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Relationships between appraisal and coping strategies used over time by myocardial infarction patients Béchard, Pâquerette 1988

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RELATIONSHIPS  BETWEEN APPRAISAL AND COPING  STRATEGIES USED OVER TIME BY MYOCARDIAL PATIENTS  INFARCTION  By LIEUTENANT  COMMANDER  PAQUERETTE BECHARD B.Sc.N., The U n i v e r s i t y  o f O t t a w a , 1977  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i  in THE FACULTY The  We a c c e p t to  OF GRADUATE  School  this  STUDIES  of Nursing  thesis  the required  as  conforming  standard  THE UNIVERSITY OF BRITISH COLUMBIA A u g u s t 1988 ©  Paquerette  Bechard,  1988  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives.  It is understood that copying or  publication of this thesis for financial gain shall not be allowed without my written permission.  Department of  NOfcSfMXr  The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date  DE-6(3/81)  ii.  ABSTRACT This was of  descriptive  designed  c o r r e l a t i o n a l and l o n g i t u d i n a l  to assess  the changes  e m o t i o n s and c o p i n g  infarction  strategies  (Ml) p a t i e n t s  the v a r i a b l e s  e m o t i o n s were  investigated  first  patients  (CCU) o f f o u r completed Coping  was  selected  hospitals  appraisal  relationships to  sample  o f 21  Scale,  appraisal  types  benefit.  Challenge  e m o t i o n s were t h e most  of t h r e a t ,  interviews.  e m o t i o n s were t h e l e a s t  frequent  harm e m o t i o n s were t h e l e a s t period.  While  c h a n g e s were threat,  found  i n the four  nature  in early  Initially-,  benefit  type,  while  a t the second significant  emotion a p p r a i s a l s over  time.  reflects  o f t h e MI s i t u a t i o n  phases  frequent  c h a n g e s , no  and b e n e f i t  Ways o f  a wide r a n g e o f  appraisal  of emotions e x p e r i e n c e d  multifacated  units  harm, c h a l l e n g e and  frequent  indicated  harm, c h a l l e n g e  complexity  patients  results  care  sheet.  experienced  four  at both  confirmed  the Revised  a s an i n f o r m a t i o n  the p a r t i c i p a n t s  type  of  i n w e s t e r n Canada. P a r t i c i p a n t s  c h e c k l i s t as w e l l  appraisal  i n time.  from c o r o n a r y  the Emotion A p p r a i s a l  Overall, the  for their  appraisal  myocardial  of c o g n i t i v e  s t r a t e g i e s . A convenience MI  which  u s e d a t two p o i n t s  Additionally,  coping  in cognitive  study  of r e c o v e r y .  of  The  the  influencing  Hi .  The  participants  which are coping  related  strategies positive coping  used  responsibility  used  types  that  coping  MI  crisis  require  found  with  the  a combination initial  with  problem-solving challenge  were f o u n d coping:  of  and  accepting  were t h e  least  a t both  findings  suggest  times.  of c o p i n g  The  i s a complex p r o c e s s .  p a t i e n t s with  multiple tasks  with  coping.  between b e n e f i t  and  p e r i o d , o n l y two  significant  positively  planful  Similarly, social  Significant  social  was  problem-solving  seeking  e m o t i o n s and  seeking  which  relationship  planful  confrontive coping.  reappraisal  The  strategies.  period, a significant  c o n f r o n t i v e and  second  types  confrontive coping  emotions c o r r e l a t e d  positive  The  of  accepting responsibility, and  of c o p i n g .  while  Harm e m o t i o n s were s i g n i f i c a n t l y  correlated  the  used,  the  d i s t a n c i n g and  problem-solving  a c a r d i a c event  present  types  strategies  were m o d e r a t e l y and  Most o f  most p r e d o m i n a n t  between t h r e a t e m o t i o n s and  coping.  and  planful  strategies  problem-focused  MI.  support,  were t h e  of c o p i n g  At the  social  i n t e r v i e w s . The  escape-avoidance  and  a l l eight available  reappraisal  self-controlling,  of c o p i n g  demands o f t h e i r  of s e e k i n g  a t both  a variety  to emotion-focused  t o manage t h e  participants  used  two  support  relationships forms  support  of  coping.  correlations  At  were  iv.  found: b e n e f i t  emotions s i g n i f i c a n t l y  self-controlling The as  findings  accepting  suggest  moderately s t r e s s f u l  phases of  recovery.  understanding of  and  of  harm, t h r e a t ,  turn  influence  The  the  the  that  a  heart  first  MI  patients'  contextual  choice  and of  with  responsibility.  by  benefit  correlated  MI  patients  is In  perception  factors  challenge coping  attack  affect  appraised early or  appraisal  emotions which  strategies.  in  T A B L E OF  CONTENTS Page  Abstract Table  i i  of Contents  v  List  of Tables  v i i i  List  of Figures  i x  Acknowledgements  x  CHAPTER  INTRODUCTION  1  t o the Problem  1  ONE  Background  Statement of t h e Problem Purpose of t h i s Study T h e o r e t i c a l Framework Hypotheses D e f i n i t i o n o f Terms Assumptions Limitations Overview of the Thesis Content  3 4 4 10 10 12 12 12  CHAPTER  14  TWO  REVIEW  OF S E L E C T E D L I T E R A T U R E  Introduction. Cognitive  14  Appraisal  Patients'  14  Appraisal  of I l l n e s s  Harm/loss Challenge Gain/benefit Threat Patients'  Appraisal  16 17 17 18 of Myocardial  Infarction Coping  15  21  Strategies Coping With  S t r e s s f u l Encounters  28 28  Coping  Myocardial  29  With  Infarction  vi Coping  as a Process Changes  i n Emotions  Relationship and  37  Coping  and Coping  Strategies..  Between C o g n i t i v e  37  Appraisal  Strategies  41  Summary  47  CHAPTER THREE  METHODOLOGY  53  Sample  53  Setting  54  Human R i g h t s  and E t h i c a l C o n s i d e r a t i o n s  54  Data  C o l l e c t i o n Procedure  55  Data  C o l l e c t i o n Instruments  56  Emotion The  Scale  R e v i s e d W a y s o£ C o p i n g  Patient Data  Appraisal Information  57 Scale  Sheet  Analysis  C H A P T E R FOUR  58 63 63  P R E S E N T A T I O N AND  D I S C U S S I O N OF  RESULTS Characteristics  64  o f t h e Sample  64  Demographic C h a r a c t e r i s t i c s o f t h e Sample Age, M a r i t a l , E d u c a t i o n a l and Occupational Status  64  Illness-Related  66  C h a r a c t e r i s t i c s . o f t h e Sample  Findings Hypothesis Hypothesis  One: C h a n g e s Two: C h a n g e s  i n Emotions i n Coping  Strategies H y p o t h e s i s Three: R e l a t i o n s h i p s Between C o g n i t i v e A p p r a i s a l and Coping S t r a t e g i e s . . Discussion of Results Characteristics Changes Changes  i n Emotions i n Coping Strategies  Relationships Appraisal Summary  o f t h e Sample  Between  and Coping  64 70 70 73 77 80 81 81 96  Cognitive Strategies  104 115  vii CHAPTER  FIVE  SUMMARY, C O N C L U S I O N S , AND RECOMMENDATIONS  IMPLICATIONS 121  Summary  121  Conclusions  129  Implications  131  Recommendatios  f o r Further  Research  134  REFERENCES  137  APPENDICES  141  Appendix  A: E m o t i o n  Appraisal Scale  Appendix  B: T h e R e v i s e d  Ways  of  Coping  Scale  143  Appendix  C: P a t i e n t I n - H o s p i t a l  Appendix  D: P a t i e n t A t - H o m e  Information  Sheet  149 Information  Sheet Appendix  141  E: I n f o r m a t i o n - C o n s e n t L e t t e r . . . .  151 153  viii LIST  OF  TABLES  Table  Page  I.  Age o f t h e S a m p l e  II.  Occupational  III.  Number  IV.  Symptoms R e p o r t e d the  V.  VI.  VIII.  Between t h e F i f t h  Appraisal  and  Weeks P o s t  Types and  MI....  68  Changes 71  Appraisal  and the Seventh  Between  Days and  Eight  MI....  Strategies  72 Types and Changes  Time  74-75  Changes i n Coping S t r a t e g i e s Between t h e F i f t h and t h e S e v e n t h Days and E i g h t Weeks P o s t  IX.  67  i n Cognitive  Fifth  coping Over  66  Time  Weeks P o s t VII.  o f t h e Sample  Seven Days and E i g h t  Changes the  Status  o f Symptoms  Cognitive Over  65  MI  Relationships  78 Between C o g n i t i v e  and  Coping  and  the Seventh  Post  MI  Strategies Days  Appraisal  Between t h e F i f t h and E i g h t  Weeks 79  ix LIST  OF  FIGURES  Figure 1.  Page C o n c e p t u a l Framework The  Stress,  Theory  Appraisal  (Lazarus  6 and  & Folkman,  Coping 1984).  X  ACKNOWLEDGEMENTS  I would  like  t o express  have h e l p e d me t h r o u g h o u t like  t o thank  Hilton  t h e members o f my t h e s i s  ( c h a i r p e r s o n ) and C a r o l  grateful  f o r the guidance  provided  me t h r o u g h o u t  I would nursing their  my g r a t i t u d e  like  staff  time.  participants I wish  t o extend would  who s h a r e d t o express  my t h a n k s  Finally, Yvonne B e c h a r d  I would  I am v e r y they  have  like  t o t h e h o s p i t a l s and  a n d gave s o g e n e r o u s l y o f t o thank  each  my  studies.  like  t o thank  me.  t o the Canadian  of N a t i o n a l Defence  f o r her support  o f t h e 21  experiences with  my a p p r e c i a t i o n  t o pursue  D r . Ann  research process.  their  Armed F o r c e s , D e p a r t m e n t the p r i v i l e g e  Jillings.  who  I would  committee,  and a s s i s t a n c e  this  who p a r t i c i p a t e d  I also  t o those  the research project.  forgiving  my m o t h e r , Madame  and h e r p r a y e r s .  me  1  CHAPTER  Background Cardiovascular worst  epidemic  close  to half  1986).  al.,  800,000  of a l l deaths  death r i s k  Hartman, 1 9 8 6 ) . self-esteem  1979;  various  heart  Therefore,  infarction  (Gulledge,  (Cassem & H a c k e t t , anger, d e n i a l ,  1971;  Wiklund  Ml  i s often a single  episode,  effects  of t h e i r  may f u r t h e r 1971;  & Cassem,  during  reported  et a l . , 1985).  1971).  psychological  attack  threat to  by p a t i e n t s  a n x i e t y and d e p r e s s i o n  f o r the remainder  Burgess &  changes,  have been  (Cassem & H a c k e t t ,  continue  illness  1986).  responses itself  1979;  Hackett  & Hartman,  of recovery  i n 1979  many  lifestyle  reactions experienced  stages  about  (MI) a s s o c i a t e d w i t h a  (Wishnie,  Burgess  (Nicholls et  a sudden  arouses  Additionally,  was  that  problems  and f e a r o f r e c u r r i n g h e a r t  Emotional the  i t i s estimated  reactions  the i n d i v i d u a l  Gulledge,  disease,  of a l l deaths  understandably  emotional-stress  stress  heart  Canadians experienced  such as a m y o c a r d i a l  and i n 1 9 8 2 , i t s  each year,  f o r almost a t h i r d  Canada, 1 9 8 5 ) .  as the  Canadians, accounting f o r  ischemic  Furthermore,  (Statistics  high  has been d e s c r i b e d  to strike  major sub-component, responsible  t o the Problem  disease  ever  ONE  Disbelief,  c o n s t i t u t e normal  Although  the event  of  I n d i v i d u a l s must lives  t o adapt  o f t h e MI. " R e c o v e r y f r o m a  to the  2 myocardial (Burish  infarction  & Bradley,  physically  i s more t h a n  1 9 8 3 , p. 8 5 ) . P a t i e n t s  and p s y c h o l o g i c a l l y  aspects  of their  leaving  t h e h o s p i t a l have  complete  just a medical  i n order  must  e f f e c t s of t h e i r  illness"  adjust  t o cope w i t h a l l  s i t u a t i o n s , a n d "many s u c h yet to feel  problem"  patients  after  and comprehend t h e  (Gulledge,  1 9 7 9 , p.  114) . Psychological recovery Hackett  following a myocardial & Cassem,  researchers  disturbances  that  other  reactions,  than  attack  that  many p a t i e n t s  physiologically  from  their  event.  A high  reported al.,  (Wishnie,  1984).  emotional  Based  and t h a t  without  symptoms t o w a r r a n t  such  Cohen and L a z a r u s play  a major  individual  role  sufficient a state  appraises  an event  with the has been et  concluded  that  o f a MI d o n o t a l w a y s become  cardiac  cardiac  damage o r  of i n v a l i d i s m .  (1979) s t a t e  i n emotions  later  1971 ; Wiklund  f i n d i n g s , they  s o m e MI p a t i e n t s  often  infarction  and depression  & Cassem,  They  recover  associated  of anxiety  on t h e i r  temporary  emotional  who  myocardial  stresses  Hackett  These  the expected  d i s t r e s s and s e r i o u s n e s s  correlate, cripples  incidence  (Wishnie,  are considerable.  explain  succumb t o p s y c h o l o g i c a l  longterm  e t a l . , 1984).  long-lasting  a f t e r a heart  to  infarction  1971; Wiklund  remark  psychological  further  distress i s destructive  that  and coping. influences  cognitive  factors  The way a n coping  and t h e  3 emotional  and  experience and  situations or  angry  ways of  coping.  a  as  recovery  period  According between s t r e s s understood, coping  a  fail  represents the  illness  "despite the factor  coping  the  individual's  strategies  severe  used  illnesses  found  a p p r a i s a l s and  coping was  no  stressful  why  their  1979).  importance  i s known a b o u t  relation  that  is  attributed  somatic  health  actual  coping  processes"  which  comprehensively  coping  strategies  in  M l - l i n k e d research showing  strategies  over  is  explain  i n p s y c h o l o g i c a l and  are  related,  and  how  MI how each  found.  individual,  and  does  anxious, the  poorly  time  a  so  & Lazarus,  coping  Furthermore,  the  As  In a d j u s t i n g d u r i n g  Statement For  progresses.  i s c o m p l e x and  emotion  over  feel  i n f o r m a t i o n may  s t u d i e s were  and  p a t i e n t may  and  No  change  or  Lazarus  stressful  the  (p.  appraisals  the  in  to  et a l . (1986),  little  patients.  changes,  stressful  to Folkman  outcomes, 992).  situation  Such  (Cohen  and  as  A  the  According  experienced  s t r e s s e s of  important. succeed  1979).  change.  Assessing  patients  assessed  the  situation  t o manage t h e  therefore  emotions  continually  of  to  & Lazarus,  (1984),  meaning  time  behavioral reactions to  (Cohen  Folkman  guilty  the  of a  the  Problem  myocardial  event  beginning  continuing throughout  infarction with the  the  onset  recovery  of  period.  To  manage  the  strategies nature used was  of  by  the  based the  on  of  patients  which  has  diagnosed  with  how  and  strategies and  eight  by  weeks  relationships strategies  of  this  compare  used  Lazarus (see to  and  the  MI  later;  study  Folkman's 1).  In  person  the in  and  acute  to  patients  study  cognitive  patients and  first,  appraisal  between the  second,  to  and  and  to coping  early  examine  appraisal  MI  period  the coping  the  used  (1984) t h e o r y model,  cognitive and  Framework  the  and  required  of  processes  a  will  be  and  coping  appraisal  refers  which  mediate  i n any  situation.  s i t u a t i o n and  involved,  manage t h e  study  stress  environment  challenges to  in this  cognitive  i n d i v i d u a l evaluates  threats  resources  from  i s twofold:  between c o g n i t i v e  evaluative  i s , the  harms,  research  between a p p r a i s a l  change  this  t h e o r e t i c a l framework  between the That  strategies  H o w e v e r , no  link  The  used.  Figure  the  situation.  rehabilitation,  Theoretical The  the  coping  MI.  purpose  describe  use  coping  clear.  they  of  of  the  the  P u r p o s e of The  patients  made o r  studied  phases  a  MI,  i s not  s t r a t e g i e s , and  convalescent  a  their appraisal  appraisals  these  found  coping  stresses  as  well  defines  as  demands. A p p r a i s a l s  the give  5 rise  to thoughts  and a c t i o n s .  The way a n i n d i v i d u a l  appraises  a s i t u a t i o n i s the basis  emotional  reactions  theory to  views  help  coping  people  and coping  s i t u a t i o n changes.  as a process  deal  with  f o r understanding  with  t h e demands  multiple of  This  functions  stressful  encounters. Cognitive  Appraisal  According situation and  to Lazarus  means  behavioral  defined  t o an  and Folkman  (1984),  i n d i v i d u a l determines  what  the emotional  responses.  Cognitive  appraisal  may  as the e v a l u a t i v e  cognitive  processes  that  between t h e s i t u a t i o n and t h e f a c t o r s w i t h i n Cognitive evaluate shape  appraisal  responses  Person-factors situation-factors predictability,  theory the  such  environmental  be mediate  the person.  individuals to to their  well-being  encounter.  as n o v e l t y ,  uncertainty  perceptions  (1984) s t r e s s  and  and  appraisals.  appraisal  and  coping  t h e r e l a t i o n s h i p between t h e person and takes  into account  the  of an i n d i v i d u a l as w e l l  situation.  Psychological  relevant  that  i s appraised  to his/her  well-being  and  specific  as the  stress  i s defined  " t h e r e l a t i o n s h i p between t h e i n d i v i d u a l and t h e  environment  and  as b e l i e f s and commitments, and  influence  emphasizes  environment,  t o any  such  and Folkman's  characteristics  as  allow  the s i t u a t i o n ' s relevance  their  Lazarus  processes  a  by t h e i n d i v i d u a l as and i n which t h e  6  PERSON  ENVIRONMENT I  Commitments Beliefs  MI Reappraisal Hospital  COGNITIVE  Home  APPRAISAL  Primary Appraisal (what i s a t s t a k e )  Irrelevant  Outcomes  BenignPositive  Stressful  Coping  Harm/loss  Challenge  Strategies  Threat  Secondary A p p r a i s a l (coping options)  r  C O P I N G P R O C E S S OVER T I M E Cognitive Appraisal  Reappraisal t  Coping  Strategies  Outcome  F i g u r e 1. T h e o r e t i c a l F r a m e w o r k f o r A p p r a i s a l a n d C o p i n g Strategies. Note. Adapted w i t h p e r m i s s i o n from Coping with the U n c e r t a i n t i e s of B r e a s t C a n c e r : A p p r a i s a l and C o p i n g S t r a t e g i e s (p. 7 ) , by B.A. H i l t o n , 1 9 8 7 . A n n A r b o r , M I : U n i v e r s i t y M i c r o f i l m s I n t e r n a t i o n a l , No. 8 7 - 0 0 , 2 0 5 .  7 individual's Lazarus  and  resources Folkman  processes:  appraisal  and  of  the  three  the  of  to  irrelevant.  Second,  that  (p.  a  the  person  not  judges  relate  when a  to  an  Individual's  has  the  already  a n t i c i p a t e s harm  or  l o s s e s . With  the  individual  perceives  a  to can of  cope w i t h be  done  success.  