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UBC Theses and Dissertations

Coping behaviours in myocardial infarction rehabilitation Dawson, Lynn Gail 1986

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COPING BEHAVIOURS IN MYOCARDIAL INFARCTION REHABILITATION By LYNN GAIL DAWSON Sc.N. , B.A., The U n i v e r s i t y o f W i n d s o r , 1975 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE FACULTY OF GRADUATE STUDIES ( S c h o o l o f N u r s i n g ) We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF B R I T I S H COLUMBIA JULY 1986 © LYNN GAIL DAWSON, 1986 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying o f t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department or by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department of The U n i v e r s i t y of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 DE-6 (3/81) i i 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 b e h a v i o u r s u s e d by p a t i e n t s s i x t o t w e l v e months f o l l o w i n g a m y o c a r d i a l i n f a r c t i o n ( M I ) . 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 was b a s e d on t h e UBC Model f o r N u r s i n g w h i c h d i r e c t e d t h e r e s e a r c h e r t o e x a m i n e c o p i n g b e h a v i o u r s u s e d t o meet t h e p a t i e n t s ' b a s i c human n e e d s . The 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 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 have 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 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 ? " S e v e n p a r t i c i p a n t s who had e x p e r i e n c e d an MI s i x t o 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 f r o m c a r d i o l o g i s t s . D a t a were c o l l e c t e d f r o m t h e p a r t i c i p a n t s d u r i n g i n t e r v i e w s u s i n g s e m i - s t r u c t u r e d o p e n - e n d e d q u e s t i o n i n g t e c h n i q u e . D a t a were c o d e d and a n a l y z e d u s i n g t h e c o n s t a n t c o m p a r a t i v e method d e v e l o p e d by G l a s e r and S t r a u s s . T h r e e themes t h a t e m e r g e d f r o m t h e d a t a w e r e : 1) 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 i s k r e d u c t i o n , 2) 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 t u r n i n g t o n o r m a l , 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 n o r m a l . i i i 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 c h a n g e s 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 b e h a v i o u r s 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 t o meet s u b j e c t s ' b a s i c human n e e d s . C e r t a i n unmet b a s i c human n e e d s were 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 p a t i e n t s i n d e v e l o p i n g c o p i n g b e h a v i o u r s t o meet t h e i r b a s i c human n e e d s . 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 o f c o p i n g b e h a v i o u r s i d e n t i f i e d i n t h i s s t u d y may s e r v e 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 w i t h c h a n g e s i n t h e i r l i v e s and d e v e l o p n e c e s s a r y c o p i n g b e h a v i o u r s t o meet t h e i r b a s i c human n e e d s . i v TABLE OF CONTENTS Page ABSTRACT i i TABLE OF CONTENTS i v L I S T OF TABLES v i i ACKNOWLEDGEMENTS v i i i CHAPTER ONE: INTRODUCTION 1 B a c k g r o u n d t o t h e S t u d y 1 P r o b l e m S t a t e m e n t 5 P u r p o s e 5 UBC Model f o r N u r s i n g 6 D e f i n i t i o n o f Terms 7 A s s u m p t i o n s 8 L i m i t a t i o n s 9 Summary 10 CHAPTER TWO: REVIEW OF THE RELATED LITERATURE 11 C o p i n g 12 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 t o L o s s 15 L o s s L e a d i n g t o t h e Change P r o c e s s 15 C h a r a c t e r i s t i c s o f L o s s 16 L o s s L e a d i n g t o t h e G r i e v i n g P r o c e s s . . . . 16 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 17 D e n i a l 17 A n g e r 18 D e p r e s s i o n 19 R e o r g a n i z a t i o n 20 R i s k F a c t o r R e d u c t i o n 22 D i e t a r y C h a n g e s 22 Smoking C e s s a t i o n 23 S t r e s s R e d u c t i o n 23 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 I n f a r c t i o n 26 R e t u r n t o Work 26 S e x u a l i t y 29 C o p i n g B e h a v i o u r s i n t h e UBC Model f o r N u r s i n g 31 V CHAPTER THREE: METHODOLOGY 36 S e l e c t i o n o f P a r t i c i p a n t s 38 C h a r a c t e r i s t i c s o f P a r t i c i p a n t s 40 E t h i c a l C o n s i d e r a t i o n s 41 D a t a C o l l e c t i o n 42 D a t a A n a y l s i s 44 Summary 45 CHAPTER FOUR: FINDINGS OF THE STUDY 46 . 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 i s k R e d u c t i o n . 47 D i e t a r y M o d i f i c a t i o n 47 Smoking C e s s a t i o n 52 M e d i c a t i o n Regimen 54 E x e r c i s e 56 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 60 R e a l i z a t i o n o f t h e Need f o r Change 60 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 63 O t h e r P h y s i c a l Symptoms - 65 G e t t i n g O t h e r s t o H e l p 68 R e t u r n t o Work 70 W o r k i n g P a r t i c i p a n t s 70 S t i g m a 72 Time O f f 73 R e t i r e d P a r t i c i p a n t s 74 R e l a t i o n s h i p s and R o l e C h a n g e s 76 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 85 CHAPTER F I V E : DISCUSSION OF THE FINDINGS I n t r o d u c t i o n 90 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 i s k R e d u c t i o n . 91 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 101 F o r c e s A f f e c t i n g C o p i n g B e h a v i o u r s 103 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 112 CHAPTER S I X : SUMMARY AND IMPLICATIONS FOR NURSING.... 119 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 122 I m p l i c a t i o n s f o r N u r s i n g R e s e a r c h 128 Summary 132 BIBLIOGRAPHY 133 v i APPENDICES A p p e n d i x A: S u b s y s t e m s , Needs and G o a l s 140 A p p e n d i x B: I n f o r m a t i o n R e l a t e d t o C a r d i a c R e s e a r c h S t u d y 141 A p p e n d i x C: C o n s e n t Form 142 A p p e n d i x D: Sample Q u e s t i o n 143 A p p e n d i x E: D a t a C o l l e c t i o n T o o l 144 L I S T OF TABLES T a b l e 1 : C h a r a c t e r i s t i c s o f t h e P a r t i c i p a n t s . v i 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 , C a r o l J i l l i n g s and J a n e t G o r m i c k f o r t h e i r e n c o u r a g e m e n t , p o s i t i v e s u p p o r t and e x p e r t g u i d a n c e t h r o u g h o u t t h i s r e s e a r c h p r o c e s s . I w o u l d l i k e t o e x t e n d a s p e c i a l t h a n k s t o t h e p a r t i c i p a n t s who were 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 e x p e r i e n c e s a b o u t c r i s e s i n t h e i r l i v e s . T h e i r o p e n n e s s p r o v i d e d a f i r s t hand a c c o u n t o f t h e MI e x p e r i e n c e . I w i s h t o t h a n k my c l a s s m a t e s who have 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 and my f a m i l y . I a l s o w o u l d l i k e t o t h a n k Bob who has 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 t h i s r e s e a r c h p r o j e c t . F i n a l l y , 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 and j o y t o c o m p l e t e t h i s t h e s i s . 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 c a u s e o f d e a t h i n C a n a d i a n s o c i e t y ( C a n a d a , 1 9 8 3 ) . A c u t e and c h r o n i c h e a l t h p r o b l e m s w i t h 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 (Bauwens, A n d e r s o n , & B u e r g i n , 1 9 8 3 ) . A m y o c a r d i a l i n f a r c t i o n (MI) 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 a c u t e e v e n t t h a t p o s e s a s e r i o u s t h r e a t t o i n d i v i d u a l s . A f t e r t h e i n i t i a l a c u t e e v e n t has p a s s e d , c o r o n a r y a r t e r y d i s e a s e i s v i e w e d as a c h r o n i c i l l n e s s , l o n g t e r m 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 , w i t h o u t 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 , 1 9 8 4 ) . A s i t u a t i o n i s c r e a t e d r e q u i r i n g a d j u s t m e n t t o a new c o n d i t i o n . W h e t h er t h i s i s t h e f i r s t o r l a t e s t o f 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 t h e d i f f i c u l t t a s k o f r e s u m i n g l i f e w i t h some d e g r e e o f u n c e r t a i n t y ( M u l l e n , 1 9 7 8 ) . B a c k g r o u n d t o t h e S t u d y Homecoming f o r p a t i e n t s who h a v e e x p e r i e n c e d an a c u t e m y o c a r d i a l i n f a r c t i o n c a n be a s t r e s s f u l e v e n t f o r p a t i e n t s , s p o u s e s and f a m i l i e s as t h e y a d j u s t t o 2 n e c e s s a r y c h a n g e s i n l i f e s t y l e ( P i n n e o , 1 9 8 4 ) . 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 c h a n g e i n a s p e c i f i c a r e a o r b e h a v i o u r o f o n e ' s l i f e 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 p r o b l e m 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. A r e a s o f 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 s u c h 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 i n a n c i a l s i t u a t i o n s , f a m i l y and s o c i a l r e l a t i o n s h i p s , s e x u a l i t y and p e r s o n a l i d e n t i t y may 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 m y o c a r d i a l 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 t h e p e r s o n a l w o r l d w i t h o u t p r e v i o u s w a r n i n g . P e r s o n s a r e i m m e d i a t e l y f a c e d w i t h t h e q u e s t i o n , ' W i l l I l i v e ? ' and t h e n , 'How w e l l w i l l I l i v e ? ' . The m y o c a r d i a l i n f a r c t i o n r e h a b i l i t a t i o n p e r i o d i s 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 " ( M u l l e n , 1 9 7 8 ) . P a t i e n t s a r e t o l d t o e l i m i n a t e v a r i o u s f o o d 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 s i t u a t i o n s f r o m d a i l y l i f e . T h i s i s i n c o n t r a s t t o i n d i v i d u a l s s u f f e r i n g f r o m o t h e r c h r o n i c i l l n e s s e s s u c h as u l c e r a t i v e c o l i t i s o r 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 p r o c e d u r e s t o p e r f o r m w h i c h l e a v e a v i s i b l e and p e r m a n e n t r e m i n d e r o f t h e i l l n e s s . The 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 may have c h e s t p a i n o r may r e m a i n s y m p t o m - f r e e . He may 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 b ack b e c a u s e o f symptoms. P a t i e n t s who a r e g i v e n 3 i n s t r u c t i o n t o ' t a k e i t e a s y ' o r ' r e l a x ' w i t h o u t s p e c i f i c g u i d e l i n e s may f i n d t h i s f r e e d o m o f c h o i c e f r u s t r a t i n g and c o n f u s i n g . P a t i e n t s a r e on t h e i r own as t h e y r e d e s i g n t h e i r l i f e s t y l e . F e a r , a n x i e t y and f e e l i n g s o f l o s s c h a r a c t e r i z e t h e r e s p o n s e s o f i n d i v i d u a l s e x p e r i e n c i n g an MI ( S c a l z i , 1973, 1 9 8 2 ) . R e a c t i o n s t o t h e l o s s p e r c e i v e d by i n d i v i d u a l s f o l l o w t h e p a t t e r n o f t h e g r i e v i n g p r o c e s s . S h o c k , d i s b e l i e f , a n g e r , d e n i a l and d e p r e s s i o n a r e e x p e r i e n c e d i n a v a r i e t y o f ways by t h e i n d i v i d u a l . The e x t e n t o f t h e c h a n g e s i n l i f e s t y l e , s e l f c o n c e p t and r o l e b e h a v i o u r r e f l e c t s i n d i v i d u a l s ' p e r c e p t i o n s o f t h e l o s s ( R i z z u t o , 1983, P a r k e s , 1 9 7 1 ) . I f i n d i v i d u a l s a r e s u c c e s s f u l i n d e a l i n g w i t h f e a r , a n x i e t y , and f e e l i n g s o f l o s s i n t h e i n i t i a l p e r i o d f o l l o w i n g an MI, t h i s c a n a f f e c t t h e i r a b i l i t y t o c o p e w i t h f u r t h e r c h a n g e s i n l i f e s t y l e , s e l f c o n c e p t and r o l e b e h a v i o u r . C h a n g i n g a b e h a v i o u r o r a c t i v i t y i n i s o l a t i o n i s r a r e l y p o s s i b l e as a c h a n g e i n one a r e a has c o n s e q u e n c e s i n o t h e r a r e a s o f l i f e ( M u l l e n , 1 9 7 8 ) . In t h e l i t e r a t u r e t h e t e r m c o p i n g r e f e r s t o d e a l i n g w i t h s i t u a t i o n s 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 t h e 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; L i p o w s k i , 1970; L a z a r u s , 1 9 6 6 ) . As i n d i v i d u a l s c o p e w i t h t h r e a t e n i n g s i t u a t i o n s , l i f e s t y l e c h a n g e s r e s u l t . 4 L i f e s t y l e c h a n g e s a r e 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 n e e d s . In w o r k i n g w i t h 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 , t h i s a u t h o r o b s e r v e d t h a t i n d i v i d u a l s use a number o f 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 t h e i r b a s i c human n e e d s . T h e s e may be c o p i n g b e h a v i o u r s 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 o n e s 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 i m p o r t a n t t o i d e n t i f y and e v a l u a t e t h e e f f e c t i v e n e s s o f t h e c o p i n g b e h a v i o u r s u s e d by p a t i e n t s i n o r d e r t o i n t e r v e n e a p p r o p r i a t e l y . P r e v i o u s l y l e a r n e d , e f f e c t i v e c o p i n g b e h a v i o u r s n o t p r e s e n t l y b e i n g u s e d may need t o be s t r e n g t h e n e d o r r e i n f o r c e d . N u r s i n g has 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 b e h a v i o u r s 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 ne e d s i n s u c h a way as t o m i n i m i z e t h e 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 d e s c r i b e d p s y c h o l o g i c a l , s o c i a l and f a m i l y p r o b l e m s and t h e 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 m y o c a r d i a l i n f a r c t i o n ( S c a l z i , 1973; C r o o g , 1966; M u l l e n , 1978; Doehrman, 1 9 7 7 ) . 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 as 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 have n o t been w i d e l y e x p l o r e d i n n u r s i n g l i t e r a t u r e . 5 P r o b l e m S t a t e m e n t To g a i n u n d e r s t a n d i n g o f 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 t h e s t u d y w i l l a n s w e r t h e f o l l o w i n g q u e s t i o n : 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 have 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 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 ? P u r p o s e The a r e a s 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 i n d i v i d u a l s . The p u r p o s e 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 u s e d by i n d i v i d u a l s i n an a t t e m p t 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 f t e r an MI. The UBC Model f o r N u r s i n g w i l l 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 Model f o r N u r s i n g A b e h a v i o u r a l s y s t e m a p p r o a c h 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 ( 1 9 8 0 ) w i l l be u s e d i n e x a m i n i n g t h e c o p i n g b e h a v i o u r s 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 . In t h e UBC Model f o r N u r s i n g t h e i n d i v i d u a l i s v i e w e d as a b e h a v i o u r a l s y s t e m w i t h n i n e s u b s y s t e m s ( s e e A p p e n d i x ) . E a c h s u b s y s t e m r e p r e s e n t s a b a s i c human need and n e e d - r e l a t e d g o a l . The e f f e c t i v e n e s s o f t h e c o p i n g b e h a v i o u r 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 and t h e r e b y d e c r e a s e t e n s i o n . T e n s i o n i s a n e e d - r e l a t e d s e n s a t i o n 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 v a r y i n g i n t e n s i t y d e p e n d i n g on t h e d e g r e e o f need s a t i s f a c t i o n . P a t t e r n s o f c o p i n g b e h a v i o u r s a r e u s e d t o 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 n e e d s i n o r d e r t o a c h i e v e b e h a v i o u r a l s y s t e m b a l a n c e . B e h a v i o u r a l s y s t e m b a l a n c e i s p r e s e n t when t h e n e e d s and g o a l s o f t h e n i n e s u b s y s t e m s a r e met. A c r i t i c a l p e r i o d w h i c h i s a m a t u r a t i o n a l o r u n p r e d i c t a b l e e v e n t ( e g , MI) t h r e a t e n s need s a t i s f a c t i o n . The d e v e l o p m e n t 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 t h e n e e d s a f f e c t e d i s n e c e s s a r y . P r e v i o u s c o p i n g b e h a v i o u r s i n o n e ' 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 c r i t i c a l p e r i o d and may f a i l t o p e r m i t s a t i s f a c t i o n o f one o r more o f t h e b a s i c human n e e d s . C o p i n g b e h a v i o u r s w i l l be r e f e r r e d t o i n t h i s s t u d y as t h o s e r e s p o n s e s t h a t a t t e m p t t o s a t i s f y b a s i c human n e e d s (UBC Model f o r N u r s i n g , 1 9 8 0 ) . The t e r m s " l i f e s t y l e c h a n g e s " and " c o p i n g " i n t h e l i t e r a t u r e e n compass o n l y t h o s e r e s p o n s e s o r c h a n g e s t h a t d e a l w i t h a t h r e a t t o o n e ' s b o d i l y i n t e g r i t y w h e r e a s " c o p i n g b e h a v i o u r " i n t h i s s t u d y i n c l u d e s a l l t h e b e h a v i o u r s u s e d t o s a t i s f y b a s i c human n e e d s . D e f i n i t i o n o f Terms 1. B a s i c Human Need - a f u n d a m e n t a l r e q u i r e m e n t f o r s u r v i v a l and g r o w t h o f t h e b e h a v i o u r a l s y s t e m (UBC Model f o r N u r s i n g , 1980) 2. C o p i n g B e h a v i o u r - 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 a s u b s y s t e m i s a t t e m p t i n g t o s a t i s f y a b a s i c human need f o r t h e s y s t e m (UBC Model f o r N u r s i n g , 1 9 8 0 ) . 3. L i f e s t y l e Change - a c h a n g e 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 o n e ' s l i f e as a r e s u l t o f a t h r e a t o r i l l n e s s . 8 4. M y o c a r d i a l I n f a r c t i o n - m y o c a r d i a l i s c h e m i a r e s u l t i n g f r o m t h e o c c l u s i o n o f b l o o d f l o w p r o d u c i n g n e c r o s i s o f t h e h e a r t m u s c l e . ( S o l a c k , 1 9 8 2 ) . A s s u m p t i o n s 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 h e a r t d i s e a s e c a u s e s c h a n g e s i n t h e l i f e s i t u a t i o n s o f i n d i v i d u a l s and t h e i r f a m i l i e s . 2. I n d i v i d u a l s w i t h a m y o c a r d i a l i n f a r c t i o n a r e v a l i d s u b j e c t s t o r e p r e s e n t t h e c o p i n g b e h a v i o u r s u s e d t o d e a l w i t h t h i s i l l n e s s . 3. T h o s e i n d i v i d u a l s e x p e r i e n c i n g m y o c a r d i a l 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 s h a r e t h e c o p i n g b e h a v i o u r s t h e y 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 w i t h m y o c a r d i a l i n f a r c t i o n use common c o p i n g b e h a v i o u r s as t h e y l i v e w i t h t h e i r i l l n e s s . 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 a t t e m p t t o r e d u c e 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 Model f o r N u r s i n g , 1 9 8 0 ) . 9 L i mi t a t i ons T h i s s t u d y may be l i m i t e d i n r e l y i n g on r e f e r r a l s f r o m p h y s i c i a n s i n o r d e r t o g a i n a c c e s s t o p a r t i c i p a n t s . The s t u d y i s d e p e n d e n t on t h e 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 t o e x p r e s s h i s e x p e r i e n c e s and c o p i n g b e h a v i o u r s . C o n t i n u a l v a l i d a t i o n and c l a r i f i c a t i o n w h i l e c o l l e c t i n g t h e d a t a s h o u l d r e d u c e t h e l i m i t a t i o n . 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 o f t h e s t u d y have been i n t r o d u c e d w i t h b a c k g r o u n d i n f o r m a t i o n s u p p o r t i n g t h e s t u d y . The l i t e r a t u r e r e l a t e d t o c o p i n g and p o s t MI b e h a v i o u r i s r e v i e w e d i n C h a p t e r 2. C h a p t e r 3 i s a d e s c r i p t i o n o f t h e m e t h o d o l o g y u s e d t o i m p l e m e n t t h e s t u d y . The a n a l y s i s o f t h e d a t a w i l l be 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. C h a p t e r 5 w i l l 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 . The i m p l i c a t i o n s o f t h e f i n d i n g s o f t h e s t u d y f o r n u r s i n g w i l l be d i s c u s s e d . 1 1 CHAPTER TWO REVIEW OF THE RELATED LITERATURE A r e v i e w o f t h e l i t e r a t u r e r e l a t e d t o 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 t e r m . F o r t h e p u r p o s e o f t h i s s t u d y i t i s i m p o r t a n t t o r e v i e w t h e l i t e r a t u r e i n o r d e r t o d i f f e r e n t i a t e t h e m e a n i n g o f c o p i n g w i d e l y u s e d i n t h e l i t e r a t u r e f r o m t h a t 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 as c o p i n g b e h a v i o u r s . I t i s t h e l a t t e r m e a n i n g t h a t w i l l be e x p l o r e d i n t h i s s t u d y . 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 c h a n g e s u s e d 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 i n f a r c t i o n r e h a b i l i t a t i o n w i l l be p r e s e n t e d . An MI may l e a d t o a 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 . The l o s s o f s o m e t h i n g m e a n i n g f u l o r o f v a l u e may p r e c e d e t h e e m o t i o n a l r e s p o n s e s o f g r i e v i n g ( S c a l z i & B u r k e , 1 9 8 2 ) . S p e c i f i c r e s p o n s e s s u c h as s h o c k , d i s b e l i e f , d e n i a l , a n g e r , a n x i e t y and d e p r e s s i o n a r e e x p e r i e n c e d i n a 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 t h e i n d i v i d u a l . A r e a s where s i g n i f i c a n t l i f e s t y l e c h a n g e s c a n 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 c h a n g e s , 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 . In an a t t e m p t t o r e t u r n t o a normal l i f e s t y l e , a d d i t i o n a l 12 c h a n g e s 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 a r e a s w i l l p r o v i d e a t h e o r e t i c a l b a c k g r o u n d f o r t h i s s t u d y . C o p i n g The c o n c e p t o f c o p i n g has 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 t h e p s y c h o l o g i c a l l i t e r a t u r e and m e d i c a l and n u r s i n g j o u r n a l s . The word ' t o c o p e ' comes f r o m t h e F r e n c h ' c o u p e r ' m e a n i n g t o s l a s h o r t o s t r i k e . I t s u g g e s t s t h e a b i l i t y t o f i g h t back ( W e b s t e r , 1 9 8 3 ) . R i c h a r d L a z a r u s ( 1 9 6 6 ) , 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 o r harm. C o p i n g i s c o g n i t i v e a c t i v i t y i n t h e f o r m o f c o g n i t i v e a p p r a i s a l 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 t h e d e t e r m i n a t i o n o f a c o u r s e o f a c t i o n b a s e d on r e a p p r a i s a l . C o p i n g r e f e r s t o d e a l i n g w i t h s i t u a t i o n s 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; L i p o w s k i , 1970; L a z a r u s , 1 9 6 6 ) . P e a r l i n ( 1 9 7 8 , 1981) s u g g e s t s t h r e e m a j o r t y p e s o f c o p i n g w i t h d i f f e r e n t f u n c t i o n s . T h e s e a r e r e s p o n s e s t h a t c h a n g e t h e s i t u a t i o n o u t o f w h i c h a s t r e s s f u l e x p e r i e n c e a r i s e s ; r e s p o n s e s t h a t c o n t r o l t h e m e a n i n g o f t h e 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 o c c u r s b u t b e f o r e 1 3 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 t o c o n t r o l e m o t i o n a l s t r e s s a f t e r i t has e m e r g e d . Weisman ( 1979, p.27) t a k e a b r o a d e r v i e w o f c o p i n g . " C o p i n g c o m b i n e s p e r c e p t i o n , p e r f o r m a n c e , 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 and p r o b l e m s o l v i n g b e h a v i o u r " . The aim o f c o p i n g i s m a s t e r y , c o n t r o l o r r e s o l u t i o n (Weisman & Worden, 1 9 7 6 - 7 7 ) . C o p i n g has been f u r t h e r e x p l a i n e d u n d e r t h e 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 c o p i n g b e h a v i o u r s . A c c o r d i n g t o L a z a r u s ( 1 9 6 6 ) c o p i n g b e h a v i o u r s 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 o r 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 u s e d c h a r a c t e r i z e t h e c o p i n g b e h a v i o u r s ( L i p o w s k i , 1 9 7 0 ) . C o p i n g t a s k s a r e t h e p a r t i c u l a r c h a l l e n g e s t h a t must 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 i n t e g r i t y , r e s t o r e o r m a i n t a i n a p o s i t i v e c o n c e p t o f 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; Hamburg & Adams, 1 9 6 7 ) . A c o p i n g b e h a v i o u r 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 meet t h e c h a l l e n g e s p r e v i o u s l y m e n t i o n e d . R o s k i e s and L a z a r u s ( 1 9 8 0 ) 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 i s e f f e c t i v e when a t a s k i s a c c o m p l i s h e d . 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 t h r o u g h and a r o u n d o b s t a c l e s t o 14 r e d u c e t e n s i o n . I t i s s o m e t i m e s u s e d t o d e s c r i b e s m a l l e v e r y d a y a d j u s t m e n t s . P e o p l e a c t t o meet n e e d s and t o a c h i e v e g o a l s and d e v e l o p r e l a t i v e l y s t a b l e p a t t e r n s o f b e h a v i o u r . A d i s r u p t i o n o f t h i s p a t t e r n r e s u l t s i n i n c r e a s e d t e n s i o n s i n c e b o t h n e e d s and g o a l s a r e t h r e a t e n e d . C o p i n g i s a r e s p o n s e t o i n c r e a s e d t e n s i o n whose p u r p o s e 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 met. As one 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 v i e w e d as 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 , c o p i n g p r o c e s s e s and c o p i n g b e h a v i o u r s . I t i s d i f f i c u l t t o come t o a c o n s e n s u s on 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 f r o m t h i s l i t e r a t u r e i n o r d e r t o p r o v i d e u t i l i t y and d i r e c t i o n f o r n u r s i n g p r a c t i c e . I t i s i m p o r t a n t t o d e f i n e c o p i n g o p e r a t i o n a l l y w i t h i n a f r a m e w o r k i n o r d e r t o p r o v i d e t h e u t i l i t y 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 p r a c t i c e . 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 Model f o r N u r s i n g t h a t t h e t e r m c o p i n g b e h a v i o u r w i l l be u s e d i n t h i s s t u d y . C o p i n g b e h a v i o u r i n t h e UBC Model f o r N u r s i n g i s a r e s p o n s e t h a t a t t e m p t s t o s a t i s f y a b a s i c human need f o r t h e s y s t e m . 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 P e r i o d L e a d i n g t o L o s s F o l l o w i n g a m y o c a r d i a l i n f a r c t i o n , an i n d i v i d u a l e x p e r i e n c e s l o s s o r t h r e a t o f l o s s w i t h c o - e x i s t i n g g a i n . A c r i t i c a l p e r i o d s u c h as an MI r e q u i r e s t h e d e v e l o p m e n t 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 Model f o r N u r s i n g , 1980) . L o s s L e a d i n g t o t h e Change P r o c e s s 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 t h e 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 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 s a t i s f i e d . L e w i n ( 1 9 5 1 ) d e s c r i b e d t h r e e s t e p s i n t h e c h a n g e p r o c e s s : 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 and r e f r e e z i n g . D u r i n g t h e u n f r e e z i n g p h a s e , t h e i n d i v i d u a l r e c o g n i z e s t h e need f o r a c h a n g e and s e l e c t s a number o f a p p r o a c h e s . M o v i n g t o a new l e v e l i n v o l v e s t h e a c t u a l b e h a v i o u r c h a n g e . R e f r e e z i n g i s t h e p h a s e where t h e b e h a v i o u r becomes p a r t o f o n e ' s l i f e s t y l e . L e w i n ( 1 9 5 1 ) a l s o i n t r o d u c e d t h e c o n c e p t s o f d r i v i n g and 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 p r o c e s s o f c h a n g e . 