27, 3, 1 4 8 - 1 5 0 . Parkes, CM. (1971). Psychosocial transitions: A f i e l d f o r s t u d y . S o c i a l S c i e n c e and M e d i c i n e , 5, 101-115. ~~ P e a r l i n , L., L i e b e r m a n , M., M e n a g h a n , E . , & M u l l e n , J . (1981). The s t r e s s p r o c e s s . J . o f H e a l t h and S o c i a l B e h a v i o u r , 22, 3 3 7 - 3 5 6 . P e a r l i n , L . , S c h o o l e r , C. (1978). The s t r u c t u r e o f c o p i n g . J . o f H e a l t h and S o c i a l B e h a v i o u r , _19, 2-21. P e l l e t i e r , K. R. ( 1 9 7 7 ) . M i n d as h e a l e r , m i n d as s i a y e r . New Y o r k : Delacorte Press. P e r e t z , D. (1970). Development, o b j e c t r e l a t i o n s h i p s and l o s s . In B. S c h o e n b e r g ( E d . ) . L o s s and g r i e f : P s y c h o l o g i c a l management i n m e d i c a l p r a c t i c e . (pp . 3-9 ) . New Y o r k : Columbia U n i v e r s i t y P r e s s . Pinneo, Rose. (1984). L i v i n g with coronary a r t e r y d i s e a s e : The n u r s e s ' r o l e . N u r s i n g C l i n i c s o f N o r t h A m e r i c a , 19, 1, 4 5 9 - 4 6 7 . P r i t i k i n , Nathan. (1979). d i e t and e x e r c i s e . New  The P r i t i k i n p r o g r a m f o r York: G r o s s e t & Dunlop.  R e e d e r , L. G. (1965). E m p l o y m e n t p r a c t i c e s and t h e c a r d i a c . J . o f C h r o n i c D i s e a s e , 18, 9 5 1 - 9 6 3 . R i z z u t o , C. (1983). P s y c h o s o c i a l problems i n congestive heart f a i l u r e : Health care implications. In C. R. M i c h a e l s o n . C o n g e s t i v e heart f a i l u r e . (pp. 378-399) Toronto: C. V. M o s b y . Roberts, Sharon. (1976). B e h a v i o u r a l c o n c e p t s and the c r i t i c a l l y i l l p a t i e n t . Englewood C I i f f s : Prentice-Hal 1 Inc. R o s e n b a u m , F. F., & B e l k n a p , Work and t h e h e a r t . New  E. L. ( E d s . ) . ( 1 9 5 9 ) York: Hacker.  138 R o s k i e s , E . , & L a z a r u s , R. (1980). C o p i n g t h e o r y and the t e a c h i n g of c o p i n g s k i l l s . In P. D a v i d s o n & S. D a v i d s o n ( E d s . ) , B e h a v i o u r a l m e d i c i n e : Changing h e a l t h l i f e s t y l e s . New Y o r k : Bruner & Mazel. S c a l z i , C.C. (1973). N u r s i n g management o f b e h a v i o u r a l r e s p o n s e s f o l l o w i n g an a c u t e m y o c a r d i a l infarction. H e a r t & L u n g , 2, 6 2 . S c a l z i , C.C. (1982). S e x u a l c o u n s e l l i n g . In S. U n d e r h i l l , S. Woods, E . S i v a r a j a n , & C. (Eds.), Cardiac Nursing, (pp. 582-592). P h i l a d e l p h i a : J . B . L i p p i n c o t t Company.  Halpenny  S c a l z i , C . C , & Burke, L.E. ( 1982). Myocardial infarction: B e h a v i o u r a l r e s p o n s e s o f p a t i e n t and spouse. In S. U n d e r h i l l , S. Woods, E. S i v a r a j a n , & C. H a l p e n n y ( E d s . ) , C a r d i a c N u r s i n g , ( p p . 5 6 2 - 5 7 1 ) . P h i l a d e l p h i a: J . B . L i p p i n c o t t Company. S h a f f e r , M. (1982). L i f e a f t e r s t r e s s . York: Plenum P r e s s .  New  S i e w i c k i , B., & M a n s f i e l d , L. ( 1 9 7 7 ) . Determining r e a d i n e s s t o r e s u m e s e x u a l a c t i v i t y . In A l l a b o u t s e x . . . a f t e r a c o r o n a r y . Am. J . N u r s , 77, 604. S o l a c k , S. (1982). Pathophysiology of myocardial i s c h e m i a and i n f a r c t i o n . In S. U n d e r h i l l , S. Woods, E . S i v a r a j a n , & C. H a l p e n n y ( E d s . ) , Cardiac Nursing. (pp.562-571 ). P h i l a d e l p h i a : J . B . L i p p i n c o t t Company. S o l o f f , P., & B a r t e l , A. (1979). E f f e c t s o f d e n i a l on mood and p e r f o r m a n c e i n c a r d i o v a s c u l a r rehabilitation. J . of Chronic Disease, 32, 3 0 7 - 3 1 3 . Stamler, J . (1978). L i f e s t y l e s , major r i s k f a c t o r s , p r o o f and p u b l i c p o l i c y . C i r c u l a t i o n , 58, 3-19. S t e r n , M., P a s c a l e , L . , & A c k e r m a n , A. (1977). Life adjustment postmyocardial i n f a r c t i o n . Archives of I n t e r n a l Med., 137, 1 6 8 0 - 1 6 8 5 . S t r a u s s , A.L. ( 1 9 8 4 ) . C h r o n i c i l l n e s s and t h e q u a l i t y of l i f e . 2nd e d . , T o r o n t o : CT V. Mosby Company.  139 S t r y k e r , Ruth. (1977). R e h a b i l i t a t i v e a s p e c t s of a c u t e and c h r o n i c n u r s i n g c a r e . 