coping  to  consequences  of  new  or  of  this  process,  evaluates The  prevent  are  of  available,  using  such  r e f e r s to  i n f o r m a t i o n or  one.  the  harm,  threat, challenge, gain.  through  secondary  resources  required  individual  but  In  potential  Individual determines  Reappraisal basis  gain  encounter.  succeed,  The  options  a  individual  the  loved  third recognized  individual  the  a  potential  S t r e s s - a p p r a i s a l s such  the  appraisal,  or  have  damage s u s t a i n e d  part  self  as  as  represent  individual  use  situation  situation  seems t o  challenge  relevance  p e r s o n may  the  second  to  which  well-being.  t h r e a t and the  that  the  Individual appraises  situation  In harm/loss,  the  three  a p p r a i s a l , secondary  perceives  for personal  harm/loss,  In  19).  a p p r a i s a l has  w e l l - b e i n g . The  does  person  benign-positive  kind.  exceeded"  appraisal. First,  environment the  as  his/her  primary  well-being,  advantages  primary  a p p r a i s a l , the  situation  within  or  reappraisal.  primary  kinds  taxed  (1984) c l a i m  cognitive  In  are  or  assesses  improve  not  only  a l s o what  what  chances  which  the  potential  strategies are. a  modified feedback  a p p r a i s a l on from  the  the  environment  8 and/or  the person.  appraisal both  The r e a p p r a i s a l  i n t h e same  the assessment  choices  example,  adequate degree  On t h e o t h e r  the s i t u a t i o n . Although  precedes  secondary  appraisal,  "constantly  their  relationship  to  usually  i s not  of the s i t u a t i o n . Coping changing  cognitive  as t a x i n g  are e f f o r t s the person appraisal,  to  the meaning  change  originate  conscious  1984,  i n order  as efforts to  p . 141). generates  to modify  are  Coping as a r e s u l t of  the environment  i n t e r n a l l y or e x t e r n a l l y , Lazarus  that  the resources of the  o f t h e s i t u a t i o n . These  or unconscious.  the  t o manage  i n t e r n a l demands  or exceeding  cognitive  i s defined  and b e h a v i o r a l  and/or  (Lazarus & Folkman,  strategies  appraisals,  particular coping strategies  specific external  appraised  efforts  i n s i g n i f i c a n t may  sequential.  selects  demands  person"  a  primary appraisal  on t h e p r i m a r y and s e c o n d a r y  individual  manage  hand,  Strategies  Based  the  as  i f coping resources are inadequate  overcome  Coping  are interdependent.  by an i n d i v i d u a l as  threatening  to  of a s t r e s s f u l s i t u a t i o n , the  i s decreased.  regarded  earlier  outcomes.  i f the coping resources are judged  of threat  necessarily  an  or r e s o u r c e s and the  appraisals  t o meet t h e demands  situation become  threat,  and a n t i c i p a t e d  P r i m a r y and secondary For  change  situation. Reappraisal refers  o f harm,  of actions  may  coping  a n d may  and Folkman  (1984)  be  or  9 further  suggest  functions. threat  that coping  Problem-focused  Itself,  environment  or  or  by  the  Coping  attempt  a  Coping three with  and  Third, this  person's  thoughts  evolves.  As  the  efforts  and  at  points  essence unless  i n time. of  the  we  stress, focus  on  the  and  new  distress,  the  According and  in stressful coping,  and  change,  we  concerned does.  in a  Second,  particular  changes  stressful  the  person  in a  encounter appraises  accordingly adjusts  to examine cognitive  myocardial  nature  is  with  the  demands.  i s designed  by  coping  t h i n k s or  changes,  between  used  strategies of  caused  i s a process  c o n s i d e r s the  situation,  study  strategies  coping  a  emotions  i s examined  a c t i o n s as  relationships  study  does  t o meet t h e  present  First,  approach  situation  coping  (1985),  the  serve  emotional  manner  actually  t h i n k s or  r e a p p r a i s e s the  two  in  the  function.  in this  Individual  context.  the  deal with  coping  stressful  r e g u l a t e the  when v i e w e d  what the  The  strategies  major  Process  person  and  with  main c h a r a c t e r i s t i c s .  coping  two  strategies  Emotion-focused  palliative  what the  and  to  serve  obstacles present  to deal  serving a as  the  function.  situation  thereby  coping  i n o n e s e l f . These  problem-solving strategies  with  strategies  the  appraisal  Infarction  t o F o l k m a n and content  of  changes and  patients Lazarus  individuals'  situations  is crucial.  adaptation  i s change...and  cannot  learn  how  people  "The  come  t o manage s t r e s s f u l  events  and  conditions"  150).  (p.  Hypotheses 1.  There  patients points post  diagnosed  i n time,  MI  and  2.  and  3.  and  weeks a f t e r t h e  MI.  and  process  between t h e  and  weeks a f t e r t h e  MI.  strategies that  of r e c o v e r y  from  the  infarction:  h e a r t muscle  (Miller  Cognitive mediate its  which  of blood  & Keane,  necrosis  1987)  appraisal: cognitive  between t h e  Primary  1984)  two days  cognitive use  during  infarction.  cells  o f an  area  of  as a r e s u l t of  i s caused  by  i t s coronary  the arteries  .  person  and  s i g n i f i c a n c e f o r a person's  Folkman,  of the  from  by  Terms  in turn  supply  days  seventh  patients  (myocardium) o c c u r r i n g  oxygen d e p r i v a t i o n , obstruction  the  at  by  two  seventh  a myocardial  of  used  s t r a t e g i e s used  i s a r e l a t i o n s h i p between  coping  at  infarction  fifth  Definitions Myocardial  the  in coping  with myocardial  appraisal  infarction  fifth  i s a change  eight  There  appraisal the  with myocardial  diagnosed  points, i n time,  in cognitive  between t h e  eight  There  patients  p o s t MI  i s a change  evaluative the  processes  which  s i t u a t i o n i n terms  well-being  (Lazarus  of  &  .  appraisal: cognitive  processes  i n which the  person  evaluates or  whether  stressful  appraisal  by  anticipated potential  taxed  well  or future  that  t o manage  demands  that  Folkman  specific  those  encounter.  the person  and the as r e l e v a n t  the person's 1984).  cognitive  external  and  and/or  behavioral  internal  or exceeding the  coping efforts or external  by a s t r e s s f u l  forms  stress,  appraisal  that  1984). originate  environment  event  t o meet  (Lazarus &  and c o p i n g t h e o r y  of coping: problem-focused  and  identifies  emotion-focused  coping. Problem-focused  to  resources are  (Lazarus & Folkman,  internal  imposed  to  1984).  The two  between  a r e a p p r a i s e d as t a x i n g  the person's  refers  concerns  i n h e r e n t i n an  changing  of the person  demands  are characterized  Harm/loss  (Lazarus & Folkman,  efforts  the  of an encounter i s  appraisals  b e i n g and i n which  the constantly  from  in a  i s a p p r a i s e d by the person  Strategies;  no  harm; c h a l l e n g e f o c u s e s on t h e  Coping:  Coping  irrelevant  carries  has a l r e a d y o c c u r r e d ; t h r e a t  or exceeded  resources  which  t h e outcomes  f o r g a i n or growth  environment  benign-positive,  An  well-being;  stress  the relationship  his/her  1984).  c h a l l e n g e , or harm/loss.  that  Stress:  appraisal  as p o s i t i v e ;  threat,  damage  t o an encounter  t o the person's  benign-positive construed  Is irrelevant,  (Lazarus & Folkman,  refers  implication  an event  coping strategies  deal  with the  threat  itself,  environment  or w i t h the o b s t a c l e s  or  in oneself.  problem-solving  stressful  regulate  strategies  coping strategies  emotions  caused  attempt  to  by t h e s i t u a t i o n ,  the emotional d i s t r e s s ,  palliative  serve a  function.  Emotion-focused with  These  p r e s e n t i n the  and  deal and  thus serve a  function.  Assumption. 1.  There  a r e no  good  o r bad,  right  or wrong ways o f  coping. 2.  The  emotions  participants  perceived  3.  The  and  will  be  able  coping strategies  participants  will  respond  to i d e n t i f y  the  used. h o n e s t l y to the  questionnaire.  Limitations Generalizations applied of the  from t h i s  t o other groups  cardiac  patients  convenience  One  of p a t i e n t s  because  thesis  study.  i s comprised  framework and  In Chapter  Two,  cannot  to other  sample s i z e  and  used.  of f i v e  c h a p t e r s . Chapter  to the problem,  outlines  selected  explains  the purpose  literature  of  be  groups  of the T h e s i s Content  reviews the background  conceptual  and/or  of the s m a l l  sampling technique  Overview This  study's findings  the  the  i s reviewed  under  three  strategies describes  headings:  cognitive  appraisal,  and c o p i n g as a p r o c e s s . the  description instruments, procedures.  constitutes  the  data  collection  and t h e  the  Three  including  a  sampling procedures d e s i g n ,  The d e s c r i p t i o n  data analysis  Chapter  research methodology,  of  coping  methods of  the  d i s c u s s i o n of  fourth chapter.  The  and  statistical  sample, the  results  of  the  findings  final  chapter  presents  a summary o f  the  s t u d y and c o n c l u s i o n s and a d i s c u s s i o n on  implications  for  n u r s i n g and r e c o m m e n d a t i o n s  research.  for  future  CHAPTER  Review  TWO  of Selected  Literature  introduction  The  review  sections.  of literature  The f i r s t  section  literature  and research  harm/loss,  challenge,  section  focuses  examines  coping  appraisals  presents  gain/benefit,  and coping  appraisal  According appraisal threats the  i st o evaluate  required  t h e environment.  individual  judges  benign-positive appraisal  experiences  depends  The  stakes  involve  self-esteem,  goal  over  i n emotion  as well  and Folkman  challenge  Through  time  as r e l a t i o n s h i p s  are discussed.  (1984),  i n terms  or benefit,  primary  Three  threat  t h edegree  on what concerns  a t work  theaim of o f harms, as well as  and/or t o  a p p r a i s a l , an  a situation i sirrelevant,  e x i s t : harm/loss, that  section  Appraisal  or stressful.  state  The f i n a l  t o t o l e r a t e , minimize  whether  researchers  The s e c o n d  t h e encounter  and i t s p o t e n t i a l  resources  master  t o Lazarus  and threat.  and coping  Cognitive  of  related to  Changes  strategies,  three  of illness  strategies.  as a process.  into  a discussion  on a p p r a i s a l  on c o p i n g  between c o g n i t i v e  i sd i v i d e d  forms  of stressful  and challenge. of stress  i sa t stake or threats  a  These  person  i na s i t u a t i o n . related to  o r harm t o one's w e l l - b e i n g .  I f  15  the s i t u a t i o n seems to have r e l e v a n c e well-being, that  the  done harm, or has  Lazarus  p o t e n t i a l for  of I l l n e s s  ( 1 9 8 4 ) s t a t e s t h a t p a t i e n t s view or  illness  i n s e v e r a l ways. The  or a p p r a i s a l of the s i g n i f i c a n c e of an  Illness.  i n d i v i d u a l meaning  I n d i v i d u a l meaning or  i l l n e s s s t r o n g l y i n f l u e n c e s both  p a t i e n t ' s emotional response and  the coping  the  strategies  a t d e a l i n g with the demands of the  (Llpowski,  appraise  degree of s t r e s s a  p a t i e n t e x p e r i e n c e s s t r o n g l y depends on  which aim  illness  1 9 7 0 - 1 9 7 1 ; L a z a r u s , 1 9 8 4 ) . These authors  b e l i e v e t h a t the s p e c i f i c meaning i n d i v i d u a l s a t t a c h their  i l l n e s s may  be c o n s c i o u s or unconscious, and  i n f l u e n c e d by past categories  e x p e r i e n c e s and  of p e r s o n a l  been d e s c r i b e d  i n the  weakness, a r e l i e f ,  beliefs.  literature.  be  categories  these c a t e g o r i e s  have  g a i n / b e n e f i t s , and  c o i n c i d e with the  by Lazarus and  Folkman  perceived  {Llpowski,  f u r t h e r regrouped i n t o 4 broader  harm/loss, c h a l l e n g e ,  be  an enemy, a l o s s or damage, or  1 9 7 0 - 1 9 7 1 ; Cohen & Lazarus, 1 9 7 9 ) or a t h r e a t  be  may  Several  I l l n e s s may  a punishment, a value  L a z a r u s , 1 9 7 9 ) . Since  to  meaning r e l a t e d to i l l n e s s have  as a s t r a t e g y , a c h a l l e n g e ,  they may  be  challenge.  Patients' Appraisal  their  person's  c o g n i t i v e a p p r a i s a l of emotions w i l l  i t poses t h r e a t s , has  b e n e f i t or  f o r the  (Cohen &  similarities, categories:  threat.  stress appraisals  (1984).  The  identified  H_____. L a z a r u s harm/loss,  damage t o  Harm a p p r a i s a l Monat and past  or  person the to  and  present  individual  (1985) p o i n t  damage c a n n o t  with  harm/loss  readjustments compensate  the  (1984 ) s t a t e  is characterized  Lazarus  copes  Folkman  taking  for  the  by  that  loss,  emotions.  prevented,  appraisal,  and  that  the  same m a n n e r a s  in grief.  accept  occurred.  i n harm  i n much t h e  place  In  already  negative  out be  has  that  The  i t or  person  abandon  in  tries  valued  commitments. Lipowski perceived of  as  (1970-1971) suggests an  destructive  emotional and/or  or  harmful  reactions  anger.  Patients  enemy. P a t i e n t s  who  Illness hold  sign  of  failure  and  humiliated. According  punishment  may  this  and  to  view  i s common a n d  Patients  may  regard  a  for  redemption.  chance  show g r e a t patients  energy,  view  patients their  who  and  i l l n e s s as  an  this  at  their  i l l n e s s as During and  show  signs unjust  of  a  their  a  little  as  feel  a  ashamed  i l l n e s s s e e n as take  several  fair  punishment  recovery,  and  forms. and  However, i f  final,  depression  a  patients  they  resistance.  punishment.  victims  weakness.  disease  initiative. just  as  hostility  T h e y may  v i e w may  i l l n e s s as  display  s e e n as  be  experience  fear,  control.  optimism,  will  T h e y may  (1970-1971),  their  their  become p a s s i v e  look  of  Lipowski  be  i l l n e s s may  themselves  anxiety,  also  loss  view  forces.  s u c h as  that  usually  Emotional  will  Finally, perceive reactions  17 such as anger, a n x i e t y ,  and d e p r e s s i o n  a r e common  reactions. Patients Irreparable patients  may a l s o r e g a r d  l o s s o r damage  even a minor  which the i n d i v i d u a l devastating loss.  held  Illness,  a challenge.  stressful  a form  accompanied  distress.  to deal  would w i t h  with the any other  (1984) p o i n t  out that  of c o n t r o l i n c r i s i s s i t u a t i o n s This  a p p r a i s a l Is  e m o t i o n s . The p a t i e n t  maintains  feels  confident,  t o l e r a t e s p a i n and  Here, c h a l l e n g e  means t h a t  p a t i e n t s can c o n t r o l  Gain/benefit. (Llpowski,  perspective,  perceived  as t h e y  by p l e a s u r a b l e  t h e m s e l v e s and t h e i r  illness  (1970-1971)  (1984) may f r e q u e n t l y be v i e w e d a s  of c h a l l e n g e .  p o s i t i v e outlook,  life  extensive  to Llpowski  e v e n t . L a z a r u s and Folkman  represents  hostile,  & F o l k m a n , 1984, p . 3 2 ) .  according  illness  i n d i v i d u a l ' s sense  f o r the  "The most d a m a g i n g  I l l i n d i v i d u a l s attempt  demands o f t h e i r  one f o r  may be s o  c a n be done t o c o m p e n s a t e  (Lazarus  L a z a r u s and F o l k m a n  this  value,  i n which c e n t r a l and  commitments a r e l o s t "  a  a special  or even s u i c i d a l .  Challenge.  a s an  ( L i p o v s k i , 1 9 7 0 - 1 9 7 1 ) . F o r some  Such p a t i e n t s may be d e p r e s s e d ,  events a r e those  an  illness  l o s s of f u n c t i o n , e s p e c i a l l y  that nothing  non-compliant  and  their  emotions.  S e c o n d a r y b e n e f i t may be o b t a i n e d 1970-1971; L a z a r u s Lipowski  as a r e l i e f ,  states that  a value  & Folkman, illness  or a s t r a t e g y .  from  1984). In  may be  . Some p a t i e n t s welcome their  their  daily  sick  as a r e l i e f .  In i t s extreme  form,  They  may  the stresses illness  may  of reveal  conflicts.  According  illness  illness  r o l e t o g e t away from  lives.  intrapsychic  regarded  regard  t o Lipowski  as a s t r a t e g y . as a technique  (1970-1971)  In this to gain  illnes  may a l s o  way, p a t i e n t s personal  use  benefits  be  their In their  relationships. In  some c a s e s ,  Lipowski  illness  (1970-1971)  in  o u r s o c i e t y where  to  be a v o i d e d  illness  may b e p e r c e i v e d  points  out that  illness  a t any cost.  this  view  has a negative  F o r some p e o p l e  may b e a m e a n s t o g r o w ,  as a  t o enhance  value.  i s uncommon  value  and i s  however, their  personalities. Threat. threat  refers  occurred,  According  to Lazarus  t o harms  or losses  worry and/or a n x i e t y  Based  on p r e s e n t  that  future  cues, harms.  i t Is important  present  harm,  appraisals judgment require  that  have  but are anticipated. Negative  fear,  predicts  and Folkman  characterize  The r e s e a r c h e r s  emotions threat  further  t o d i s t i n g u i s h between  i n their  of past/present d i f f e r e n t coping  Commenting  not yet  Threat  cognitive  harms  versus  such  as  appraisal.  the i n d i v i d u a l recognizes  and a n t i c i p a t e d harm.  differ  (1984),  or explain  past or and  harm  components: t h e p o t e n t i a l harm.  efforts.  on t h e d i f f e r e n t a p p r a i s a l  types  Both  previously  discussed,  threat  be  may  Cohen and  involved  i n each  one,  m e a n i n g s may  help to understand  Depending  the  on  person's  may  increase  or d e c r e a s e .  for  a person  who  perceive On  the  the  illness  contrary,  perceived  sees  as  a  threat  relief  and  threat  appraisal For  of  example,  illness as  Lazarus  as  a  (1979) add  that  that  various  appraisal. the  may  punishment  but  opportunity  may  reduced,  from  social  illness,  threat  giving be  these  for  i f the  demands  threat Increase  does  not  redemption. illness  is  and  obligations. Additionally, is  important  concerns  to understand patients  with  a  specific  emotion.  