16 C h a r a c t e r i s t i c s o f L o s s Change i s an i n h e r e n t p a r t o f t h e l o s s e s i n c u r r e d f o l l o w i n g an MI. The p r o c e s s o f c h a n g e d e s c r i b e d a b o v e may be e x p e r i e n c e d t h r o u g h e a c h new l o s s e x p e r i e n c e d . L o s s i s b e i n g w i t h o u t t h a t w h i c h has o r c o u l d have m e a n i n g f o r 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 , 1980; P e r e t z , 1 9 7 0 ) . L o s s c a n be p e r m a n e n t o r t e m p o r a r y , a c t u a l o r t h r e a t e n e d , s u d d e n o r g r a d u a l ( L a m b e r t , 1979; P e r e t z , 1 9 7 0 ) . F o l l o w i n g an MI, one may e x p e r i e n c e l o s s o f h e a l t h , j o b , f a m i l y r o l e , and s e l f - e s t e e m w h i c h t h r e a t e n s n e e d s a t i s f a c t i o n . The 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 w i l l d e p e n d on t h e m e a n i n g a t t a c h e d t o t h e p a r t i c u l a r l o s s o r t h r e a t o f l o s s . L o s s L e a d i n g t o t h e G r i e v i n g P r o c e s s The 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 l e a d t o t h e g r i e v i n g p r o c e s s . In c o r o n a r y a r t e r y d i s e a s e w h i c h i s a c h r o n i c i l l n e s s , l o s s o f p h y s i c a l i n t e g r i t y , s o c i a l r o l e and i n t e r d e p e n d e n c y r e l a t i o n s h i p s w i t h o t h e r s a r e t h r e e a r e a s t h a t may l e a d t o t h e g r i e v i n g p r o c e s s . New l o s s e s c a n be e x p e c t e d t o r e a c t i v a t e t h e g r i e v i n g p r o c e s s ( C r a t e , 1 9 6 5 ) . The g r i e v i n g p r o c e s s has been c h a r a c t e r i z e d by a s e q u e n c e o f s u b j e c t i v e b e h a v i o u r s t h a t a r e somewhat p r e d i c t a b l e . A c c o r d i n g t o 17 P a r k e s ( 1 9 7 1 ) and M a r r i s ( 1 9 7 4 ) f o u r s t a g e s accompany l o s s : g l o b a l d e n i a l and numbness; p i n i n g w i t h a f r u s t r a t e d s e a r c h f o r t h e l o s t o b j e c t ; d e p r e s s i o n , 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 t h e l o s s ; and a r e o r g a n i z a t i o n i n v o l v i n g t h e b u i l d i n g o f new 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 and o n e s e l f . T h i s c o u l d be i n t e r p r e t e d as ways t h a t i n d i v i d u a l s ' r e a c t t o and t h e n d e a l w i t h l o s s . 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, some o f t h e b e h a v i o u r a l r e s p o n s e s o b s e r v e d i n c l u d e d e n i a l , a n g e r , d e p r e s s i o n and r e o r g a n i z a t i o n . E a c h o f t h e s e r e s p o n s e s w i l l be r e v i e w e d w i t h r e s p e c t t o a d e f i n i t i o n o f t h e r e s p o n s e and an e x a m p l e o f how i t r e l a t e s t o 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 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 D e n i a l D e n i a l i s a b e h a v i o u r u s e d t o a l l e v i a t e a n x i e t y by r e d u c i n g t h e p e r c e p t i o n o f t h e t h r e a t ( S c a l z i , 1 9 7 3 ) . D e n i a l i s d e f i n e d as b e h a v i o u r t h a t i n d i c a t e s a f a i l u r e t o a c c e p t e i t h e r an o b v i o u s f a c t o r t h e m e a n i n g o f t h i s f a c t i n a s i t u a t i o n . D e n i a l may be u s e d e f f e c t i v e l y t o meet c e r t a i n b a s i c n e e d s d u r i n g t h e f i r s t 24 t o 48 h o u r s a f t e r an MI ( H a c k e t t & C assem, 1974; S o l o f f & B a r t e l , 1 9 7 1 ) . The p e r s o n may n o t be d e l i b e r a t e l y 1 8 r e f u s i n g t o b e l i e v e what has h a p p e n e d b u t r a t h e r i s u n a b l e t o b e l i e v e i t ( L e v i n e , 1 9 7 0 ) . The d e g r e e o f d e n i a l i s p r o p o r t i o n a l t o t h e e x t e n t t h a t t h e p h y s i c a l i l l n e s s t h r e a t e n s t h e s e l f . The use o f d e n i a l a t t h i s t i m e s e r v e s a b e n e f i c i a l p u r p o s e ( S c a l z i , & B u r k e , 1 9 8 2 ) . I t may a l l o w t h e p e r s o n t o a v o i d t h e a n x i e t y and d e p r e s s i o n a s s o c i a t e d w i t h n o n - d e n i a l ( H a c k e t t & Cassem, 1 9 7 4 ) . D e n i a l may c o n t r i b u t e t o m e e t i n g o n e ' 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 as 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 . However, p r o l o n g e d d e n i a l may have a n e g a t i v e e f f e c t on o t h e r b a s i c human n e e d s , s u c h as o n e ' s need f o r a b a l a n c e o f a c t i v i t y and r e s t i f one does 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 a r e a . A n g e r A n g e r , 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 r t h e l o s t o b j e c t a r e c h a r a c t e r i s t i c b e h a v i o u r s i n t h e g r i e v i n g p r o c e s s . A g a i n , t h i s r e s p o n s e w i l l be i n f l u e n c e d 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 o f t h e l o s s o r t h r e a t . A n g e r i s a r e s p o n s e t o t h e a n x i e t y e x p e r i e n c e d due t o a t h r e a t , w h i c h l e a v e s t h e i n d i v i d u a l p o w e r l e s s t o d e a l w i t h i t . A n g e r may be o b s e r v e d as a c o p i n g b e h a v i o u r t o s a t i s f y b a s i c human 19 n e e d s f o r s e l f - e s t e e m and s a f e t y and s e c u r i t y i n t h e e g o - v a l u a t i v e and p r o t e c t i v e s u b s y s t e m s . The i n d i v i d u a l ' s a n g e r may be o p e n l y e x p r e s s e d , may be k e p t 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 ( A n d r e o l i , F o w k e s , Z i p e s & W a l l a c e , 1 9 8 3 ) . I t has been o b s e r v e d t h a t p h y s i c i a n s and n u r s e s c a r i n g f o r c a r d i a c p a t i e n t s o f t e n f a i l t o d e t e c t a n x i e t y , a n g e r 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 on t h e p a t i e n t s ' p a r t . D i r e c t q u e s t i o n i n g ' i s r e q u i r e d t o d i s c o v e r t h e e m o t i o n a l s t a t e o f p a t i e n t s a t v a r i o u s t i m e s d u r i n g t h e i r i l l n e s s e x p e r i e n c e ( G r a n g e r , 1 9 7 4 ) . D e p r e s s i o n D e p r e s s i o n has been s t u d i e d i n MI p a t i e n t s and f o u n d t o be common a t v a r i o u s t i m e s t h r o u g h o u t t h e r e c o v e r y p e r i o d ( W i s h n i e , H a c k e t t & Cassem, 1971; K a v a n a u g h , S h e p a r d & T u c k , 1 9 7 5 ) . Many p a t i e n t s do n o t become d e p r e s s e d w h i l e i n h o s p i t a l b u t r a t h e r a f t e r t h e y a r e home ( F r o e s e , H a c k e t t & Cassem, 1974; Doehrman, 1 9 7 7 ) . I t has been f o u n d t h a t t h e c a r d i a c p a t i e n t d o e s n o t r e a l i z e t h e f u l l p h y s i c a l and e m o t i o n a l i m p a c t o f 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 t o h i s f o r m e r a c t i v i t i e s and f i n d s t h a t t h e y a r e l i m i t e d ( G r a n g e r , 1974; W i s h n i e , H a c k e t t , & Cass e m , 1 9 7 1 ) . 20 As t h e i m p a c t o f t h e 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 becomes d i s o r g a n i z e d . Bowlby ( 1 9 8 0 ) s u g g e s t s t h a t d e p r e s s i o n i s an a f f e c t e x p e r i e n c e d by h e a l t h y 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 t h e s u b j e c t i v e a s p e c t o f t h e s t a t e o f d i s o r g a n i z a t i o n . B o t h t h e w o r l d and t h e i n d i v i d u a l a r e c o n s i d e r e d p o o r and empty. T h i s i s why t h e l o s s o f s e l f - e s t e e m i s o f t e n c h a r a c t e r i s t i c o f d e p r e s s i o n . F e e l i n g s o f h e l p l e s s n e s s , h o p e l e s s n e s s and d e p e n d e n c y a r e c h a r a c t e r i s t i c o f d e p r e s s i o n . The immense i m p a c t o f 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 c a u s e t h e i n d i v i d u a l t o ' g i v e up' ( S c a l z i & B u r k e , 1 9 8 2 ) . D e p r e s s i o n may o c c u r when o n e ' s w e l l s c h e d u l e d 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 t o l o s s e s i n c u r r e d w i t h t h e MI, 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 f i n a l 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 new 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 and t h e s e l f a r e b u i l t up and i n t e g r a t e d i n t o o n e ' s w o r l d . The a s s u m p t i v e w o r l d i s t h e w o r l d known t o e a c h i n d i v i d u a l and i n c l u d e s e v e r y t h i n g one knows. 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 o n e ' s e x p e c t a t i o n s and p l a n s f o r t h e f u t u r e may r e q u i r e c h a n g e ( P a r k e s , 1 9 7 1 ) . 21 The v i e w t h a t one has 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 and t h e c h a n g e s made o r t o be made w i l l i m p a c t d i f f e r e n t l y on e a c h i n d i v i d u a l ( M u l l e n , 1 9 7 8 ) . The i n d i v i d u a l w i l l e x p e r i e n c e d e n i a l , a n g e r d e p r e s s i o n 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 r e c o v e r y p r o c e s s . 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 o f b e h a v i o u r 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 t o s a t i s f y o n e ' s b a s i c human n e e d s . The l o s s due t o an MI may a f f e c t one o r more s u b s y s t e m s and g a i n may be s e e n i n t h e same s u b s y s t e m 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 l o s s t o t h e p e r s o n , t h e p r e p a r a t i o n f o r t h e l o s s , t h e age and h e a l t h o f t h e i n d i v i d u a l e x p e r i e n c i n g t h e l o s s ( B o w l b y , 1 9 8 0 ) , 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 i n i t i a l 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 ) and t h e t i m e t a k e n t h r o u g h t h e g r i e v i n g p r o c e s s a r e f o r c e s t h a t i n f l u e n c e t h e d e v e l o p m e n t 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 . 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 t h e 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 t o t h e i n d i v i d u a l a l s o a f f e c t t h e s u i t a b i l i t y o f 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 f o l l o w i n g a m y o c a r d i a l i n f a r c t i o n . As an i n d i v i d u a l b e g i n s t o r e o r g a n i z e 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 s u c h as d i e t , s m o k i n g and s t r e s s r e d u c t i o n . 22 R e t u r n t o work and s e x u a l i t y a r e o t h e r a r e a s 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 be d i s c u s s e d . R i s k F a c t o r R e d u c t i o n D i e t a r y C h a n g e s A l t e r i n g e a t i n g h a b i t s may be e x t r e m e l y 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 t h e f a m i l y ( P i n n e o , 1984; Newton & S i v a r a j a n , 1 9 8 2 ) . W e i g h t r e d u c t i o n may be n e c e s s a r y b u t p r o v e t o be s l o w and d i f f i c u l t . Many p e o p l e b e g i n c h a n g i n g t h e i r e n t i r e way 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 s o m e t h i n g t h a t 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 . A l t h o u g h t h i s i s s t i l l 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 have more c h o i c e and f e e l good a b o u t a c e r t a i n amount o f c o n t r o l o v e r t h e d i e t . A l t h o u g h t h e r e i s no c o n c l u s i v e e v i d e n c 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 r e v e r s e t h e p r o c e s s o f c o r o n a r y a r t e r y d i s e a s e o r p r o l o n g l i f e by m o d i f y i n g t h e d i e t , c l i n i c a l 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 l o w - d e n s i t y l i p o p r o t e i n ( L D L ) c h o l e s t e r o l l e v e l s r e s u l t s i n a r e d u c e d r a t e o f c o r o n a r y h e a r t d i s e a s e ( S t a m l e r , 1978; H o l u b , 1 9 8 6 ) . The p a t i e n t may i n q u i r e a b o u t 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 . W h i l e 23 a l c o h o l i s n o t a r i s k f a c t o r i n c o r o n a r y a r t e r y d i s e a s e , i n e x c e s s i v e amounts 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 . The s e t t i n g i n w h i c h a l c o h o l i s consumed may i n f l u e n c e i t s i m p a c t . D r i n k i n g i n a r e l a x e d a t m o s p h e r e 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 , 1 9 8 4 ) . S m oking C e s s a t i o n S m oking i s t h e r i s k f a c t o r w h i c h i s w e l l 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 o f MI d e c r e a s e s m a r k e d l y f o r t h o s e who q u i t s m o k i n g ( M a l l a g h a n & P e m b e r t o n , 1 9 7 7 ) . P a t i e n t s who s t o p s m o k i n g 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 b e t t e r ( P i n n e o , 1 9 8 4 ) . S t r e s s R e d u c t i o n The p u b l i c i s b e i n g bombarded w i t h b o o k s , a r t i c l e 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 p o p u l a r 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 p r e v e n t e d , managed 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 , 1 9 8 4 ) . C o n c e p t s p r e v i o u s l y c a l l e d a n x i e t y , c o n f l i c t , f r u s t r a t i o n , e m o t i o n a l d i s t u r b a n c e and a l i e n a t i o n h ave now beem renamed s t r e s s ( A p p l e y & T r u m b u l l , 1 9 6 7 ) . 24 S t r e s s has been c i t e d i n t h e d e v e l o p m 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 . The e x a c t r o l e t h a t s t r e s s p l a y s i s as y e t unknown and u n d e r s t u d y . P r e s e n t l y , t h e r e a r e no c a u s e and e f f e c t m o d e l s t o e x p l a i n t h e i n f l u e n c e o f p s y c h o l o g i c a l f a c t o r s s u c h as a n x i e t y , d e p r e s s i o n , s l e e p d i s t u r b a n c e and e m o t i o n a l e x h a u s t i o n on t h e c a r d i o v a s c u l a r s y s t e m . I t i s known t h a t p a t i e n t s f a c e 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 d u r i n g r e c o v e r y f r o m an MI. E x a m p l e s o f t h e s e i n c l u d e c h a n g e s i n d a i l y r o u t i n e s , c h a n g e s i n b o d i l y r e s p o n s e t o a c t i v i t y , f i n a n c i a l c o n c e r n s , r o l e c h a n g e s w i t h t h e f a m i l y and r e t u r n i n g t o work. The r e s p o n s e t o a s t r e s s f u l s i t u a t i o n v a r i e s f r o m p e r s o n t o p e r s o n and d e p e n d s on t h e r e p e r t o i r e o f c o p i n g b e h a v i o u r s t h a t t h e i n d i v i d u a l a l r e a d y p o s s e s s e s t o meet h i s b a s i c human n e e d s . The s u c c e s s o r f a i l u r e o f p r e v i o u s a t t e m p t s a t c o p i n g w i t h 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 m a j o r i m p o r t a n c e . S t r e s s r e s p o n s e s have been d i v i d e d i n t o f o u r c a t e g o r i e s : Body symptoms s u c h as f l u s h i n g , s w e a t i n g , f a t i g u e , d r y mouth, s t u t t e r i n g , and an i n c r e a s e s o r d e c r e a s e i n a p p e t i t e , e x e r c i s e o r s l e e p h a b i t s , 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 ; Cognit ive states t h a t i n c l u d e d i s t r a c t i b i 1 i t y , w o r r y , 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 ; Feel ing states s u c h as s h a k i n e s s , a g i t a t i o n , 25 i r r i t a b i l i t y , a n x i e t y , a n g e r and d e p r e s s i o n ; Motor symptoms s u c h as m u s c u l a r t i g h t n e s s , i n c r e a s e d s t a r t l e r e a c t i o n , i n c o o r d i n a t i o n ( A p p l e y & T r u m b u l l , 1967; S h a f f e r , 1982; R i z z u t o , 1983; P e l l e t i e r , 1 9 8 4 ) . 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 st w i d e l y r e c o g n i z e d p h y s i c a l e f f e c t s o f p s y c h o l o g i c a l s t r e s s . S t u d i e s have d e m o n s t r a t e d t h a t e m o t i o n a l s t r e s s c a n 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 t a c h y c a r d i a i n p e r s o n s w i t h h e a r t d i s e a s e ( W h e e l e r & S h e e h a n , 1 9 7 8 ) . P a r k e s ( 1 9 7 1 ) has s t a t e d t h a t c h a n g e u s u a l l y l e a d s t o s t r e s s . Change t h a t i s l a s t i n g , t a k e s p l a c e i n a s h o r t p e r i o d o f t i m e o r a f f e c t s a l a r g e a r e a o f o n e ' s a s s u m p t i v e w o r l d ( l i f e s p a c e ) has t h e g r e a t e s t p o t e n t i a l t o p r o d u c e s t r e s s . M u l l e n ( 1 9 7 8 ) f o u n d t h a t c h a n g e made by 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 t h a n one 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 h a v i n g an i m p a c t on v a r i o u s a r e a s o f l i f e s t y l e . R e l a x a t i o n i s t h e p r i m e s t r a t e g y a f f e c t i n g t h e s t r e s s r e s p o n s e 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, 1984; J a c o b s o n , 1 9 6 4 ) . T e c h n i q u e s t h a t a r e h e l p f u l a r e m e d i t a t i o n , b i o f e e d b a c k , p r o g r e s s i v e r e l a x a t i o n u s i n g 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 a s p e c t s . J a c o b s o n ( 1 9 6 4 ) has d e s c r i b e d p r o g r e s s i v e r e l a x a t i o n t e c h n i q u e s d i r e c t e d t o w a r d 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 by c o n t r a c t i o n and r e l a x a t i o n o f 26 v a r i o u s m u s c l e s . The i s o m e t r i c c o m p o n e n t o f t h e s e e x e r c i s e s may n o t be a d v i s a b l e i n t h e e a r l y r e c o v e r y a f t e r an MI. R e l a x a t i o n t e c h n i q u e s a r e o n l y one a s p e c t o f s t r e s s r e d u c t i o n o r s t r e s s management. W h i l e i t may n o t be p o s s i b l e t o c h a n g e c e r t a i n s o u r c e s o f s t r e s s i n a p e r s o n ' s l i f e , one c a n c h a n g e t h e r e a c t i o n t o i t . R e c o g n i t i o n o f e v e n t s t h a t a r e s t r e s s f u l and r e c o g n i t i o n o f o n e ' s own p h y s i c a l and e m o t i o n a l r e s p o n s e s t o t h e s e s t r e s s e s i s a b e g i n n i n g . C o n s c i o u s l y c h o o s i n g t o r e a c t t o t h e s i t u a t i o n s i n a new way and t h e n p r a c t i c i n g t h e s e new r e s p o n s e s i s a way o f d e a l i n g w i t h s t r e s s ( N e w t o n , S i v a r a j a n , 1 9 8 2 ) . 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 I n f a r c t i o n R e t u r n t o Work D e s p i t e t h e aim f o r e a r l y m o b i l i z a t i o n f o l l o w i n g an MI, s t u d i e s show t h a t h a l f t h e p a t i e n t s p e r m i t t e d t o r e t u r n t o work a r e r e l u c t a n t t o do so ( W i s h n i e , H a c k e t t & C a s s e m , 1 9 7 1 ) . Many e x p r e s s a n x i e t i e s c o n c e r n i n g t h e i r a b i l i t y t o work f u l l o r p a r t t i m e , p e r f o r m t h e same d u t i e s a d e q u a t e l y , f e a r o f r e c u r r i n g c h e s t p a i n and f e a r o f h a v i n g a n o t h e r h e a r t a t t a c k . Some p a t i e n t s 27 use t h e i r h e a r t a t t a c k as a r e a s o n t o r e t i r e f r o m work ( P i n n e o , 1984; W i s h n i e , H a c k e t t & C assem, 1 9 7 1 ) . 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 e a r n i n g a l i v i n g . I t i s a key e l e m e n t i n i n t e r p e r s o n a l a s s o c i a t i o n s , d e t e r m i n e s t h e s t a t u s p o s i t i o n i n s o c i e t y and o n e ' s l i f e s t y l e . I n d i v i d u a l s d e r i v e m e a n i n g f r o m t h e i r work and t h e l o s s o f o r c h a n g e i n e m p l o y m e n t b e c a u s e o f an MI may have s e r i o u s e f f e c t s on t h e i r l i v e s ( C r o o g , L e v i n e & L u r i e , 1 9 6 8 ) . The c a r d i a c r e h a b i l i t a t i o n l i t e r a t u r e has 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 t h e p a t i e n t ' s d e c i s i o n t o r e t u r n t o work. Commonly i n c a r d i a c d i s e a s e t h e p h y s i c a l d i s a b i l i t y i s n o t o f o v e r w h e l m i n g s i g n i f i c a n c e . The f e a r o f h e a r t d i s e a s e and i t s c o n s e q u e n c e s r e i n f o r c e d by t h e p a t i e n t and h i s f a m i l y i s t h e 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 a l a c k o f r e t u r n t o work and a c t i v i t y (Rosenbaum & B e l k n a p , 1 9 5 9 ) . A n x i e t y and d e p r e s s i o n a f t e r a h e a r t a t t a c k p o s e o b s t a c l e s t o r e h a b i l i t a t i o n e f f o r t s and r e t u r n t o w ork. I t i s e s t i m a t e d t h a t b e t w e e n 20% t o 60% o f p o s t - M I p a t i e n t s e i t h e r n e v e r r e t u r n t o work o r r e m a i n u n d e r e m p l o y e d f o r t h e r e m a i n d e r o f t h e i r w o r k i n g l i v e s ( S t e r n , P a s c a l e , & A c k e r m a n , 1 9 7 7 ) . A n o t h e r f a c t o r a f f e c t i n g t h e p a t i e n t ' s d e c i s i o n o r a b i l i t y t o r e t u r n t o work may d e p e n d on s u p p o r t f r o m 28 t h e s p o u s e , f a m i l y and s o c i a l n e t w o r k . I n s u f f i c i e n t s u p p o r t 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 f a m i l y p r o d u c e s s t r e s s and t a k e s i t s t o l l on t h e e m o t i o n a l , s o c i a l and p h y s i c a l h e a l t h and f u n c t i o n i n g o f MI p a t i e n t s and t h e i r s p o u s e s . A s e r i o u s d i s r u p t i o n i n t h e f a m i l y may e n s u e . S t u d i e s on t h e r a t e o f r e t u r n t o work by h e a r t 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 work s e t t i n g s a r e more c o n d u c i v e t h a n o t h e r s t o t h e r e h a b i l i t a t i o n p r o c e s s ( D u r b i n & G o l d w a t e r , 1 9 5 6 ) . R e e d e r ( 1 9 6 5 ) r e p o r t e d a d i f f e r e n c e i n t h e a t t i t u d e s and p o l i c i e s o f w h i t e and b l u e c o l l a r w o r k e r s . W h i t e 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 i n t h e work p l a c e t h a n b l u e c o l l a r e m p l o y e e s b e c a u s e o f t h e n a t u r e o f t h e i r j o b s . W h i t e c o l l a r w o r k e r s o f t e n 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 r e g a r d i n g work s c h e d u l e s c a n be made. The b l u e c o l l a r w o r k e r f r e q u e n t l y has a p h y s i c a l l y s t r e n u o u s j o b where a l t e r n a t i v e s and f l e x i b i l i t y may n o t be c o n s i d e r e d . E m p l o y e e s a r e r e l u c t a n t t o h a v e t h e c a r d i a c p a t i e n t d o i n g t h e s e j o b s due t o t h e p o s s i b i l i t y o f h i s e x p e r i e n c i n g a h e a r t a t t a c k a t w o r k . Thus t h e b e t t e r 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 t o and a d a p t s t o r e e m p l o y m e n t t h a n t h e b l u e c o l l a r w o r k e r who i s more 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 o r r e t i r e ( D o e h r m a n , 1 9 7 7 ) . 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 by t h e a t t i t u d e s o f e m p l o y e r s t o w a r d t h e c a r d i a c p a t i e n t . The p r o b l e m o f p a t i e n t s who a r e f i t t o r e t u r n t o work and c a n n o t f i n d s u i t a b l e e mployment i l l u s t r a t e s t h e s t i g m a a t t a c h e d t o c a r d i a c d i s e a s e ( G r o d e n , 1967; B u r g e s s , L e r n e r , & H a r t m a n , 1 9 8 3 ) . B u r g e s s , L e r n e r , & Hartman ( 1 9 8 3 ) n o t e t h a t few r e h a b i l i t a t i o n p r o g r a m s have been d i r e c t e d a t r e t u r n i n g p a t i e n t s t o work. W o r k i n g demands a r a n g e o f e m o t i o n a l , s o c i a l and p h y s i c a l s k i l l s t h a t may have been a l t e r e d by h e a r t d i s e a s e and t h e r e s u l t i n g l o s s e s . C o p i n g b e h a v i o u r s t o d e a l w i t h t h e demands o f w o r k i n g must be d e v e l o p e d i n o r d e r t o p r o m o t e a s u c c e s s f u l r e h a b i l i t a t i o n and r e t u r n t o work. S e x u a l i t y One o f t h e l o s s e s p e r c e i v e d by t h e MI p a t i e n t i s t h e l o s s o f p h y s i c a l c a p a c i t y . T h i s may t h r e a t e n t h e i n d i v i d u a l ' s s e l f - e s t e e m and t h e c o n c e p t o f m a s c u l i n i t y o r f e m i n i n i t y . "The p a t i e n t e x p e r i e n c e s a g e n e r a l f e a r o f b e i n g i m p o t e n t t o f a c e t h e c o n t i n u i n g c h a l l e n g e o f l i f e and t h i s a n x i e t y i s s y m b o l i z e d i n t h e i n a b i l i t y t o p e r f o r m s e x u a l l y " (Wagner, 1976, p . 1 1 9 ) . Many p a t i e n t s r e l y on t h e i r own k n o w l e d g e , myth, and m i s c o n c e p t i o n s r e g a r d i n g s e x u a l i t y a f t e r an MI. T h i s may be due t o 30 t h e 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 r e g a r d i n g s e x u a l i t y a f t e r an MI. A l l t h e s t u d i e s r e v i e w e d r e f e r r e d t o m a l e p a t i e n t s and f e m a l e s p o u s e s . The 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 as p a t i e n t s has n o t been 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 c o n s e q u e n c e s ( S t e r n , 1977; T u t t l e , Cook & F i t c h , 1 9 6 4 ) . When p a t i e n t s were q u e s t i o n e d a b o u t t h e i r d e c r e a s e i n t h e f r e q u e n c y o f s e x u a l a c t i v i t y , 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 ' s e x u a l d e s i r e , f e a r o f h a v i n g a n o t h e r h e a r t a t t a c k o r o f s u d d e n d e a t h , 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 , s p o u s e ' s f e a r and symptoms o f c o r o n a r y d i s e a s e ( H e l l e r s t e i n & F r i e d m a n , 1970; McLane, K r o p & M e h t a , 1 9 8 0 ) . 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 p a r t n e r s . R e d u c e d s e x u a l a c t i v i t y a f t e r a m y o c a r d i a l i n f a r c t i o n 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 p a r t n e r s and m a r i t a l p r o b l e m s w h i c h may impede t h e r e c o v e r y p r o c e s s ( S c a l z i , 1982; K o l l e r , Kennedy & B u t l e r , 1 9 7 2 ) . 