2nd e d . (pp 2 9 - 4 1 ) . P h i 1 a d e l p h i a : WT B. S a u n d e r s . T u t t l e , W., C o o k , W., & F i t c h , E. ( 1 9 6 4 ) . Sexual behaviour in post-myocardial i n f a r c t i o n p a t i e n t s . Am. J . C a r d i o l o g y , 13, 140. UBC  School of Nursing. (1980). UBC M o d e l f o r Nursing. Vancouver: Univer s i ty of B r i t i s h Columbi a.  U n d e r h i l l , S., Woods, S., S i v a r a j a n , E . , & H a l p e n n y , C (Eds.). (1983). Cardiac nursing. P h i l a d e l p h i a : J . B. L i p p i n c o t t Company. W a l t z , C , & B a u s e l l , R. (1981). Nursing research d e s i g n s t a t i s t i c s and c o m p u t e r a n a l y s i s . P h i l a d e l p h i a : F. A. D a v i s Company. Web s t e r ' s n i n t h new c o l 1 e g i a t e d i c t i o n a r y • ( 1983 ) S p r i n g f i e l d : M e r r i am-Web s t e r I n c . W e i s m a n , A. (1979). Coping with cancer. M c G r a w - H i l l , p. 27.  New  York:  W e n g e r , N. (1976). Some s e x u a l a s p e c t s o f t h e r e h a b i l i t a t i o n o f c a r i d a c p a t i e n t s . In S t o c k m e i e r , U. ( E d . ) . P s y c h o l o g i c a l a p p r o a c h t h e r e h a b i l i t a t i o n o f c o r o n a r y p a t i e n t s . New Spri nger-Verlag.  to York  W h e e l e r , E. 0., & S h e e h a n , D. V. (1978). Emotional s t r e s s : c a r d i o v a s c u l a r d i s e a s e and c a r d i o v a s c u l a r s y m p t o m s . In H u r s t , J . W. & L o g u e , R. B. ( E d s . ) , The h e a r t . New Y o r k : M c G r a w - H i l l Book Co. W i s h n i e , H. A., H a c k e t t , T. P., & C a s s e m , N. H. ( 1 9 7 1 ) Psychological hazards of convalescence f o l l o w i n g m y o c a r d i a l i n f a r c t i o n . JAMA, 2 1 5 , 8, 1 2 9 2 - 1 2 9 6 .  140  Appendix A S u b s y s t e m s , Needs, and G o a l s  Subsystem  Need  Goal  Ac h i e v i ng  For  A f f e c t i ve  For l o v e , b e l o n g i n g n e s s , and dependence  F e e l i n g s of 1ove, belongi ngness, and dependence  E g o - v a l u a t i ve  For r e s p e c t o f s e l f by s e l f a n d o t h e r s  Self-esteem  Excretory  For c o l l e c t i o n removal of accumulated wastes  Absence of accumulated wastes  I n g e s t i ve  For i n t a k e o f f o o d and f l u i d ; n o u r i shment  N o u r i shment; s a t i s f a c t i o n of hunger and t h i r s t  P r o t e c t i ve  For s a f e t y securi ty  I n t e g r i t y of the system  R e p a r a t i ve  For b a l a n c e between p r o d u c t i o n and u t i l i z a t i o n of energy  Capaci ty for acti vi ty  Respi r a t o r y  For i n t a k e of oxygen  Oxygenation; easy r e s p i r a t i ons  S a t i a t i ve  For the  Sensory s a t i s f a c t i on  Feelings of a c c o m p l i shment; s a t i s f a c t i o n with a c c o m p l i shments  mastery  and  and  stimulation of system s senses 1  142  APPENDIX  C  CONSENT FORM I, , agree to p a r t i c i p a t e i n t h e r e s e a r c h s t u d y "COPING BEHAVIOURS IN MYOCARDIAL INFARCTION R E H A B I L I T A T I O N " b e i n g c o n d u c t e d by L y n n Dawson as p a r t o f h e r m a s t e r ' s o f n u r s i n g p r o g r a m a t UBC. I u n d e r s t a n d t h a t t h i s s t u d y d e a l s w i t h d e s c r i b i n g t h e e x p e r i e n c e s and changes t h a t i n d i v i d u a l s h a v e made a f t e r a h e a r t a t t a c k . I u n d e r s t a n d t h a t my p a r t i c i p a t i o n w i l l i n v o l v e two t a p e d i n t e r v i e w s a p p r o x i m a t e l y one t o two h o u r s i n l e n g t h . I u n d e r s t a n d t h a t t h e i n f o r m a t i o n o f t h e t a p e s w i l l be a v a i l a b l e o n l y t o t h e i n v e s t i g a t o r a n d t h e members o f h e r t h e s i s c o m m i t t e e . I u n d e r s t a n d t h a t I may r e f u s e t o p a r t i c i p a t e o r am f r e e t o w i t h d r a w f r o m t h e s t u d y a t any t i m e a n d t h a t t h i s w i l l n o t a f f e c t my m e d i c a l o r nursing care.  Signed: Wi t n e s s e d : Date:  143 APPENDIX D Sample Q u e s t i o n s  1.  T e l l me a b o u t y o u r e x p e r i e n c e s i n c e y o u r MI.  2.  What h a v e y o u d o n e t o m e e t y o u r b a s i c  3.  What c h a n g e s  4.  How i s y o u r l i f e d i f f e r e n t now t h a n b e f o r e y o u r MI?  h a v e y o u made i n y o u r  needs?  lifestyle?  APPENDIX E Data C o l l e c t i o n Demographic Data Date Name Age Marital  Status  Occupation D a t e o f MI Additional  Problems  Cardi o l o g i s t I n t e r v i e w Data Observable Data  Tool  

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