particular  coping  a  emotional  different  threats  (1979) s t a t e  various  severe  threats  illness.  In t u r n , effort  A  i t  and  threat  this  which  that  emotion  regulates  the  response.  Cohen and  physical  Lazarus  the  of  generates requires  Cohen and  Lazarus  threats illness.  have  that  (1979) have may  occur  They s t a t e  i n the  that  been s y n t h e s i z e d  categorized  these  from  the  the  context  of  categories work  of  of  several  researchers: 1.  Threats  to  2.  Threats  to bodily  the  life  diagnostic  and  fears  of d y i n g  Integrity  procedures,  and or  itself;  comfort  (from  the  medical  and  future  Illness,  treatment  itself); 3.  Threats  t o one's  self-concept  plans;  4.  Threats  to  necessity other  Threats and  6.  t h a t come a b o u t  the  illness.  i s , the  of a n x i e t y , anger, as  a  result  of  and  other  of  customary  social  roles  to  understand  According  quality  of  such  challenge related  emotion  Folkman  and  According  emotions.  or  to  or  aspect the  represents  how  stem  new  physical  harm and not  to  appraisal  and  the  occur  can  stressful  Intensity  of  v a l u e s and  people  well-being.  that threat  on  and  appraisals,  a  are  single  simultaneously. are  complex  and  negative  s i m u l t a n e o u s l y because  situation.  what  and  evaluate  e v a l u a t i v e response  emotions  interpret  way  positive  occur  coping  intensity  to their  illnesses  both  severe  the  benefit  poles  r e p r e s e n t s an  of a  to their  from  cognitive  responses  i s happening  involve  they  of  experienced,  (1984),  These emotions  and  stress,  They a r e  can  concept  emotional  t h e r e f o r e can  and  refers  to adjust to a  (1984) emphasize  to Lazarus  situations  specific  what  appraisals,  continuum,  relation  of  concepts.  the  to the  emotion  significance and  need  (1984) uses  f o r each  Lazarus  the  environment.  theory,  types  fulfillment  involving  social  appraisal  each  feelings  that  activities;  Lazarus  the  equilibrium;  described; to  Threats or  to deal with  emotions  stresses 5.  one's e m o t i o n a l  Therefore,  patients  in  a  the  experience  i s happening  commitments.  to  In explore  their  earlier  cognitive  appraisal  students  preparing  provides  evidence  emotional  about the  extent  emotions  Lazarus the  midterm  assessment,  related On  they  to  and  three  exam  was As  five  days a f t e r  ( o u t c o m e s t a g e ) . The  data  obtained  time  one,  elevated, whereas time  both and  t h r e a t and  each  These  findings  by  be  confirmed  appraisal  emotions  depending  how  Patients'  A p p r a i s a l of M y o c a r d i a l  Literature  can  findings  of  a  study indicate number  were  benefit  days  the  before the  announced were  For  emotions of  of  days a f t e r  reflected  94%  the  completed  two  grades  the  the  announced emotions  example,  at  were students;  were more e l e v a t e d that different  experienced  situation  a to  they  stage.  b e n e f i t emotions  the  each  grades  challenge  were e x p e r i e n c e d  harm and  two.  at  of  stage), five  s t a g e ) , and  experienced  is a  part  Stress Questionnaire:  before  students  shape  s e l e c t e d as  in class  days  the  processes  harm, c h a l l e n g e and  two  (waiting  study  were asked  experienced  (anticipatory  exam and  This  emotion.  study.  occasions  (1985)  among c o l l e g e  that there  students  threat,  & Folkman's  midterm  found  f o r the  to which  appriasals.  They  Lazarus  examination.  college examination  encounter  stress  emotions  that appraisal-related  between a p p r a i s a l  A midterm stressful  of  f o r a midterm  responses.  relationship  s t u d i e s F o l k m a n and  at  types  of  simultaneously,  i s perceived. Infarction  report that a  heart  a t t a c k may  be  perceived threat,  as  an  experience  harm/loss,  Myocardial the  patient and  these  entail  MI  infarction  a l l the  emotional  several  f a c t o r s may  such  the  Burgess patients'  and  itself the  will  shape  person's  revealed  the  psychological indicated as  a  serious  of  a  as  lethal;  with  perceived  a  the  their  one  and  patients'  to  heart  Ml;  82%  the  attacks  almost  of  pain  and  heart  half  patients 31%  attack  of  the  stigma.  be  1975). on  how  researchers the  will  MI  have  for  findings  the  findings  their  feared  patients  associated  with to  These  t h e y were 52%  responses,  study  The  that  influenced  viewed  while  understand  and  a  MI  life.  that  that  (Pranulis,  perceptions  felt  to  b e l i e f s about  patients  and  must remember  crisis.  future  which  health  reactions  meaning  in  commitments  illness  patients'  of  to  attempting  cardiac  whatever  94.4%  63%  severe  In  event  (1986) conducted  their  illness;  further  and  distress. Specifically,  that  susceptible  of  immediate  that  threat  objects  Hartman  that  a  affect their  perceive  hypothesized  stressful  reactions,  perception  for  benefit.  Is a with  valued  carries potential  and  ( G a r r i t y , 1975).  patients'  as  challenge  i s confronted  life,  which  the More  moderately  heart highly the  threat  viewed  heart than to  attack  the  Ml  attack 90%  highly  life-threatening. Cassem and their  earlier  Hackett  studies,  (1973), indicated  reporting that  the  anxiety  findings and  of  depression and  w e r e common a m o n g MI p a t i e n t s  the rehabilitative  selected  a t random  patients  showed  follow-up  signs  o f home v i s i t s  these  researchers  signs  of anxiety  sleep  disturbances,  that  found  that  and/or  145 ( 3 3 % ) r e q u i r e d  Anxiety  and depression Based  (1977) have anxiety  and depression  case  the patient  Scalzi the  attack  anxiety  surveyed  t h e most  suddenly  danger.  During  anxiety  appears  several  emotional  likely  frightened  the first  that  t o be a t i t s peak The p a t i e n t  by t h e threatening  shortness  of breath  imminence  of death.  (1977) p o i n t o u t a fifteen  month  consultation.  frequently  reported  reactions  such as  o f MI  patients.  as a threat.  life  In this  anxiety.  (1977) have  attack  their  few days  percent had  t o work f o r  to experience  When a h e a r t  realize  days.  over  reported  Cassem and H a c k e t t  may b e p e r c e i v e d  reaction.  patients,  to return  seem t o be t y p i c a l  i s more  In another  Fifty-five  (1973) and Cassem and H a c k e t t  patients  next  that  76% o f  80% of t h e p a t i e n t s  on t h e s t u d y d a t a ,  concluded  A heart  t o t w e n t y MI  psychiatric  were  patients  unit,  Cassem and H a c k e t t  period,  the acute  of depression.  and 38% f a i l e d  reasons.  care  depression.  o u t o f 4 4 5 MI p a t i e n t s  problems.  I n 5 0 % o f MI  from a c o r o n a r y  objective  study  psychological  phases.  during  described  strikes, i s i n immediate  of h o s p i t a l i z a t i o n , and decreases  over the  I s overwhelmed and event.  are a constant  Crushing  reminder  pain and  of the  G e n t r y and Haney displayed  more c o n c e r n s  more s i g n s important such  (1975) r e p o r t e d about  response  one's  1973; Granger,  life,  patients  manage  depending  their  on t h e i r  Contrary  days  of h o s p i t a l i z a t i o n ,  reactions  anxiety  anxiety  peak  i s observed  hospitalization,  This  recur  prior  the  during  anxiety threats  to and  believes  to the f i r s t  few  of death.  normal  The  Shine first  period  of death.  A  of  second  of transfer  i s r e f e r r e d t o as  the level  to discharge,  article,  a t the time  episode  Finally,  t o resume  (1984)  the i n i t i a l  be o b s e r v e d  second  anxiety.  tries  reactions,  but f l u c t u a t e throughout the  and i s due t o f e a r  separation  patient  i s an  anxiety;  Shine  i s due t o f e a r  r e a c t i o n may  just  showed  differently  In a clinically-oriented  that  t h e CCU.  reactions  are not limited  remarks  from  provoke  who  cause.  anxiety  anxiety  many o t h e r  t o Cassem and H a c k e t t ,  period.  Anxiety  For example,  or health  anxiety  that  recovery  also  o r i g i n a t e from  1974).  self-concept  i n CCU.  because  as d e n i a l and d e p r e s s i o n  (Scalzi,  patients  imminent death  of subjective anxiety emotional  that  of anxiety  and reappear activities  again  after  will when t h e  leaving  hospital. When a h e a r t  depression  attack  f e e l i n g s may  i s appraised be m a r k e d .  reaction  to the experience  (Scalzi,  1973; Cassem  loss/harm,  Depression  of having  & Hackett,  as a  a heart  1977).  After  i s a common attack a period  of  shock  and d i s b e l i e f ,  realities  the patient  infarct,  be"  (Cassem  & Hackett,  and  Hackett  (1978),  t h e more p r o f o u n d  Depression  series  the heart  of lesser  Invariably  i ti s a valued  Independence"  (Cassem  (1973) e x p l a i n s anger  self-imposed The  has  also  Cassem  (1978) d e s c r i b e d  strength,  of  oneself  energy,  1 9 7 8 , p. 2 4 3 ) . S c a l z i may s t e m  from anger and  as applied  from  t o a type of  i n the literature. t h e m o s t common  related to cardiac  anxiety  and depression,  anecdotal  a part  made f o l l o w i n g m y o c a r d i a l  factors  other  one has l o s t  a MI, one a l m o s t  habits.  of denial  obtained  a  related to physical  "Following  part:  patient  has t o cope w i t h  the v i c t i m and g u i l t  been d i s c u s s e d  information  he/she  depression  lifestyle  appraisal  and fear of  Even though a  & Hackett,  a t being  concept  challenge  that  a t home.  by f e e l i n g s of sadness,  roles,  f e e l s as though  t o Cassem  i n t h e CCU a n d  of health  harms and l o s s e s  and s o c i a l  usually  guilt:  attack,  begins  after discharge  and hopelessness.  limitations  ...  again  and i s c h a r a c t e r i z e d  survives  i s likely to  1977, p. 7 1 5 ) .A c c o r d i n g  r e s u l t s from a l o s s  helplessness  the effects of  the depression  the depression  becomes e v i d e n t  death;  faces the  o f t h e M I , "The more d e v a s t a t i n g  the  often  finally  from  records,  remark  patients'  that, case  the appraisal  Hackett and  psychological  rehabilitation.  they  infarction  In addition to based  on  h i s t o r i e s and  of a heart  attack  may  a l s o be  Hackett forms  and  of  examined months  one  hope and the  MI.  and  consequences  and  of a  6%  benefits.  from  had  the  an  event  five  unexpected  and  a  two  life,  39%  were  attack  as of  five  a MI  are  heart  According  have d e s c r i b e d of  the  otherwise  MI  be  add  a  attack  after  the  the  findings, period  marital the  that a  may  Meddin  recovery  Despite  concluded of  to  improved  changes.  not  couples,  small-scale study  i n terms  as  positive  Using  consequences  small such  positive  stressful  and  appraisal  and  experience.  Summary. A c c o r d i n g  evaluate  future at  patients  heart  stressful  researchers  t o what would  the  pessimistic.  MI.  lifestyle  positive  theory,  a  the  on  experience  from  experience  life-threatening  coping  the  couples  s t u d i e d , the  dimension  as  In  to  a l . (1984)  the  outlook  benefits.  recovered  relationships  of  Generally,  (1983) conducted  positive  sample  were  et  towards  percent  according  i s present  findings also report a  b r i n g unexpected  husbands  as  only  case,  wiklund  positive  Nevertheless,  Brelje  two  Fifty-five  potential  expected.  this  optimism  confidence,  maintaining a  Empirical  also  (1978),  In  patients' attitudes  indifferent,  having  optimism.  Cassem  post  reported  of  to  the  stress,  c o g n i t i v e a p p r a i s a l processes  situation,  with  respect  an  I n d i v i d u a l ' s w e l l - b e i n g . Through  of  harm and  t h r e a t , the  focus  to  are  used  i t s significance  stressful  i s placed  to for  appraisals  negatively  on  possible place  risks,  while  t h e emphasis  growth.  influence  regard  Each  of these  particular findings shape of  illness,  reactions.  as a challenge,  appraisal  provide  emotional  situation.  types  evidence  harm, c h a l l e n g e  attack  as a moderate  depending  on what a s p e c t s  depression experienced patients  were  myocardial  found  experience  by  processes  and i n t e n s i t y  on t h e demands  A myocardial  of a  may b e findings  for threat, i n f a r c t i o n was  s t r e s s f u l experience  of the s i t u a t i o n the person i s  findings  a heart  suggest types attack.  that  anxiety  of emotions  findings  attack  of personal  report  may b e a and s o c i a l  and  patients  Conversely,  t o have a p o s i t i v e outlook  a heart  i n terms  and b e n e f i t .  Research  types  potential  to highly  i n f a r c t i o n . Other  life-threatening,  illness  Similarly, literature  a r e t h e m o s t common following  meaning can  appraisal-related  depending  and b e n e f i t .  Empirical  emotions.  ways  that  harm, t h r e a t  as having  described  evaluating.  a n d how t h i s  different appraisals  simultaneously.  a heart  the different  Different  are experienced  and  are characterized  that  reactions.  Consequently,  experienced  appraisals  They suggest  positive or negative  emotions  report  have d e s c r i b e d their  emotional  may b e p e r c e i v e d  and b e n e f i t  p o s i t i v e l y on p o t e n t i a l g a i n  Researchers  individuals  challenge  many  following  that  a  although  positive benefits.  Coping Coping  With  Stressful  According defined and  to Lazarus  Within this  automatized  adaptive  Automatized  individual  environmental everything  refer deal  behaviors  does  regardless of their  between  refer  strategies  efforts  emotional  responses Lazarus  need  have  to control such  coping  refers  that  to  and i n v o l v e s a l l  problem-focused  the stress  itself,  demands o r  external  or cope  as d e n i a l  or  and  and  avoidance.  such  before  function,  with somatic  increase emotional worse  or t o  function.  (1984) s t a t e  strategies,  to feel  and  strategies  a palliative  and Folkman  coping  s e l f - p u n i s h m e n t , may individuals  to skills  Problem-focused  made t o m a n a g e  represent  emotion-focused  and  i n the following  and imply a p r o b l e m - s o l v i n g  Furthermore,  efforts  and t h i n k s ,  with the internal  Emotion-focused  one's  outcomes.  strategies.  to efforts  problems,  and  t h e f u n c t i o n s o f c o p i n g , Coburn and  (1979) d i s t i n g u i s h  directly  external  a u t o m a t i c a l l y t o manage  an i n d i v i d u a l  emotion-focused  of p s y c h o l o g i c a l  framework, coping  adaptive  coping i s  as exceeding  demands. C o n v e r s e l y ,  Discussing Lazarus  process  behaviors d i f f e r  performs  (1984),  t o manage s p e c i f i c  demands t h a t one j u d g e s  resources.  efforts  and Folkman  as a c o n s t a n t l y changing  Internal  an  Encounters  behavioral efforts  way.  Strategies  that  some  as s e l f - b l a m e and distress,  they  can  "Some  feel  (p. 150).  better" these  two t y p e s  complement each  Cohen and L a z a r u s of coping  one a n o t h e r ;  coping  theory,  differently,  hinder  o r work  against  used  changeable likely  Both  types  who  strategies  the absence  should  used of  c a n be  Emotion-focused feels  powerless  the situation.  c a n be a l l e v i a t e d coping  few, i f any, options  cases,  and  perceives that the situation  t o use problem-focused  these  of coping  and i s f o r c e d t o accept  the person  be  appraisal  when t h e p e r s o n  or t h a t the problem  situations  will  i n t h e same s i t u a t i o n .  a r e used  change a n y t h i n g ,  of coping  appraisal  on t h e i n d i v i d u a l ' s  encounter.  strategies  Conversely,  In  may  that  can enhance or  to the stress,  two forms  depending  stressful  coping  according  these  simultaneously  to  or they  also state  other. Additionally,  the  strategies  (1979)  i s more  strategies.  I n some  f o r problem-solving  of problem-focused  be i n t e r p r e t e d  exist.  coping  as a f u n c t i o n of the  situation. Coping  With  Myocardial  A myocardial  Infarction  infarction  i m p o s e s many  potential  threats  f o r t h e p a t i e n t and r e q u i r e s a wide  complex  coping  integrated place,  strategies.  whole,  and whenever  a l l aspects  patient's mobilize  task  An  a major  of the person  during this  a l l coping  individual  transitional  resources  variety  t o manage  of  f u n c t i o n s as an  disruption  are affected. period  Is  takes  The i s to  the physical  and  30 psychological  d e m a n d s o f t h e MI  Cohen and L a z a r u s modes o f c o p i n g : intrapsychic others  use  provides  of these  to  action  Lazarus,  1979).  disturbed  or  from  dangerous Miller  used  refers  strategies stressful engaging  arguing  These d i r e c t  energy  a myocardial  away  Fifty  into  Conversely, embarassing  of action. strategies  had p r e v i o u s l y  Actual to  coping handle  two main c a t e g o r i e s :  activities  ( 6 8 % ) , and  (21%). Engaging i n  included coping  expressing  &  t o change t h e  percent  by people  does  tothe  (Cohen  studied coping  stressors  activities  (36.5%),  as adhering  are impulsive,  infarction.  grouped  environmental  such  as i n h i b i t i o n  i n energy-generating  as praying  one  an i n d i v i d u a l  relationship.  f r e q u e n t l y used  generating  will  literature  a c t i o n s attempt  e t a l . (1985) have  were  section  strategies,  or running  a c t i o n s which  events  decreasing  such  event,  may b e v i e w e d  most  coping  to anything  i n 480 c a r d i a c p a t i e n t s .  