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 have 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 . C h a n g e s i n body image may o c c u r . H e a r t a t t a c k s o c c u r i n g d u r i n g m i d d l e age ( 5 0 - 6 0 ) may augment t h e i m p a c t and f e a r o f a g i n g and s e x u a l i n a d e q u a c y . B e f o r e s e x u a l a c t i v i t y i s r e s u m e d , 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; The e x t e n t o f m y o c a r d i a l damage and f r e q u e n c y o f a n g i n a and a r r h y t h m i a s ( S c a l z i , 1 9 8 2 ) . S t a i r c l i m b i n g has been shown t o be a hemodynamic i n d i c a t o r o f h e a r t work n e e d e d f o r s e x u a l a c t i v i t y ( G r e e n , 1 9 7 5 ) . S i e w i c k i and M a n s f i e l d ( 1 9 7 7 ) showed t h a t t h e m y o c a r d i a l o x y g e n r e q u i r e m e n t t o c l i m b two f l i g h t s o f s t a i r s i s s i m i l a r t o t h a t r e q u i r e d f o r s e x u a l a c t i v i t y . The d e f i n i t i o n o f a f l i g h t o f s t a i r s and t h e r a t e o f c l i m b i n g s h o u l d be g i v e n t h e p a t i e n t d u r i n g t h e c o u n s e l l i n g p e r i o d . D o u g l a s and W i l k e s ( 1 9 7 5 ) c o n c l u d e d t h a t s e x u a l a c t i v i t y i s w e l l w i t h i n t h e c a p a c i t y o f most c a r d i a c p a t i e n t s . A c o m b i n a t i o n o f t h e s e p h y s i c a l and p s y c h o l o g i c a l 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 i n t i m a c y b e t w e e n t h e c o u p l e . The e f f e c t o f u n s u i t a b l e c o p i n g b e h a v i o u r s i n t h e a r e a o f s e x u a l i t y may i m p a c t n e g a t i v e l y on v a r i o u s s u b s y s t e m s w i t h a s u b s e q u e n t r i s e i n t e n s i o n s i g n a l l i n g an unmet n e e d . C o p i n g B e h a v i o u r s i n t h e UBC Model f o r N u r s i n g F o l l o w i n g a r e v i e w o f t h e r e s p o n s e s and c h a n g e s 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, c o p i n g b e h a v i o u r s i n t h e UBC Model f o r N u r s i n g w i l l be e x a m i n e d . Many o f t h e r e s p o n s e s and c h a n g e s made by an i n d i v i d u a l a r e 32 c o p i n g b e h a v i o u r s u s e d i n a a t t e m p t t o s a t i s f y o n e ' s b a s i c human n e e d s . The UBC Model f o r N u r s i n g d e f i n e s a c o p i n g b e h a v i o u r as 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 w h i c h a s u b s y s t e m i s a t t e m p t i n g t o s a t i s f y a b a s i c human need 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 f u n d a m e n t a l r e q u i r e m e n t f o r s u r v i v a l and g r o w t h o f t h e b e h a v i o u r a l s y s t e m . A c o p i n g b e h a v i o u r i s s u i t a b l e 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 need and t h e r e s p o n s e i s a p p r o p r i a t e t o 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 Model 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 as 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 . E a c h s u b s y s t e m 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 need ( A p p e n d i x A ) . N u r s i n g a u t h o r s have u s e d a n e e d s 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 , i m p l e m e n t i n g and e v a l u a t i n g n u r s i n g c a r e . The 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 Model f o r N u r s i n g b u t n o n e t h e l e s s may mean t h e same t h i n g . C a r d i a c 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 n e e d f o r m o b i l i t y , f o r s l e e p and 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 and c o m p l i c a t i o n s when t h e s e n e e d s a r e l a c k i n g ( U n d e r h i l l , 1982; S a n f o r d , 1983; Homan, 1 9 8 3 ) . C o n c e r n s r e g a r d i n g body image and s e l f - c o n c e p t , t h e r o l e o f t h e f a m i l y , t h e i m p o r t a n c e o f 33 t h e e n v i r o n m e n t a r e o t h e r n e e d s t h a t a r e d i s c u s s e d i n t h e c r i t i c a l c a r e l i t e r a t u r e ( R o b e r t s , 1976; K i n n e y , D e a r , P a c k a , & Voorman, 1 9 8 1 ) . D i e t a r y n e e d s , r e s p i r a t o r y n e e d s r e l a t e d t o t h e e f f e c t s o f s m o k i n g 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 a r e p r e s e n t e d 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 , 1 9 8 2 ) . 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 has e x p e r i e n c e d an MI. A c o m p a r i s o n w i t h t h e n e e d s and g o a l s o f t h e UBC Model f o r N u r s i n g r e v e a l s some s i m i l a r i t i e s . 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 a r e s i m i l a r t o t h o s e l i s t e d as c r i t e r i a f o r m e a s u r i n g e f f e c t i v e c o p i n g b e h a v i o u r s 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 c o n c e p t o f s e l f , a d j u s t i n g t o a l t e r e d s o c i a l 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 c h a n g e 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 , 1983; Hamburg & Adams, 1 9 6 7 ) . I n t e g r i t y o f t h e 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 c o n c e p t a r e o t h e r a r e a s m e n t i o n e d i n t h e r e v i e w e d 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 s u b s y s t e m s i n t h e UBC Model f o r N u r s i n g . I d e a l l y t h e s u b s y s t e m s a r e i n a b a l a n c e d r e l a t i o n s h i p w i t h e a c h o t h e r ( b e h a v i o u r a l s y s t e m b a l a n c e ) . A r a n g e o f c o p i n g b e h a v i o u r s i s u s e d i n an 34 a t t e m p t t o r e d u c e t e n s i o n , w h i c h 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 . C o p i n g b e h a v i o u r s w h i c h a r e b o t h i n n a t e and a c q u i r e d a r e o r g a n i z e d i n t o r e p e t i t i v e , p r e d i c t a b l 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 c h a r a c t e r i s t i c 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 n e e d s . 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 n e e d s o f t h e i n d i v i d u a l . The need f o r n o u r i s h m e n t i n t h e 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 n e e d 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 c h a n g e s . The l o s s o f o n e ' s h e a l t h may have e v e n more g l o b a l e f f e c t s and t h 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 p r o p e r t i e s o f t h e s u b s y s t e m s a r e r e a l i z e d as o n e ' s need f o r 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 and 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 . E a c h s u b s y s t e m i s v i e w e d as a l i f e s p a c e . T h i s 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 and 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 ) t o s a t i s f y t h e n e e d . 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 g o a l and f o r c e s t h a t a r e m e a n i n g f u l t o t h e s u b s y s t e m . 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 w h i c h a r e c o m p o n e n t s o f 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 t h e c a p a c i t y 35 t o know and 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 i n f l u e n c e c o p i n g b e h a v i o u r s . C o p i n g b e h a v i o u r s f a c i l i t a t e 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 s u b s y s t e m (UBC Model f o r N u r s i n g , 1 9 8 0 ) . 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 Model f o r N u r s i n g t h a t t h e t e r m c o p i n g b e h a v i o u r w i l l be u s e d i n t h i s s t u d y . C o p i n g b e h a v i o u r w i t h i n t h i s f r a m e w o r k 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 o n e ' s i n t e g r i t y e l i c i t i n g a n x i e t y , f e a r and g r i e f . I t 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 o v e r s t r e s s f u l e x p e r i e n c e s . I t i s more t h a n a l i f e s t y l e c h a n g 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 l i f e s t y l e c h a n g e s 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 f o r t h 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 n e e d s . 36 CHAPTER THREE METHODOLOGY A d e s c r i p t i v e s t u d y c o n s t r u c t s a p i c t u r e o r a c c o u n t o f e v e n t s 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 , 1 9 8 1 ) . 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 o r c o n c e p t u a l i z e s i t u a t i o n s . In o r d e r t o 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 u s e d by MI p a t i e n t s i n m e e t i n g 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 e l i c i t e d . The m e t h o d o l o g y u s e d i n t h i s s t u d y , g r o u n d e d t h e o r y , was d e s c r i b e d by G l a s e r and S t r a u s s ( 1 9 6 7 ) . T h i s method i s a p r o c e s s o f m o v i n g f r o m t h e d a t a t o t h e c o n c e p t 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 . D i e r s ( 1 9 7 9 ) d e s c r i b e s t h i s method as a p s y c h o l o g i c a l t h i n k i n g p r o c e s s u s i n g d i s c r i m i n a t i o n , d e f i n i t i o n and c l a s s i f i c a t i o n . The r e s e a r c h e r must t r e a t " a l l t h e 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 o r f r o m t h e l i t e r a t u r e , i t i s t o be c o m p a r e d t o -the o n g o i n g d a t a f o r t h e p u r p o s e o f 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 i d e a s ( G l a s e r , 1978) . G r o u n d e d t h e o r y v i e w s t h e d e v e l o p m e n t o f t h e o r y as an o n - g o i n g c o n c e p t u a l p r o c e s s w i t h s t e p s , so t h a t one c a n s e e how c o n c e p t s h a v e b e e n d e v e l o p e d . The m e t h o d 37 has f o u r s t a g e s : 1) c o m p a r i n g d a t a i n e a c h c a t e g o r y , 2) i n t e g r a t i n g t h e c a t e g o r i e s and t h e i r p r o p e r t i e s , 3) d e l i n e a t i n g t h e t h e o r y and 4) w r i t i n g t h e t h e o r y ( G l a s e r & S t r a u s s , 1 9 6 7 ) . 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 c h a n g e s i n 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 . D a t a were c a t e g o r i z e d by s o r t i n g d a t a u n d e r t h e s u b s y s t e m s o f t h e UBC Model f o r N u r s i n g t o c a t e g o r i z e common themes 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 . The c o p i n g b e h a v i o u r s u s e d t o s a t i s f y n e e d s o f t h e s y s t e m were d e s c r i b e d . The m e t h o d o l o g y o f g r o u n d e d t h e o r y was u s e f u l f o r i d e n t i f y i n g t h e 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 . 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 and 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 were e l i c i t e d t h r o u g h t h i s p e r s p e c t i v e . 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 i m p a c t on i n d i v i d u a l s were a l s o d e s c r i b e d . In t h i s way f u r t h e r u n d e r s t a n d i n g was g a i n e d i n t h e a r e a o f c o p i n g b e h a v i o u r s 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. D a t a u s e d 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 6-12 months a f t e r t h e s u b j e c t s ' MI. 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 h o u r i n l e n g t h were c o n d u c t e d w i t h e a c h p a r t i c i p a n t . A s a m p l e s i z e o f s e v e n p r o v i d e d d a t a n e c e s s a r y t o d i s c o v e r and v a l i d a t e r e c u r r i n g e l e m e n t s . S e l e c t i o n o f P a r t i c i p a n t s P a r t i c i p a n t s s e l e c t e d f o r t h e s t u d y were r e q u i r e d t o meet t h e f o l l o w i n g c r i t e r i a : 1) 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 a g e . 2) The p a r t i c i p a n t s w i l l be a d u l t s who had a m e d i c a l d i a g n o s i s o f an i n i t i a l m y o c a r d i a l i n f a r c t i o n 6-12 months p r e v i o u s . 3) The p a r t i c i p a n t s must be a b l e t o u n d e r s t a n d , s p e a k and r e a d E n g l i s h . 4) The p a r t i c i p a n t s must l i v e i n t h e g r e a t e r V a n c o u v e r a r e a t o be a c c e s s i b l e f o r i n t e r v i e w s . P a r t i c i p a n t s were o b t a i n e d f o r t h i s s t u d y o v e r a t h r e e month p e r i o d w i t h t h e h e l p o f t h e head n u r s e i n t h e c o r o n a r y c a r e u n i t o f one V a n c o u v e r h o s p i t a l who had a c c e s s t o t h e r e c o r d s c o n t a i n i n g t h e names o f p a t i e n t s p a s s i n g t h r o u g h t h e c o r o n a r y c a r e u n i t . 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 d i a g n o s i s o f m y o c a r d i a l 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 h e r c o n s e n t and h e l p i n r e c r u i t i n g p a r t i c i p a n t s . The 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 p e r s o n s t h a t she was s t i l l f o l l o w i n g and t h a t l i v e d i n t h e g r e a t e r V a n c o u v e r a r e a . Her s e c r e t a r y was w i l l i n g t o c o n t a c t t h e p a t i e n t s and 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 RELATED TO CARDIAC RESEARCH STUDY ( A p p e n d i x B ) . I f t h e p e r s o n 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 and phone 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 t h e n 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 s t u d y 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 t h e s t u d y . E a c h o f t h e s e v e n p a r t i c i p a n t s c o n t a c t e d a g r e e d 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 t i m e was a r r a n g e d t o meet i n t h e i r homes. One g e n t l e m a n was v e r y b u s y and i t was more c o n v e n i e n t t o a r r a n g e a m e e t i n g 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 a t t h e b e g i n n i n g o f t h e i n t e r v i e w . W r i t t e n c o n s e n t 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 . 40 C h a r a c t e r i s t i c s o f t h e P a r t i c i p a n t s D a t a were o b t a i n e d f r o m a s t u d y s a m p l e 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 were m a r r i e d , one was widowed and t h e woman was widowed. T h r e e men were e m p l o y e d , two were r e t i r e d and one man and woman were 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 s e v e n t o t w e l v e 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 o n . T a b l e 1 P a r t i c i p a n t Sex Age M a r i t a l S t a t u s Work S t a t u s R e c e n c y o f MI(mos.) 1 M 45 M E 10 2 M 63 M R 12 3 F 60 W U 7 4 M 69 M R 9 5 M 58 M E 8 6 M 54 M E 10 7 M 66 W R 12 M - m a r r i e d W-widowed E- e m p l o y e d U - u n e m p l o y e d R-r e t i r e d 41 E t h i c a l C o n s i d e r a t i o n s 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 o b t a i n e d f r o m UBC E t h i c s C o m m i t t e e f o r R e a s e a r c h S t u d i e s . 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 t h e 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 t o p a r t i c i p a n t s p r i o r t o o b t a i n i n g c o n s e n t ( A p p e n d i x B ) . W r i t t e n c o n s e n t was r e c e i v e d f r o m t h e p a r t i c i p a n t p r i o r t o t h e i n t e r v i e w ( A p p e n d i x 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 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 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 m e d i c a l o r n u r s i n g c a r e . 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 t h e t a p e d i n t e r v i e w w o u l d be k e p t c o n f i d e n t i a l and t h e i r name w o u l d n o t be u s e d i n any w r i t t e n o r p u b l i s h e d m a t e r i a l . The t a p e s w o u l d be e r a s e d upon c o m p l e t i o n o f t h e s t u d y . 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 t h e r e were no r i s k s a s s o c i a t e d w i t h p a r t i c i p a t i o n i n t h i s s t u d y . The p o t e n t i a l b e n e f i t s o f t h e s t u d y w o u l d be r e a l i z e d 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 i n s i g h t f r o m t h e e x p e r i e n c e s o f t h e s e p e o p l e . 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 t h e y w o u l d 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 . D a t a C o l l e c t i o n D a t a 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 g u i d e w i t h o p e n - e n d e d q u e s t i o n s ( A p p e n d i x D ) . The q u e s t i o n s were n o t s t a n d a r d i z e d b u t were u s e d as a - g u i d e t o e x p l o r e t h e 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 d e v e l o p e d 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 meet t h e i r b a s i c human n e e d s . O b s e r v a t i o n a l m e t h o d s were a l s o u s e d w i t h v e r b a l ( 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 n o n - v e r b a l ( 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 ) b e h a v i o u r s n o t e d . C o p i n g b e h a v i o u r s t h a t were 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 . T h i s 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 a b o u t t h e b a s i c human need 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 b e h a v i o u r , t h e f o r c e s ( s o c i o c u l t u r a l , p e r s o n a l o r i m p e r s o n a l ) t h a t a f f e c t e d o r 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 and t h e 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 ) t h a t d e t e r m i n e d t h e c o p i n g b e h a v i o u r . 43 The i n t e r v i e w s were 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 had 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 t o e a s y c o n v e r s a t i o n . R a p p o r t was e s t a b l i s h e d e a s i l y t h r o u g h a t i m e o f s o c i a l c o n v e r s a t i o n p r i o r t o t h e i n t e r v i e w where d e m o g r a p h i c d a t a was g a t h e r e d ( A p p e n d i x E ) . Many p a r t i c i p a n t s e x p r e s s e d 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 t o c o n t r i b u t e t o t h e r e s e a r c h e r ' s l e a r n i n g and t o n u r s i n g k n o w l e d g e . The i n t e r v i e w s r a n g e d f r o m t h i r t y t o s i x t y m i n u t e s i n l e n g t h . F o l l o w i n g t h e i n t e r v i e w , t h e r e s e a r c h e r n o t e d 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 b e h a v i o u r o r o t h e r o b s e r v a t i o n s 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 o r i n t e r e s t . F i e l d n o t e s were made o f c e r t a i n i d e a s o r m a j o r c o n c e r n s o f t h e 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 were p l a n n e d w i t h e a c h p a r t i c i p a n t . S e c o n d 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 t h e s e v e n p a r t i c i p a n t s as two r e f u s e d f u r t h e r q u e s t i o n i n g b e c a u s e t h e y f e l t t h e y had p r o v i d e d a l l t h e i n f o r m a t i o n a t t h e f i r s t i n t e r v i e w . F o l l o w u p i n t e r v i e w s i n q u a l i t a t i v e r e s e a r c h i s f o r t h e p u r p o s e o f r e l i a b i l i t y where t h e f o c u s i s on i d e n t i f y i n g and d o c u m e n t i n g r e c u r r e n t , a c c u r a t e , c o n s i s t e n t o r 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 , t h e m e s , v a l u e s o r e x p e r i e n c e s ( L e i n i n g e r , 1 9 8 5 ) . 44 The 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 f r o m t h e 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 f r o m i n t e r v i e w s o f o t h e r p a r t i c i p a n t s . D a t a 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 and f i e l 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 a s y s t e m o f c o n s t a n t c o m p a r i s o n . D a t a were c o d e d a c c o r d i n g t o t h e s u b s y s t e m s o f t h e UBC Model f o r N u r s i n g . W h i l e c a t e g o r i z i n g d a t a , t h e y were c o m p a r e d w i t h p r e v i o u s 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 . T h i s c o n s t a n t c o m p a r i s o n g e n e r a t e s p r o p e r t i e s o f t h e c a t e g o r y . F o r e x a m p l e e x a m i n i n g d a t a i n t h e a c h i e v i n g s u b s y s t e m 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 need f o r m a s t e r y . 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 became a p p a r e n t . C o p i n g 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 c o m p a r e d w i t h t h e d a t a t h r o u g h o u t t h e c a t e g o r i e s o f t h e n i n e s u b s y s t e m s . Common themes a r i s i n g f r o m t h e d a t a and 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 s u b s y s t e m s were n o t e d . The 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 ( f o r c e s , a b i l i t i e s ) were r e v i e w e d r e p e a t e d l y u n t i l t h e themes c o u l d be c l e a r l y d e s c r i b e d . 45 Summary T h i s c h a p t e r o u t l i n e d t h e p r o c e s s u s e d t o a p p l y t h e m e t h o d o l o g y o f g r o u n d e d t h e o r y i n t h i s s t u d y t o i d e n t i f y 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 u s e d by MI p a t i e n t s as t h e y meet 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 l i t a t i o n . The f i n d i n g s and a c c o u n t s o f t h e 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 be d e s c r i b e d i n C h a p t e r 4. 46 CHAPTER FOUR FINDINGS OF THE STUDY T h i s c h a p t e r o u t l i n e s t h e f i n d i n g s o f t h e r e s e a r c h s t u d y . 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 and d e s c r i b e d t h r o u g h t h e a c c o u n t s o f t h e p a r t i c i p a n t s and t h e 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 e x p e r i e n c e s o f t h e p a r t i c i p a n t s . " R i s k R e d u c t i o n " i s t h e f i r s t theme d e s c r i b i n g many o f t h e c o p i n g b e h a v i o u r s 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 n e e d s 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 and r e c u r r a n c e o f an MI. " G e t t i n g Back 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 i n i t i a l r e a l i z a t i o n o f t h e need f o r c h a n g e 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 . The f i n a l theme " R e a c h i n g a New N o r m a l " o u t l i n e s t h e p e r s o n a l a t t i t u d e s and 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 o v e r t i m e . T h e r e i s a d e s c r i p t i o n o f t h e c o p i n g b e h a v i o u r s u s e d t o meet t h e i r b a s i c human n e e d s . C h a n g e s 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 . T h r o u g h o u t t h e d e s c r i p t i o n o f t h e s e t h e m e 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 t h a t a f f e c t n e e d s a t i s f a c t i o n and g o a l a c h i e v e m e n t a r e a d d r e s s e d . 47 1. 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 i s k R e d u c t i o n Some o f t h e f i r s t c h a n g e s t h a t were 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 were i n t h e a r e a o f d i e t a r y m o d i f i c a t i o n , c o n s i s t e n t m e d i c a t i o n t a k i n g , s m o k i n g c e s s a t i o n and commencement o f e x e r c i s e . T h e s e a r e a s 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 r e d u c t i o n . D i e t a r y M o d i f i c a t i o n A l l 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 v e r b a l a n d / o r w r i t t e n i n f o r m a t i o n f r o m 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 t h e i r d i e t w h i l e i n h o s p i t a l f o l l o w i n g t h e i r MI. The i n f o r m a t i o n , as u n d e r s t o o d by t h e p a r t i c i p a n t s , v a r i e d g r e a t l y . Some c l a i m e d t h a t t h e y were t o l d t o c o m p l e t e l y a v o i d c e r t a i n f o o d s s u c h as e g g s , b a c o n , f a t t y f o o d s , and r e d meat w h i l e o t h e r s 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 . Some were p u t on a s p e c i f i c d i e t and g i v e n new c o o k i n g i n s t r u c t i o n s w h i l e o t h e r s were g i v e n more g e n e r a l g u i d e l i n e s . F o u r o f t h e p a r t i c i p a n t s c h a n g e d 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 home. T h i s i n v o l v e d a h o u s e h o l d c h a n g e w i t h d i f f e r e n t c o o k i n g h a b i t s as w e l l 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 . A n x i e t y was 48 an i n i t i a l f o r c e t h a t i n f l u e n c e d t h e d e s i r e t o e a t . One man commented. I'm s t i l l on t h e d i e t t h e y g a v e me - low c h o l e s t e r o l . . . . I was a n x i o u s , d i d n ' t f e e l l i k e e a t i ng. A n o t h e r man s t a t e d . I f o l l o w e d what t h e y t o l d me t o do. Change y o u r d i e t . We had 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 d o n ' t use h i g h 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 and b a c o n and a l l t h e h e a v y f a t s t u f f . I t ' s a c h a n g e . A n o t h e r man e x p l a i n e d t h e c h a n g e 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 r e d u c e h i s r i s k o f f u r t h e r p r o b l e m s . I t r y t o do good 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 meat, no f r i e d f o o d s . I d o n ' t use s a l t i n my f o o d . I c u t down on c o o k i e s and c a k e s . I l o s t 40 pou n d s s i n c e t h e 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 r e c e i v e d f r o m h e a l t h p r o f e s s i o n a l s w h i l e i n h o s p i t a l . He began t h e f a t - f r e e , low s u g a r , h i g h f r u i t , v e g e t a b l e and g r a i n d i e t known as 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 ) . T h i s 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 h a b i t s . Some a r e a s were l e s s o f a p r o b l e m as he s t a t e d . 49 In any c a s e i t was e a s y b e c a u s e we were 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 meat end o f i t and we're b i g f i s h e a t e r s anyway. 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 c l o s e t o 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 m e n t i o n e d t h a t t h e y had n o t c h a n g e d t h e i r d i e t . However, one woman f o u n d t h a t she no l o n g e r l i k e d c e r t a i n f o o d s , some o f w h i c h were h i g h c h o l e s t e r o l f o o d s . She e x p l a i n e d . 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 b u t t h i n g s t h a t I u s e d t o e a t b e f o r e I d o n ' t l i k e . Now I u s e d t o l i k e b a c o n and e g g s and 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 any d i e t b u t t h e r e a r e f o o d s I l i k e o r d o n ' 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 ( e g g s and b a c o n ) . I t ' s n o t j u s t f r o m r e a d i n g t h a t i t ' s bad f o r y o u r h e a r t . F o r t h i s woman, h e r need f o r s a f e t y and 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 w h i c h she had been c o u n s e l l e d n o t t o e a t . Her ne e d s 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 f o o d s 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 c h a n g e d h e r e a t i n g h a b i t s . 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 and 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 and was u n a b l e t o r e m a i n on a d i e t . I t was a l s o n o t e w o r t h y t h a t s m o k i n g c e s s a t i o n was a n e g a t i v e 50 f o r c e i n t h i s a r e a . The n e e d s f o r s e n s o r y s a t i s f a c t i o n and s e l f - e s t e e m 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 o f t h i s man i n r e l a t i o n t o h i s need f o r s a f e t y and s e c u r i t y . He e x p l a i n e d . I t h i n k t h a t ' s why i t ' s so h a r d t o keep on t h e d i e t b e c a u s e I ' v e g o t t a have s o m e t h i n ' t o f i l l me. F i v e o f t h e s e v e n p a r t i c i p a n t s l o s t 20-40 pounds f o l l o w i n g t h e i r MI. A l l o f them were c o u n s e l l e d by h e a l t h p r o f e s s i o n a l s t o r e d u c e t h e i r w e i g h t . One s a i d she p u t on 3 o r 4 p o u n d s and a n o t h e r t h o u g h t h i s w e i g h t had n o t c h a n g e d . F o u r o f t h e p a r t i c i p a n t s m e n t i o n e d t h e i r p r e v i o u s a l c o h o l h a b i t s . Two a d m i t t e d t h a t t h e y d r a n k h e a v i l y and have s t o p p e d c o m p l e t e l y . I d r a n k q u i t e a b i t b e f o r e and I c u t t h a t o u t . I u s e d t o d r i n k a l o t . S c o t c h , y o u know. N o t now, no s c o t c h i n t h e h o u s e . 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 t h a t t h e y a r e c o n t i n u i n g t o d r i n k a l c o h o l i c b e v e r a g e s . I d i d n ' t q u i t d r i n k i n 1 b e e r . J u s t c u t down on i t , y o u know, c o n s u m p t i o n . * • • • M i n d y o u , I d i d n ' t ask D r . B. a b o u t d r i n k i n g . I f i g u r e d she may s a y no. ( 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 t h e c o g n i t i v e a b i l i t y t o u n d e r s t a n d t h e i r n e e d s i n r e l a t i o n t o t h e f o r c e s i n f l u e n c i n g t h e g o a l . 