experienced  p r o b l e m - s o l v i n g and  another.  person-environment  refraining  both  modes. Because most  f o rdefining  regimen,  main  t o v a r i o u s r e s e a r c h e r s , MI p a t i e n t s  deal with a stressful  therapeutic  five  of action,  f u n c t i o n s . The f o l l o w i n g  mode may o v e r l a p w i t h Direct  identified  i n f o r m a t i o n - s e e k i n g and t u r n i n g t o  coping  no s y s t e m  1979).  inhibition  E a c h mode s e r v e s  how, a c c o r d i n g  each  action,  processes,  emotion-regulation present  (1979) have  direct  f o rhelp.  (Cook,  feelings  strategies (34.4%),  exercising  (31.5%),  taking  medication  taking  naps  included  using (18%),  developing  ( 0 % ) .Decreasing  avoiding  (4.2%) as coping  stressful  another  report,  towards  Illness  and work  patients  1984).  This  somatic, MI.  situations  were s t u d i e d  a t two months  social,  Patients  environmental  post  was t h e n  behavior  what  (45%) and  retiring  and a t t i t u d e  i n 201  (Wiklund  consecutive et a l . ,  examined i n r e l a t i o n  factors  their  patient's  M l , two o u t of t h r e e  avoidance  behaviors.  and  and  stressors  factors  they avoided  M I . The r e s e a r c h e r s  Alcohol  state  patients  to  prior to the  was one o f t h e s t r a t e g i e s  cope w i t h  by  MI  and p s y c h o l o g i c a l  were asked  some e x t e n t  (14.2%),  s i c k - r o l e behaviors  information  Avoidance  hobbies  (22.3%),  strategies.  In  male  relaxation techniques  studied.  t h e most t o  that  after the  displayed  was a v o i d e d ,  very  much/to  b y 7 7 % o f t h e p a t i e n t s , a s was d r i v i n g a c a r  68%. Going travelling  to the countryside,  walking  by a i r were each a v o i d e d  I n t h e woods,  by 53% of the  patients. Intrapsychic processes other  such  defenses  further  often,  except  (Cohen & L a z a r u s ,  important  little  to find  refer  as d e n i a l , r e p r e s s i o n ,  emphasize that  "particularly so  modes o f c o p i n g  Cohen and  and Lazarus  modes a r e  i n the context  c a n be d o n e d i r e c t l y  some s e r v i c e a b l e  minimization  1979).  Intrapsychic  to cognitive  of i l l n e s s  because  by t h e p a t i e n t  way t o t h i n k  about  ...  what i  happening" the  (p.  greater The  used  the  MI  1973; the of  of  As  the  patient a  heart  handle  or  illness.  cope w i t h and  some  in  e a r l y stage  denial  form  of  an  extended  become h a r m f u l  to  them.  Cassem and 50%  of  MI  patients  Denial  may  of  illness  the  take  Hackett,  1977;  patients  may  attack;  or  associated point  out  Hackett will  refuse  with that  to  the at  of  a  common  prepared  that  that  to  by in  the some  patients  the  patients  denial  may  approximately  form on  of  denial.  what  a c t u a l l y denying  f e e l i n g s of  time  Implications  i f the  depending  that  (1973),  imposed  time,  and  (Scalzi,  Scalzi  be  But,  some  According  Illness.  the  of  experience  are  decrease  the  may  the  the  b e n e f i c i a l to  (1977) c l a i m  believe  deny the  to  (1984) e x p l a i n  period  patients  in  coping  demands  be  strategy  and  adequately  illness.  Cook, 1979).  may  not  d i f f e r e n t forms, the  with  denial  may  their  for  coping  to  of  According  stressful  Folkman  of  pattern  of  are  denial  a  coping.  much e m p h a s i s  confronted  period  the  to  l e v e l s tend  1977).  patients  cases, the  A  individual i s ,  symptoms s u b s i d e  predominant  attack.  Lazarus  applied  anxiety  i s suddenly  because  as  physical  the  the  i n t r a p s y c h i c modes o f  been g i v e n  Cassem & H a c k e t t ,  reaction  use  has  feels better, becomes  more h e l p l e s s  denial  patients  literature. patient  The  r e l i a n c e on  concept  by  denial  221).  to  Cook  they  have  aspects  (Cassem  &  (1979), had  f e a r , anger  a  or  heart anxiety  Cassem and  Hackett  (1977)  discharge  after a  heart  33 attack,  one-third  illness. to  the  from  This  of  lack  the  of  understanding  natural process  t h i n k i n g about  disease"  (p.  CCU.  patients'  on  In the  aggressive follow  first  by  change  that  The  protect  related  themselves  i m p l i c a t i o n s of  (1982)  over  behavioral  the  a  were c l a s s i f i e d adaptive the  rejection idea  and  that  interviewed  three  and  year  post  reactions  MI to  they  period  their  i n three  have  in  behaviors. is  These a  heart  s y m p t o m s . T h e y may  hyperactive.  These  p a t i e n t s may  may  Ignore  illness,  even  i n the  lifestyle.  The  authors  by  category,  the  self-control.  lives,  Motivation  taking  adaptive Here  into  f o r work  a l . (1985) r e p o r t e d  CCU,  that  to  restrictions or  is  be  refuse  may  remark,  f o r work  refuse  however,  good.  behavior,  is  patients control  r e a c t i o n s . They makes p l a n s their  the  the  illness,  behavior  had  to  broad  aggressive  impulsive  304  while  minimization.  patients' motivation  restrictions. et  be  their  their  characterized  reorganize  to  their  minimize  second  emotional  people  reactions  category,  t r y to  their  these  Miller  by  and  age  professional advice,  imposed to  their  r e j e c t the and  Grevisse  behavioral  Impulsive,  characterized  attack,  understand  "appears  threatening  working  behaviors  categories:  patients  of  their  Based  which  not  716).  patients  determine  by  the  D e g r e - C o u s t r y and male  p a t i e n t s do  their  to o b j e c t i v e l y  account  the  Imposed  remains e x c e l l e n t . in their  study,  only  11% of  of  cardiac  patients  used  strategies  controlling feelings. Controlling  coping  strategies  avoiding  mental  such  as  stress,  not  calm  category  feelings  getting  staying  i n the  upset and  Included  or  excited,  ignoring  situations. In  the  patient  are  are  symptoms and  adequately behavior work  by  adapted.  by  by  The  increased  the  patients'  concerns  Here,  s i t u a t i o n , and  their emotional  behavior,  the  about  patients  consequently  responses.  fail  to  Their  p a s s i v i t y , d e p e n d e n c y and  lowered  motivation.  1984;  the  place  Burgess MI  literature  the &  factors  tended  Patients  caused on  that  majority  MI.  smoking  Burgess  findings.  More  t h e i r heart  patients the  blamed  patients  of  and than  a  the  often These risk  (Wiklund  sources  same p a t i e n t s  smoking  attacks.  They a l s o  found  their  for  job  than  placed the  were smokers  (1986) r e p o r t e d  MI,  stress.  less fact  prior  to  similar to  that yet  et  related  factor, despite  the  et a l . ,  Wiklund  work  perceived  reported  to  the  other  believed  patients  jobs  where  According  blame  Hartman 15%  explains  t h e i r MI  1986).  most  as  also  for  to  t h e i r MI.  emphasis the  blame  Hartman,  patients  themselves.  of  the  i s marked  patients  of  poorly  aggressive  their disability.  control  Some o f  the  as  the  characterized  overwhelmed  al.,  category,  is described  responses their  third  be 33%  the of  more t h a n  cause the 90%  Information coping  (Cohen  remark  that  forms et  seeking  & Lazarus,  information  of coping  used  1979). seeking  coping  strategies patients  professionals  For this  provided.  was  the avoidance  43%  of the patients  acknowledged  they  they  The  support  the majority patients  as r e l e v a n t  ignore  system,  and l a s t mode  emotional  used  advice however, from  Is defined  they  use only  to their  (1987) p o i n t s  coping  on what  health  out that they  decisions" mode  s e e a s most  to learning  information  (p.  i s turning  545). to  as the person's  of assistance  s t r a t e g i e s . Turning support,  of advice  strategies of the  narrowly  or a l l forms  coping  health  much o f t h e i n f o r m a t i o n  coping  Burckhardt  t o focus  and t h e advice frequently  their  compared t h e  r e c e i v i n g no a d v i c e  t h e m t o make s o u n d  This  may e n h a n c e includes  i l l ,  fifth  help.  perceive  the study  and a r e most r e c e p t i v e  enables  used  s t r e s s management; a n d t h e  not using  Discussing  tend  problematic  patients  s i t u a t i o n s (18%);  r e c e i v i n g . Because  receive.  "patients  for  The most  reported  t h e y may w e l l  chronically  that  used,  of s t r e s s f u l  57% were  problems,  basic  i n new s i t u a t i o n s . M i l l e r  purpose,  p r o f e s s i o n a l s about  information  (1979)  r e l a t e d t o s t r e s s management t o enhance  efforts.  remaining  & Lazarus  I s one o f t h e most  how c a r d i a c  coping  health  t h e f o u r t h mode o f  Cohen  by p a t i e n t s  a l . (1985) s t u d i e d  information  represents  others  social  available  t o others  d i r e c t a s s i s t a n c e and  that  f o r help  information  support  (Folkman  & Lazarus,  study  of the p a t i e n t s ' s i c k - r o l e  their  illness  discussed  earlier,  were asked  how  significant they  others  In  before  and 31% w i t h avoided  very  t h e same  treated  being with  the onset  shown c o m p a s s i o n , significant  had w i t h  an  increased  friends.  their  Forty-six  contact  contact  Furthermore,  from  close  50% of  being  Eighty percent  with  with  alone.  p a t i e n t s were a l s o asked  families.  how  they  of p a t i e n t s  p h y s i c a l e x e r t i o n , 68%  67% shown c o n s i d e r a t i o n , 62%  47% r e s p o n s i b i l i t y  and 14% i n i t i a t i v e others  Patients  to the contact  of t h e MI.  a decreased  understanding, help,  examined.  m u c h / t o some e x t e n t  protected  practical  was  they  towards  e t a l . , 1984)  i n comparison  other  study,  t r e a t e d by t h e i r  reported  from  changed  of p a t i e n t s reported  patients  given  support  f a m i l y ; 20% r e p o r t e d  friends  were  social  In the  and a t t i t u d e s  (Wiklund  much t h e c o n t a c t  experienced  percent their  a t two months  1985).  i n these  taken  taken  cases  away,  away.  36%  Support  suggests  overprotection. Summary. framework, efforts  problem  coping  used  demands.  Within  itself  emotional  represents  to deal  Coping  with  efforts  a p p r a i s a l and  specific  serve  internal  and e x t e r n a l  two f u n c t i o n s : t o manage coping),  (emotion-focused  strategies  coping  a l l c o g n i t i v e and b e h a v i o r a l  (problem-solving  distress  emotion-focused  the stress,  promote  the  or t o regulate  coping).  Some f o r m s  problem-focused  of  coping, while others seem to increase emotional Both forms of coping may  distress.  be used d i f f e r e n t l y and  simultaneously, depending on the individual's appraisal of the s t r e s s f u l s i t u a t i o n . Research findings show that patients use a wide v a r i e t y of coping strategies to manage t h e i r myocardial i n f a r c t i o n . More s p e c i f i c a l l y , most coping strategies Ml patients used were related to the f i v e main modes of coping suggested  by the s t r e s s ,  appraisal and coping theory: d i r e c t action, i n h i b i t i o n of action, intrapsychic processes, information-seeking and turning to others for help.  Coping Changes  i n Emotions and  as  a  Coping  Process Strategies  Lazarus and Folkman's (1984) stress, appraisal and coping theory defines coping as the constantly changing cognitive and behavioral e f f o r t s to manage the demands that are appraised as exceeding the resources of the Individual. Within t h i s framework, coping i s viewed as a process rather than t r a i t - o r i e n t e d coping. The t r a i t - o r i e n t e d approach defines coping as the c h a r a c t e r i s t i c s of individuals used to predict what they would do in a p a r t i c u l a r s i t u a t i o n , but not what they are a c t u a l l y doing; and does not consider the contextual changes. According to Lazarus and Folkman (1984), the changes  38 that  characterize  continuous  c o p i n g as  appraisals  person-environment  emotions which  were  examined.  Threat  and  time  one  to time  two,  time  two  to time  t h r e e . Harm and  one  to time  time  t h r e e . The  Folkman's  During  students  but  two,  but  findings  thesis benefit  the  d i d not  that  and  benefit  confirmed  while at  emotions  the  benefit  rose  and  can  from  and  less  two  to  and or  likely As  significant  of  the  c h a l l e n g e emotions  the  under  94%  waiting  stage,  conditions  harm  of  maximum  to experience  both  the  unfolds  encounter  f o r an  at  results  i n f o r m a t i o n Is added, a m b i g u i t y decreases becomes  from  time  Lazarus  were e l e v a t e d . These  challenge emotions.  which  challenge emotions,  two,  hypothesis that  emotions  occur simultaneously.  threat  time  change  (time one),  threat  situation  elevated at  significantly  support  state  are  emotions  from  individuals  and  were  of  significantly  ambiguity, and  four types  decreased  also  emotions,  examination  from  d i d not  experienced both  same t i m e ;  shifting  significantly  threat  anticipatory  the  the  of  change  outcome a p p r a i s a l s  time  function  challenge  appraisals  one  harm and  and  i n the  and  time  represented  of  a  (1985) midterm  changes  anticipatory  two  are  reappraisals  Lazarus'  earlier,  reflected  process  relationship.  In F o l k m a n and study mentioned  and  a  and  the  individual's  well-being. McCorkle  and  Qulnt-Benoliel  (1983) have  investigated  the  coping  conducted  process  a study which  symptom d i s t r e s s , associated different  that  how p e o p l e  although  occasions concerns  reduce  groups,  any designed the concerns  researchers  both  this  was  between  patients* by t h e  n u r s i n g and medical  concluded  by  finding  i n patients  second  occurred  interventions  to  mood d i s t u r b a n c e . The  that the patients  internally  because  and  months p o s t - d i a g n o s i s , t h e y  second  of  significantly  and decrease  was t o  unchanged  groups  change  a t two  Imposed  most s i g n i f i c a n t  Improved  Furthermore,  disturbance  purpose  remained  have  of  infarction  w i t h t h e changes  symptom d i s t r e s s  a n d moods  a n d mood  The s t u d y ' s  cope  They  the differences  and m y o c a r d i a l  The s t u d y ' s  f o r both  occasion. without  compared  points i n time.  illness.  a n d MI p a t i e n t s .  current concerns,  with cancer  understand severe  i n cancer  adjusted  o f how d i f f e r e n t l y ,  between t h e appraised  first  their  illness. Lazarus process  and Folkman  also  Implies changes  stressful  situation  situation  evolves  In 1985), on  they  showed  In thoughts  i s illustrated  the students  examination were asked  of Coping  had used  that the coping and a c t i o n s as a  u n f o l d s . The way p e o p l e  the midterm  t h e Ways  (1984) e x p l a i n  study a t each  studies.  (Folkman stage  used  to the examination. combinations  of  &  to  Questionnaire the coping  in relation  that students  I n two  cope as a  Lazarus, indicate  strategies The  findings  problem-focused  and  emotion-focused  Different  forms  anticipation coping  such  analyze  coping  of coping  were  as t r y i n g  used  to control  during  coping,  d i s t a n c i n g , was more  thing" doing  a particular  Problem-focused  forms o f  oneself, trying  to  o f a c t i o n were  of  stage.  distancing waiting,  prominent.  Distancing  form  but waiting  strategies  happen  before  t o Folkman and Lazarus  may b e a n a p p r o p r i a t e  of coping  During the  as " t r y t o f o r g e t t h e whole  According  since nothing  more  emotion-focused  a n d "I'm w a i t i n g t o s e e w h a t w i l l anything".  types  such  form  stage.  during the  the anticipation  stage,  strategies  a t every  and making a p l a n  waiting  Included  used  and w a i t i n g s t a g e s .  the problem  frequently  strategies  such  positive  aspects  of a s t r e s s f u l  support,  and w i s h f u l t h i n k i n g  (1985),  of coping f o r  i s p o s s i b l e . Other  as emphasizing event,  the  seeking  a l s o changed  social  from  stage  to  stage. Wiklund coping MI.  model  identified  reorientation  phase.  following  a s h o r t moment  patients because  find  used  the coping four  the r e a c t i o n phase,  immediately from  to describe  They have  phase, the  e t a l . (1985) have  theory  following  a  t h e shock  t h e r e c o n s t r u c t i o n phase, and  the heart  phase  begins  attack. This  t o a few days.  of the s i t u a t i o n ' s  process  main phases:  The s h o c k  i td i f f i c u l t  the c r i s i s  During  period  this  period,  t o come t o t e r m s w i t h novelty. This  lasts  phase i s  reality  characterized confusion, phase  denial  usually  months a f t e r patients they and  by e m o t i o n a l  begins  they  their  occur.  The  a few days and l a s t s this  they  find  up t o two  period,  c a r d i a c and emotional future,  reaction  symptoms;  life  meaningless,  Instability  s t i l l  a n d may be c h a r a c t e r i z e d b y d e p r e s s i o n ,  irritability,  avoidance,  reconstruction  phase  dependency and/or  begins  last  the  reactions decline,  emotional  up t o t w e l v e  to reorganize  characterized responses The  last  phase,  and  Is complete  the  crisis.  During  life.  This  second  this  patients face  In previous  reorientation,  phase,  reality  and  phase I s  achieve  some c a s e s ,  p h a s e s may a l s o  begins  after  w h e n t h e p a t i e n t h a s come  The a u t h o r s  pathological  months.  the  The  by m i l d a n x i e t y and t e n s i o n , but t h e  experienced  eventually  their  passivity.  at approximately  m o n t h a n d may  In  Anxiety,  lose self-confidence. Emotional  persists,  attempt  may  attack. During  on t h e i r  about  assertion  after  the heart  focus  worry  and/or  instability.  remark  the ideal  emotional  a n d may  that  state  only  twelve  with  months,  t o terms  with  few p a t i e n t s  of emotional  the normal  will  stability.  and b e h a v i o r a l responses  interfere  occur.  become  recovery  process.  Relationship  Between C o g n i t i v e A p p r a i s a l and  Coping  strategies  According  to the stress,  appraisal  and c o p i n g  theory,  the  way  an  coping  individual appraises  strategies  used  to  a  manage  situation  influences  i n t e r n a l and  the  external  demands. Folkman  et  a l .  between c o g n i t i v e encounter  analysis  in order  situations,  couples, month the  or  herself  and  to  The  and  for  final the  types  across  sample  relationships  and  immediate  lntraindividual compare  several the  the  same  i n t e r r e l a t i o n s among of  75  interviewed  s i x months. P a r t i c i p a n t s  were a s k e d  had  the  married  were  they  person  stressful  consisted  participants  findings  indicated  that  between primary a p p r a i s a l of  coping  differed  (primary appraisal). were  to  the  once to  experienced  a  describe  during  the  week.  The exists  an  understand  most s t r e s s f u l e v e n t  previous  coping  They used  himself  variables.  appraisal,  outcomes.  (ipsative) with  (1986) examined  used  potential planful  problem  solving  where a  goal  work  strategies requiring  were more  where  was  and at  responsibility  coping  on  w h a t was coping  control  stake.  at  used  in  and more  stake  strategies  proved  in  that  to  have  used  situations  Emotion-focused  Confrontive  were used  and  example, people  self  escape-avoidance,  relationship  coping,  appraisal  frequently  more a c c e p t a n c e .  self-control,  and  depending  Improvement. For  at  strong  Problem-focused  in situations for  a  coping-  situations coping,  accepting frequently  when  43 people's  self-esteem  escape-avoidance well-being and  threatened.  at  health, were  when  People  support  stake.  coping  to  their  manage  Llpowski attributed  who  and  one's  coping  and  was  seeking  resources  were  own p h y s i c a l  escape-avoidance  describe  how a p p r a i s a l  strategies individuals  (1970-1971) s t a t e s t h a t d i f f e r e n t  to Illness  can Influence  u s e . He e x p l a i n s t h a t  perceives  coping  particular  forms  harm a p p r a i s a l . I n t h i s  illness  a s a n e n e m y may  and use other  forms  Illness  by denying  of  activities  to  be  such  a s a w e a k n e s s may the Illness  o r may  as attempting  meanings  strategies of  coping  case,  the  place the  of coping  p r o j e c t i o n , dependency and p a s s i v i t y .  regards  use  illness.  on o t h e r s ,  reality  support  and  f o r someone e l s e  i n v o l v e d one's  to coping  be a s s o c i a t e d w i t h  denial,  confrontive  financial  w r i t e r s or researchers are related  blame  used  confrontive coping  of s o c i a l  coping  more when a l o v e d  loss of respect  used  processes  p e s o n who  Confrontive  more.  Other  may  People  When t h e s i t u a t i o n  used  used  more h e a v i l y when  seeking  patients  were  was a t s t a k e .  self-control  social  was a t s t a k e .  related The  to  person  t r y t o escape engage  either  i n a  t o look  variety  healthy or  over-compliant. Llpowski  illness master  (1970-1971)  i s perceived the situation  further explains that  as a c h a l l e n g e , using  when  p a t i e n t s t r yt o  the available resources.  They  take  an a c t i v e  coping  role  patterns  in their  such  illness  as o b t a i n i n g  and d i s p l a y  professional  adaptive  advice  and  information. Particular  forms  of coping  strategies  d i f f e r e n t types  of benefit  associated  with  (Lipowski,  1970-1971).  perceive  their  technique case,  illness  i n their  illness  For example,  i s a means  compliance  from  be  of prolonging  a means  sick  role  beyond  patients  may  numerous  somatic  McNett threat  others.  effectiveness subjects.  support and  as a r e l i e f  and m a i n t a i n i n g  recovery  use medical  period.  may  the  These  resources  the effects  and c o p i n g  and  responses  of s o c i a l on  i n 50 f u n c t i o n a l l y d i s a b l e d  She f o u n d  that  availability  related  t o reduced  Additionally, threat  significantly  attention,  this  have  complaints.  was s i g n i f i c a n t l y 0.29).  disability  (1987) s t u d i e d  appraisal  who  may u s e i t a s a  I l l n e s s perceived  excessively  appraisals  relationships. In  of getting  the normal  be  individuals  as a s t r a t e g y  interpersonal  may  related  appraisal  coping wheelchair-bound  of s o c i a l threat was  to emotion-focused  support,  support  appraisal  (r_ =  also coping  (r_ =  0.23) . Research appraise  findings  the heart  indicate  attack  will  that  t h e way  influence  patients  coping  strategies  used. Garrity  (1975) d i s c u s s e s  t h e r e s u l t s o f two  earlier  45 studies The  on  patients*  studies  patients'  searched  success  psychologically. variables findings  were  predictor well  as  of of  of  for  that  factors  failure  Clinical,  selected  showed  perception  or  perceptions  their return  to  work  and  of  that  status  explain  the  MI  and  psychological  predictors  health  attacks.  physically  and  evidence  heart  could  adjust  social  as  striking  to  their  was  adjustment.  The  patients' the  most  useful  leisure activities,  as  positive attitude.  G e n t r y and relationships patients'  Haney  within  (1975) have and  Investigated  between v a r i o u s  dimensions  characteristics, pre-hospital  coronary  care  hospitalized Included  unit for  behaviors  acute  variables  decision-making,  such  MI.  and  as  in  and  patients CCU  behaviors  symptoms a t t r i b u t i o n ,  perceived  illness,  and  of  behaviors,  outcomes  Pre-hospital  the  fear  of  delay, pain  and  death. The  most  relationship behaviors. viewed of  pain  younger  significant between death  Patients  themselves and  patients  older  less  concerned  seeking  who  as  were  The  were more  patients. about  medical  concern  and  highly  s i c k e r , and  discomfort.  than  in  finding reported  other  a  also  A d d i t i o n a l l y , younger  help  were  patients'  to  about  greater  their patients  Decision-making  related  close  and  patients'  death degree  indicated  o p t i m i s t i c about  finances.  the  concerned  reported  findings  was  that  future were delay  subjective perceived death. help  but  and  who  thought  attention,  tended  meet t h e support  and  continuous  is  Support  a  heart  changes  strategies coping  as  support,  time  medical  support.  However,  their  appraisal a  efforts  responses  The  coping  stages  tenet  Research  MI  findings  a  f u n c t i o n of  the  shifting  definition  of  coping  w i t h changes  encounter  unfolds.  was  in  framework  found  of  crisis  p a t i e n t s i n each provide  in  research  recovery  r e a c t i o n s and  findings  to  theory's  are  relevant to  emotional by  the  change  Research  coping  coping  That i s ,  continually  and  as  and  process.  occurring in stages,  i s adopted  stages.  seek  social  i n coping  theoretical  p a t t e r n of  to  r e a p p r a i s a l s of  a t t a c k . Within the  dominant  on  relationship.  action  investigating  themselves  the  situation.  a p p r a i s a l s and  for this  viewed  medical  at  social  appraisal  t h a t the  and  about  s u s t a i n e d a MI  stress,  the  c o n c e p t u a l i z e d as  thoughts  were  finances.  behavioral efforts  person-environment  they  to  Is d e f i n e d as  stress,  formulation  they  related  rely  on  sick  denial.  s t r e s s e s of the  had  to  Summary. W i t h i n t h e  cognitive  concerns  how  in seeking  and  t o have d e c i d e d  relied  coping  delay  concerns  they  c a t e g o r i z e d by  framework,  worried  less  fewer  r a t h e r than  p a t i e n t s who  illness,  how  showed  indicated  admission  were  their  r e p o r t e d more d e a t h  Patients  for  of  themselves,  P a t i e n t s who  sicker,  of  appraisal  following  theory,  a  coping of  the  evidence  four  that  appraisal-related people  used  to  processes  manage t h e  Studies  Investigated  attack.  Findings  the  most u s e f u l  or  indicate  of  and  CCU  of  related  coping  following  a  heart  of  behavioral  ajustment  recognition  d e a t h were a s s o c i a t e d  symptoms a t t r i b u t i o n and  a situation.  perception  to  behaviors  strategies  demands o f  coping  that  determinant  fear  pre-hospital  specific  patients*  outcomes. A p p r a i s a l s symptoms  influence  illness  of  cardiac  with  including variables  delay  is  in seeking  such  as  professional  help.  Summary of A review  of  and  situations, stress, of  three  stress a  types:  help  strategies  and  coping  determine  damaging or  understanding  used  theory,  of  the  and  to  Review that  explain  t h e y change over  harm, t h r e a t ,  appraisals  s i t u a t i o n as  their  how  appraisal  suggests  processes  coping  and  Literature  literature  appraisal-related reactions  the  emotional  in stressful time. According  stress appraisals  challenge.  what d e g r e e  the  are  These  people  evaluate  p o t e n t i a l l y damaging based power o f  to  s i t u a t i o n to  on cause  harm. Similarly, ways  researchers  i n d i v i d u a l s regard  meaning can strategies  influence  have d e s c r i b e d  their  I l l n e s s e s , and  emotional  used. They s u g g e s t  the  reactions  that  different  how  and  I l l n e s s may  this  the be  coping  perceived  as c h a l l e n g e ,  Person-characteristics personal  resources  threat,  challenge  Illness as  destructive illnesses  such  or as  as anger,  characterize  irreparable  depression,  patients  will  tasks  h a v e t o be m a s t e r e d .  stressful  i s perceived  the form  threats  may  with  or  and  of their  unfair Emotions  hostility  i s perceived  the i l l n e s s  appraisal  as  as a  they  particular is  as hope and c o n f i d e n c e .  as g a i n / b e n e f i t , value  involved  i n each  this  or strategy. type  appraisal  as a t h r e a t ,  implies  anticipated  different  kinds.  w o r r y and a n x i e t y  If may  Different  of a p p r a i s a l .  perceived  Fear,  regard  o r damage.  Challenge  forms:  as v i c t i m s  s i t u a t i o n s where  such  harm,  several  fair  If illness  of r e l i e f ,  be  take  humiliation  deal  by emotions  as a  loss  and  a r e made.  themselves  of f a i l u r e ;  i n any other  take  that  of  as a weakness, p a t i e n t s  would  illness  benefit.  the appraisals  a s a h a r m may  harm a p p r a i s a l .  characterized  or  as a t t i t u d e s , b e l i e f s  i n d i v i d u a l s view  as a s i g n  challenge,  threat  and b e n e f i t  forces;  punishment;  such  influence  perceived  a n enemy,  harm,  Illness  harms/losses  of  a r e common  reactions. Studies' coping  premise  emotional Relevant such  findings that  reactions, literature  as a heart  support  these  the s t r e s s , appraisal  types  of appraisals  and c a n o c c u r Indicates  attack  that  and  shape  simultaneously. a stressful  carries possible  risks  experience as w e l l  as  potential  benefits. A  fears  concerns,  of  and  and  s t r e s s depending  the  person  attack  are  on  MI,  most  simultaneously, the  process  the  situation.  of  of  their  outlook  be  gained  the  stress, as  serve  e x t e r n a l and  two  broad  the  heart  beliefs. two  the  types  of  occur  a  demands  were  of  found  to  attacks.  result  of  the  functions  or  i n order  To  manage t h e  situation,  strategies.  These  coping  categories framework:  to  various  p a t i e n t s use  behavioral  i s to  be  environment  theory,  a  alter  second,  exigencies  wide  variety  s t r a t e g i e s are  suggested direct  the  by  the  Coping  the  purpose  the  troubled  the  directed at  regulate  efforts  demands.  functions. First,  f u n c t i o n s may  coping  of  heart  internal  emotion-regulating  and  situation  coping  a l l c o g n i t i v e and  problem-solving  main  on  as  a p p r a i s a l and  and  five  levels  fluctuate during  their  relationship;  MI  Ml  many i n d i v i d u a l s  also  high  experience.  is defined  emotions.  may  depending  regarding  various  These emotions  person-environment  the  the  personal  intensity  Conversely,  to  to  experience  depression.  convalescence  manage s p e c i f i c  the  what a s p e c t s  individuals  b e n e f i t s may  strategies of  and  positive  Within  to  moderate  by  a n x i e t y and  coping  rise  influenced primarily  emotions:  stressful  generates  gives  perceptions  a  Possible  attack  i s e v a l u a t i n g . These  Following  have a  heart  the  self  patient's imposed  of  the  coping  categorized  stress,  by  under  appraisal  action, inhibition  of  action,  Intrapsychic others may  for  serve  processes,  help. both  Coping  of  MI  of  action  These  two  personal  and  attack.  Types  denial,  rejection,  of  and  coping  seem t o  coping  a  such  what  to  Research as a  a  see  heart  of  mode  and  that  a  In d i r e c t of  coping  coping  large  during  mainly  demands  the  recovery  at  managing  aim  following a  mainly  are  Is  during  self. the of  frequently  used,  early stages  one  the  situations.  Patients  seem t o  as  relevant  to  health  report  that  i s increased  to  during  of  T h e s e modes  of  period  and  may  of  recovery.  most b a s i c  turning  forms  Intrapsychic  i n the  their  include  initial  Some f o r m s  of  heart  coping  than  patients  coping  and  sources  other  percentage  action  self-control  denial  the  i s viewed  changing demands  to  be  forms  focus  of  only  on  problems. others  the  for  help  recovery  from  attack.  Within coping  of  attack.  findings  form  turning  i n each  minimization,  used  seeking  i n new  they  be  as  included  i n t r a p s y c h i c modes o f  heart  Information coping  forms  forms  blaming  beneficial  indicated  environmental  coping  and  emotion-focused  were engaged  period.  following  of  seeking  coping.  findings  patients  inhibition  strategies  purposes  problem-focused Research  information  stress, appraisal as  cognitive of  a  a  process.  and  situation.  and  That  coping i s , as  behavioral  efforts  Research  findings  framework,  the to  constantly  manage  support  the  the  theoretical  premise  that continuous  reappraisals  are determinants  characterize  coping  Different on  types  demands  appraisals  of t h e changes  as a process  following  that  a heart attack.  of s t r e s s f u l  appraisals  a r e made  of the s i t u a t i o n .  The c o p i n g  process  involves  changes  i n coping  efforts  as the  evolves.  Studies' findings  suggest  t h a t people  forms  of emotion-focused  every  stage  are especially  illness  such  stages  infarction:  have  phase.  Each  each  Crisis-oriented to  acute  phase  when  phase,  phase,  strategies.  the patient  the  and t h e  i s characterized  and coping  theory,  been d e s c r i b e d f o l l o w i n g  t h e shock  the reconstruction  reached  use v a r i o u s  coping at  relevant with regard  phase,  reactions  also  as a heart a t t a c k . Within the c r i s i s  main c o p i n g  myocardial  encounter.  depending  situation  and problem-focused  of a s t r e s s f u l  aspects  four  and  reaction  reorientation  by s p e c i f i c  Emotional  has s u c c e s s f u l l y  a  emotional  stability  i s  worked  through  the relationship  between  phase. Studies  appraisal coping  which  investigated  and coping  suggest  that particular  are associated with specific  Although  both  forms  emotion-focused health-related efforts findings  are used,  coping  a r e used indicate  more  coping  a r e used  situations;  stressful  more  whereas  efforts  forms of encounters. related  frequently i n  problem-focused  i n work-related situations.  that the coping  to  strategies  coping Research  patients  used  are  l a r g e l y determined  Perceptions successful  o f t h e MI  of b e h a v i o r a l  appraisals  and  CCU b e h a v i o r s a n d outcome  and  o f d e a t h were a l s o  a t t r i b u t i o n , delay  functional  adjustment  such as r e c o g n i t i o n  fear  status.  associated including  i n seeking  made.  t o be t h e most  t o work and l e i s u r e a c t i v i t i e s .  and  symptoms  of a p p r a i s a l s  s i t u a t i o n proved  determinants  such as r e t u r n related  by t h e type  Threat  of c a r d i a c with  patterns,  symptoms  pre-hospital  variables  such as  professional  help  53 CHAPTER  THREE  Methodology This settings  chapter  f o r the study  Additionally, data  In  This  sample,  and data  instruments.  and data study  longitudinal time.  describe the design  human r i g h t s  collection  reviewed. a  will  used  design  A l l data  collection  and e t h i c a l c o n s i d e r a t i o n s ,  analysis  procedures  a descriptive  w i t h measures  were g a t h e r e d  will  be  correlational  obtained  and  a t two p o i n t s  by t h e I n v e s t i g a t o r by  means o f q u e s t i o n n a i r e s a n d p a t i e n t I n f o r m a t i o n  sheets.  Sample  A convenience  sample  in  accordance  with  1.  The p a r t i c i p a n t s  o f 21 p a r t i c i p a n t s  the Inclusion  was  obtained  criteria:  were a d u l t s between t h e ages  o f 41 a n d  73 . 2.  The p a r t i c i p a n t s  were a d m i t t e d  with  first  by  a confirmed  the usual  and/or 3.  criteria  of c l i n i c a l  infarction history,  were a b l e  t o understand,  No o t h e r patients'  major  lived  i n metropolitan  illnesses  medical  were  history.  indicated  unit  diagnosed  enzyme  read and  English.  4. T h e p a r t i c i p a n t s 5.  myocardial  care  e l e c t r o c a r d i o g r a p h i c changes.  