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 were t h e i r w i v e s and f a m i l i e s who a s s i s t e d them by c h a n g i n g ways and h a b i t s o f c o o k i n g . N e g a t i v e 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 where t h e f o o d s e r v e d d i d n o t c o m p l y w i t h t h e i r d i e t . M o s t m e n t i o n e d t h a t t h e y w o u l d r e a l l y e n j o y t h e meal and t h e n go back t o t h e i r new e a t i n g h a b i t s l a t e r . One g e n t l e m a n t r a v e l l e d e x t e n s i v e l y w i t h h i s j o b and f o u n d t h a t e a t i n g o u t , p a r t i c u l a r l y e a t i n g a i r l i n e f o o d , p o s e d a p r o b l e m . The n e e d s t h a t were most a f f e c t e d by t h e d i e t a r y c h a n g e t h a t t h e s e p a r t i c i p a n t s m e n t i o n e d were t h e need 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 o f t h e s y s t e m ' s s e n s e s ( s m e l l , t a s t e ) and t h e need f o r s a f e t y and s e c u r i t y . I t was t h e n e e d o f t h e p r o t e c t i v e s u b s y s t e m f o r s a f e t y and s e c u r i t y t h a t p r o v i d e d t h e i m p e t u s f o r r i s k r e d u c t i o n c h a n g e s . The f o r c e s t h a t i n f l u e n c e d d i e t a r y m o d i f i c a t i o n s i n a p o s i t i v e way were f a m i l y members, 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 r e s u l t s w i t h w e i g h t l o s s . S moking c e s s a t i o n , a n x i e t y and d e p r e s s i o n had n e g a t i v e 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 t o c h a n g e t h e i r d i e t s . 52 S m o k i n g C e s s a t i o n S i x o f t h e s e v e n p a r t i c i p a n t s i n t h e s t u d y smoked p r i o r t o t h e i r MI. A l l b u t one has now s t o p p e d s m o k i n g . 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 t h e s i x who q u i t s m o k i n g c l a i m t h a t t h e y s t o p p e d a b r u p t l y . They e x p l a i n how t h e y s t o p p e d . I q u i t s m o k i n g . J u s t c u t ' e r r i g h t o f f . W o u l d n ' t g i v e y o u a dime f o r a t h o u s a n d o f them. 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 a t t a c k . The d o c t o r s a i d , "No more s m o k i n g " , so I h a v e n ' t t o u c h e d o n e . I t ' s been god a w f u l h a r d , I ' l l t e l l y o u . I s t i l l m i s s i t w i t h c o f f e e i n t h e m o r n i n g , b u t 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 w a s n ' t a h e a v y smoker anyway. Maybe a pack w o u l d l a s t me two d a y s . I f o l l o w e d what t h e y t o l d me. Q u i t s m o k i n g , q u i t d o i n g t h i s and d o i n g t h a t . I had smoked a pack a day and I q u i t . I had no c h o i c e , d i d I? I t ' s e i t h e r q u i t o r d i e , r i g h t and my d o c t o r t e l l s me, " I f y o u want me t o be y o u r c a r d i o l o g i s t y o u d o n ' t smoke. So t h a t was i t , I q u i t s m o k i n ' . F o r t h e s e p a r t i c i p a n t s 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 i n t h e p r o t e c t i v e s u b s y s t e m 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 o f a b r u p t l y s t o p p i n g s m o k i n g . F o r m o s t , t h e i r d o c t o r was a s t r o n g p o s i t i v e f o r c e i n s i s t i n g t h a t t h e y s t o p s m o k i n g o r f i n d a n o t h e r d o c t o r . A n o t h e r f o r c e was h o s p i t a l i z a t i o n where s m o k i n g was n o t p e r m i t t e d . 53 Some s t a t e d t h a t t h e y f e l t b e t t e r and were b r e a t h i n g 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 b u t t h i s had 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 s m o k i n g . The need f o r s t i m u l a t i o n o f t h e s y s t e m ' 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 by s m o k i n g was no l o n g e r met i n t h a t way. One man m e n t i o n e d t h a t he had been e a t i n g more; o t h e r s f o u n d t h a t s m o k i n g and c o f f e e o r a l c o h o l i c d r i n k went t o g e t h e r and t h e s e s u b s t a n c e s had a l l been s i g n i f i c a n t l y r e d u c e d . One p a r t i c i p a n t s t o p p e d s m o k i n g j u s t p r i o r t o h i s MI. He was e x p e r i e n c i n g d i f f i c u l t y b r e a t h i n g , and n o i s y s n o r i n g and was p r e s s u r e d by h i s f a m i l y t o s e e a d o c t o r . He e x p l a i n e d h i s c o n d i t i o n . 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 ven now I have a l i t t l e b i t o f p r o b l e m s . I ' d g e t b r e a t h l e s s a l l o f a s u d d e n . 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 ack t o n ormal 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 s m o k i n g f o r a l l t h o s e y e a r s . 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 t h a t I q u i t s m o k i n g . My son u s e d t o smoke b u t when he saw me q u i t t i n g he d o e s n ' t t o u c h i t a n y m o r e . The c o p i n g b e h a v i o u r u s e d by t h i s man t o meet h i s need f o r p h y s i c a l s a f e t y was t o q u i t s m o k i n g . H i s f a m i l y and h i s d o c t o r 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 t h e c o p i n g b e h a v i o u r . 54 The o n l y woman i n t e r v i e w e d had n o t s t o p p e d s m o k i n g and smoked t h r o u g h o u t t h e i n t e r v i e w . She had a l o o s e , h a c k i n g c o u g h and a d m i t t e d l y had some d i f f i c u l t i e s w i t h b r e a t h l e s s n e s s . However, o t h e r f o r c e s seemed t o 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 e x p l a i n e d . 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 oking c e s s a t i o n was an a r e a where 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 , o x y g e n a t i o n and s t i m u l a t i o n o f o n e ' s s e n s e s were t h e p r i m e n e e d s a f f e c t e d by t h e a t t e m p t s o f t h e i n d i v i d u a l s t o s t o p s m o k i n g . The 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 n e g a t i v e l y i n c l u d e d t h e i r f a m i l y , t h e i r d o c t o r , t h e i r h e a l t h n e e d s , d e p r e s s i o n 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 . M e d i c a t i o n Regimen T h r e e o f t h e p a r t i c i p a n t s had n o t been u s e d t o t a k i n g p r e s c r i b e d m e d i c a t i o n p r i o r t o t h e i r MI. M o s t o f them were s t i l l q u e s t i o n i n g t h e i r need t o t a k e t h e p r e s c r i b e d m e d i c a t i o n o v e r a c o n t i n u e d p e r i o d o f t i m e . F o u r 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 h y p e r t e n s i o n f o r w h i c h t h e y had been p r e s e n t e d an a n t i - h y p e r t e n s i v e m e d i c a t i o n . However, a l l s a i d t h a t t h e y d i d n o t t a k e 55 t h e 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 t a k e 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 one t o d a y , t h e n m i s s two da 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 has t o be t a k e n . T h i s c h a n g e i n t a k i n g m e d i c a t i o n r e l i g i o u s l y was e c h o e d 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 c u r e o r c o n t r o l o f t h e i r d i s e a s e . A n o t h e r 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 on [ m e d i c a t i o n ] t h e y made me p e r s p i r e so much b u t now i t d o e s n ' t b o t h e r me. I ' v e a l w a y s had h i g h b l o o d p r e s s u r e . I'm s u r p r i s e d I'm n o t on t o o much m e d i c a t i o n now ( o n l y one m e d i c a t i o n ) . One man e x p r e s s e d some d i f f i c u l t y u n d e r s t a n d i n g 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 b e w i l d e r m e n t s p i l l e d o v e r i n t o h i s v i e w o f m e d i c i n e as a vague s c i e n c e s i n c e t h e r e were no d e f i n i t e a n s w e r s f o r 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 , a h , 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 d o n ' t t h i n k i t ' s a n y b o d y ' s f a u l t and I ' v e a l m o s t 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 any 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 w h a t e v e r d i s c o m f o r t I have o t h e r w i s e , i t 56 must be w i t h i t . . . . I w o u l d have 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've been 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 ) , b u t I ' v e been t a k i n g t h o s e f o u r t i m e s a d a y . A c c o r d i n g t o t h e p a r t i c i p a n t s , m e d i c a t i o n s were t a k e n f o l l o w i n g an MI i n o r d e r t o p r o t e c t t h e i r h e a l t h and meet t h e need f o r s a f e t y and s e c u r i t y . C e r t a i n f o r c e s s u c h as u n d e r s t a n d i n g o r m i s u n d e r s t a n d i n g t h e p r e s c r i b e d m e d i c a t i o n a f f e c t e d w h e t h e r o r n o t one a d h e r e d t o t h e p r e s c r i b e d r e g i m e n . S i d e e f f e c t s were n e g a t i v e f o r c e s i n f l u e n c i n g t h e n e e d s i n o t h e r s u b s y s t e m s . One man c o m p l a i n e d o f t h e d i s t u r b i n g s i d e e f f e c t s o f P r o p r a n o l o l d e c r e a s i n g h i s s e x u a l d e s i r e . 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 f o r c e s i n a d h e r e n c e t o t h e p r e s c r i b e d m e d i c a t i o n r e g i m e n w h i c h u l t i m a t e l y a f f e c t e d t h e s a t i s f a c t i o n o f 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 . One man r e l i e d t o t a l l y on h i s w i f e t o o r g a n i z e h i s m e d i c a t i o n and g i v e him h i s d a i l y p i l l s . E x e r c i se A l l o f t h e p a r t i c i p a n t s b e gan t o e n g a g e i n p h y s i c a l e x e r c i s e i n a new way a f t e r t h e i r M i ' s . F o r m o s t , r e g u l a r e x e r c i s e had n o t been a normal p a r t o f t h e i r l i v e s . One man had w a l k e d two m i l e s d a i l y s i n c e h i s s t r o k e s i x y e a r s p r e v i o u s . Some r e c e i v e d e n c o u r a g e m e n t and g u i d a n c e r e g a r d i n g p h y s i c a l a c t i v i t y 57 f r o m t h e i r d o c t o r . 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 " t a k e i t e a s y " o r " d o n ' t o v e r d o i t " n o t s p e c i f i c e n o u g h . A l l o f t h e p a r t i c i p a n t s b e gan a p r o g r a m o f w a l k i n g 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 d o c t o r . T hey were u n c l e a r a b o u t t h e g u i d e l i n e s o f w a l k i n g and p a c e d t h e m s e l v e s a c c o r d i n g t o t h e i r own a b i l i t y and t h e 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 on t h e i r a c t i v i t y . They e x p l a i n e d . 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 w a l k , t h e n t h a t w e a r s o f f . I t h i n k i t d o e s 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 t o i n j u r e i t . F o u r o f t h e p a r t i c i p a n t s t h o u g h t t h a t t h e i r j o b o r p r e v i o u s s p o r a d i c w a l k i n g h a b i t s c o n s t i t u t e d e x e r c i s e , 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 . They became 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 e n g a g i n g i n a r o u t i n e o f d a i l y w a l k i n g c o n s t i t u t i n g e x e r c i s e . 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 what 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 , b u t y o u d o n ' t g e t e n o ugh e x e r c i s e . As t i m e went 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 been 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 weekends 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 have 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 noon h o u r a t work j u s t t o g e t o u t o f t h e 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 e v e n t . The p r i m a r y p u r p o s e o f an e x e r c i s e p r o g r a m d i f f e r e d among t h e p a r t i c i p a n t s . F o r f o u r o f t h e 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 d e s c r i b e d as a r e g u l a r e v e n t , was u n d e r t a k e n by them i n o r d e r t o meet t h e need f o r a b a l a n c e b e t w e e n t h 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 . However, f i v e o f t h e p a r t i c i p a n t s a l s o m e n t i o n e d t h e p r e v e n t i v e n a t u r e o f an e x e r c i s e p r o g r a m a g a i n s t f u t u r e M i ' s as an i m p e t u s f o r a c t i v i t y . T h i s a c h i e v e d t h e g o a l o f t h e p r o t e c t i v e s u b s y s t e m , i n t e g r i t y o f t h e s y s t e m . 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 e x e r c i s e p r o g r a m , f i v e o f t h e p a r t i c i p a n t s f o u n d a d d e d b e n e f i t s i n o t h e r a r e a s . The n e e d f o r m a s t e r y , s e l f - e s t e e m , i n t a k e o f o x y g e n and s t i m u l a t i o n o f t h e s y s t e m ' s s e n s e s were e n h a n c e d t h r o u g h a c t i v i t y . Thus a c t i v i t y was a p o s i t i v e f o r c e i n t h e a c h i e v i n g , e g o - v a l u a t i v e , r e s p i r a t o r y and s a t i a t i v e s u b s y s t e m s . One man commented. I g u e s s I g o t up t o t h a t p o i n t where 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 and as t i m e g o e s on I have f e l t l e s s d i z z y a t t i m e s t h a n I d i d i n t h e e a r l y c o n v a l e s c e n t p e r i o d . So now most 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, and t h e way I w o u l d 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 o r b r e a t h l e s s n e s s . E x e r c i s e 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 f o l l o w i n g t h e i r MI a f f e c t e d t h e need f o r a b a l a n c e b e t w e e n t h 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 and 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 . The r e s u l t s d e r i v e d f r o m t h e e x e r c i s e p o s i t i v e l y i n f l u e n c e d t h e need f o r m a s t e r y , s e l f - e s t e e m , i n t a k e o f o x y g e n and s t i m u l a t i o n o f t h e s y s t e m ' s s e n s e s . N e g a t i v e f o r c e s r e s u l t i n g f r o m t h e e x e r c i s e were c h e s t p a i n and f a t i g u e w h i c h i n f l u e n c e d 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 b e t w e e n t h 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 . As d e s c r i b e d i n t h e f i n d i n g s on r i s k r e d u c t i o n 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 , s m o k i n g , 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 . 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 have been p e r m a n e n t o n e s . T h e s e were a r e a s o v e r w h i c h 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. The a b i l i t y t o u n d e r s t a n d and make a l i f e s t y l e c h a n g e d u r i n g a c r i t i c a l 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 . O t h e r n e e d s t h a t p r e c i p i t a t e d r i s k r e d u c t i o n c h a n g e s were t h e need f o r 60 o x y g e n a t i o n and t h e need f o r a b a l a n c e b e t w e e n 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 . M a k i n g c h a n g e s t o r e d u c e t h e i r r i s k o f a s e c o n d MI seemed t o be t h e f i r s t s t e p i n g e t t i n g back t o n o r m a l . 2. 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 A l l o f 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 e v e n t u a l l y 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 e x p e r i e n c e . Many s h a r e d t h e i r b e l i e f s a b o u t what c a u s e d t h e i r MI and t h e e v e n t s p r e c e d i n g and l e a d i n g t o i t . T hey 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 f r o m r e l a t i n g t h e i r p e r s o n a l s t o r y t o a c o n c e r n e d l i s t e n e r . The r e c o u n t i n g o f t h i s p e r s o n a l e x p e r i e n c e may h e l p p e o p l e 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 , and h e l p them f o r m u l a t e a new image o f t h e m s e l v e s w i t h new o r r e v i s e d g o a l s . The n e e d s 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 f o r s e l f r e s p e c t and r e s p e c t f r o m 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 e x p e r i e n c e . R e a l i z a t i o n o f t h e Need f o r Change M o s t 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 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 . One p a r t i c i p a n t upon f i n d i n g o u t h i s c o r o n a r y 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 . 6 1 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 have t o c h a n g e and I d i d n ' t know r e a l l y what t h a t m eant. A n o t h e r p a r t i c i p a n t who had s u f f e r e d a m i l d CVA s i x y e a r s p r e v i o u s l y 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 g o t t o 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 , y o u 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 . P r e v i o u s c o p i n g b e h a v i o u r s d e v e l o p e d a f t e r a s t r o k e h e l p e d t h i s man t o meet h i s n e e d s a f t e r h i s MI b e c a u s e he u s e d c o p i n g b e h a v i o u r s t h a t were a l r e a d y p a r t o f h i s 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 p a r t i c i p a n t . Even b e i n g i n t h e h o s p i t a l f o r two w e e ks, I d i d n ' t a g r e e i n my own s e l f t h a t I had a h e a r t a t t a c k . I d i d n ' t b e l i e v e i t . . . I w a s n ' t e v e n s u r e , e v e n t h o u g h t h e y t o l d me, t h a t I had a h e a r t a t t a c k , I w o u l d n ' t a g r e e t o i t . • • • • I f e l t more 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 what 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 . D e n i a l d u r i n g t h e i n i t i a l weeks f o l l o w i n g an MI was 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 . D e n i a l i n 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 b e h a v i o u r u s e d t o s a t i s f y t h e need f o r s e l f r e s p e c t 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 and s a f e t y and s e c u r i t y i n t h e p r o t e c t i v e s u b s y s t e m . D u r i n g t h e i n i t i a l p h a s e , i t was i m p o r t a n t f o r t h e i n d i v i d u a l s t o m a i n t a i n s e l f r e s p e c t by d e n y i n g t h a t t h e y had a s e r i o u s i l l n e s s . Thus 62 d e n i a l as a c o p i n g b e h a v i o u r i n f l u e n c e d t h e 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 e n v i r o n m e n t o f t h e h o s p i t a l m i g h t f a c i l i t a t e d e n i a l and meet t h e need f o r s a f e t y and s e c u r i t y . F o r h a l f o f t h e p a r t i c i p a n t s , t h e i d e a o f c h a n g i n g t h e i r l i f e s t y l e was d i f f i c u l t . 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 done i n an h o u r o r i n a d a y , i t has t o be g r a d u a l . F o r o t h e r s , c h a n g e d i d n o t p o s e a l a r g e p r o b l e m . 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 were as f a r as t h e l i f e o f t h e house i s c o n c e r n e d and 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 v e r y o f t e n l o s e h a b i t s u n l e s s y o u ' r e y o u n g e r . H a b i t s a r e 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 gonna be a l l r i g h t . R e s p e c t o f s e l f by s e l f and o t h e r s was a need 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 h e r s e l f . 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 ways. I'm n o t as c a r e f r e e as 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 a b o u t 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 i n v a r i o u s a r e a s , t h e i r s e n s e 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 . S u i t a b l e c o p i n g b e h a v i o u r s a l r e a d y d e v e l o p e d t o meet a c r i t i c a l p e r i o d s u c h as 63 t h i s h e l p e d one t h i r d o f t h e p a r t i c i p a n t s t o meet t h e i r n e e d f o r s e l f - e s t e e m . One o f t h e p a r t i c i p a n t s was u n a b l e t o d e a l w i t h t h e 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 c r i t i c a l p e r i o d had been e x p e r i e n c e d . The d i f f e r e n c e i n c o p i n g b e h a v i o u r s may have been i n r e l a t i o n t o t h e 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 t h e i n d i v i d u a l d u r i n g t h e c r i t i c a l p e r i o d . 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 A n g i n a p e c t o r i s i s a s y n d r o m e o f c o r o n a r y a r t e r y d i s e a s e w i t h t r a n s i e n t m y o c a r d i a l i s c h e m i a 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 . I t i s u s u a l l y 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 , 1 9 8 3 ) . The p a r t i c i p a n t s u s e d t h e t e r m s " c h e s t p a i n " and " a n g i n a " i n t e r c h a n g e a b l y i n t h e i r a c c o u n t s . A l l 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 have had a n g i n a symptoms a f t e r 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 f r o m a n g i n a became p a r t o f t h e i r e v e r y day l i f e . S i x o f them d e a l t w i t h t h e i r symptoms and one was u n a b l e t o h a n d l e them as e v i d e n c e d by t h e i r n e e d s b e i n g met. 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 d e a l w i t h a n g i n a i n c l u d e d 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 t o r e a l i z e p h y s i c a l , e m o t i o n a l and s o c i a l l i m i t a t i o n s . T h i s i n v o l v e d t h e 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 t o 64 d e t e r m i n e t h e r e s t r i c t i o n s o r c h a n g e s i n a c t i v i t y t h a t were n e c e s s a r y . 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 o f t e n d e t e r m i n e d t h e c o p i n g b e h a v i o u r s w h i c h r e s u l t e d d i r e c t l y f r o m t h e c h e s t p a i n . F o r e x a m p l e , t h e c o p i n g b e h a v i o u r o f r e s t i n g d u r i n g and f o l l o w i n g a b o u t o f c h e s t p a i n o r f a t i g u e d e v e l o p e d b e c a u s e o f t h e i n a b i l i t y o f t h e i n d i v i d u a l t o e x e c u t e a c t i v i t y a t t h a t t i m e . The i n a b i l i t y o f t h e i n d i v i d u a l t o c o n t i n u e a c t i v i t y , was a f o r c e i n f l u e n c i n g n e e d s a t i s f a c t i o n . Even t h o u g h t h e 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 was s t r o n g , t h e y l e a r n e d how 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 . F o r t h r e e o f t h e p a r t i c i p a n t s , t h e f o r c e o f a n g i n a was t o o s t r o n g t o d e a l w i t h a t home and r e q u i r e d r e a d m i s s i o n t o h o s p i t a l . A l l 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 need t o p a c e t h e m s e l v e s and t h e i r a c t i v i t i e s i n o r d e r t o m i n i m i z e c h e s t p a i n and o t h e r p h y s i c a l symptoms. They u s e d v a r i o u s t e c h n i q u e s t o c o n t r o l t h e i r symptoms. T h e s e f o r m e d t h e i m p o r t a n t c o p i n g b e h a v i o u r s u s e d t o meet t h e i r n e e d s . I had a n g i n a down t h e arms 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 have 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 t h e 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 and h a r d e r t o w a l k w i t h o u t c h e s t p a i n . H i s o v e r w h e l m i n g symptoms n e c e s s i t a t e d a n o t h e r a d m i s s i o n t o h o s p i t a l f o r m e d i c a t i o n a d j u s t m e n t and c o n s i d e r a t i o n o f a c o r o n a r y a r t e r y b y p a s s g r a f t . He d e s c r i b e d i t t h i s 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 . I was h a v i n g more p a i n when I w a l k e d . Not too, s e v e r e a t f i r s t , b u t t h e n 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 weeks, t h e n I had t o go back i n t o t h e h o s p i t a l . A n o t h e r man e x p l a i n e d h i s management o f 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 n o t l i k e b e f o r e , y o u d o n ' t know what i t was a l l a b o u t b e f o r e , where 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 have a r e s t f o r a m i n u t e o r two. He went on t o e x p l a i n . I ' v e g o t t a t a k e i t e a s y . 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 awn 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 a w h i l e . . . m y e l b o w s t a r t s a c h i n ' . O t h e r P h y s i c a l Symptoms The p a r t i c i p a n t s m e n t i o n e d o t h e r b o t h e r s o m e symptoms b e s i d e s c h e s t p a i n . F a t i g u e was one o f t h e 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 i n t h e i n i t i a l few weeks f o l l o w i n g t h e i r homecoming. 66 I h a v e bad 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 has made a d i f f e r e n c e i n m y s e l f . I had 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 and 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 b e i n g t i r e d . I had t o t a k e 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 ' e v e r y 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 as 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 and c h e s t t i g h t n e s s . He a l s o e x p e r i e n c e d d i z z i n e s s i n t h e e a r l y c o n v a l e s c e n t p e r i o d . He commented t h a t t h e s e symptoms were 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 . He d e s c r i b e d h i s p r o g r e s s t o w a r d f e e l i n g n o r m a l . Now most 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 and t h e way I w o u l d n o r m a l l y w a l k 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 o r b r e a t h l e s s n e s s . 