The p a r t i c i p a n t s speak  to a critical  Vancouver. from t h e  6.  A l l participants  had e x p e r i e n c e d  seven  to this  days p r i o r  Seven days and e i g h t critical the to  weeks p o s t - M I  phase b e g i n  a few weeks  reconstruction after  were c h o s e n  patients  (Wiklund  than  as  because  theory,  appears  p h a s e and t h e  following  t h e MI, a n d may  e t a l . , 1 9 8 5 ) . The at approximately  eight  weeks  e p i s o d e . A c c o r d i n g t o Wenger a n d  (1978),  within eight  a r e expected  following  The s h o c k  immediately  phase b e g i n s  the acute  Hellerstein  process  of coping, a c c o r d i n g t o c r i s i s  be r e l e v a n t f o r t h e s t u d y .  reaction  MI no more  study.  p o i n t s i n t h e MI r e h a b i l i t a t i o n  process  last  their  t o twelve  t o resume t h e i r  an u n c o m p l i c a t e d  weeks, most  normal  activities  MI.  Setting Participants western acute  were r e c r u i t e d  C a n a d a . The i n i t i a l  or subacute  from  data  coronary care  four h o s p i t a l s i n  were c o l l e c t e d units.  questionnaire  was a n s w e r e d a t e i g h t  participants'  home o r o f f i c e ,  i n the  The s e c o n d  weeks a t t h e  whichever  was c o n v e n i e n t t o  them.  Human R i g h t s and E t h i c a l Permission University Screening  t o conduct  of B r i t i s h committee.  Considerations  t h e s t u d y was o b t a i n e d  Columbia Permission  from t h e  Behavioral Sciences t o implement  t h e s t u d y was  also  obtained  from  Committee and  four s e l e c t e d  the  study.  contact  H o s p i t a l and  H o s p i t a l Research  the  potential  the  hospitals  Nursing  staff  Nursing  Committees.  received a  assisted  who  was  either  Additionally,  letter explaining  i n the  s u b j e c t s a c c o r d i n g to the  person  Research  selection  sample c r i t e r i a .  a clinical  nurse  I.C.U. c o o r d i n a t o r or head n u r s e  identified  subjects  t o them. The  then and In  d e s c r i b e d the  approached seventh  addition  patients E)  and  study  a l l identified  d a y s p o s t MI  t o d i s c u s s the  which e x p l a i n e d  the  nature,  investigator  the  letter  p u r p o s e and  the (Appendix  the  study  the  q u e s t i o n n a i r e s were a n s w e r e d and  those  patients  who  agreed  consent.  patients  r e t a i n e d a copy of the  consent  was  questionnaire  to p a r t i c i p a t e  obtained,  i n the  M e a s u r e s were t a k e n confidentiality  questions  them.  of the  After  Any  study,  fifth  implications or  study.  potential  study with  information-consent  A  specialist,  p a t i e n t s between t h e  t o a v e r b a l e x p l a n a t i o n of the  r e c e i v e d an  of  of  the  use  D a t a were c o l l e c t e d  post  first MI;  time the  was  second  the  at  two  between t h e time  was  the  The  form.  completed  the  investigator.  participants'  o f code  Data C o l l e c t i o n  The  participants  to p r o t e c t the  with  the  about  information-consent  the  presence  signed  raised  numbers.  Procedure different fifth  and  points the  In  seventh  a t e i g h t weeks p o s t MI.  time. days The  investigator participant convenient post  A total  original  units  MI p a t i e n t s  and the seventh  admitted  diagnosed  f o rthe first  MI  or subacute  investigator  In the  w a s s e t a t 70 y e a r s o f i n obtaining  participants,  The i n v e s t i g a t o r  MI a t t h e i r  Interviews  home  were h e l d  o f age  were v i s i t e d i n  f o r a convenient  f o r t h e f o l l o w - u p q u e s t i o n n a i r e . A phone  obtained.  criteria.  CCU.  arranged  further  staff  patients  interview.  i n the study. Patients  t o permit  days  to the c r i t i c a l  i f t h e y met t h e s a m p l i n g  of the d i f f i c u l t y  the acute  at a  t h e q u e s t i o n n a i r e . The n u r s i n g  t h e sample  included  address  post  care  with the  t w o s u b j e c t s o f 7 1 a n d t w o o f 73 y e a r s  The place  between t h e f i f t h  t o determine  Because  either  or subacute  p r o p o s a l t h e age l i m i t  however, were  individually  o f 21 c o n s e c u t i v e n e w l y  comprised  age.  time  a l l first  units  t o meet  i n the acute  MI t o c o m p l e t e  screened care  arranged  time and number a n d  contact with the individual phoned  or o f f i c e  t h e s u b j e c t s seven  as agreed,  i n locations  selected  was weeks  and t h e by the  participants.  Data The  following  Collection  Instruments  i n s t r u m e n t s were  Emotion  Appraisal  Scale  (Folkman  Revised  Ways o f C o p i n g  patient  information sheet.  used  i n the study:  & Lazarus,  (Lazarus & Folkman,  1985), 1984),  The and a  The  57 Emotion A p p r a i s a l Scale The  Emotion A p p r a i s a l Scale  measure c o g n i t i v e a p p r a i s a l . checklist a  with  a  great deal).  scales: and  potential  harm and  a n x i e t y and  excitement disgust  24  by  and  refer  pleasure,  items  are  appraisal  relief  was  developed  formulated  emotion. Examining  the  relationships  predictions provides & Hungler,  that a person  positive  negative  feeling harm and The  by  both  the  1983).  findings.  internal  as  eagerness, guilt  benefit content  and  based  evidence In t h e  on  validity. of  a theory  the  study  of  the  Lazarus  (1985)  experienced was  students  reported  c h a l l e n g e e m o t i o n s , as w e l l  emotions a t each stage  of  of c o n s t r u c t  F o l k m a n and  expected,  as  appraisal.  findings  simultaneously  As  as  is  emotions. T h i s hypothesis  t h r e a t and  benefit  on  cognitlve-phenomenological  hypothesized  supported  the  emotions  emotions such  reflect  from  s t u d e n t s ' midterm examination,  and  while  to support  4 emotion  emotions such  sadness,  to  24-item  harm  focuses  p l e a s u r a b l e emotions such  and  used  at a l l ; 4 =  into  worry; c h a l l e n g e a p p r a i s a l  is available  (Polit  (0 = n o t  classified  anger,  was  is a  c h a l l e n g e emotions,  exhilaration;  Instrument  theoretical  Scale  t o harm a p p r a i s a l ;  Evidence  validity  Likert  A)  instrument  i s c h a r a c t e r i z e d by  happiness  previously  The  emotions. Threat  characterized  The  The  t h r e a t emotions,  benefit  fear,  5-point  (Appendix  of t h e  as  event.  c o n s i s t e n c y r e l i a b i l i t y f o r each  of  these  scales  (Folkman threat  & Lazarus,  emotions  emotions for  thebenefit  scale  midterm  1985) r e v e a l s  scale  scale;  Lazarus,  be  f o r thestudents'  scale;  emotions  t o Folkman and  scale.  theresults  interpreted  with  caution.  thepresent  initial .75;  study,  (Cronbach's f o r each  period,  Scale;  the  second  for  the four  Challenge results  Alpha)  scale  Emotion  Scale  Scale;  s c a l e s was  .64, a n d B e n e f i t  with  Emotion  Threat  scale  Scale. At  reliability . 4 4 , Harm . 7 7 ,  Indicates  caution  one, and t h e t h r e a t  was  .73 f o r t h e C h a l l e n g e  .82. T h i s  be i n t e r p r e t e d  At the  reliability  the Internal consistency was a s f o l l o w s :  should  consistency  f o r t h e four  a n d .66 f o r t h e B e n e f i t  scales  a t time  on challenge  o f t h e two a d m i n i s t r a t i o n s .  t h eThreat  period,  must  based  a n d .78  of the challenge  theinternal  .58 f o r t h e H a r m E m o t i o n  Emotion  According  lowr e l i a b i l i t y  that  calculated  for the  .84 f o r t h e h a r m e m o t i o n s  suggests  reliability  a mean a l p h a  study  o f . 8 0 ; .59 f o r t h e c h a l l e n g e  ther e l a t i v e l y  In  examination  that  f o r t h e harm a t t h e second  interview. Revised  Ways  The  Coping  Revised  designed coping  of  Ways  by Lazarus  Scale  of Coping  and Folkman  s t r a t e g i e s . The r e v i s e d  checklist 3 = used  with  a 4-point  a great  deal),  Likert  Scale  ( A p p e n d i x B)  (1984) was u s e d version scale  and measures  Is a  67-item  (0 = does a wide  t o measure  not apply;  range o f  cognitive  and b e h a v i o r a l  coping  s t r a t e g i e s people  manage t h e demands o f a s t r e s s f u l  situation.  the  functions  c h e c k l i s t cover  emotion-focused Evidence the  Revised  from  and problem-focused  from  relevant  to several  incorporated  on  of  content  Coping  validity  strategy  The Ways samples  of Coping  i n t o the Instrument  as w e l l  Scale  of people,  of  items  own t h e o r e t i c a l f r a m e w o r k ,  literature.  been a d m i n i s t e r e d revisions  their  Scale.  The i t e m s  coping.  i s a v a i l a b l e t o support  Ways o f C o p i n g  were d e r i v e d as  t h e two b r o a d  use t o  has  with  based  on t h e  results. Factorial construct point  validity  validity.  out that  Furthermore,  factor analysis  statistical  technique  instrument,  because  factors  which  i s one method  group  f o re s t a b l i s h i n g  Burns  and Grove  i s t h e most  (1987)  important  f o r v a l i d a t i n g the structure  this items  method that  organizes  items  have a s i m i l a r  of an  into underlying  theme. Factor performed Oblique  analysis  using  of  principal  people  of coping  strategy Three  because  are expected  factor structures Scale.  Folkman  of an have  was rotation.  from a t h e o r e t i c a l  t o choose  strategies, rather  to the exclusion  Ways o f C o p i n g  Scale  f a c t o r i n g and oblique  r o t a t i o n was s e l e c t e d  perspective, variety  o f t h e Ways o f C o p i n g  than  from a  wide  t o u s e one  type  other. been  identified  f o r the  e t a l . (1986) r e p o r t e d  a 6  factor  solution  examination  f o r the  study;  study  Hilton  in  her  of  community middle-aged  solution  was  study,  the  sample  study  based  of  college students'  on  (1987)  women w i t h  found  found  breast  married  (Folkman  et  a  used  broad  because  sampling  of  5  cancer;  factor and  couples,  the  the  solution  In the  an  a l . , 1986).  f a c t o r s t r u c t u r e from was  a  midterm  study  8 factor  For  the  middle-aged  present  community  factor structure  p a r t i c i p a n t s and  was  stressful  situations. The  8  f a c t o r s are  distancing, accepting  responsibility, and  coping  describes  (e.g.,  " t r y to  the or  do  oneself  happened"), (e.g., serious  about  light  regulate  one's  feelings  to  bridges,  but  own  of  planful  to alter  the  which  suggest  anger  to  a  the  (e.g.,  to  to  create  degree person  "I take  the  believe a  a  Self-controlling f e e l i n g s (e.g.,  things  actions  caused  big  chance to  has  I refuse  describes  t r y not  open somewhat").  who  outlook  "I t r y to ("I  of  efforts  i t  positive  situation;  situation  change  Distancing describes  m y s e l f " ) , and leave  support,  responsible to  "I refuse  efforts  it").  efforts  risk-taking  (e.g.,  and  " I make  items  risky").  social  coping,  reappraisal. Confrontive  person  "I express  and  something  detach  and  (e.g.,  problem"),  positive  the  seeking  escape-avoidance,  aggressive  get  mind"),  hostility  following: confrontive  self-controlling,  problem-solving  his/her  the  to  get  to  efforts  to  keep to  my burn  Accepting  my  responsibility  acknowledges  (e.g.,  "I r e a l i z e  trying  t o put t h i n g s  something wishful  I brought right  the problem (e.g.,  t o make up f o r i t " ) .  thinking  (e.g.,  away o r somehow be o v e r escape  o n e ' s own r o l e  or a v o i d  "I a p o l o g i z e  "I wish t h e s i t u a t i o n and o t h e r  "I a v o i d  being  general"). P l a n f u l problem-solving problem-solving  efforts  on m y s e l f " ) , o r o r do  Escape-avoidance  with"),  (e.g.,  In t h e p r o b l e m  to alter  describes  would go  efforts to  with  people i n  describes deliberate  the s i t u a t i o n  (e.g., "I  know what h a s t o be done, s o I d o u b l e my e f f o r t s things  work"), combined  problem-solving it").  Positive  positive have  describes  reappraisal describes  efforts  Lastly,  t o seek e m o t i o n a l  support  more a b o u t  cognitive primary  efforts  to create  growth social  support  (e.g., "I support  ( e . g . , "I  from someone"), and  "I t a l k  t o someone t o f i n d  the s i t u a t i o n " ) .  evidence  t h e ways o f C o p i n g  relationships  (e.g.,  approach t o  o f a c t i o n and f o l l o w  seeking  sympathy and u n d e r s t a n d i n g  Further on  " I make a p l a n  new f a i t h " ) .  informational out  an a n a l y t i c  m e a n i n g b y f o c u s i n g on p e r s o n a l  found  accept  (e.g.,  with  t o make  based  of c o n s t r u c t v a l i d i t y Scale  from t h e s t u d y  couples,  as d i s c u s s e d  c o n s i d e r a t i o n s . The  predicts a relationship  a p p r a i s a l (various stakes)  obtained  obtained  by e x a m i n i n g t h e e x p e c t e d  on t h e o r e t i c a l  a p p r a i s a l theory  was  and c o p i n g .  of the middle-aged  earlier,  supported  between  The r e s u l t s  married  this  hypothesis.  In  the study  reliability  of the middle-aged  alpha  coefficients  married  provided  Instrument's  internal  coefficients  f o r the confrontive coping  for  support .72  Scale;  .66  evidence  c o n s i s t e n c y . The  the d i s t a n c i n g scale;  .76  f o r the s e l f - c o n t r o l l i n g  for  the present  study,  planful  reliability  scale.  alpha  p e r i o d were  coefficients confrontive  coping  .44, d i s t a n c i n g .47, s e l f - c o n t r o l l i n g  .35,  social  support  .53,  positive  .68, a c c e p t i n g  .55,  responsibility  .74, p l a n f u l  problem-solving  r e a p p r a i s a l .85. A t t h e s e c o n d  reliability  alpha  coefficients  were  .86, a c c e p t i n g  responsility  interview,  .68,  planful  problem-solving  .86.  At both  testings confrontive coping,  problem-solving reliabilities. distancing  Additionally,  Results  social  escape-avoidance  positive reappraisal planful  responsibility at the i n i t i a l  and s e l f - c o n t r o l l i n g  reliability. cautiously.  and a c c e p t i n g  coping  .69, s e e k i n g  .46,  .56, a n d  seeking  .59, and  confrontive  d i s t a n c i n g .76, s e l f - c o n t r o l l i n g  support  scale;  f o r the positive reappraisal  the 8 scales at the i n i t i a l  escape-avoidance  .61  social  .68 f o r t h e  scale; In  .70;  responsibility  scale;  .70  alpha  s c a l e was  problem-solving and,  .79  scale;  of the  reliability  f o r the seeking  f o r the accepting  f o r the escape-avoidance  couples,  a l s o had a  had  low  period low  m u s t , t h e r e f o r e , be i n t e r p r e t e d  Patient  Information  The sheet  Sheet  investigator  a t each p o i n t  pertinent  developed a patient  i n time  demographic  information  ( A p p e n d i c e s C & D) t o r e c o r d  d a t a , and r e l e v a n t  illness-related  information.  Data  Data  o b t a i n e d were a n a l y s e d u s i n g  statistics tests  and nonparametr1c  were s e l e c t e d  convenience not  Analysis  descriptive  statistics.  because, a s m a l l  Nonparametric  sample  size  and a  s a m p l i n g t e c h n i q u e were u s e d . N o r m a l i t y c o u l d  be assumed. The W i l c o x o n m a t c h e d - p a i r s s i g n e d - r a n k s  test  and t h e Spearman r a n k  comparative level  and c o r r e l a t i o n a l  of s i g n i f i c a n c e  because  of a r e l a t i o n s h i p .  computer  to test  The l e v e l  were c o d e d  program.  A  f o r the  two-tailed  the hypotheses  had n o t p r e d i c t e d  the d i r e c t i o n  of s i g n i f i c a n c e  a t 0.05 f o r t h e s t u d y . D a t a  questionnaires  were u s e d  data analysis.  was u s e d  the investigator  established  correlation  was  o b t a i n e d from t h e  and a n a l y z e d u s i n g  t h e SPSS-X  CHAPTER FOUR  Presentation This first  chapter  the  three  discussion  Discussion  is divided  section reports  characteristics of  and  of  the  the  the  into three  s a m p l e . The  sample  f o r the  participated who  d i d not  died,  and  emotionally at  newly d i a g n o s e d first  other  overwhelmed. A  At  i n the the  MI,  days post visited  8  first  with  90%  MI.  At  to  the  Nineteen  second  MI.  He  sufficiently analysis  marital,  sample w i l l occupational  Of  enough  three.  subjects  two  subjects one  had  he  was  for  felt  visited  complete i t to  p a t i e n t s were 5  the  interview,  MI  who  the  the be  process.  second  (H  =  discussed  and  these  the  d i d not  between t h e  be  of  interview,  = 5.7)  9 weeks p o s t  each A  p a t i e n t s comprised  fifth  and  patients  9  to  days  seventh  were  8.1).  D e m o g r a p h i c C h a r a c t e r i s t i c s of The  in section  further subject  interview, (H  r e l a t e d to  to p a r t i c i p a t e because  a second  data  health-related  Sample  interview.  refused  questionnaire  included  post  Interview. second  the MI  p a r t i c i p a t e i n the  e i g h t weeks had  second  of  The  i n s e c t i o n two.  f i n d i n g s i s presented  i n the  the  sections.  results  outlined  Characteristics T w e n t y one  Results  d e m o g r a p h i c and  hypotheses are  of  of  the  Sample  i n t e r m s o f age,  educational  s t a t u s . The  sex, sample  consisted ranged Table  o f 16 m a l e s  from  4 1 t o 73 y e a r s  I ) . Seventeen  e a c h was  (76.2%) and  single,  occupations  (11), professionals/managers  secretaries/office  had  completed  I I ) . over  workers  ( 1 ) . In terms  half  had completed  high  participants  h a d some s e c o n d a r y  school  a grade  I  Age of t h e Sample Age  Frequency  Percent  40-44  1  4.8  45-49  0  0.0  50-54  2  9.5  55-59  3  14.4  60-64  6  28.6  65-69  5  24.0  70-74  4  19.0  Total  21  100. 