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 can o n l y do so much a t one t i m e . He d e s c r i b e d h i s c o n t i n u i n g 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 as 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 s h a r p p a i n . I d o n ' t r e a d mine t h a t way, I r e a d i t as 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 t o p l a y l a c r o s s e , y o u ' d r u n a l l d a y , 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 and have 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 t h e p a r t i c i p a n t s s t a t e d t h a t t h e y 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 p h y s i c a l symptoms. T h i s has h e l p e d them t o r e s p o n d a p p r o p r i a t e l y o r i n a p p r o p r i a t e l y t o t h e i r symptoms. One 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 and I'm r e a l l y f o r c e d t o s t o p and I u n d e r s t a n d t h a t and I l i s t e n now. I g u e s s t h a t ' s one 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 what my body i s d o i n g a t any g i v e n t i m e . I m i g h t n o t u n d e r s t a n d i t , t h o u g h . One woman f o u n d t h a t she t o o was i n t o u c h w i t h h e r body symptoms b u t t h a t t h i s c a u s e d f e a r and a n x i e t y due to t h e t h r e a t o f a n o t h e r MI. She a l s o e x p r e s s e d a l a c k o f k n o w l e d g e a b o u t t h e p a i n and 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 d o n ' t t e l l y o u , l i k e t h e y d o n ' 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 and t h e p a i n h a s n ' t gone away so y o u t a k e a n o t h e r one and t h e n t h e r e ' s more p a i n and maybe t h a t p a i n has 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 a t a l l . I d o n ' t t h i n k y o u ha v e enough i n f o r m a t i o n on what i s a h e a r t p a i n o r what 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 a c h e s and p a i n s a l s o p o s e d a t h r e a t and 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 n e d . I f y o u have 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", ' c a u s e i f t h e y were t h a t b a d , I w o u l d have s e e n a b o u t i t . You p r o b a b l y had a l l t h e s e t h i n g s g o i n g t h r o u g h y o u b e f o r e and y o u d i d n ' t know i t . And 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 and s a y i n g , "Oh, I had t h e s e p a i n s on S a t u r d a y and t h e y l a s t e d f o r so many h o u r s and I h a v e n ' t had them s i n c e . " P r i o r t o h i s MI, one 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 b e t w e e n p a i n f r o m a h i a t u s h e r n i a and t h a t f r o m a h e a r t a t t a c k . T h i s i n f o r m a t i o n 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 had h i s MI. Th 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 and 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 Sunday 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 and I had a cup o f warm t e a and I t o o k some M a a l o x and 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 and down t h e r e [ h e i n d i c a t e s c h e s t and a r m s ] . I f i n a l l y p h o n e d my boy and 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 t h o u g h t 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 as 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 t a k e 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 d o n ' 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 ? G e t t i n g O t h e r s t o H e l p 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 managed t h e i r p h y s i c a l symptoms and t h e r e s t r i c t i o n s c a u s e d by t h e s e was t o o b t a i n h e l p w i t h some o f t h e h o u s e h o l d j o b s n o r m a l l y 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 . One man e x p l a i n e d . A l o t o f t h e p h y s i c a l t h i n g s I m i g h t have d o n e , now my son t a k e s i t on o r we g e t i t done by somebody e l s e . A window w a s h e r o n c e 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 man d i d n o t f i n d i t t o o d i f f i c u l t t o a d j u s t t o h i s 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 done a l l t h e g a r d e n i n g f o r t h e t o w n h o u s e c o m p l e x where 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 went 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 s m a l l p a t c h o f t o m a t o e s i n h i s b a c k y a r d f o r g a r d e n i n g e n j o y m e n t . The woman i n t e r v i e w e d had a d i f f i c u l t t i m e r e l i n q u i s h i n g h o u s e h o l d t a s k s . She d i d n o t t h i n k t h a t some h o u s e h o l d 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 n o t v i s u a l i z e a s k i n g f o r h e l p . I c o u l d n ' t p i c t u r e somebody 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 t o 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 ave a vacuum 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 have t o do i s push t h e h a n d l e . They were s a y i n g , " D o n ' t vacuum!" W e l l , i f y o u ' v e g o t t a vacuum, where y o u s t a n d t h e r e p u s h i n g t h e 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 vacuum o r i f y o u c a n ' t p u t y o u r d i s h e s i n t h e d i s h w a s h e r . Y o u ' r e n o t 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 w i t h t h e i r c h e s t p a i n and 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 ways. The n e e d s t h a t a r o s e b e c a u s e o f t h e s e symptoms were t h e need f o r s a f e t y and s e c u r i t y , t h e n e e d f o r a b a l a n c e 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 , t h e n e e d f o r m a s t e r y and s e l f - e s t e e m . C h e s t p a i n and o t h e r 70 p h y s i c a l symptoms were n e g a t i v e f o r c e s i m p i n g i n g on t h e 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 o f t h e i n d i v i d u a l t o d e v e l o p 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 meet t h e n e e d s was an i m p o r t a n t f a c t o r . R e t u r n t o Work F o u r o f t h e p a r t i c i p a n t s were s t e a d i l y e m p l o y e d p r i o r t o t h e i r MI and t h r e e o f them r e t u r n e d t o work. The 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 v a r i e t y o f r e a s o n s . W o r k i n g P a r t i c i p a n t s One g e n t l e m a n had 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 f o u n d r e t u r n i n g t o work d i f f i c u l t . He e x p l a i n e d . I'm back 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 had t o o much s t r a i n i n i t . I went back t o work S e p t e m b e r 30, 1985 (5 months a f t e r MI) f u l l t i m e . I s h o u l d n ' t h ave done t h a t . I made a wrong 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 and 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 has made some c h a n g e s i n h i s j o b and h i s work h a b i t s i n o r d e r t o 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 b e t w e e n 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 . 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 l i f t i n g . I w a t c h what and how I l i f t . I h a v e t o b e c a u s e I'm j u s t n o t gonna t a k e t h e c h a n c e . No j o b i s w o r t h h u r t i n g y o u r s e l f and g o i n g t h r o u g h t h a t s t u f f a g a i n . I t was s u g g e s t e d t o one man t h a t he t a k e f i v e m onths o f f b e f o r e r e t u r n i n g t o wor k . He c o m p l i e d w i t h t h i s a d v i c e and f o u n d i n r e t r o s p e c t t h a t i t was a good i d e a . 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 d e a l o f 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 r e a d i n g and c o u r s e s . He was a b l e t o work h a l f d a y s when he f i r s t r e t u r n e d t o work. A l t h o u g h t h i s j o b was n o t one 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 m e n t a l l a b o u r . 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 j o b 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 o r v e r y s t r e s s f u l t o r e t u r n . He s t a t e d . I w o u l d n ' t have c o n s i d e r e d my j o b anywhere n e a r as s t r e s s f u l as some p e o p l e ' s . And t h e r e was a l o t o f s a t i s f a c t i o n t h a t I t h i n k w o u l d c o m p e n s a t e f o r any s t r e s s t h e r e was. T h i s man made c h a n g e s where he no l o n g e r b r o u g h t work home a t n i g h t . T h i s was a m a j o r c h a n g e f o r a man who had 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 work. He made t h i s s t a t e m e n t a b o u t t h e c h a n g e s . 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 d o n e . I g u e s s I n e v e r o p e r a t e d t h a t way. Now I do. Work had f u l f i l l e d h i s need f o r m a s t e r y and s e n s o r y s t i m u l a t i o n i n t h e p a s t . He c o n t i n u e d t o e x p r e s s s a t i s f a c t i o n and e n j o y m e n t f r o m h i s j o b w h i c h met t h e s e n e e d s . A n o t h e r c h a n g e he made was h i s p r e p a r a t i o n t i m e f o r work. He went t o bed e a r l y i n t h e e v e n i n g ( 2 1 : 0 0 h o u r s ) and a r o s e e a r l y i n t h e m o r n i n g (05:00 h o u r s ) . T h i s a l l o w e d him 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 and e a t i n g and s o m e t i m e s w a t c h i n g t e l e v i s i o n . 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 and t h e r e s p o n s e he had r e c e i v e d a t work by h i s e m p l o y e r and f e l l o w w o r k e r s when t h e y h e a r d he had an MI. I c o u l d n ' t s h i f t a r o u n d i n h e r e ( c h a n g e j o b s w i t h i n t h e c o m p a n y ) . I ' d have t o f i n d s o m e t h i n g e l s e and who's gonna 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 as t h e y h e a r t h e word HEART...hoo 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 has 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 want 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 work." 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 much. Who's gonna h i r e y o u t o do much s i t t i n g ? The r e s p o n s e t h a t t h e p a r t i c i p a n t s r e c e i v e d f r o m e m p l o y e r s and 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 t o r e t u r n t o work and g e t b a c k t o n o r m a l , a f f e c t e d t h e i r need 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 a f f e c t e d t h e i r r e s p e c t f o r s e l f . Time O f f One p a r t i c i p a n t who owned h i s own b u s i n e s s r e t u r n e d 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 no l o n g e r d i d h e a v y l a b o u r . He was a m e c h a n i c and w o r k e d w i t h h i s son and t h e y were a b l e t o h i r e a n o t h e r w o r k e r t o f i l l 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 most o f t h e 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 . T h i s s i t u a t i o n a l l o w e d him t o meet h i s need f o r m a s t e r y and s e n s o r y s t i m u l a t i o n . One o f t h e p a r t i c i p a n t s w i t h a h e a v y l i f t i n g j o b has t a k e n a g r e a t d e a l o f h i s s i c k t i m e s i n c e r e t u r n i n g t o work. He has been q u e s t i o n e d a b o u t t h i s by h i s e m p l o y e r . 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 t i m e ? " 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 t i m e b u t 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 work 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. R e t i r e d P a r t i c i p a n t s T h r e e o f t h e p a r t i c i p a n t s were r e t i r e d , e a c h a minimum o f f o u r y e a r s p r i o r t o t h e i r h e a r t a t t a c k . E a c h o f them s a i d t h a t t h e y had a d j u s t e d w e l l t o t h e i r r e t i r e m e n t . One had w o r k e d f o r t h e C a n a d i a n Armed F o r c e s , and two were r e t i r e d bus d r i v e r s , one h e r e i n V a n c o u v e r and one i n F i j i . E a c h o f t h e s e p a r t i c i p a n t s a r e now i n v o l v e d i n o t h e r 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 a s e n s e o f a c h i e v e m e n t . P h y s i c a l a c t i v i t i e s i n c l u d e d b o w l i n g , g o l f i n g , g a r d e n i n g , c a m p i n g and d r i v i n g t h e c a r . F o r one man, h i s r e t u r n t o t h e p o s i t i o n o f a c h u r c h l e a d e r s i g n i f i e d a r e t u r n t o f o r m e r normal a c t i v i t i e s f o r h i m . A f t e r t h e i r h e a r t a t t a c k s , t h e s e p a r t i c i p a n t s have been a b l e t o resume t h e a c t i v i t i e s t h a t t h e y p r e v i o u s l y e n g a g e d . They d e s c r i b e i t i n t h i s m anner. 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 work. I'm n o t c r i p p l e d y o u know. I went 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 month o r two b e f o r e I s t a r t e d g o l f i n g a g a i n . I b o u n c e d back f a i r l y q u i c k l y . 75 R e g a r d i n g t h e m a t t e r o f d r i v i n g h i s c a r , one p a r t i c i p a n t c o n f e s s e d . 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 gonna 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 ! " B u t 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 she 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 see h e r , s h e ' d have had a f i t . R e t u r n i n g t o work was an a r e a o f g r e a t i m p o r t a n c e t o t h e p a r t i c i p a n t s . M o s t o f them d i d n o t want t o w a i t o u t t h e p r e s c r i b e d t i m e t h a t t h e i r d o c t o r s s u g g e s t e d and r e t u r n e d a t d i f f e r i n g t i m e s . T h o s e who had f l e x i b l e s c h e d u l e s w i t h o u t d e m a n d i n g , p h y s i c a l l a b o u r and who c o u l d work p a r t t i m e as t h e y e a s e d back i n t o t h e i r n o rmal r o u t i n e s , were a b l e t o d e a l w i t h t h e i r r e t u r n t o work more e a s i l y . T h o s e who had h e a v y p h y s i c a l l a b o u r j o b s w h i c h were i n f l e x i b l e and who a l s o r e c e i v e d a n e g a t i v e r e s p o n s e t o t h e i r d i a g n o s i s o f h e a r t d i s e a s e f r o m t h e i r e m p l o y e r s and f e l l o w w o r k e r s had a more d i f f i c u l t t i m e r e t u r n i n g t o work. 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 t o r e t u r n t o p r e v i o u s a c t i v i t i e s w i t h i n t h r e e t o s i x m onths a f t e r t h e i r MI. T h e i r a d j u s t m e n t t o t h e i r f o r m e r s i t u a t i o n d i d n o t p o s e any p a r t i c u l a r p r o b l e m s . 76 R e l a t i o n s h i p s and R o l e 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 s p o k e o f t h e i r MI and s u b s e q u e n t 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 o n l y f o r t h e m s e l v e s b u t a l s o f o r t h e i r f a m i l i e s . F i v e o f 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 on t h e i r s p o u s e and c l o s e f a m i l y members. Two o f t h e p a r t i c i p a n t s were widowed and s p o k e o f t h e i r i m m e d i a t e f a m i l y and how t h e i r r e l a t i o n s h i p was a f f e c t e d . The s i x men i n t h e s t u d y s p o k e o f t h e i r w i v e s ' h e l p i n s p e c i f i c a r e a s o f r i s k r e d u c t i o n . D i e t c h a n g e s w h i c h p o t e n t i a l l y a f f e c t t h e 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 s p o u s e . She l o o k e d a f t e r me, f o o d and e v e r y t h i n g i n g e n e r a l . 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 need good w i f e . She i s good w i f e . She cook good 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 use 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 meat, more f i s h , more w h i t e meat, 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 t h e y c h a n g e d t h e i r d i e t a l s o a c k n o w l e d g e d t h e i r w i v e s ' h e l p and s u p p o r t as h e r d i e t c h a n g e d as w e l l . 77 I have i n f a c t r e d u c e d t h e s a l t f o r s o m e t i m e 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 good f o r e i t h e r o f u s . She has a s l i g h t b l o o d p r e s s u r e p r o b l e m . One man d e s c r i b e d g i v i n g h i s w i f e t h e t a s k o f r u n n i n g t h e f a m i l y f i n a n c e s . The r o l e o f f i n a n c e manager c h a n g e d 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 good 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 we're g o i n g t o p u r c h a s e s o m e t h i n g o r n o t . B u t I d o n ' t have 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 d o i n g t h e r i g h t t h i n g o r n o t . F o u r 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 p o s i t i v e t h i n g s t h a t h a v e 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 r o l e s s i n c e t h e i r M i ' s . One man e x p l a i n e d how h i s son b e n e f i t e d f r o m t h i s e x p e r i e n c e . 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 awn 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 o f t h e p h y s i c a l t h i n g s I m i g h t have d o n e , now my son t a k e s i t on o r we g e t i t done by somebody 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 been b e t t e r f o r him t o o . So I t h i n k good t h i n g s have come o u t o f i t and may be good 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 v e r y l o n g ' c a u s e I have a good f a m i l y . They a r e a v e r y s u p p o r t i v e f a m i l y . When a s k e d how h i s h e a r t a t t a c k a f f e c t e d h i s f a m i l y , he r e p l i e d . 78 They a r e w i t h me and i t ' s so e a s y ' c a u s e t h e y t r y t o u n d e r s t a n d . Y o u r t e m p er g e t bad and t h e y s e e i t r i g h t on y o u r f a c e . They know i f y o u ' r e l y i n g . T h e y ' v e 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 s p o k e o f h i s s o n s ' 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 eep t e l l i n g them, "What am I gonna do w i t h a l l t h e s t u f f I g o t h e r e ? " They want 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 them. A n o t h e r man s p o k e o f h i s c l o s e k n i t f a m i l y . He 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 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 ave 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 a r e a l l h e r e ( i n V a n c o u v e r ) . They a r e v e r y good t o me and my w i f e . They 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 have 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 week. We have d i n n e r , we v i s i t , we have p r a y e r s . He went 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 M u s l i m f a i t h . 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 and b e l o n g i n g f r o m h i s f a i t h . He d e s c r i b e d i t t h i s way. My f a i t h 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 p r a y . I b e l i e v e God h e a l s me. I f e e l g o o d . I p r a y f i v e t i m e s a d a y . I go t o mosque. I t i s my l i f e . 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 t h e 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 t h e community t o p r a y w i t h t h e 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 t i m e s i n t h e 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 and h i s f a m i l y had 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 need f o r l o v e and b e l o n g i n g . I t a l s o c o n t r i b u t e d t o m e e t i n g 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 and 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 t h e i r 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. One man e x p l a i n e d t h a t t h e o v e r p r o t e c t i v e b e h a v i o u r o f h i s 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. They were 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 m o n t h. They d i d n ' t a f t e r t h a t . They d e c i d e d , "Ah, h e ' s a l r i g h t . L e t 'im go." 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 p r e v i o u s c r i t i c a l 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 c a n c e r . They had p u l l e d t o g e t h e r as a f a m i l y t o s u p p o r t h e r and he f e l t t h e y were 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 adamant as she c o m p l a i n e d a b o u t h e r f a m i l y p a m p e r i n g 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 want 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 had a h e a r t a t t a c k , y o u ' r e t i r e d a l l t h e t i m e . T h e y ' r e a l w a y s t e l l i n g y o u , "Oh, y o u c a n ' t do t h i s and y o u c a n ' t do t h a t . " I t seems l i k e t h e y want t o s t a y away f r o m me f o r some r e a s o n as i f s o m e t h i n g ' s gonna happen t o me. 80 She went 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 h e r son and d a u g h t e r i n d i v i d u a l l y . My son 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 onths ago and 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 want 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 . " And 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 has been v e r y s t r a n g e and d i f f e r e n t . We were 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 and we're 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 im. 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 and 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 him t h r e e m onths t o d i e . One day she 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 want 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 what t h e y went t h r o u g h . She t a l k e d a b o u t h e r i n a b i l i t y t o s h a r e h e r f e e l i n g s w i t h h e r f a m i l y and i n s t e a d o f a n o t h e r c r i t i c a l p e r i o d b r i n g i n g t h e f a m i l y t o g e t h e r , i t c a u s e d a r i f t . She e x p l a i n e d . My h e a r t a t t a c k h as 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 b a d l y . 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 them. 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 gonna happen t o me. I t r e a l l y d e s t r o y s t h e 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 t o f o r m e r way o f l i f e w i t h h e r f a m i l y i s e x p r e s s e d by t h i s p a r t i c i p a n t . 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 t h e y c a r e a b o u t y o u and t h a t y o u ' v e 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 have 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 wrong 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 been 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've n e v e r been s i c k a day i n my l i f e . I ' v e n e v e r had t o have 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 month and I c o u l d n ' t d r i v e y e t . I j u s t 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 somebody 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 need 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 somebody 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 n e e d s o f t h i s p a r t i c i p a n t 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 , f o r s e l f - e s t e e m and f o r m a s t e r y were a f f e c t e d as she f o u g h t t o r e t u r n t o h e r f o r m e r l i f e s t y l e . Her need f o r s e l f - e s t e e m 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 c o n t r o l o v e r h e r l i f e . Her f a m i l y and f r i e n d s were p e r c e i v e d by h e r as a n e g a t i v e f o r c e i n h e r l i f e a f f e c t i n g n e e d s a t i s f a c t i o n i n t h e a f f e c t i v e and e g o - v a l u a t i v e s u b s y s t e m s . In c o n t r a s t , t h e p a r t i c i p a n t who d e s c r i b e d h i s f a m i l y ' s s u p p o r t a t t h i s t i m e had a v e r y d i f f e r e n t e x p e r i e n c e and p e r c e p t i o n o f t h e s i t u a t i o n . 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 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 on t h e i r r e l a t i o n s h i p and f r i e n d s . They were t h e o n e s who d i d n o t h a v e a s p o u s e and l i v e d a l o n e . One p a r t i c i p a n t f o u n d 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 t h e s o c i a l c o m m i t t e e o f t h e c o n d o m i n i u m c o m p l e x 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 c o m p l a i n e d . 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 o r a r e a l i n v a l i d . I f i n d t h a t r e a l h a r d t o d e a l 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 h a n d i c a p p e d . 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 s p o k e o f b e i n g d e p r e s s e d b e c a u s e o f t h e 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 f r i e n d s . 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 p e o p l e . H a v i n g a h e a r t a t t a c k a l s o h e l p e d t h i s p a r t i c i p a n t t o meet p e o p l e i n h e r c o - o p c o m p l e x and she become 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 done 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 have 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 were 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 ( a l m o s t s p o u s a l ) r o l e o f c o o k i n g f o r h e r , m a k i n g s u r e she had enough 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 t y p e o f c a r e v e r y 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 o t h e r p a r t i c i p a n t who was widowed, s p o k e h i g h l y o f h i s " l a d y f r i e n d " who had him o v e r f o r m e a l s q u i t e f r e q u e n t l y . She p r o v i d e d s u p p o r t and c o m p a n i o n s h i p f o r him d u r i n g t h i s t i m e o f c h a n g e . T h i s p a r t i c i p a n t a l s o k e p t i n t o u c h w i t h h i s m a l e f r i e n d s . D e s p i t e t h e f a c t t h a t he was n o t p h y s i c a l l y a b l e t o g o l f , he went o u t t o t h e g o l f c o u r s e and d r a n k c o f f e e w i t h t h e 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 , t h e p a r t i c i p a n t s e x p r e s s e d c h a n g e s t h a t t o o k p l a c e i n t h e i r f a m i l y r o l e s and r e l a t i o n s h i p s and a l s o w i t h t h e i r f r i e n d s . The need 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 and t h e n e e d f o r s e l f - e s t e e m were 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 d e p e n d i n g on t h e s i t u a t i o n . The f a m i l y was a p o s i t i v e o r n e g a t i v e f o r c e i n o t h e r a r e a s 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 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 and t h u s had an i m p o r t a n t r o l e i n a s s i s t i n g t h e i n d i v i d u a l t o " g e t b a c k t o n o r m a l ." A l l o f t h e p a r t i c i p a n t s v o i c e d a r e a l i z a t i o n t h a t c h a n g e was n e c e s s a r y i n t h e i r l i f e s t y l e f o l l o w i n g t h e i r MI. D e a l i n g w i t h v a r i o u s p h y s i c a l and e m o t i o n a l symptoms was a common o c c u r e n c e f o r t h e p a r t i c i p a n t s . The a f f e c t o f c h a n g e and o f t h e p h y s i c a l and e m o t i o n a l symptoms were 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 r e t u r n t o t h e i r f o r m e r j o b s . T h o s e who were r e t i r e d 84 e x p e r i e n c e d t h i s g r a d u a l r e t u r n t o normal i n t h e i r h o b b i e s and r e g u l a r a c t i v i t i e s . R e l a t i o n s h i p s i n t h e f a m i l y and w i t h f r i e n d s were a n o t i c e a b l e a r e a o f p e r c e i v e d s u p p o r t o r l a c k t h e r e o f by t h e p a r t i c i p a n t s . T h i s was o b s e r v e d as t h e y s t r u g g l e d t o d e a l w i t h t h e c h a n g e s 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 t h e f a m i l y and i n t h e i r s o c i a l c i r c l e . The n e e d s most a f f e c t e d i n t h i s a r e a i n v o l v e d t h 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 , t h e need f o r 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 o f s e l f by s e l f and o t h e r s , t h e need f o r a b a l a n c e b e t w e e n 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 and t h e need f o r s t i m u l a t i o n o f t h e s y s t e m s s e n s e s . F o r c e s t h a t i n f l u e n c e d need s a t i s f a c t i o n were t h e p e r c e p t i o n o f t h e need f o r c h a n g e , t h e a t t i t u d e t o w a r d 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 t h e p e r s o n h a d , 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 and t h e e f f e c t o f any r o l e c h a n g e s were o t h e r f o r c e s i n f l u e n c i n g n e e d s a t i s f a c t i o n . T h e s e were b o t h p o s i t i v e and n e g a t i v e f o r c e s , o f t e n d e p e n d i n g on t h e a t t i t u d e p e r c e p t i o n and o n e ' s a b i l i t y t o use 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 meet t h e i r n e e d s . 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 A f t e r r e l a t i n g t h e f i n d i n g s o f 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 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 N o r m a l " w i l l 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 o n e ' 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 have been 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 have 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 . 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 have 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 h a v e had l i t t l e c o n t r o l . B e h a v i o u r a l S y s t e m B a l a n c e , where t h e n e e d s o f e a c h 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 t h e o u t c o m e 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 n i n e months 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 do, I c a n do. As f a r as I'm c o n c e r n e d , 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 . I t h i n k i t ' s gonna be a l l r i g h t . A n o t h e r d e s c r i b e d h e r p e r c e p t i o n o f h e r c u r r e n t s t a t u s s e v e n m o n t h s . Maybe my k i d s a r e r i g h t and 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 s a y i t ' c a u s e 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 been a c h a n g e and 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 need 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 . ( 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 s a y 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 ask you...who 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 b i g g e s t s t r e s s . I s i t and t h i n k a b o u t 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 p r o b l e m . I t ' s a p e r s o n a l p r o b l e m 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 as 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 h a p p e n e d a t a bad t i m e ( o n e month a f t e r t h e d e a t h o f h e r h u s b a n d ) . 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 and use h e r c o g n i t i v e a b i l i t y t o c h a n g e h e r f e e l i n g s o f a n g e r 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 has a l s o had an MI and 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 b u t I d o n ' t want t o h e a r a l l a b o u t h i s c o n d i t i o n ' c a u s e I t h i n k h e ' s b e i n g w e l l t a k e n 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 have many unmet n e e d s i n h e r 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 s u b s y s t e m s a month l a t e r a t t h e t i m e o f t h e s e c o n d i n t e r v i e w . 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 and f e e l i n g s . She v o i c e d t h e need t o c h a n g e b u t a d m i t t e d t h a t i t was n o t p o s s i b l e . 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 and how y o u we 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 s o m e t h i n g t o happen a l l t h e t i m e . I d o n ' t know what 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 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 y e a r a f t e r h i s MI. He has been m e e t i n g h i s b a s i c human n e e d s . H i s a p p r o a c h i s v e r y m a t t e r o f f a c t and t o p o i 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 y o u 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 p a r t i c i p a n t , r e v i e w i n g t h e a f f e c t o f t h e MI on h i s l i f e o v e r t h e p a s t t e n m onths r e l a t e d h i s p e r c e p t i o n s 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 more 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 d o n ' t have t o 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 edge 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 t o c h a n g e c e r t a i n t h i n g s and o t h e r a r e a s where 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 p e r m a n e n t o r n o t b u t a r e p h y s i c a l l i m i t a t i o n s ( h e c a n no l o n g e r do g a r d e n i n g , wash window, wash c a r ) . B u t I ' v e 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 were 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 ' v e g o t a b i t b e t t e r 88 o r g a n i z e d and I've l e a r n e d t o r e l a x more o r w o r k e d a t r e l a x i n g . He e x p r e s s e d 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 be p e r m a n e n t . No, maybe I c a n g e t back t o some o f t h e s e t h i n g s i f i t ' s a m a t t e r o f s t a m i n a . T h a t ' s what 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 where t h a t w i l l go as f a r as 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 va g u e t h i n g s i n my m i n d . He a d m i t t e d t h a t p a r t o f h i s d e t e r m i n a t i o n t o 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 were b e c a u s e o f t h e hope he had f o r a c u r e . He had been t o l d t h a t h i s c o r o n a r y 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 f o r a n g i o p l a s t y . H i s hope 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 D i e t ( P r i t i k i n , 1 9 7 9 ) . 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 h o p i n g t h a t (he l a u g h s ) i f I s t a y w i t h t h i s d i e t , i f t h e y d o n ' 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 have s e m i - s o l v e d t h e p r o b l e m o f t h o s e t h a t a r e n ' t a l r e a d y d e t e r m i n a t e d . A n o t h e r p a r t i c i p a n t who a l s o had i n o p e r a b l e c o r o n a r y a r t e r y d i s e a s e and had 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 t o h i s f a i t h i n God. The Musi em r e l i g i o n i s my l i f e . I p r a y . I b e l i e v e God h e a l s me. I f e e l g o o d . 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 where c h a n g e s had been made i n o r d e r t o meet t h e i r n e e d s . T h e i r n e e d s were n o t a l l met a t t h i s t i m e , however t h e y were d e v e l o p i n g 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 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 image 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 and 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 . The need f o r r e s p e c t o f s e l f by s e l f and o t h e r s and t h e need f o r m a s t e r y were t h e two m a j o r n e e d s 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 b a l a n c e t o t h e i r s y s t e m . 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 were r e p o r t e d u s i n g t h r e e main themes t o d e s c r i b e t h e e x p e r i e n c e s 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. R i s k R e d u c t i o n , G e t t i n g Back t o Normal and R e a c h i n g a New Normal were t h e themes u s e d t o d i s c u s s t h e v a r i o u s c o p i n g b e h a v i o u r 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. 90 CHAPTER F I V E DISCUSSION OF THE FINDINGS I n t r o d u c t i on T h i s c h a p t e r w i l l d i s c u s s t h e f i n d i n g s o f t h e s t u d y 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: 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 i s k R e d u c t i o n , 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 and 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 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 p u r p o s e o f p r o v i d i n g a b a c k g r o u n d f o r t h e s t u d y and w i l l be r e f e r r e d t o as i t a p p l i e s t o t h e f i n d i n g s . T h i s c h a p t e r w i l l 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 o f t h e r e p o r t s r e l a t e d t o t h e c a t e g o r i e s d e v e l o p e d d u r i n g t h e d a t a a n a l y s i s . 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 and 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 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 . T h e r e i s l i t t l e n u r s i n g r e s e a r c h l i t e r a t u r e d i r e c t e d t o w a r d t h e s t u d y o f c o p i n g b e h a v i o u r s d e s i g n e d t o meet b a s i c human n e e d s . The i n t e r p r e t a t i o n o f d a t a f r o m t h i s s t u d y w i l l f o r m 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 w i t h l i t e r a t u r e u s e d t o 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 i n l i g h t o f o t h e r a u t h o r s ' work. 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 i s k R e d u c t i o n The p a r t i c i p a n t s i n t h i s s t u d y were w i l l i n g t o s h a r e t h e i r e x p e r i e n c e s 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 . T hey t o l d o f t h e p e r s o n a l o u t c o m e s r e s u l t i n g f r o m t h e MI and t h e c h a n g e s t h a t t h e y made w i l l i n g l y and t h o s e t h a t were f o r c e d upon them. D u r i n g t h e f i r s t few weeks 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 n e c e s s a r y . Many were 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 what t h e s e c h a n g e s were b u t had a s e n s e t h a t t h i n g s w o u l d be d i f f e r e n t f r o m now o n . In t h e e a r l y p h a s e o f r e c o v e r y , 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 e x p e r i e n c e d c e r t a i n f o r c e s t h a t were s t r o n g e n o ugh t o impose c h a n g e on them. E x a m p l e s o f t h e s e f o r c e s i n c l u d e d s m o k i n g c e s s a t i o n w h i l e h o s p i t a l i z e d as 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 t h a t t h e p a t i e n t s s t o p s m o k i n g o r f i n d a n o t h e r d o c t o r and 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 p r o f e s s i o n a l s i n t h e a r e a o f p h y s i c a l a c t i v i t y , r e t u r n t o work and d i e t a r y c h a n g e . The p h y s i c a l i n a b i l i t y t o p e r f o r m p r e v i o u s a c t i v i t i e s b e c a u s e o f c h e s t p a i n , f a t i g u e o r 92 o t h e r p h y s i c a l symptoms was a n o t h e r f o r c e b r i n g i n g a b o u t c h a n g e i n b e h a v i o u r . F o r c e d c h a n g e t h r o u g h h o s p i t a l i z a t i o n o r r e s t r i c t i v e 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 i n t h e 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 t e r m b e n e f i t 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 c h a n g e s n e c e s s a r y 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 one p a r t i c i p a n t who had 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 i n i t i a l i n a b i l i t y t o make d e c i s i o n s may be due t o s h o c k , d i s b e l i e f and d e n i a l 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. D e n i a l 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 and d e p r e s s i o n by r e d u c i n g t h e p e r c e p t i o n o f t h e t h r e a t ( S c a l z i , 1 9 7 3 ) . D e n i a l may be c a l l e d a c o p i n g b e h a v i o u r as i t i s a t t e m p t i n g 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 s e l f - e s t e e m . C h a n g e s were made b e c a u s e o f t h e l o s s e s i n c u r r e d f o l l o w i n g an MI. 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 and v a l u e a t t a c h e d t o t h e p a r t i c u l a r l o s s . One r e s p o n s e t o t h e t h r e a t o f 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 t o w a r d t h e i r f a m i l i e s , e m p l o y e e s , 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 s e l d o m v e r b a l i z e d t o any o n e 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 e x p r e s s e d 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 need f o r s e l f - e s t e e m . A n g e r may be c a l l e d a c o p i n g b e h a v i o u r t h a t was u s e d t o d e a l w i t h t h e t h r e a t t o s e l f - e s t e e m . . The 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 o f c e r t a i n h o u s e h o l d r o l e s w h i c h i m p a c t e d on t h e s e n s e o f s e l f - i d e n t i t y . A n g e r was n o t t h e e x p e r i e n c e o f a l l o r t h e p a r t i c i p a n t s m e n t i o n e d t h a t t h e y c o u l d n o t remember h a v i n g f e e l i n g s o f a n g e r . F e e l i n g s o f d e p r e s s i o n were a r e a l i t y f o r most o f t h e p a r t i c i p a n t s . Coming 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 and t h a t t h e y d i d n o t f e e l l i k e t h e i r f o r m e r s e l v e s , r e s u l t e d i n f e e l i n g s o f d e p r e s s i o n . None o f t h e p a r t i c i p a n t s e x p r e s s e d f e e l i n g s o f d e s p a i r , h e l p l e s s n e s s o r h o p e l e s s n e s s . T hey d i d n o t s e n s e t h e need t o ' g i v e up' as d e s c r i b e d by S c a l z i and B u r k e ( 1 9 8 2 ) . However, t h e l o s s o f s e l f - e s t e e m and s e n s e o f m a s t e r y i n r e l a t i o n t o t h e need t o f e e l p r o d u c t i v e a g a i n d i d o c c u r . P e r h a p s t h e i n i t i a l p h a s e s o f d e n i a l , a n g e r and d e p r e s s i o n , w h i c h may be v i e w e d as c o p i n g b e h a v i o u r s , a r e more v i v i d l y d e s c r i b e d and remembered w h i l e t h e p a r t i c i p a n t i s e x p e r i e n c i n g them o r s h o r t l y t h e r e a f t e r . The i n t e n s e f e e l i n g s g e n e r a t e d i n t h e i n i t i a l r e c o v e r y 94 p h a s e may become b l u r r e d w i t h t h e p a s s i n g o f t i m e and t h e p a r t i c u l a r c o n c e r n s a t t h a t t i m e . F o r t h e p a r t i c i p a n t s i n t h i s s t u d y , who had e x p e r i e n c e d t h e MI s e v e n t o t w e l v e months a g o , t h e b e h a v i o u r s a s s o c i a t e d w i t h r e o r g a n i z a t i o n as d e s c r i b e d by P a r k e s ( 1 9 7 1 ) were t h e most v i v i d and e a s i l y remembered d u r i n g t h e i n t e r v i e w s . T h i s was p r o b a b l y b e c a u s e t h e y 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 t h e i r w o r l d , e x p e r i e n c i n g c h a n g e and t h e r e v i s i n g o f t h e i r e x p e c t a t i o n s and v i e w o f t h e m s e l v e s . They had moved f r o m t h e u n f r e e z i n g p h a s e ( L e w i n , 1951) i n t h e c h a n g e p r o c e s s where t h e y r e c o g n i z e d t h e n e e d f o r c h a n g e , s e l e c t e d an a p p r o a c h and were now m o v i n g t o a new l e v e l i n v o l v i n g b e h a v i o u r a l c h a n g e . The t i m i n g o f t h i s p r o c e s s i s v e r y i n d i v i d u a l b u t f r o m t h e d a t a i t w o u l d 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 b e h a v i o u r s i n t o 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 . F o r some, i t may t a k e l o n g e r d e p e n d i n g on t h e number and e x t e n t o f t h e l o s s e s and a l s o t h e t y p e s o f p o s i t i v e f o r c e s a v a i l a b l e i n o n e ' s l i f e . O t h e r n e e d s t h a t were i d e n t i f i e d as t h r e a t e n e d a t t h i s t i m e were t h e n e e d f o r s e n s o r y s t i m u l a t i o n , f o r m a s t e r y , 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 and t h e n e e d f o r a b a l a n c e b e t w e e n a c t i v i t y and r e s t . The a r e a s o f 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 c o n s i s t e n t 95 m e d i c a t i o n - t a k i n g were a r e a s o f c h a n g e t h a t r e q u i r e d c o n s c i o u s 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 . H a v i n g r e c e i v e d o n l y m i n i m a l i n s t r u c t i o n and g u i d a n c e f r o m 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 t h e s e a r e a s , t h e p a r t i c i p a n t s were on t h e i r own t o c a r r y o u t t h e s e c h a n g e s . 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 had 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 t o w h i c h t h e y made a c h a n g e r a t h e r t h a n h a v i n g i t f o r c e d upon them. F o r e x a m p l e , 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 when i n d i v i d u a l s a t e o u t i n a r e s t a u r a n t . P o s i t i v e f o r c e s t h a t i n f l u e n c e d c h a n g e were s u p p o r t i v e f r i e n d s and f a m i l y who e n c o u r a g e d and h e l p e d t h e 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 a r e a o f d i e t , e x e r c i s e and i n c r e a s i n g s e l f - e s t e e m . T h e s e same f o r c e s c o u l d a l s o be n e g a t i v e f o r c e s a f f e c t i n g t h e e f f o r t s t o a d h e r e t o t h e i r r e g i m e n . M e d i c a t i o n - t a k i n g was a c o p i n g b e h a v i o u r 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 meet 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 . However, some were q u e s t i o n i n g i t s use s i n c e t h e y f e l t w e l l o r b e c a u s e 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 n e e d 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 s t i m u l a t i o n and t h e need f o r a b a l a n c e b e t w e e n a c t i v i t y and r e s t . A l l 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 f o r m a t i o n w h i l e i n t h e h o s p i t a l w i t h r e g a r d t o d i e t , e x e r c i s e and 96 a c t i v i t y r e s t r i c t i o n s , t h e i r m e d i c a t i o n s and s m o k i n g c e s s a t i o n . 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 few 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 n u r s e s b u t 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 p e r c e i v e d as c o m i n g f r o m t h e i r d o c t o r . A l l b u t one p a r t i c i p a n t i n t h i s s t u d y had t h e same c a r d i o l o g i s t . A f t e r t h e i n i t i a l f o l l o w u p v i s i t s , t h e f r e q u e n c y o f v i s i t s t o t h e c a r d i o l o g i s t v a r i e d a c c o r d i n g t o t h e i r i n d i v i d u a l n e e d s . The f a m i l y p h y s i c i a n was now t h e main 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 t o m e d i c a l c o n c e r n s and q u e s t i o n s . The p a r t i c i p a n t s had q u e s t i o n s r e g a r d i n g a s p e c t s o f c h a n g e o r e x p e r i e n c e s b u t were o f t e n r e l u c t a n t t o " b o t h e r t h e d o c t o r " w i t h t h e i r q u e s t i o n s . Some f o u n d t h e i r a n s w e r s t h r o u g h t h e r e a d i n g o f l a y l i t e r a t u r e . One p a r t i c i p a n t a t t e n d e d a c a r d i a c 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 where t h e r e was a v a r i e t y o f 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 . The m a j o r i t y a l s o r e c e i v e d i n f o r m a t i o n f r o m f r i e n d s who had e x p e r i e n c e d an MI t h e m s e l v e s o r knew someone who h a d . The i n f o r m a t i o n 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 c o n t a i n e d t h e p e r c e p t i o n s and b e l i e f s o f c o n c e r n e d i n d i v i d u a l s . 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 were made "on t h e i r own" and were n o t m o n i t o r e d by h e a l t h p r o f e s s i o n a l s . P e r s o n a l a d j u s t m e n t s were 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 a v o i d e d d i s c u s s i n g c e r t a i n t o p i c s w i t h t h e i r d o c t o r b e c a u s e t h e y 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 . Even among t h o s e who had t h e same c a r d i o l o g i s t and 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 r e v i e w e d v a r i e d g r e a t l y . T h i s may have been due t o t h e i n d i v i d u a l s ' p e r c e p t i o n s and i n t e r p r e t a t i o n s o f what t h e y 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 were i n h o s p i t a l , no f o r m a l t e a c h i n g 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 w i t h 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 and r i s k r e d u c t i o n s u g g e s t i o n s . W r i t t e n m a t e r i a l may be h e l p f u l as a r e i n f o r c e m e n t t o i n f o r m a t i o n w h i c h i s f i r s t p r e s e n t e d . T h i s a l l o w s t h e i n d i v i d u a l s o p p o r t u n i t y t o t a k e t h e i n f o r m a t i o n w i t h them and 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 more a p t t o a b s o r b , u n d e r s t a n d r e v i e w o r q u e s t i o n t h e c o n t e n t and i m p l i c a t i o n s f o r them. T h e r e i s g r e a t c o n t r o v e r s y i n t h e l i t e r a t u r e r e g a r d i n g t h e o p t i m a l t i m e f o r t e a c h i n g and l e a r n i n g e s p e c i a l l y d u r i n g a c r i t i c a l p e r i o d s u c h as an MI. The b e s t t i m e f o r l e a r n i n g may v a r y f r o m i n d i v i d u a l t o i n d i v i d u a l and t h u s t h e n u r s e r e q u i r e s s k i l l i n 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 f o r i n f o r m a t i o n r e g a r d i n g t h e i r i m m e d i a t e and f u t u r e s i t u a t i o n s . In f a c t , t h e p a t i e n t ' s l e v e l o f p s y c h o l o g i c a l a n x i e t y may 98 be t h e c r i t i c a l v a r i a b l e i n t e a c h i n g , r a t h e r t h a n t h e t i m e p e r i o d . ( G u z z e t t a , 1 9 7 9 ) . The i n d i v i d u a l s i n t h i s s t u d y were 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 c o n d i t i o n . I t i s b e y o n d t h e s c o p e o f t h i s s t u d y t o c o n c l u d e as G u z z e t t a ( 1 9 7 9 ) d o e s , t h a t a c r i t i c a l e v e n t s u c h as an MI may be t h e t u r n i n g p o i n t t o b r i n g a b o u t p o s i t i v e c h a n g e i n t h e i r l i v e s . C a r d i a c r e h a b i l i t a t i o n p r o g r a m s have been b a s e d i n h o s p i t a l s b e c a u s e o f a r e c o g n i z e d need and b e l i e f t h a t p a t i e n t s r e c o v e r i n g f r o m a m y o c a r d i a l i n f a r c t i o n n e e d k n o w l e d g e a b o u t t h e i r c o n d i t i o n ( G e r a r d & P e t e r s o n , 1984; Owens, McCann & H u t e l m y e r , 1 9 7 8 ) . However, e m p i r i c a l e v i d e n c e r e l a t e d t o t h e t e a c h i n g l e a r n i n g p r o c e s s has n o t been f u l l y e v a l u a t e d i n t e r m s o f t h e e f f e c t i v e n e s s o f p a t i e n t e d u c a t i o n p r o g r a m s n o r has i t been u s e d t o d e v e l o p p a t i e n t e d u c a t i o n t e c h n i q u e s ( G u z z e t t a , 1 9 7 9 ) . T e a c h i n g t h a t i s begun a t t h e wrong t i m e may be t o t a l l y i n e f f e c t i v e . W i l l t h e i d e n t i f i c a t i o n o f l a c k o f a b a s i c human need b e i n g met r e v e a l l e a r n i n g n e e d s ? 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 t h e i n d i v i d u a l t o b e g i n g i v i n g i n f o r m a t i o n . F o r i n s t a n c e , 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 c h e s t p a i n when w a l k i n g i t w o u l d be u s e f u l t o b e g i n t e a c h i n g a b o u t c o p i n g b e h a v i o u r s t o d e a l w i t h c h e s t p a i n and how t o b a l a n c e a c t i v i t y and r e s t . An e x p l a n a t i o n o f b a s i c 99 anatomy and p h y s i o l o g y w h i c h i s o f t e n p r e s e n t e d f i r s t d u r i n g a t e a c h i n g p r o g r a m , may o r may n o t be u s e f u l a f t e r t h e i n d i v i d u a l l e a r n s how t o d e a l w i t h h i s symptoms. 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 i s k r e d u c t i o n i n t h e i n i t i a l p e r i o d f o l l o w i n g an 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 i m p o r t a n t t e a c h i n g i t e m s . 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 "how t o " a s p e c t s s u c h as "how t o d e c r e a s e c h a n c e s o f a n o t h e r MI", "how 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 them. N u r s e s were more c o n c e r n e d w i t h t h e "whys" and r a n k e d "why p a t i e n t s had c h e s t p a i n s " , "why a c t i v i t y was l i m i t e d " and "why e a c h m e d i c a t i o n was b e i n g t a k e n " as most i m p o r t a n t . P e r h a p s n u r s e b e l i e v e t h a t i f p e o p l e u n d e r s t a n d t h e "why" t h e y w i l l c o m p l y . R i s k 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 o n s e t o f h e a r t d i s e a s e , how t o r e d u c e r e c u r r e n c e o f h e a r t a t t a c k and how r i s k f a c t o r s a f f e c t t h e h e a r t were o f p r i m a r y c o n c e r n t o 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 p a s s e d t h e i n i t i a l p h a s e o f t h e i r i l l n e s s and had c o n c e r n s r e l a t e d t o t h e r e a s o n s "why" w i t h r e g a r d t o 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 . P e r h a p s t h i s 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 need s p e c i f i c 100 g u i d a n c e a b o u t "what" t o do and 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 l a t e r . B e g i n n i n g t o t e a c h p e o p l e w h i l e i n h o s p i t a l a b o u t t h e a r e a s 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 n e c e s s a r y 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 , t h e n u r s e 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 p a t i e n t . H e l p i n g i n d i v i d u a l s r e t u r n t o t h e i r f o r m e r j o b s , f a m i l y l i f e a nd p l a c e i n s o c i e t y i s a g o a l t h a t has f a r r e a c h i n g demands and a t i m e f r a m e n o t c o n f i n e d t o t h e h o s p i t a l . The d a t a f r o m t h i s s t u d y r e v e a l s a need f o r t e a c h i n g and 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 have someone l i k e t h e i n v e s t i g a t o r t o c a l l and d i s c u s s c o n c e r n s , p r o b l e m s and q u e s t i o n s . A n o t h e r s a i d he had many q u e s t i o n s a f t e r g o i n g home f r o m h o s p i t a l w h i c h r e m a i n e d u n a n s w e r e d . P r e s e n t l y , i n t h e community t h e r e i s no one f o r p e o p l e t o c a l l t o d i s c u s s t h e i r c o n c e r n s , e s p e c i a l l y s e v e n t o t w e l v e months a f t e r an MI. I n i t i a l f o l l o w u p may be done by p u b l i c h e a l t h o r home c a r e n u r s e s 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 p a t i e n t s i s n o t a r e g u l a r o c c u r r a n c e . T h e r e seems t o be a gap 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 and t h e community a g e n c i e s . 101 A d i s c u s s i o n o f t h 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 i s k r e d u c t i o n e x p l a i n e d t h e i n d i v i d u a l s r e s p o n s e t o l o s s t h r o u g h d e n i a l , a n g e r , d e p r e s s i o n and r e o r g a n i z a t i o n . M ost 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 as t h e y made c h a n g e s i n t h e i r d i e t , s m o k i n g h a b i t 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 . R e d u c i n g r i s k f a c t o r s were t h e c o p i n g b e h a v i o u r s i n t h e i n i t i a l p h a s e u s e d 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 and 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 b e t w e e n r e s t and a c t i v i t y . A d i s c u s s i o n o f t h e s e c o p i n g b e h a v i o u r s l e d t o a d i s c u s s i o n o f t h e g i v i n g o f i n f o r m a t i o n t o e n h a n c e and pr o m o t e t h e s e c o p i n g b e h a v i o u r s . 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 E x p e r i e n c i n g symptoms s u c h as 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 aware o f t h e i r b o d i e s and o f t h e f a c t t h a t t h e y were n o t n o r m a l . D e a l i n g w i t h t h e i r symptoms became a t a s k t o m a s t e r . Some d e v i s e d t h e i r own d a i l y s c h e d u l e w h i c h became t h e i r own p e r s o n a l t r e a t m e n t r e g i m e n . 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 s u c h as r e g u l a r 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 . I t i s d i f f i c u l t t o c o n c l u d e f r o m t h i s s t u d y e x a c t l y what a r o l e c h a n g e and t h e l e v e l o f k n o w l e d g e o r t h e l a c k t h e r e o f p l a y e d i n 102 d e v e l o p i n g s u i t a b l e c o p i n g b e h a v i o u r s . S p e c i f i c m e n t i o n was made by t h e p a r t i c i p a n t s a b o u t t h e p e r c e i v e d l a c k o f s u f f i c i e n t k n o w l e d g e a b o u t c a r d i a c d i s e a s e and how t o manage i t . I t w o u l d seem t h a t c o g n i t i v e a b i l i t i e s p l a y a l a r g e r o l e i n t h e a c q u i s i t i o n and 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 been i m p a r t e d . 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 p a s s e d and t h e y have s u r v i v e d t h e t h r e a t o f d e a t h , t h e g o a l o f 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 as p o s s i b l e d e s p i t e t h e i r symptoms and i l l n e s s . S t r a u s s ( 1 9 8 4 ) comments t h a t how n ormal t h e y make t h e i r l i v e s and t h e i r 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 symptoms, t h e r e g i m e n s t h e y must f o l l o w and t h e i r k n o w l e d g e o f t h e i r d i s e a s e . 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 t u r n s 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 have t o work v e r y h a r d a t c r e a t i n g some s e m b l a n c e o f n ormal l i f e f o r t h e m s e l v e s . C e r t a i n l y t h e s e f a c t o r s a r e i m p o r t a n t as f o r c e s t h a t i n f l u e n c e t h e c o p i n g b e h a v i o u r s p e r s o n s use t o meet t h e i r b a s i c human n e e d s . 103 F o r c e s A f f e c t i n g C o p i n g B e h a v i o u r s In a t t e m p t i n g t o g e t ba c k t o n o r m a l , c e r t a i n f o r c e s a f f e c t e d t h e n e e d s and a b i l i t i e s o f t h e p a r t i c i p a n t s . 