0  8  6  (28.6%), 8  (1)  participants  (38.1%),  education  at least  4  program (19%),  (14.3%). Table  (3),technicians  ( 2 ) , manual l a b o u r e r s  a c o l l e g e or u n i v e r s i t y  3 had a c h i e v e d  of the subjects  of education,  participants  remaining  1  were c a t e g o r i z e d by t h e  were r e t i r e d  homemakers  (see  widowed.  (see Table  or  Ages  2 were d i v o r c e d , and  investigator  (3),  (23.8%).  a mean o f 6 2 . 3 % y e a r s  were m a r r i e d ,  and  Participants'  with  5 females  and t h e  education  Table I I occupational  status  of  samples  Occupation Status  Frequency  Retired  Percent  11  52.4  Professional/manager  3  14.3  Technician  3  14.3  Secretary/office Manual  2  worker  labourer  9.5  Homemaker  1  Total  21  4.8  100.0  Illness-Related  C h a r a c t e r i s t i c s o f t h e Sample  Illness-related  variables will  follows: admission  time  that  elapsed  tohospital,  medical/health CCU  4.8  1  number  problems  and t h eh o s p i t a l ,  from  be d i s c u s s e d a s  suspected  symptoms t o  o f symptoms a n d o t h e r  reported,  and previous  length  of stay  knowledge  i n the  of heart  attacks. Patients to and  two days their  period  a period  (_ = 7 h o u r s )  admission  were a d m i t t e d appeared.  reported  of delay  between  tohospitals.  t h e onset Sixteen  t o h o s p i t a l s o n t h e same  Of t h e f i v e  of delay  remaining  ranging  from  ranging  from  zero  o f symptoms  patients  daythat  (76.2%)  symptoms  p a t i e n t s who r e p o r t e d  one t o two days,  three  a  patients for  had sought  conditions  decided  other  t o seek  attempts  medical than  medical  to relieve  assistance  b u t were  a n M I . Two o t h e r  help  after  what t h e y  their  treated  patients unsuccessful  had appraised  as "stomach  problems". At  the first  Interview,  patients  reported  patients  (57.1%) r e p o r t i n g  second  interview,  ranged  from  The  number  decreased having  zero  ranged  t o four,  four  no symptoms  symptoms  during  from  zero  (Table  o f symptoms  with  half  reporting  at the first  with  12  I I I ) . At the  patients  reporting  having  t o one; a l l four  their  o f symptoms  t o three,  one symptom  t h e number  of patients from  t h e number  reported  one symptom.  no symptoms  patients  interview  who  reported  had developed  convalescence.  Table I I I Number  o f Symptoms  Number o f symptoms  First Interview Frequency Percent  0  4  1  12  2  4  3 4 Total  1  5.3  10  52.6  19.0  4  21.0  1  4.8  2  10.5  0  0.0  1  5.3  100.0  19  100.0  21  19 .0  Second i n t e r v i e w Frequency Percent  57.1  Fatigue both the  time  had  three  hospital. pain these  of  first mild  breath  two  chest  as a p e r s i s t i n g  had s u b s i d e d  shortness  (42.1%).  mild  Five  chest  patients  Two  of  complained  reported  interviews. At  symptom. A l t h o u g h  shortness  shortness  p a t i e n t s , four  of breath  chest  pain at  patients  a t both  they  having  one p a t i e n t r e p o r t e d  i n four  other  following  of  patients  discharge  from  IV  Symptoms R e p o r t e d Between and E i g h t Weeks P o s t MT  Symptoms pain  Shortness of b r e a t h Fatigue Other  having  of breath  interview, only  second  from the  reported  (9.5%) t o e i g h t  pain.  I V ) . Of  patients stated that  o f p a t i e n t s who  shortness  developed  Chest  fatigue for a  i n t e r v i e w ; and t h e s i x other  to severe  second  Table  from  (Table  since discharge  p a t i e n t s had r e p o r t e d  breath had  symptom  The number  experiencing the  seven  symptom a t  of f a t i g u e a t the second  patients reported  this  increased  10 s u b j e c t s  complained  and t h e remaining  developed  frequently reported  by a t l e a s t  10 p a t i e n t s who  time,  of  t h e most  periods  interview,  the  was  symptoms  the F i f t h  First interview Frequency Percent  and  the Seventh  Davs  Second i n t e r v i e w Frequency Percent  2  9.5  8  42.1  5  23.8  5  26.3  11  52.4  10  52.6  5  23.8  4  21.1  the  h o s p i t a l . At  reported  by  (1),  pain  and  five  Interview, one  to  the  due  a  tenderness  to  interview, swelling or  infection  (1)  to  patients from  with  seventeen care  to  eight  s i x to  patients days.  second  three  patients:  another who  had  s i x weeks  prior  incisional  ankles. problems  hernia  the  reported  SD  i n the  (90.4%)  care =  days  (H  ranged  The  from  majority  coronary  care  the  patients  patients treadmill readmitted  eight  had  coronary  were w a i t i n g test  or  for a  week  =  12.3,  were d i s c h a r g e d  to  period  between  units  SD  =  six  4.2),  to  from  subacute  interviews,  a n g i o g r a p h y and get  a  angiography. medication  firm date One  of  of h o s p i t a l i z a t i o n  h o s p i t a l i z e d from  A l l patients  mild  units  3.4).  acute  length  twenty-two  (2),  seven  (1).  6.8;  The  by  respiratory tract  coronary  (tl =  days.  the  patient,  of  tearfulness  units. During  two  days  by  surgery  ( 1 ) , upper  (76.2%) remained  from  most  In  third  complained  hiatus  stay  fifteen  three  ranged  of  ( 1 ) . At  loneliness;  graft  of  symptoms  (3),  (2), hypertentlon  ( 1 ) , glaucoma and  a  health  were d i a b e t e s  arm  reported  report  bypass  other  loneliness  fractured  arthritis  three  were  symptoms were  medical  Length  Interview,  disturbances;  and  Other  a  coronary  second  patients  to  continued  sleep  undergone  first  patients  other  patient  reported  the  at for  patient  reaction, while  least  four  either  had  been  another  had  undergone c o r o n a r y bypass Patients who  had  friend  were a l s o  asked  a heart attack. or r e l a t i v e ,  Information  was  graft  surgery.  i f t h e y knew o f o t h e r  Most had  yet only  helpful  known someone,  2 of s u b j e c t s  t o them  people  whether  said  that  the  now.  Findings The  findings  relation  to each  Hypothesis Data on t h e  of the t h r e e  Changes  emotion  a t two  in Cognitive  scales  different  appraisal  Additionally, presented In  scale  in Table  the  Appraisal  of t h r e a t ,  points  a t two  will  harm, c h a l l e n g e and  be  in cognitive  i n time  scale  (see T a b l e V ) .  i t e m means a r e  VI.  immediate  p o s t MI  period,  threat  emotions  ranged  from  0 t o 10  (M_ = 4 . 0 ,  SD  = 2 . 8 ) , harm  ranged  from  0 t o 15  (tt = 6.4,  SD  = 4.2), challenge  emotions benefit  ranged emotions  At  eight  (H  = 3 . 7 , SD  = 5 . 6 , SD  of  provided before  t o changes  points  means and  obtained  i n time. A d e s c r i p t i o n  hypothesis 1 related In p a t i e n t s  presented in  the score r e s u l t s  f r e q u e n c y of each a p p r a i s a l  addressing  be  hypotheses.  are presented using  four  benefit the  1;  of the study w i l l  from  2 t o 12  ranged  weeks p o s t MI,  from  (M. = 6 . 1 , SD 0 t o 12  threat  ranged  ranged  = 4 . 6 ) , c h a l l e n g e emotions  = 3 . 5 ) , and  (ft = 3 . 3 , SD  emotions  = 2 . 1 ) , harm e m o t i o n s  emotions  from  ranged  = 3.5).  from  1 to 9  0 t o 17  from  2 to  (H 11  Table V Cognitive  Total  A p p r a i s a l T y p e s and Changes Over  score  5 and 7 Days P o s t MI Frequency Percent  0-2 3-5 6-8 9-11  Threat 8 6 5 2  Total  21  Appraisal 38.1 28.6 23.8 9.6  8 Weeks P o s t MI Percent Frequency  (a)  100.0  Harm A p p r a i s a l  Time  7 8 2 1  38.9 44.5 11.2 5.6  18  100.0  (M  0-3 4-7 8-11 12-15 16-19  7 6 6 2 0  33.4 28.5 28.6 9.6 0.0  8 5 2 2 1  44.6 27.8 11.2 11.2 5.6  Total  21  100.0  18  100.0  Challenge 2-4 5-7 8-10 11-13  Total  0-3 4-7 8-11 12-15 16-19  Total Note.  Appraisal  (a)  9 6 2 4  42.8 28.6 9.6 19.1  5 6 5 2  27.8 33.4 27.9 11.1  21  100.0  18  100.0  7 7 2 1 1  39.0 39.0 11.2 5.6 5.6  18  100.0  B e n e f i t A p p r a i s a l (c) 12 6 2 1 0  21  57 . 1 28.6 9.6 4.8 0.0  100.0  ( a ) Maximum s c o r e p o s s i b l e = 12 (b) Maximum s c o r e p o s s i b l e = 20 ( c ) Maximum s c o r e p o s s i b l e = 16  (3 (5 (4  items items items  x 4). x 4). x 4).  ( H = 6 . 3 , SD = 2 . 9 ) , a n d b e n e f i t 16  emotions  ranged  from  0 to  ( f t = 5 . 3 , SD = 4 . 4 ) . Each  five  appraisal  t o seven  challenge  days  emotions  reflected  post MI, s c a l e were most  harm and t h e n b e n e f i t challenge  emotions  increased  considerably  followed  by t h r e a t  To a d d r e s s changes  i n each  Wllcoxon  range  item  frequent,  emotions.  predominated.  means  weeks  by  that  threat,  emotions  i n frequency,  emotions.  appraisal  signicant time, the  matched-pairs slgned-ranks test  was u s e d .  differences  At  post Ml,  However, b e n e f i t  the hypothesis predicting cognitive  indicate  followed  At eight  and were second  and harm  of scores.  over  significant  Table  a wide  were  found  No  i n a l l cognitive  VI  Changes Seventh  i n Cognitive A p p r a i s a l Between D a y s a n d E i g h t W e e k s P o s t MI  Emotional Appraisals  n  Threat emotions  21  1  4.1  (3)  1.37  18  2  3.7  (3)  1.23  21  1  6.4  (5)  1.28  18  2  5.6  (5)  1.12  21  1  6.1  (3)  2 .03  18  2  6.3  (3)  2.10  21  1  3.3  (4)  0.83  18  2  5.3  (4)  1.33  Harm/loss emotions Challenge emotions Benefit emotions  Time  the F i f t h  M.  Number of items  I tern mean  and t h e  Z.  D.  -.63  NS  -.97  NS  -.44  NS  -1.39  NS  appraisal  emotions  between  the i n i t i a l  period,  and  eight  weeks p o s t MI. T h e r e f o r e , t h e r e s u l t s do n o t s u p p o r t hypothesis cognitive  1. T h e r e  were  no s i g n i f i c a n t c h a n g e s i n  appraisal  over  time.  Hypothesis Data of  2;  related points and  will  i n time  At from  strategies seeking 10.7,  of t h e frequency of each  i n the coping strategies  (see Table  the f i r s t  from  planful  ranged  from  1 t o 10 ranged  3 t o 15  1 t o 21  At eight from  0 t o 11  ranged  ranged  from  VIII.  1 t o 20  (tl = 11.48,  2 t o 17  strategies  self-controlling  from  4 t o 18  (tl =  = 3.2), escape-avoidance  ( H = 7 . 7 , SD = 5 . 4 ) , ranged  from  reappraisal SD  .  2 t o 15  (H  strategies  = 5.8).  weeks p o s t MI, c o n f r o n t i v e ( t l = 4 . 4 , SD  ranged  responsibility strategies  problem-solving strategies  from  means  (M_ = 9 . 9 , SD = 3 . 1 ) ,  ( 1 1 = 6 . 0 , SD  from  a t two  strategies  ( t i = 8 . 9 1 , SD = 3 . 2 ) ,  = 8 . 3 , SD = 3 . 7 ) , a n d p o s i t i v e ranged  i n Table  confrontive  s o c i a l support strategies  strategies  used  ( H = 4 . 7 , SD = 2 . 6 ) , d i s t a n c i n g 3 t o 16  from  In  coping  VII). Additionally, scale  interview,  SD = 4 . 0 ) , a c c e p t i n g  ranged  each  a t two d i f f e r e n t p o i n t s  i t e m means a r e p r e s e n t e d  1 t o 10  ranged  o b t a i n e d on  be p r o v i d e d b e f o r e a d d r e s s i n g h y p o t h e s i s 2  t o changes  scale  Strategies  the results  coping strategies  A description  strategy  i n Coping  are presented using  the eight  time.  Changes  strategies  = 3.2), distancing  ( t l = 9 . 4 , SD = 4 . 2 ) ,  ranged  strategies  self-controlling  Table Coping  Total  VII Strategies  score  Types and  changes  5 a n d 7 D a y s P o s t MI Frequency Percent Confrontive  0-2 3-5 6-8 9-11  4 11 3 3  Total  21  Total  0-3 4-7 8-11 12-15 16-19  Total 0-3 4-7 8-11 12-15 16-19  Total  Total  8 W e e k s P o s t MI Frequency Percent  Copina  lb) 5 7 4 2  100.0  3 9 8 1 21  21 5._Kinq 0 5 5 8 3  Copina  21  4 4 7 6 21  4 5 6 3  100.0  100.0  CoDina (c) 3 3 9 2 1  Support  100.0  Responsibility  16.7 16.7 50.0 11.2 5.6  18  CoDina  100.0  (b)  0.0 23.8 23.8 38.1 14.3  100.0  22.4 27.8 33.4 16.8  18  100.0  19.0 19 .0 33.3 28.6  100.0  (b)  14.3 42.8 38.2 4.8  Social  27.8 39.0 22.3 11.2  18  self -controllina l 4.8 3 14 .3 11 52.4 6 28.6 0 0.0  Accepting 0-2 3-5 6-8 9-11  Time  19.1 52.4 14.3 14.3  Distancing 2-5 6-9 10-13 14-17  Over  6 4 5 2 1  33. 3 22.3 27.9 11.2 5.6  18  Copinq  100.0  (a) 6 6 5 .1  18  33.3 33.3 27.8 5.6 100.0  Table  Total  0-4 5-9 10-14 15-19 20-24 Total 0-3 4-7 8-11 ' 12-15  VII  score  (continued)  5 a n d 7 D a y s P o s t MI Frequency Percent Escape-avoidance Copina 6 28.6 7 33.4 5 23.8 2 9.6 1 4.8 21  Planful Problem-solving 3 14 .3 28.7 6 8 38.2 4 19.1 21  100.0  0-4 5-9 10-14 15-19 20-24  Positive 3 4 6 7 1  ReaDDraisal 14.4 19.1 28.6 33 . 4 4.8  Total  21  100.0  (a) Maximum s c o r e (b) Maximum s c o r e ( c ) Maximum s c o r e (d) Maximum s c o r e  (d)  100.0  Total  Note.  8 W e e k s P o s t MI Frequency Percent  possible possible possible possible  CoDina  8 7 1 2 0  44.5 39.0 5.6 11.1 0.0  18  100.0  (b) 3 5 10 0  16.7 27.9 55.6 0.0  18 CoDina  100.0  le) 3 7 1 6 1  16.8 39.0 5.6 33. 4 5.6 100.0  18  = = = =  12 18 21 24  (4 (6 (7 (8  items items items items  x x x x  3) . 3) . 3). 3).  strategies social  ranged  from  1 t o 16  support strategies  (H = 8 . 7 ,  ranged  from  SD  1 t o 18  = 5.2), accepting  responsibility strategies  to  = 2.7), escape-avoidance  9  (_ = 4.6,  ranged  from  SD  0 t o 15  problem-solving SD  strategies  = 2 . 9 ) , and p o s i t i v e  2 t o 20 In at  (fci = 6 . 3 ,  (_ = 1 0 . 3 , SD comparing  five to eight  seeking positive  ranged  from  reappraisal  days,  i t e m means  1 t o 11  were  used  of  most  time  frequently;  used  of distancing,  coping, escape-avoidance, planful  strategies  Considerable  with  used  with  less  variability  self-controlling  was  positive  t h e most  with  accepting  noted  i n t h e use of  accepting  and p o s i t i v e  variability  and p l a n f u l  noted  for  reappraisal confrontive,  problem-solving strategies.  Wllcoxon matched-pairs  examine whether  eight  frequently.  escape-avoidance less  and  p r o b l e m - s o l v i n g and s e e k i n g s o c i a l  seeking s o c i a l support,  responsibility,  from  period,  l e s s . At  confrontive  to  ranged  r e s p o n s i b i l i t y and  and s e l f - c o n t r o l l i n g were used  The  7.1,  distancing,  reappraisal  strategies,  (_. =  strategies  the strategies  the strategies  responsibility,  1  strategies  f o r each  problem-solving strategies  distancing,  from  coping, s e l f - c o n t r o l l i n g , escape-avoidance  weeks p o s t MI,  support  ranged  SD  = 5.7).  scale  reappraisal  (fci = 7 . 1 ,  = 4.6), p l a n f u l  s o c i a l support, accepting  confrontive planful  SD  = 4.3), s e e k i n g  slgned-ranks test  or n o t t h e r e were  was  used  s i g n i f i c a n t changes  for  each  strategy  Significant support,  a t two p o i n t s  differences  planful  strategies. accepting  i n seeking  were  responsibility, confrontive  Although  responsibility Therefore,  distancing,  the findings  hypothesis  strategies  over  coping  of t h i s  There  strategies  social reappraisal  found f o r  coping,  accepting  had a p r o b a b i l i t y  2 related  time.  VIII).  and s e l f - c o n t r o l l i n g  not s i g n i f i c a n t ,  strategies  (see table  and p o s i t i v e  No s i g n i f i c a n t c h a n g e s  strategies.  three  found  problem-solving,  escape-avoidance,  support  were  i n time  study  only  t o changes  level  o f 0.07.  partially  i n coping  were s i g n i f i c a n t changes I n  but the remaining  five d i d not  change.  Hypothesis 3; and  Coping  R e l a t i o n s h i p s Between C o g n i t i v e  Strategies  A Spearman rank the  relationship  appraisal of  relationships  correlation  between  scales  t h e two time  emotions  each  of the four  and t h e eight periods  were  noted  and coping  was p e r f o r m e d  coping  (see Table  strategies.  post  related  only  t o t h e use of p l a n f u l  strategies.  were  MI, t h r e a t  Although  of any coping  emotions  harm e m o t i o n s  strategies  positively related  IX).  Between  days  t o examine  emotion  strategies Some  between c o g n i t i v e  seventh  use  Appraisal  a t each  significant  appraisal  of  t h e f i f t h and  were  positively  problem-solving were n o t r e l a t e d  a t the second  to confrontive,  period,  accepting  tothe they  Table  VIII  Changes Seventh  In Coping S t r a t e g i e s Between t h e F i f t h D a y s a n d E i g h t W e e k s P o s t MI  Coping Strategies  n  Confrontive coping  21  1  4.67  (6)  0.78  18  2  4.44  (6)  0.74  21  1  8.91  (6)  1.49  18  2  9.44  (6)  1.57  21  1  9 .86  (7)  1.41  18  2  8.72  (7)  1.25  21  1  10.71  (6)  1.79  18  2  7.11  (6)  1.19  21  1  6 .00  (4)  1.50  18  2  4.56  (4)  1.14  21  1  7.71  (8)  0.96  18  2  6.33  (8)  0.79  21  1  8.29  (6)  1.38  18  2  7 .06  (6)  1.18  21  1  11.48  (7)  1.64  18  2  10.33  (7)  1.48  Distancing  Self-controlling  Seeking Support  Social  Accepting Responsibility  Escape-avoidance  Planful Problem-solving Positive Reappraisal  Time  tl  Number of items  I tern mean  and t h e  Z.  EL  -.14  NS  -.50  NS  -1.22  NS  -2.74  .01  -1.82  .07  -1.11  NS  -1.92  .055  -2.15  .03  79 Table  IX  R e l a t i o n s h i p - Between c o g n i t i v e A p p r a i s a l and c o p i n g S t r a t e g i e s Between t h e F i f t h and t h e S e v e n t h Days and E i g h t Weeks p o s t MI  1  2  Coping 3  S t r a t e g i e s (a) 4 5  6  7  8  .28 NS  ,34 NS  ,49 .026  .08 NS  .13 NS  .27 NS  .19 NS  .19 NS  .62 .00  .34 NS  .47 .03  .37 NS  -.12 NS  .04 NS  .056 NS  .05 NS  .13 NS  .16 NS  . 29 NS  .45 .04  .23 NS  .17 NS  -.02 NS  .18 NS  -.32 NS  .25 NS  .18 NS  .30 NS  .42 .04  -.05 NS  .21 NS  .00 NS  Threat Time 1 .  P-  .28 NS  .13 NS  .19 NS  .35 NS Time  Kho P.  .11 NS  .01 NS  . 03 NS  .15 NS  rho  2.  Harm Time 1 . rho P.  .49 .03  rho P.  .23 NS  .18 NS .27 NS  .18 NS .21 NS  .13 NS Time  2.  .05 NS Challenge Time 1 .  rho P-  .37 NS  . 42 .057  rho P.  .19 NS  .04 NS  .11 NS  .73 .00 Time  -.11 NS  .11 NS  2.  Benefit Time 1 .  P-  .44 .05  rho P.  .02 NS  rho  .17 NS  .09 NS  .54 .01 Time  . 38 .06  .50 .02  .09 NS  2.  (a) N o t e . l = c o n f r o n t i v e c o p i n g ; 2=distancing; 3=self-controlling; 4=seeking s o c i a l support; 5=accepting r e s p o n s i b i l i t y ; 6=escape-avoldance; 7=planful problem-solving; 8=positive reappraisal.  responsibility  and  at  period.  