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 f o r c e o f c h e s t p a i n a f f e c t e d t h e c o p i n g b e h a v i o u r s o f t h e i n d i v i d u a l s . One p a r t i c i p a n t had s t a i r s i n h e r home l e a d i n g t o h e r b a t h r o o m and f o u n d i t t i r i n g and s o m e t i m e s d e v e l o p e d c h e s t p a i n g o i n g up and down t h e s t a i r s . The p h y s i c a l e n v i r o n m e n t and l o c a t i o n o f t h e home was a n o t h e r i m p e r s o n a l f o r c e . F i n a n c i a l c o n c e r n s were m e n t i o n e d by one 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 d i f f i c u l t y r e t u r n i n g t o h i s f o r m e r j o b . T h i s c a u s e d a n x i e t y and w o r r y a b o u t p r o v i d i n g f o r h i s f a m i l y . The 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 a n o t h e r s t r o n g 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 i n t h e s t u d y . A j o b 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 was a n e g a t i v e f o r c e as 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 b e t w e e n r e s t and a c t i v i t y as t h e i d i v i d u a l o f t e n e x p e r i e n c e d c h e s t p a i n and f a t i g u e due t o t h e n a t u r e o f work. F l e x i b l e j o b s a l l o w i n g i n d i v i d u a l s a g r a d u a l r e - e n t r y i n t o t h e work f o r c e were 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 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 . 104 The r e s p o n s e o f i n d i v i d u a l s t o p o s i t i v e o r 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 t h e c o p i n g b e h a v i o u r s u s e d t o a t t e m p t t o meet t h e i r b a s i c human n e e d s . W o r k i n g h a l f t i m e , c h a n g i n g j o b s , t a k i n g s i c k t i m e and a d j u s t i n g w o r k i n g h o u r s were m e t h o d s t h a t were u s e d . T h o s e who were r e t i r e d r e s p o n d e d t o o t h e r f o r c e s i n t h e i r e n v i r o n m e n t s u c h as t h e 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 , c a m p i n g and d r i v i n g t h e c a r . T h e s e were t h e a r e a s o f c h a n g e as t h e y a t t e m p t e d t o r e t u r n t o f o r m e r h o b b i e s and a c t i v i t i e s . F a m i l i e s were 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 o f t h i s s t u d y . S u p p o r t i v e , u n d e r s t a n d i n g f a m i l i e s were s e e n 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 n e e d s . 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 and d e p e n d e n c e was e v i d e n t when met 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 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 y was n o t met, o t h e r unmet n e e d s a r o s e as w e l l . The f a m i l y was t h e n v i e w e d as a n e g a t i v e f o r c e i m p e d i n g need s a t i s f a c t i o n . The need f o r r e s p e c t o f s e l f by s e l f and 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 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 . I f t h e i n d i v i d u a l d i d n o t e x p e r i e n c e 105 i n t i m a c y w i t h t h e i r f a m i l i e s d u r i n g t h i s t i m e o f 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 . F e e l i n g s o f 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 a r e i n t e r r e l a t e d and e a c h must 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 t o o c c u r i n t h e a f f e c t i v e s u b s y s t e m . The need 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 g i v e r i s e t o q u e s t i o n s r e g a r d i n g d e p e n d e n c e v e r s u s i n d e p e n d e n c e . 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 had 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 a r e a s o f i n d e p e n d e n c e and a l l o w i n g t h e m s e l v e s t o d e p e n d on o t h e r s . S i t u a t i o n s w i t h b o t h f a m i l y and 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 . D e p e n d e n c e i n v o l v e s e x p e c t i n g o r a c t i v e l y s e e k i n g h e l p f r o m o t h e r s ( S t r y k e r , 1 9 7 7 ) . R e f u s a l o r r e s i s t a n c e t o s e e k o u t h e l p f r o m o t h e r s w i l l a f f e c t t h e f e e l i n g s o f 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 . D u r i n g a c r i t i c a l p e r i o d s u c h as an MI, v a r i o u s t y p e s o f 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 e x p r e s s i o n o f 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 . S o c i o c u l t u r a l f o r c e s i n f l u e n c i n g t h i s need a r e t h e 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. I m p e r s o n a l f o r c e s i n c l u d e t h e p r o x i m i t y o f f a m i l y members, t h e 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 t h e a v a i l a b i l i t y o f o t h e r f r i e n d s h i p s . C o p i n g b e h a v i o u r s 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 i n t h e a f f e c t i v e s u b s y s t e m i n c l u d e t h e a b i l i t y t o g i v e 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 need 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 i n d i v i d u a l s s t r u g g l e t o meet t h e i r n e e d f o r m a s t e r y , t h i s may i n t e r f e r e w i t h t h e i r need t o ask f o r h e l p . I f 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 n e e d s 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 w i l l be met. R o l e s w i t h i n t h e f a m i l y u n i t s o f t h e p a r t i c i p a n t s u n d e r w e n t some c h a n g e s . The r o l e c h a n g e s d i s c u s s e d by t h e 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 s u c h as t h e 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 b r e a d w i n n e r . M u r r a y and Z e n t n e r ( 1 9 8 5 ) d e s c r i b e e m o t i o n a l r o l e s s u c h 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 . They m a i n t a i n t h a t t h e e m o t i o n a l r e s p o n s e o f a p e r s o n t o t h e r o l e he f u l f i l l s 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 may p e r f o r m a j o b c o m p e t e n t l y b u t h a t e d o i n g i t . D a t a f r o m t h e s t u d y showed t h a t e m o t i o n a l c h a n g e s 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 o f t h e o t h e r . The i m p a c t o f t h e r o l e c h a n g e 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 months t o a y e a r as most 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 c h a n g e and i t may be t o o soon t h e j u d g e t h e t o t a l i m p a c t . The n e e d s f o r s e l f - e s t e e m and m a s t e r y may be 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 . 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 f r o m o n e ' s s p o u s e a n d / o r f a m i l y a f f e c t e d t h e l i f e s t y l e c h a n g e s t h a t were made. A l l t h e m a r r i e d men commented 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 l i f e s t y l e . 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 i n e x e r c i s e p r o g r a m s , 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 t o t h e h u s b a n d . T h o s e p a r t i c i p a n t s who d i d n o t have a s p o u s e commented 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 w i t h o u t 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 . 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 o v e r to c a r e f o r them. They t e n d e d t o e x c e e d t h e i r c a p a c i t y f o r a c t i v i t y w i t h t h e i r q u e s t f o r i n d e p e n d e n c e . R e a c t i o n s were 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 t h a t t h e y 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 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 l i v e s and l e a r n s w i l l d e t e r m i n e t o some e x t e n t how p r o b l e m s a r e s o l v e d 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 , 1 9 8 1 ) . R e l i g i o u s b e l i e f s w i l l a f f e c t t h e o v e r a l l v i e w and m e a n i n g o f l i f e i n f l u e n c i n g t h e ways i n w h i c h an i n d i v i d u a l d e a l s w i t h s i t u a t i o n s . C u l t u r a l g r o u p s may 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 p e r i o d s . 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 c a n a l s o i n f l u e n c e t h e d e v e l o p m e n t o f c o p i n g b e h a v i o u r s . The a v a i l a b i l i t y o f f a m i l y and f r i e n d s and t h e i r r e s p o n s e t o t h e c r i t i c a l p e r i o d w i l l i n f l u e n c e c o p i n g b e h a v i o u r s . A s t a b l e f a m i l y s t r u c t u r e i s i m p o r t a n t t o o n g o i n g d e v e l o p m e n t ( K e a n e , 1 9 8 1 ) . M u r r a y and Z e n t n e r ( 1 9 8 5 ) s t a t e d t h a t t h e l e s s r e a d i l y a v a i l a b l e t h e p e r s o n ' s e n v i r o n m e n t a l o r e m o t i o n a l s u p p o r t s y s t e m s a r e 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 h a z a r d o u s he w i l l d e f i n e t h e e v e n t . W h e t h er o r n o t t h e 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 s i t u a t i o n , i t i s i m p o r t a n t t h a t r o l e r e s p o n s i b i l i t i e s a r e i n i t i a l l y s h i f t e d away f r o m t h e p a t i e n t . S i n c e 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 o f r o l e s , 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 p r o t e c t i v e 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 need i n a n o t h e r a r e a . The s e v e n p a r t i c i p a n t s r a n g e d i n age f r o m 45 t o 69. F o u r o f t h e p a r t i c i p a n t s were w o r k i n g and t h r e e were r e t i r e d a t t h e t i m e o f t h e MI. A l l b u t one o f t h e w o r k i n g p a r t i c i p a n t s has r e t u r n e d t o work. T h e r e a r e many i n f l u e n c e s t h a t d e t e r m i n e t h e c o p i n g b e h a v i o u r s t h a t i n d i v i d u a l s use t o meet t h e i r b a s i c human n e e d s . C o g n i t i v e a b i l i t i e s a r e one s u c h i n f l u e n c e t h a t a f f e c t t h e c o p i n g b e h a v i o u r . 109 I t i s n o t p o s s i b l e t o d e t e r m i n e t h e l e v e l o f i n t e l l e c t u a l o r c o g n i t i v e d e v e l o p m e n t o f t h e i n d i v i d u a l b a s e d on t h e i r c u r r e n t o r f o r m e r j o b . However, t h o s e who 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 e d u c a t i o n o r who had b u i l t up a b u s i n e s s seemed t o have more i n s i g h t and k n o w l e d g e a b o u t t h e i r c o n d i t i o n and how t o manage i t e f f e c t i v e l y . T h e r e was a l s o a n o t i c e a b l e d i f f e r e n c e i n 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. B e c a u s e t h i s s t u d y d i d n o t m e a s u r e c o g n i t i v e d e v e l o p m e n t i t i s n o t p o s s i b l e t o r e l a t e c o p i n g b e h a v i o u r s t o t h e c o g n i t i v e a b i l i t y o f e a c h i n d i v i d u a l . However, 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 e d u c a t i o n 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 d e v e l o p 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 meet t h e i r n e e d s . One 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 e n e r g y a t t e m p t i n g t o r e s o l v e c e r t a i n p r o b l e m s r e g a r d i n g t h e f a m i l y . Good j u d g m e n t and d e c i s i o n - m a k i n g a b i l i t y were 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 n o t p o s s i b l e t o know i f t h i s was a c h a n g e f r o m p r e v i o u s a b i l i t i e s b r o u g h t a b o u t 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 p o o r . Keane ( 1 9 8 1 ) s t a t e s t h e t h e l e v e l o f i n t e l l e c t u a l 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 be a 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 t h e i n d i v i d u a l d e f i n e s h i s i l l n e s s and w i l l a f f e c t h i s a b i l i t y t o d e a l w i t h i t . 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 f r o m p r e v i o u s l o s s e s were n e v e r r e s o l v e d . The 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 t h e p r e s e n t l o s s and t h i s new t h r e a t o f d e a t h . R e s o r t i n g t o p r e v i o u s h a b i t s were n o t 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 t h i s s i t u a t i o n . 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 o r 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 o f m a s t e r y . A n o t h e r p a r t i c i p a n t who a l s o e x p e r i e n c e d a number o f p e r s o n a l l o s s e s u s e d 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 meet h i s n e e d s . P a s t e x p e r i e n c e w i t h a CVA and t h e 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 l o s s e s 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 a f t e r MI. P r e v i o u s c o p i n g b e h a v i o u r s i n h i s r e p e r t o i r e were u s e d i n t h e new s t r e s s f u l s i t u a t i o n . P e r h a p s one who has met h i s b a s i c human n e e d s t h r o u g h o u t v a r i o u s m a t u r a t i o n a l e v e n t s and u n p r e d i c t a b l e e v e n t s w i l l u t i l i z e t h e r e p e r t o i r e o f c o p i n g b e h a v i o u r s a l r e a d y d e v e l o p e d . The way i n w h i c h p r e v i o u s c h a n g e was d e a l t w i t h w i l l a f f e c t p r e s e n t c o p i n g b e h a v o u r s . The number o f u n p r e d i c t a b l e e v e n t s 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 i s d e a l i n g w i t h a t any g i v e n t i m e w i l l a l s o a f f e c t t h e a b i l i t y t o r e s p o n d a p p r o p r i a t e l y . I l l The p a r t i c i p a n t ' s p e r c e p t i o n o f t h e u n p r e d i c t a b l e e v e n t (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 m e a n i n g o f t h e e v e n t i n t e r m s o f t h e i m p a c t o f t h e l o s s e s a f f e c t e d t h e r e s p o n s e u s e d t o d e a l w i t h t h e l o s s . T h i s r e s p o n s e may be c a l l e d a c o p i n g b e h a v i o u r as i t a t t e m p t s t o r e d u c e t e n s i o n i n one o r more s u b s y s t e m s and meet a b a s i c human n e e d . C e r t a i n i n d i v i d u a l s i n t h e s t u d y assumed more r e s p o n s i b i l i t y f o r t h e i r i l l n e s s s i t u a t i o n and 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 c o n t r o l t h e c h a n g e p r o c e s s f o r them. I t i s i m p o r t a n t to d e t e r m i n e 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 e a c h i n d i v i d u a l r a t h e r t h a n how o t h e r s t h i n k someone s h o u l d f e e l o r b e h a v e i n a s i t u a t i o n . D e t e r m i n i n g t h e m e a n i n g o f t h e e v e n t f o r t h e i n d i v i d u a l w i l l h e l p n u r s e s 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 and s t r e n g t h e n i n g c o p i n g b e h a v i o u r s . 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 a l s o d e t e r m i n e s t h e c o p i n g b e h a v i o u r s . The a b i l i t y t o e x e c u t e 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 s t u d y d e s c r i b e d t h e i r e x p e r i e n c e 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 n e e d s a t i s f a t i o n i n t h e 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 t o p e r f o r m h o u s e h o l d t a s k s and r o l e s r e q u i r e d new c o p i n g 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 t h e t a s k s o r r e l i n q u i s h i n g r o l e s . T h i s may l e a d t o unmet n e e d s i n o t h e r s u b s y s t e m s g e n e r a t i n g f e e l i n g s o f i n a d e q u a c y and b o r e dom. The age o f a p e r s o n a t t h e o n s e t o f any p h y s i c a l o r e m o t i o n a l i m p a i r m e n t i s an i m p o r t a n t f a c t o r a f f e c t i n g a p e r s o n ' s a b i l i t y t o c o p e ( S t r y k e r , 1 9 7 7 ) . M a t u r a t i o n a l 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 a f f e c t n e e d s a t i s f a c t i o n i n one o r more s u b s y s t e m s . F o r e x a m p l e , one man i n t h e s t u d y i n t h e h e i g h t o f a f u l f i l l i n g 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 i m p e d i n g 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 p a c e . T h i s r e q u i r e d a c h a n g e . A n o t h e r p a r t i c i p a n t who had 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 i l l n e s s 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 c o p i n g b e h a v i o u r s . 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 were s h a r e d o f how t h e y were f e e l i n g a b o u t t h e m s e l v e s . T h e r e was o f t e n a r e f u s a l t o r e c o n c i l e t h e c h a n g e s a f f e c t i n g them. 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 t i m e were 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 and t h e n e e d f o r r e s p e c t by s e l f and o t h e r s . The c h a n g e s i n s e l f - e s t e e m ( t h e i n d i v i d u a l ' s j u d g m e n t o f h i s w o r t h ) t h a t r e s u l t e d f r o m an a l t e r a t i o n i n s e l f c o n c e p t a f f e c t e d t h e p a r t i c i p a n t s i n t h i s s t u d y . T h i s was o b s e r v e d i n t h e i r p e r c e p t i o n o f t h e i r s i t u a t i o n and i n comments made a b o u t t h e m s e l v e s , s u c h as " I d o n ' t f e e l n o r m a l " , and " I d o n ' t t h i n k I ' l l e v e r g e t b a c k t o work." R o l e p e r f o r m a n c e i n t h e c h a n g e s and l o s s i m p o s e d by them a l s o t h r e a t e n e d t h e i r s e l f - e s t e e m . S o c i a l r e l a t i o n s h i p s and i n t e r a c t i o n s r e v e a l e d a d e q u a c i e s and i n a d e q u a c i e s r e l a t e d t o t h e r e s u l t a n t e f f e c t i n t h e i r s e l f - e s t e e m . A n e g a t i v e a t t i t u d e t o w a r d s e l f , r e s e n t f u l f e e l i n g s t o w a r d o t h e r s , 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 i n 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) were e v i d e n t i n d i c a t i o n s o f t h e n e e d f o r s e l f - e s t e e m o b s e r v e d i n t h e i n t e r v i e w s d u r i n g t h i s s t u d y . C o p i n g b e h a v i o u r s were d e v e l o p e d i n o r d e r t o meet b a s i c human n e e d s . The c o p i n g b e h a v i o u r s u n d e r w e n t some r e v i s o n s i n o r d e r t o meet t h e i r n e e d s w h i c h do n o t c h a n g e . In some c a s e s t h e way o f r e a c h i n g t h e g o a l o f t h e s u b s y s t e m u n d e r w e n t r e v i s i o n i n o r d e r t o meet t h e n e e d . F o r i n s t a n c e , a man who f o r m e r l y d i d a l l t h e 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 e n j o y m e n t f o u n d he was u n a b l e t o do t h i s . H i s 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 t o d e l e g a t e t h e s e t a s k s t o o t h e r f a m i l y members. H i s e n e r g y was e x p e n d e d by r e t u r n i n g t o work and commencing a r e g u l a r w a l k i n g p r o g r a m . He f o u n d t h a t he had t o r e s t b e t w e e n a c t i v i t i e s . H i s need f o r a c t i v i t y and r e s t was now met b u t i n a v e r y d i f f e r e n t way. H i s need f o r s e n s o r y s t i m u l a t i o n was n o t met a t t h i s t i m e b u t t h i s man was s e a r c h i n g f o r new i n t e r e s t s and new ways t o s a t i s f y h i s n e e d s . T h i s w i l l be an o n g o i n g p r o c e s s as he c o n t i n u e s 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 u s e d t o meet h i s n e e d s . As a p e r s o n ' s v i e w o f h i s i l l n e s s u n d e r g o e s c h a n g e due t o t h e s u b s e q u e n t l o s s e x p e r i e n c e s , o n e ' s s e n s e o f p e r s o n a l 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 . I t may 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 s o c i a l s i t u a t i o n t h a t a f f e c t s t h e s e l f - i m a g e . H i s v i e w s o f h i m s e l f c a n n o t r e m a i n u n a l t e r e d . R e g a r d l e s s o f t h e s e v e r i t y o f t h e i l l n e s s , t h e p e r s o n ' s e f f o r t s t o even m a i n t a i n s o c i a l r e l a t i o n s h i p s and b u i l d t h e new o n e s n e c e s s a r y t o d e a l w i t h new d i s a b i l i t i e s w i l l f o s t e r a c h a n g e d s e n s e o f i d e n t i t y ( S t r a u s s , 1 9 8 4 ) . A f t e r an MI, t h e p a r t i c i p a n t s i n t h i s s t u d y e a c h e x p e r i e n c e d p h y s i c a l d i s a b i l i t y l i m i t i n g t h e i r " n o r m a l l i f e " t o w h i c h t h e y were p r e v i o u s l y a c c u s t o m e d . A l t h o u g h c a r d i a c d i s e a s e i s n o t o f t e n v i s i b l e , t h e p h y s i c a l 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 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 c o n c e p t o f s e l f . T h i s r e v i s i o n may be a c o n t i n u o u s p r o c e s s as t h e i l l n e s s p r o g r e s s e s and as t h e p e r s o n ' s d i s a b i l i t y c h a n g e s . 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 ( M a r t i n , 1 9 7 0 ) . M u l l e n ( 1 9 7 8 ) d e s c r i b e s an e q u a t i o n f o r c l a r i f y i n g s e l f - e s t e e m . S e l f - e s t e e m = s u c c e s s p r e t e n t i o n s 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 p h y s i c a l c a p a c i t y i s c h a n g e d , m a i n t e n a n c e o f s e l f - e s t e e m d e p e n d s upon d e c r e a s i n g t h e d e n o m i n a t o r . T h i s may mean t h a t t h e h o u s e need n o t be k e p t so c l e a n o r t h a t t h e y a r d so p r e c i s e l y c a r e d f o r p e r s o n a l l y . C u t t i n g back i n what one c a n now do c a n be o f f s e t by c u t t i n g back on what one t h i n k s n e e d s t o be d o n e . S e l f - e s t e e m , t h e n d e p e n d s 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 s e l f " . P a r t i c i p a n t s r e l a t e d how t h e i r a t t i t u d e s and p e r s p e c t i v e s had c h a n g e d a f t e r t h e MI. One p a r t i c i p a n t e x p l a i n e d 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 a b o u t were n o t w o r t h t h e e n e r g y . He w a n t e d t o p u t h i s r e d u c e d e n e r g y i n t o o t h e r a r e a s s u c h as s p e n d i n g more t i m e w i t h f a m i l y and l e s s t i m e a t work and on t i m e c o n s u m i n g h o u s e h o l d t a s k s . C o p i n g b e h a v i o u r s t h a t were 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 a new n ormal and a c h i e v e b e h a v i o u r a l s y s t e m b a l a n c e i n c l u d e d an 116 a t t i t u d i n a l 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 o n e ' s 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 c e r t a i n t h i n g s . T h i s was i n c o n t r a s t t o t h e b e g i n n i n g s t a g e s o f c h a n g e 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 t o c h a n g e r a t h e r t h a n c h o o s i n g t o do s o . T h o s e who c o n s c i o u s l y r e s i s t e d o r were u n a b l e t o v i e w t h e m s e l v e s d i f f e r e n t l y c o n t i n u e d t o e x p e r i e n c e d e n i a l , a n g e r and d e p r e s s i o n a t d i f f e r e n t t i m e s . P e r h a p s t h o s e who u s e d d e n i a l were a l s o u n a b l e t o v i e w t h e m s e l v e s d i f f e r e n t l y . A r e v i s i o n o f o n e ' s s e l f c o n c e p t d i d seem t o be n e c e s s a r y f o r 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 be d e v e l o p e d . B e h a v i o u r a l s y s t e m b a l a n c e i s a d y n a m i c s t a t e i n w h i c h t e n s i o n s a r e b e i n g r e d u c e d by c o p i n g b e h a v i o u r s s u c h t h a t t h e s y s t e m i s i n a b a l a n c e d r e l a t i o n s h i p w i t h i t s e n v i r o n m e n t (UBC Model f o r N u r s i n g , 1 9 8 0 ) . R e a c h i n g a new normal i s e m b o d i e d i n t h e c o n c e p t o f b e h a v i o u r s y s t e m b a l a n c e as i n d i v i d u a l s a r e r e d u c i n g t e n s i o n s u s i n g s u i t a b l e c o p i n g b e h a v i o u r s . The i d e a o f a new n o r m a l r e f e r s t o t h e c h a n g e i n a t t i t u d e o r 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 s u b s y s t e m s w i t h t h e r e s u l t t h a t t h e n e e d s o f t h e i n d i v i d u a l a r e met b u t p e r h a p s 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 f o r m e r 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 p h y s i c a l and e m o t i o n a l c o n d i t i o n t h e y e x p r e s s e d hope f o r c o n t i n u e d s u c c e s s e s . Some hoped t h a t t h e i r 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 w o u l d c o n t i n u e t o i m p r o v e . O t h e r s h oped f o r a c u r e i f t h e y had c o r o n a r y a r t e r y b y p a s s s u r g e r y o r f o l l o w e d a c e r t a i n d i e t . One man s p o k e o f h i s hope f o r h e a l i n g b a s e d on h i s f a i t h i n God. One o f a human b e i n g ' s most v a l u e d , p r i v a t e and p o w e r f u l r e s o u r c e s i s h o p e . Hope i s t h e a f f e c t t h a t a c c o m p a n i e s and i s b a s e d upon f a i t h ( M i l l e r , 1 9 8 3 ) . 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 w i s h . P e r s o n a l g o a l s e t t i n g , m o d i f i c a t i o n o f g o a l s and 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 f u t u r e w i t h p l a n s t o r e a c h g o a l s i s i m p o r t a n t i n m o v i n g t o w a r d h o p e . P e a c e o f m i nd t h r o u g h t h e f u l f i l l m e n t o f g o a l s and h o pes w i l l meet n e e d s t h e 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 s u b s y s t e m s . M u l l e n ( 1 9 7 8 ) f o u n d t h a t " w h i l e t h e MI i s s t i l l p r o m i n e n t , p a t i e n t s r e a s s e s s t h e i r l i f e g o a l s w i t h r e f e r e n c e t o t h e i r p e r s o n a l d e f i n i t i o n s o f t h e q u a l i t y o f 1 i f e " ( p . 2 2 9 ) . P a t i e n t s i n t e r v i e w e d i n t h i s s t u d y d e s c r i b e d 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 . W i t h any l o s s , may 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 o f 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 , 1 9 8 0 ) . A d e e m p h a s i s on work and an e m p h a s i s on f a m i l y r e l a t i o n s h i p s was 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 o f p h y s i c a l c a p a c i t i e s . One man f e l t t h a t 118 h i s i l l n e s s was a b e n e f i t t o h i s f a m i l y b e c a u s e o f t h e new r e s p o n s i b i l i t i e s t h a t i t g a v e t o h i s w i f e and s o n . 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 t h e i r r i s k 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 moved between 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 b e t w e e n 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 were 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 d u r i n g 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 . B e c a u s e t h e n e e d s o f t h e s u b s y s t e m s a r 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 , t h e e f f e c t s o f c h a n g e w i l l c o n t i n u e t o be s e e n t h r o u g h o u t t h e s y s t e m . W i t h t i m e however and w i t h t h e r e p e a t e d r i s e o f e f f e c t i v e c o p i n g b e h a v i o u r s , t h e i n d i v i d u a l s w i l l a c h i e v e b e h a v i o u r a l s y s t e m b a l a n c e and s t a b i 1 i t y . 119 CHAPTER SIX SUMMARY AND IMPLICATIONS FOR NURSING T h i s s t u d y was d e s i g n e d t o g a i n u n d e r s t a n d i n g o f 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 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 u t i l i z e d by 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 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 . L i t t l e has been w r i t t e n a b o u t c o p i n g b e h a v i o u r s i n r e l a t i o n 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 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 dds a d i f f e r e n t p e r s p e c t i v e by v i e w i n g b e h a v i o u r c h a n g e i n r e l a t i o n t o m e e t i n g b a s i c human n e e d s . T h i s v i e w p o i n t was b a s e d upon a s y s t e m f r a m e w o r k f o u n d i n t h e UBC Model f o r N u r s i n g . From t h i s p e r s p e c t i v e , t h e i l l n e s s e x p e r i e n c e o f t h e i n d i v i d u a l was d e s c r i b e d t h r o u g h e x a m i n a t i o n o f t h e n e e d s and g o a l s o f a b e h a v i o u r a l s y s t e m . B e c a u s e t h e s u b s y s t e m s i n t h e b e h a v i o u r a l s y s t e m a r e 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 v a r i o u s s u b s y s t e m s . A q u a l i t a t i v e m e t h o d o l o g y u s i n g g r o u n d e d t h e o r y was 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 t h e i r e x p e r i e n c e . S e v e n p a r t i c i p a n t s , s i x m a l e and one f e m a l e , r a n g i n g i n age 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 s e v e n t o t w e l v e months a f t e r t h e i r i n i t i a l 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 w i t h o p e n - e n d e d q u e s t i o n s . T h r e e i n t e r r e l a t e d themes were d e v e l o p e d f r o m t h e r e s e a r c h f i n d i n g s : 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 i s k r e d u c t i o n , g e t t i n g back t o normal and r e a c h i n g a new n o r m a l . The f i r s t theme a d d r e s s e d c h a n g e s t h a t i n d i v i d u a l s made t o r e d u c e t h e i r r i s k o f a s e c o n d MI. Some c h a n g e s were i m p o s e d by s t r o n g f o r c e s and o t h e r c h a n g e s were made by c h o i c e . N u r s e s were n o t m e n t i o n e d i n t h i s p r o c e s s o f c h a n g e p e r h a p s b e c a u s e t h e y d i d n o t a s s i s t i n c h a n g e 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 c h a n g e s were h a p p e n i n g . 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 b e h a v i o u r s were u t i l i z e d and new ones were d e v e l p e d t o meet t h e ne e d s t h a t a r o s 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 s p o u s e s 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 p o s i t i v e f o r c e i n f l u e n c i n g 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 h e s e 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 . B e c a u s e o f t h e i n t e r r e l a t i n g , i n t e r d e p e n d e n t n a t u r e o f t h e s u b s y s t e m s i n t h e b e h a v i o u r a l s y s t e m e v e n t s and f o r c e s may a f f e c t t h e n e e d s o f v a r i o u s s u b s y s t e m s . L o s s e x p e r i e n c e d f o l l o w i n g an MI d o e s n o t a l w a y s f o l l o w a p a r t i c u l a r 121 p a t t e r n o r r e s p o n s e b u t has many d i m e n s i o n s e x p e r i e n c e d i n v a r i o u s ways. A r e a s o f c h a n g e w h i c h were made i n t h e i n i t i a l few weeks f o l l o w i n g t h e i r MI were d i e t a r y m o d i f i c a t i o n s , s m o k i n g 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 p a t t e r n 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 t h e i r n e e d s . 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 p e o p l e i n a n o t h e r s i x t o t w e l v e months i n o r d e r t o compare r e s u l t s . The s e c o n d theme a l s o i n v o l v e d c h a n g e s made i n t h e i r s e a r c h f o r n o r m a l i t y . The p a r t i c i p a n t s m e n t i o n e d t h e a r e a s o f r e t u r n i n g t o t h e i r work, c h a n g e s 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 p h y s i c a l l i m i t a t i o n s i m p o s e d by c h e s t p a i n and o t h e r symptoms where c o p i n g b e h a v i o u r s were r e q u i r e d t o meet t h e i r n e e d s . L o s s e s e x p e r i e n c e d as a r e s u l t o f t h e MI were r e a l i z e d and had an i m p a c t on f o r m e r r o l e s i n t h e f a m i l y and s o c i e t y . The p a r t i c i p a n t s ' d e s c r i p t i o n s o f t h e i r a t t i t u d i n a l and p e r s p e c t i v e c h a n g e s were d e v e l o p e d i n th e theme, 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 N o r m a l . Coming t o g r i p s w i t h t h e m e a n i n g 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 f o r t h e m s e l v e s e m b o d i e d 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 t h e p r e s e n c e o f low o r h i g h 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 , hope was a c o n c e p t t h a t emerged f r o m t h e d a t a . 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 t r e a t m e n t s and hope and f a i t h i n God. S t u d y i n g t h e c h a n g e s e x p e r i e n c e d 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 r e s e a r c h . I m p l i c a t i o n s f o r N u r s i n g P r a c t i c e The UBC Model f o r N u r s i n g ( 1 9 8 0 ) s t a t e s t h a t n u r s i n g n u r t u r e s i n d i v i d u a l s d u r i n g 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 and use a r a n g e o f 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 t h e i r b a s i c human n e e d s . The r e s u l t s o f t h i s s t u d y s u g g e s t t h a t n u r s i n g does n o t c u r r e n t l y have 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. I t w o u l d seem t h a t t h e r e h a b i l i t a t i o n p e r i o d i s s t i l l a c r i t i c a l p e r i o d b e c a u s e i t i s a t t h i s t i m e when p a t i e n t s s t i l l n eed a s s i s t a n c e i n d e v e l o p i n g 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 meet 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 a b i l i t i e s 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 c o p i n g b e h a v i o u r s a r e s u i t a b l e . N u r s i n g n e e d s t o be aware o f 123 t h e p r o b l e m s and c o n c e r n s t h a t c o n f r o n t p a t i e n t s d u r i n g 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 t o h e l p p a t i e n t s meet t h e i r b a s i c human n e e d s . The f i n d i n g s o f t h e s t u d y s u g g e s t t h a t t h e a r e a o f 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 t h e c o n t r i b u t i o n t h a t t h e n u r s i n g p r o f e s s i o n s has t o o f f e r . The m e d i c a l model o f d i s e a s e and t r e a t m e n t has been t h e main f o c u s t h u s f a r . 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 and how t o meet 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 i n d i v i d u a l 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 b e f o r e and a f t e r t h e e v e n t o f an MI. The f i n d i n g s p r o v i d e s p e c i f i c 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 i n d e v e l o p i n g and s t r e n g t h e n i n g p a t i e n t and f a m i l y c o p i n g b e h a v i o u r s d i r e c t e d a t 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. N u r s e s 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 t h e i r f e e l i n q s a b o u t t h e e x p e r i e n c e and l i s t e n t o t h e f a m i l y members e x p r e s s i o n s and r e s p o n s e s t o l o s s and g r i e f . As f a m i l y members were f o u n d t o be a v e r y i m p o r t a n t s o u r c e o f s u p p o r t , n u r s i n g i n t e r v e n t i o n s t o w a r d s u p p o r t i n g and t e a c h i n g them w i l l a s s i s t i n m e e t i n g b o t h t h e n e e d s o f t h e i n d i v i d u a l and f a m i l y . P a t i e n t t e a c h i n g has be e n an i d e n t i f i e d a r e a o f t h e 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 i m p a r t i n g m e d i c a l i n f o r m a t i o n r a t h e r t h a n i n f o r m a t i o n on how t o s t r e n g t h e n and d e v e l o p c o p i n g b e h a v i o u r s t h a t w i l l meet i n d i v i d u a l and f a m i l y n e e d s . N u r s i n g s h o u l d 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 be e n c o u n t e r e d and ways t o d e a l w i t h them. From t h i s s t u d y , i t i s i m p o r t a n t t o see t h a t 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 t h e i r l i f e s t y l e s o n c e t h e y a r e o u t o f h o s p i t a l . T h i s s h o u l d be begun 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 t h e d e v e l o p m e n t o f c o p i n g b e h a v i o u r s t h a t c a n be t r a n s f e r r e d o n c e t h e y go home. 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 p r o g r a m w h i l e i n h o s p i t a l i n p r e p a r a t i o n f o r d i s c h a r g e . P a t i e n t s s h o u l d be g i v e n 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 s i d e e f f e c t s . T h i s w i l l h e l p them a v o i d t h e undue a n x i e t y t h a t a r i s e s f r o m l a c k o f u n d e r s t a n d i n g . 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 p r i m e manager o f t h e e f f e c t s o f h i s i l l n e s s , h e l p i s r e q u i r e d to 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 d e c i d e d u p o n . The s t u d y i l l u s t r a t e d some o f t h e n e e d s o f MI p a t i e n t s s e v e n t o t w e l v e months p o s t MI. U s i n g t h e 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 t h e n e e d s most a f f e c t e d a t v a r i o u s s t a g e s d u r i n g r e h a b i l i t a t i o n were 125 i d e n t i f i e d . 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 p r o g r a m s w i t h i n d i v i d u a l s h a v i n g v a r y i n g n e e d s a t d i f f e r e n t t i m e s . T h i s does 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 good a s s e s s m e n t o f t h e l e a r n e r s h o u l d t a k e p l a c e w i t h a p r o g r a m s u i t e d t o t h e n e e d s 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 as t h e UBC Model 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 p r o g r a m s t o 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 . A n u r s i n g model w o u l d p r o v i d e a way o f v i e w i n g 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 s t u d y , 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 t h e same t i m e a r e a t v e r y 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 c h a n g e and t h e d e v e l o p i n g o f b e h a v i o u r s . Group 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 h e a r a b o u t t h e p r o b l e m s o f o t h e r s t h a t a r e s i m i l a r t o t h e i r own and a b o u t how o t h e r s have s u i t a b l y c o p e d o r n o t c o p e d w i t h them. The p a r t i c i p a n t s i n t h i s s t u d y r e c e i v e d l i t t l e o r no t e a c h i n g on an o n g o i n g f o r m a t i v e b a s i s a f t e r d i s c h a r g e f r o m t h e h o s p i t a l . The m a j o r s o u r c e o f i n f o r m a t i o n when t h e y went 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 i n p u t , b u t had n o t e x p e r i e n c e d c o u n s e l l i n g o r t e a c h i n g f r o m n u r s e s f o l l o w i n g d i s c h a r g e f r o m h o s p i t a l . P a r t i c i p a n t s 126 were n o t a l w a y s c o m f o r t a b l e " b o t h e r i n g t h e d o c t o r w i t h t h e i r q u e s t i o n s " . R e d u c i n g t h e i r r i s k f a c t o r s was somewhat c o n f u s i n g o r vague f o r t h o s e r e a d i n g and 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 r e s e a r c h o f c e r t a i n a r e a s s u c h as d i e t and e x e r c i s e . I t i s n e c e s s a r y t o e x a m i n e t h e r e a c t i o n s and b e h a v i o u r s 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 n o t j u s t w h i l e i n h o s p i t a l o r i n t h e p h y s i c i a n ' s o f f i c e . Community n u r s i n g f o l l o w u p and t e a c h i n g i s n e e d e d f o r i n d i v i d u a l s who have had an MI and a r e now a t t e m p t i n g t o r e v i s e t h e i r f o r m e r p a t t e r n s o f l i v i n g . A n u r s i n g 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 community n u r s i n g a g e n c i e s m i g h t p r o v i d e c o n t i n u i t y f o r t h e p a t i e n t s and t h e i r n e e d s . C l i n i c a l n u r s e s p e c i a l i s t s who work i n h o s p i t a l s and have t h e n e c e s s a r y t h e o r y , p r a c t i c e and r e s e a r c h s k i l l s c o u l d be i n s t r u m e n t a l i n s e t t i n g up a l i a i s o n f r o m 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 r e s e a r c h 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 and 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 f o l l o w i n g t h e i r h o s p i t a l e x p e r i e n c e . L i t t l e a t t e n t i o n has been g i v e n by n u r s i n g and o t h e r h e a l t h p r o f e s s i o n a l s t o t h e p e r s o n a l g r o w t h e x p e r i e n c e d by t h o s e w i t h s e r i o u s and c h r o n i c i l l n e s s e s . 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 , p e r s o n a l g r o w t h may be o v e r l o o k e d 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 d e a l 127 o v e r l o o k e d 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 d e a l f r o m t h o s e l i v i n g w i t h i l l n e s s e s . C h a n g e s i n v a l u e s and 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 t h o s e s e n s i t i v e t o t h e n e e d s o f t h e i n d i v i d u a l . T h i s r e s e a r c h s t u d y o f t h e c o p i n g b e h a v i o u r s u s e d 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 k n o w l e d g e b a s e t h a t n u r s e s c a n use t o i m p r o v e t h e c a r e g i v e n t o t h e s e p a t i e n t s . By u s i n g a s y s t e m model and s t u d y i n g 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 i n t e r d e p e n d e n t n e e d s . F u r t h e r 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 . S t u d i e s s h o u l d be d e v i s e d b a s e d on a n u r s i n g model i n o r d e r t o e x a m i n e f u r t h e r t h e u n i q u e 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 t o t h e c a r e o f t h e i n d i v i d u a l . The UBC Model f o r N u r s i n g ( 1 9 8 0 ) u s e d i n t h i s s t u d y s t a t e s t h a t n u r s i n g ' s u n i q u e f u n c t i o n i s t o n u r t u r e i n d i v i d u a l s e x p e r i e n c i n g c r i t i c a l p e r i o d s . To n u r t u r e 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 . F u r t h e r s t u d y i n t o t h e s e a r e a s o f n u r s i n g i n t e r v e n t i o n w o u l d 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 t o d e v e l o p and use s u i t a b l e c o p i n g b e h a v i o u r s . I n t e r v e n t i o n s t r a t e g i e s t o h e l p i n t h e d e v e l o p m e n t o f a r a n g e o f c o p i n g b e h a v i o u r s w o u l d be u s e f u l t o p r o m o t e need s a t i s f a c t i o n f o r t h e MI p a t i e n t . 128 I m p l i c a t i o n s f o r N u r s i n g R e s e a r c h A l t h o u g h n u r s i n g r e s e a r c h has been done w i t h 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 f o c u s e d on t h e c o p i n g b e h a v i o u r s t h a t p a t i e n t s have u s e d t o meet t h e i r b a s i c human n e e d s . T h i s s t u d y i s o n l y a b e g i n n i n g p o i n t t o t h e s t u d y o f c o p i n g b e h a v i o u r 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 Model f o r N u r s i n g ( 1 9 8 0 ) . F u r t h e r r e s e a r c h i s n e e d e d t o s t u d y s p e c i f i c n eeds and how t o d e v e l o p and s t r e n g t h e n c o p i n g b e h a v i o u r s t o meet c e r t a i n n e e d s . The s t u d y has 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 b e h a v i o u r s . How d o e s one d e v e l o p and s t r e n g t h e n c o p i n g b e h a v i o u r s so t h a t t h e y w i l l e f f e c t i v e l y meet t h e 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 t h e 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 h a n g e c l i e n t b e h a v i o u r . F u r t h e r s t u d i e s a r e n e e d e d t o 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 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 how t o e f f e c t a b e h a v i o u r c h a n g e i n p e o p l e p r i o r t o an MI and a f t e r an MI. In t h i s s t u d y , 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 i n f o r m a t i o n 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 . F u r t h e r s t u d y m i g h t a t t e m p t t o a n s w e r t h e q u e s t i o n s : Does t h e 129 e x t e n t o f d i s e a s e a f f e c t t h e d e v e l o p m e n t and u t i 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 t o meet b a s i c human n e e d s ? A r e t h o s e w i t h more s e v e r e d i s e a s e more o r l e s s m o t i v a t e d 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 ? What a r e t h e most i m p o r t a n t f a c t o r s i n f l u e n c i n g b e h a v i o u r c h a n g e ? 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 were 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 showed 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 meet 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 an i m p o r t a n t 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 . I t i s 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 t h e MI and i t s e f f e c t s b e c a u s e a p r e v i o u s m e a s u r e o r 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 t h e i l l n e s s was n o t a v a i l a b l e . I t w o u l d be i n t e r e s t i n g t o s t u d y t h e e f f e c t o f t h e i l l n e s s w i t h t h e v a r i o u s c h a n g e 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 o f t h e 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 t h e i r 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 p l a c e . I t i s t h e t h o u g h t o f t h i s r e s e a r c h e r t h a t t h o s e w i t h h i g h o r 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 e v i d e n c e d by t h e n e e d s and g o a l s met i n o t h e r s u b s y s t e m s and 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 d e t e r m i n i n g p r e v i o u s c o p i n g b e h a v i o u r s w i l l meet t h e i r need f o r s e l f - e s t e e m u s i n g s u i t a b l e c o p i n g b e h a v i o u r s a f t e r a c r i t i c a l p e r i o d . 1 3 0 A l t h o u g h t h i s s t u d y d i d n o t d e a l d i r e c t l y w i t h f a m i l y members and 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 a b o u t t h i s 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 v e p r o c e s s was g a i n e d t h r o u g h t h e a c c o u n t o f t h e 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 f o r c e s p l a y i n g l a r g e 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 meet t h e i r b a s i c human n e e d s . A s t u d y o f f a m i l y c o p i n g b e h a v i o u r s as a r e s u l t o f t h e i l l n e s s o f one member m i g h t g i v e 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 f a m i l y u n i t . I n t e r v i e w i n g f a m i l y members w o u l d p r o v i d e t h e p e r s p e c t i v e o f t h o s e c l o s e l y i n v o l v e d w i t h t h e i l l n e s s o f a l o v e d o n e . A q u e s t i o n f o r f u t u r e r e s e a r c h 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 o f f a m i l i e s o f a p a t i e n t w i t h an MI? What a r e t h e c o p i n g b e h a v i o u r s d e v e l o p e d and u s e d by f a m i l i e s t o meet t h e i r b a s i c human n e e d s when one member has an MI? A model d e a l i n g w i t h f a m i l y f u n c t i o n i n g and 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 i n p u t o n c e 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 . The e x p e r i e n c e o f MI p a t i e n t s and t h e c o p i n g b e h a v i o u r s t h e y u s e must be e x a m i n e d o v e r a c o n s i d e r a b l e l e n g t h o f t i m e . 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 o f f i c e a r e n o t e n o u g h . N u r s e s need t o be i n v o l v e d w i t h t h e s e p a t i e n t s t h r o u g h community f o l l o w u p o r community g r o u p s 1 3 1 t o f a c i l i t a t e t h e 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 . S t u d i e s need t o be c o n d u c t e d u t i l i z i n g community f o l l o w u p f o r t h e s e p a t i e n t s t o d e t e r m i n e 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 n e e d s 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 f r o m t h i s s t u d y r e g a r d i n g p a t i e n t t e a c h i n g . Does p a t i e n t t e a c h i n g d e v e l o p c o p i n g b e h a v i o u r s t o meet b a s i c human n e e d s ? When i s t h e most e f f e c t i v e t i m e f o r t e a c h i n g ? What s h o u l d be t a u g h t ? R a t h e r t h a n 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 o f 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 t h e 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 meet t h e i r b a s i c human n e e d s t h r o u g h t h e 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 . 132 Summary T h i s s t u d y was d e s i g n e d t o e x a m i n e t h e c o p i n g b e h a v i o u r s t h a t i n d i v i d u a l s use t o meet 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 l i t a t i o n f o l l o w i n g an MI. The f i n d i n g s o f t h e s t u d y r e v e a l e d t h a t MI p a t i e n t s u s e d c o p i n g b e h a v i o u r s t h a t were c a t e g o r i z e d u s i n g t h r e e e m e r g i n g t h e m e s . 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 i s k r e d u c t i o n , g e t t i n g back t o n ormal and r e a c h i n g a new n o rmal were d e s c r i b e d and d i s c u s s e d . The f i n d i n g s may 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 i n d i v i d u a l s i n d e v e l o p i n g and u s i n g 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 meet t h e i r b a s i c human n e e d s d u r i n g MI r e h a b i 1 i t a t i o n . 133 BIBLIOGRAPHY A m e r i c a n P s y c h o l o g i c a l A s s o c i a t i o n . ( 1 9 8 3 ) . Manual  o f t h e A m e r i c a n 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 . e d . ) . A n d r e o l i , K., Fowkes, V., Z i p e s , D., W a l l a c e , A . ( E d s . ) . ( 1 9 8 3 ) . C o m p r e h e n s i v e c a r d i a c c a r e . ( 5 t h e d . ) . S t . L o u i s i C. V. Mosby Company. A p p l e y , M & T r u m b u l l , R. ( 1 9 6 7 ) . P s y c h o l o g i c a l  s t r e s s . 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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 : C o l u m b i a U n i v e r s i t y P r e s s . P i n n e o , R o s e . ( 1 9 8 4 ) . L i v i n g w i t h c o r o n a r y a r t e r y d i s e a s e : 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 , N a t h a n . ( 1 9 7 9 ) . The P r i t i k i n p r o g r a m f o r  d i e t and e x e r c i s e . New Y o r k : G r o s s e t & D u n l o p . R e e d e r , L. G. ( 1 9 6 5 ) . Employment 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. ( 1 9 8 3 ) . P s y c h o s o c i a l p r o b l e m s i n c o n g e s t i v e h e a r t f a i l u r e : H e a l t h c a r e i m p l i c a t i o n s . In C. R. M i c h a e l s o n . C o n g e s t i v e  h e a r t f a i l u r e . ( p p . 378-399) T o r o n t o : C. V. Mosby. R o b e r t s , S h a r o n . ( 1 9 7 6 ) . B e h a v i o u r a l c o n c e p t s and  t h e c r i t i c a l l y i l l p a t i e n t . E n g l e w o o d C I i f f s : P r e n t i c e - H a l 1 I n c . Rosenbaum, F. F., & B e l k n a p , E. L. ( E d s . ) . ( 1 9 5 9 ) Work and t h e h e a r t . New Y o r k : H a c k e r . 138 R o s k i e s , E . , & L a z a r u s , R. ( 1 9 8 0 ) . C o p i n g t h e o r y and t h e t e a c h i n g o f 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 :  C h a n g i n g h e a l t h l i f e s t y l e s . New Y o r k : B r u n e r & M a z e l . S c a l z i , C.C. ( 1 9 7 3 ) . 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 i n f a r c t i o n . H e a r t & L u n g , 2, 62. S c a l z i , C.C. ( 1 9 8 2 ) . 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. 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 8 2 - 5 9 2 ) . 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 c a l z i , C . C , & B u r k e , L . E . ( 1 9 8 2 ) . M y o c a r d i a l i n f a r c t i o n : B e h a v i o u r a l r e s p o n s e s o f p a t i e n t and s p o u s e . 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 . 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 h a f f e r , M. ( 1 9 8 2 ) . L i f e a f t e r s t r e s s . New Y o r k : Plenum P r e s s . S i e w i c k i , B., & M a n s f i e l d , L. ( 1 9 7 7 ) . D e t e r m i n i n g r e a d i n e s s t o resume 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. ( 1 9 8 2 ) . P a t h o p h y s i o l o g y o f m y o c a r d i a l 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 . ) , 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 o l o f f , P., & B a r t e l , A. ( 1 9 7 9 ) . 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 r e h a b i l i t a t i o n . J . o f C h r o n i c D i s e a s e , 32, 3 0 7 - 3 1 3 . S t a m l e r , J . ( 1 9 7 8 ) . L i f e s t y l e s , m a j o r 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 on, 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. ( 1 9 7 7 ) . L i f e a d j u s t m e n t p o s t m y o c a r d i a l i n f a r c t i o n . A r c h i v e s o f  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 o f 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 , R u t h . ( 1 9 7 7 ) . R e h a b i l i t a t i v e a s p e c t s o f  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., Cook, W., & F i t c h , E. ( 1 9 6 4 ) . S e x u a l b e h a v i o u r i n 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. J . C a r d i o l o g y , 13, 140. UBC S c h o o l o f N u r s i n g . ( 1 9 8 0 ) . UBC Model f o r N u r s i n g . V a n c o u v e r : U n i v e r s i t y o f B r i t i s h C o l u m b i 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 ( E d s . ) . ( 1 9 8 3 ) . C a r d i a c n u r s i n g . 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. ( 1 9 8 1 ) . N u r s i n g r e s e a r c h  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 . Weisman, A. ( 1 9 7 9 ) . C o p i n g w i t h c a n c e r . New Y o r k : M c G r a w - H i l l , p. 27. Wenger, N. ( 1 9 7 6 ) . 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 o  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 Y o r k S p r i n g e r - V e r l a g . W h e e l e r , E. 0., & S h e e h a n , D. V. ( 1 9 7 8 ) . E m o t i o n a l 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 symptoms. 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., & Cassem, N. H. ( 1 9 7 1 ) P s y c h o l o g i c a l h a z a r d s o f c o n v a l e s c e n c e f o l l o w i n g m y o c a r d i a l i n f a r c t i o n . JAMA, 215, 8, 1292-1296. 140 A p p e n d i x A S u b s y s t e m s , N e e d s , and G o a l s S u b s y s t e m Need Go a l Ac h i e v i ng A f f e c t i ve E g o - v a l u a t i ve E x c r e t o r y I n g e s t i ve P r o t e c t i ve R e p a r a t i ve R e s p i r a t o r y S a t i a t i ve F o r m a s t e r y 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 F o r r e s p e c t o f s e l f by s e l f and o t h e r s F o r c o l l e c t i o n and r e m o v a l o f a c c u m u l a t e d w a s t e s F o r i n t a k e o f f o o d and f l u i d ; n o u r i shment F o r s a f e t y and s e c u r i t y F o r 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 o f e n e r g y F o r i n t a k e o f o x y g e n F o r s t i m u l a t i o n o f t h e s y s t e m 1 s s e n s e s F e e l i n g s o f a c c o m p l i shment; s a t i s f a c t i o n w i t h a c c o m p l i shments F e e l i n g s o f 1 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 S e l f - e s t e e m A b s e n c e o f a c c u m u l a t e d w a s t e s N o u r i shment; s a t i s f a c t i o n o f h u n g e r and t h i r s t I n t e g r i t y o f t h e s y s t e m C a p a c i t y a c t i v i t y f o r O x y g e n a t i o n ; e a s y r e s p i r a t i ons S e n s o r y s a t i s f a c t i on 142 APPENDIX C CONSENT FORM I, , a g r e e t o 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 REHABILITATION" b e i n g c o n d u c t e d by Lynn 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 c h a n g e s t h a t i n d i v i d u a l s have 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 and 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 and 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 n u r s i n g c a r e . S i g n e d : Wi t n e s s e d : D a t e : 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 have y o u done t o meet y o u r b a s i c n e e d s ? 3. What c h a n g e s have y o u made i n y o u r l i f e s t y l e ? 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? APPENDIX E D a t a C o l l e c t i o n T o o l D e m o g r a p h i c D a t a D a t e Name Age M a r i t a l S t a t u s O c c u p a t i o n D a t e o f MI A d d i t i o n a l P r o b l e m s C a r d i o l o g i s t I n t e r v i e w D a t a O b s e r v a b l e D a t a 

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