Similarly, challenge  the  of  the  not  initial  related  second  to  time,  support  and  but  planful  use  were  positive  problem-solving  any  coping  at  emotions  were  strategies  positively related reappraisal  strategies  to  strategies  at  the  seeking  social  at  Initial  the  Interview. Benefit at  each  point  positively social  emotions in time.  related  support  the  second  strategy,  of  use  Only  were  found.  Interview,  were  only  the  not  eight  between v a r i o u s at  and  four  second  emotions,  will  sample  changes  use  form  was  not  No  other  to  and  were  seeking  of  of  strategies  coping  related  to  any  of  the  significant the  findings  relationships strategies.  s i g n i f i c a n t . At  the  and  support  between  The  majority  of  initial  significant correlations  emotion appraisals  results  headings:  one  strategies  emotions  responsibility  coping  were  coping  found  strategies,  interview.  Discussion The  the  Therefore,  3 related  different  confrontive  to  accepting  to  benefit  of  and  emotions.  appraisal  correlations  two  and  hypothesis  cognitive  and  the  interview.  types  correlations part  Initially,  escape-avoidance,  assessed  in  to  related  strategies,  self-controlling at  were  be  of  Results  discussed  under  the  following  c h a r a c t e r i s t i c s , changes  in coping  strategies,  and  in  relationships  81 between c o g n i t i v e results  of t h i s  theoretical the  study w i l l  methodological  No with  terms  be e x a m i n e d  problems  how  of demographic  data  general  t r e n d s were  this  from  a large  According  MI v i c t i m s  are of working  to  July  Changes  however,  appear  of age, and i n t h i s  this  Canada  higher  (1987),  age. In the present age. Therefore,  to reflect  men  e x p e r i e n c i n g MI. I n  reflects  to Statistics  Is  50% of  study's  with  respect  age, t h e sample of  these  broad  national  trends.  i n Emotions  The  frequency  appraisals these  attacks  of those  which  of working  study appears  available  (Statistics  26, 1988),  40 y e a r s  s e x , age i n g e n e r a l , and w o r k i n g  this  will  of the four types  be d i s c u s s e d b e f o r e  of  emotional  a d d r e s s i n g changes i n  emotions. At  both  appraisal all  over  percentage  7 6 % w e r e men  43% were  are currently  4 1 t o 73 y e a r s . A s a g r o u p ,  incidence.  sample,  and  to the study.  I n d i c a t e d . Heart  In persons  age ranged  study,  of  findings,  characteristics  personal communication,  represent  The  r e p r e s e n t a t i v e t h e sample  Canada,  study,  in light  empirical  related  statistical  t o determine  predominantly  strategies.  o f t h e Sample  specific  which  and c o p i n g  formulations, other  Characteristics  in  appraisal  times,  type.  four types  Most  participants  r e p o r t e d more t h a n  participants  of emotions  t o some  one  concurrently experienced degree.  The d e g r e e o f  variability  i n the  same, e x c e p t a  higher  of  for  degree  variability  of  six  twelve  The the  I f the  most  means  frequent  reported  at  interviews.  of  harm and  times.  Harm e m o t i o n s  emotions  were  Initial  study  this  week 94%  by  the  In  of  of  that  Burgess  attack  least  crisis  reported  crisis.  number  at of  emotions  low  both  benefit  type  of  at  the  benefit  interview.  both  low  assessed to  (1986)  patients Although  their  being  Fifty-two  levels  measurements.  that  i n MI  were  levels  at  While  levels  Hartman  regarded  the  frequent  i s comparable and  at  moderately  moderately  at  scores  were n o t e d  hospitalization.  half  to  second to  degree  moderate  appraisal  literature  patients  illness, heart  the  cardiac their  MI  moderate  sample  However, of  the  were, r e p o r t e d  in a  perceptions  at  with  the  low  lower  larger  interview.  moderately  revealed  challenge  emotions  frequent  which  been conducted  a  Moderate  second  least  study,  found  patients.  serious  the  the  recovery.  that  were a l s o  reported  emotions  appraisals  that  at the  were  was  final  threat  Interview,  emotions  threat  type  had  with  type,  a  i n the  uneventful  appraisal  both  or  indicated  levels  appraisal  an  Possibly,  interview MI,  practically  appraisals  been noted  months p o s t  item  In  have  experiencing  remained  emotion  variability.  would  measurement  subjects  emotions  benefit  second or  four  heart  No  emotion  the  MI  studied during  the  they  found  attack  moderately percent  of  as  a  stressed reported  fear  of  threat  recurring to  appraise  their  in this  lives.  their  would e x p l a i n  future the  e m o t i o n s were explanation discover Folkman  the  and 5 0 % r e p o r t e d  appears that  as b e i n g b l e a k .  moderately  the  low  MI  moderate  patients  That  levels  of  they  do  not  don't  threat  information  patients of  to  their  Consequently, the  reported  in  this  its  can't  is  what c a u s e d my h e a r t  have t h e  to  patients  tentative the  attack; now,  other  I'll  words,  full  they  that at  are  not  are  imposed.  the  likely  to  initial  h y p o t h e s i s . He item  item  and  sort  Therefore,  related  harm e m o t i o n s .  this  to  damage d o n e .  threats  the  In  and  necessary  appraisal.  the  complete  enough on my mind r i g h t  f o c u s e d on a c t i n g  by one p a t i e n t  complete  begun  situations  understand the  situation  one o f  One p l a u s i b l e  c o n s i d e r a b l e time  or  of  new demands o r  which  harm  had j u s t  significance.  illnes  supports this  of  what h a p p e n e d . As L a z a r u s and  extent  p u r p o s e f u l l y d i d not  "I  patients  may n o t  comments o f f e r e d  "guilty",  MI  make an a c c u r a t e the  levels  i n some s t r e s s f u l  and a s s e s s  realize  interview  the of  remark,  low  both measurements.  t h e y may r e q u i r e  MI  implications  perceive  at  may be s o c o g n i t i v e l y  event  may n o t  moderately  realities  that  Initially,  low t o  reported  (1984)  reacting  stated,  It  may be t h a t  individuals  Verbal  attack,  study.  Similarly,  out  heart  because I  i n any c a s e , worry  about  to  This  patient  don't I  know  have  this  later".  Interestingly, score  o£  1  on  at the  indicates  that  unfolding  event  reassessed  may In  of  also CCU.  it  be  a  what got  me  deniers  tend  further  point  denial  may a  the  two  gave  a  statement  over  the have  was  patients  to  a  be  out be  i n the  stomach  she  In  s i t u a t i o n as make p o s i t i v e  the  less  challenge  frequent  appraisal  type  at  One  the  on  second  me,  to  while  their said,  visit,  the  in  the  I tried  to  somebody e l s e .  Hackett  than  That's  (1973) s t a t e  They  that  found  that  non-deniers.  They  illness  Consequently, threatening,  "I  convinced  while  but  period  denial  patient  afraid  early  emotions  both  appraise but  of  low  phase i f  the  use  patients  they are  more  appraisals.  fact that  Itself,  use  mechanism.  The  attack  initial  to  Cassem and  beneficial.  heart  the  CCU.  happening  that  not  at  was  less anxious  did  moderately  commented  During  defence  participants  the  p r o b l e m s . . . I'm  happening  i t was  as  for  patients'  that  through".  i s used  to  This  patient  p a r t i c i p a n t s must  harm e m o t i o n s  stated  myself  likely  the  in appraisals  attack".  knew t h i s  perceive  item.  explanation  I have  heart  patient  denial  emotion  t h e y were  that  convince  of  and  example,  think  "I  interview,  mean t h a t  possible  while  wasn't  CCU.  may  related to  For  second  guilt  differences  threat  situation s t i l l  second  its significance.  Another levels  the  times  the  instead  were may  whole  the be  most  that  some  s i t u a t i o n or  considered  the  the  positive  aspects  of  their s i t u a t i o n . Observations  made d u r i n g  the  participants, arrest  or  the  to  i f .a  to  One benefit  emotions  the  the  While appraisal  be  for  the  were  level  found  observed.  Both  four  benefit. the  increased  focusing  from  the  i t was  in benefit  on  positive  its  that  more  negative  (1984)  argument  the  the  initial  too  explain  or  worry  emerges  low  early  to  may  is  in  make  level  of  the  such  further  explain  the  emotions  reported  after  success  patients  had  in  stressful situation.  indicated time,  emotion  changes no  in  types  of  harm,  H o w e v e r , some g e n e r a l  time.  emotions  The  most  which  cognitive  s i g n i f i c a n t changes  p o s i t i v e emotions over  during  anxiety  appraisal  for  benefit  over  cardiac  s i t u a t i o n as  Folkman  participants  reflect  results  i n the and  observed  may  emotions  challenge  benefit  of  some  threat.  that  This  demands of  the of  than  may  appraisals.  managing  hope,  explanation  positive  w e e k s , and  and  a  made  have m i n i m i z e d  Lazarus  For  challenge  the  for  process  eight  by  shifts  recovery  low  may  point.  progress  appraisal  challenge  possible  moderately  on  Possibly,  aspects.  person's  of  based  therefore  f i n d i n g reasons  m o r e one  be  patients  experienced  complications,  process.  and  threatening  that  who  this  participants appraised  challenging, or  serious  appeared  recovery  aspects,  exemplify  e s p e c i a l l y those  other  appraisals their  interviews  that  of  threat, trends  challenge  important  increased,  were and  change  was  although  not  significantly. decreased In  The  negative  slightly  addition  convenience  over  to  s m a l l sample  method,  have c o n t r i b u t e d t o the emotions theory  over  time.  (Lazarus  changes  situational  and  According factors and  refer  beliefs  situation benefit.  which  to the person-  separately  simultaneously  and  at  and  contributing  the  Folkman  (1984),  refer and  to the  stressful  to the  and  human  other  the  of  changing  be  discussed  will  on  Personal  factors  challenge  change  factors  and  are  characteristics lack  or  person  will  factor.  influence  the  situation.  discussion  Situational  ambiguity  factors  commitments  the  relevant to a  the  for their  of  harm, c h a l l e n g e  situation-factors  to the  personal,  personal  of  determinants  situation  the  coping  factors.  factors  are  in  and  of  and  environmental  appraisal.  appraisal  the  may  changes  e x p l a i n e d i n terms  threat,  times  factors  factors  of  because  refer  harm  the  absence  demands of a  considered  emotions,  novelty,  of  the  however,  interdependent,  stress,  important  resources which  The  emotion  of  other  significant  1984),  be  and  person-characteristics  are  appraisals  according  the  to Lazarus  Environmental  material  be  may  of  environmental  characteristics  will  Using  to the  t h r e a t and  size  several  lack  & Folkman,  significant  of  time.  the  sampling  emotions  will  as in threat include  nature  of  the  the  situation. explain  The  the  novelty  lack  ambiguity  of  effect  threat  on  the  changing  nature  the  of  lack  of  and of  and  already  happened.  was  a  Conversely,  by  a  shift  MI  of  i n harm  p a t i e n t s was  Increase  According  to  Lazarus  investigator  found  a  appraisals  of  threat  decreasing  slightly,  and  shift  slight and  explain  of  and what  has  are  of p o t e n t i a l Although  outcomes time.  not  emotions The  slightly,  while  there  emotions.  a  (1984),  situation  change  i n these  challenge,  while  to  challenge  over  Folkman as  the  harm  events.  decreased  in benefit  a p p r a i s a l can  used  evaluations  observed  while for i t s  evaluations  future  to  emotions.  i n a n t i c i p a t o r y and  harm e m o t i o n s  slight  be  t h r e a t and  with  used  Finally,  (1984) e x p l a i n t h a t  benefit dealing  challenge  will  a p p r a i s a l s . They are  significant,  be  emotions;  emotions.  change  will  considered  outcome a p p r a i s a l s or  anticipatory  intensity  be  situation  Folkman  are  will  benefit  the  situation  in threat  situation  benefit  reported  the  change  significant  Lazarus  harm and  o£  with  challenge  threat unfolds.  and The  anticipatory  threat  emotions  emotions  increased  slightly. The  only  appraisal the They  changes  college found  reflected  study  literature  i s Folkman  students that  i n the  in a  threat  and  and  midterm  to  Lazarus'  deal  emotion  (1985) s t u d y  examination  challenge  with  emotions  of  situation. which  a n t i c i p a t o r y a p p r a i s a l s were e l e v a t e d  at  time  88 one to  and two and d i d n o t change s i g n i f i c a n t l y time  time  two, but decreased  t h r e e . Harm a n d b e n e f i t  outcome time It  significantly  appraisals  rose  midterm  t o compare  Is a d i f f e r e n t  threatening  illness  the participants  related  beliefs,  type  this  way,  than  perhaps  patients  three.  i n sample  of s t r e s s  An  than  a  life  that  to appraisal.  and Folkman  appraisal  people  reflect  may  represents  motivates  Such a p a t t e r n  these  They  personality  numerous  in different  ways.  i s important  and h e l p s  behaviors  two  generate  t o cope w i t h t h e i r  (1984) e x p l a i n  of commitment  and  In future  manner.  through  n o t o n l y what  as  occasions  of commitments  (1984) e x p l a i n  tried  positive  determines  processes.  to  and hope, and t h e r e f o r e r e g u l a t e emotions.  Lazarus  what  t o time  t h r e a t e n i n g on b o t h  and Folkman  In an a n t i c i p a t o r y  also  one  had a p p r a i s e d t h e s i t u a t i o n  main p e r s o n - f a c t o r s c o n t r i b u t e confidence  to  to the students'  to the personal factors  Lazarus  two  event.  more c h a l l e n g i n g  be  results  one  represented time  two  time  time  and t h e c o n t e x t of t h e s t u d y .  examination  That  from  time  exam b e c a u s e o f d i f f e r e n c e s  characteristics  being  from  from  which  significantly  two, but d i d not change  is difficult  may  emotions  from  that  mechanisms  be  to a person, maintain  reflected  or i n t h e use of  which  Commitment  the person may  commitment  but hope.  i n Type  denial-like  A  A3 Lazarus  (1984)  and Folkman  p e r s o n a l i t y may be r e g a r d e d but  n o t o n l y as a c o p i n g  to Jenkins  predisposed  stressful  (1975),  to perceive  situation,  a coronary-prone  elements  albeit  pleasant (1983)  had  a more p o s i t i v e  regarding  did  cancer  (1984) with  stressful the  p a t i e n t s . Furthermore,  state that  their  available  illness  demands a s t h e y  found  t h a t MI p a t i e n t s  their  Lazarus  may a t t e m p t would  and Cassem  in their  hope. In t h i s anxieties.  (1978)  elaborate  d i s c u s s i o n of d e n i a l .  case,  using  on an a s p e c t o f T h e y remark  the person  i s not negating  but r a t h e r a c c e n t u a t i n g  aspects  in activity encouraging  of the s i t u a t i o n ,  level,  positive  explanations.  of d e n i a l . In  the heart  i t s positive  The p a r t i c i p a n t s v e r b a l l y made t h i s  on s p e c i f i c  that  alleviates  i n t e r v i e w s . Many p a r t i c i p a n t s made t h e i r  staff's  in this  i m p l i e s optimism or  view, s u c c e s s f u l d e n i a l  Here,  itself,  increase  to deal  i n any other  the s i t u a t i o n  i n s t a n c e s , t h e use o f d e n i a l  based  than  and Folkman  a r e s e v e r a l dimensions t o the concept  aspects.  illness  resources.  commitment  attack  i n any  or t r o u b l i n g .  They a l s o e x p l a i n t h a t  would t r y t o master  Hackett  some  some i n d i v i d u a l s  situation.  person  there  outlook  individual  of c h a l l e n g e  McCorkle and Q u i n t - B e n o l i e l  the  style,  a l s o a s a s t a b l e p a t t e r n o f commitments a n d b e l i e f s .  According is  r e m a r k , t h e Type A  test  In t h i s  point  during  appraisals w h e t h e r an  results  or t h e  way, n o t o n l y  was  danger  aspects good  minimized,  of  the  future.  confidence  Folkman,  personal  The  1984).  control  a  In  and  Burgess of  may  this  just  for  s u r v i v a l but  of  fear  becomes  and  and  other  hope,  that  low  level  Interview.  For  the  patients,  skilled  nurses  and  monitoring  some o f  the  have a d j u s t e d  to  this  that  found  heart  (71%). attack  reducing  as  These is  life  help  the  stress.  i n t e n s i t y of  change  the  attacks  s i t u a t i o n may  the  be  threat  a  such  over  threat  time. have  However, contributed  change.  moderately  After  heart  (Lazarus  stress-reducing.  f a c t o r s may  f a c t o r s may of  a  thereby  significant  fears.  and  create  in  they  their  i n the  situational  Environmental  hope  as  (1984) s t a t e  although  significantly  of  of  such  important  controllable  did  lack  beliefs,  perceived  Indicate  and  one  for  situations  (1986) s t u d y ,  results not  in a l l  people  controllable is  factors  maintain  of  Folkman  also  that  help  in difficult  particularly  patients  explain  environmental to  are  Hartman's  MI  threatening,  emotions  not  Some a s p e c t s  (66%),  individual  hope  s i t u a t i o n as  preventable  The  present  worry.  Lazarus  appraising  facts  was  appraisal  maintain  situations.  majority  optimism  commitments, b e l i e f s a l s o  m e a n i n g and &  situation,  replaces  Like  but  emotions  the  at  presence  equipment  few  secure  r e l a t e d to  days  the of  may  in a  environment.  the initial highly have  CCU,  reduced  patients  Shine  (1984)  may  remarks  that  help  alleviate  to  the  constant  hospitalization, positively It  i s not  feelings the  to  staff  extent threat.  the  novelty  (1984), that  a  novel  a  previously  for  first  the  s o m e o n e who study a  the  patients  and  had  MI  and  and  MI  lack  a  the of  may  provided. derived  functioning  of  initially Lazarus  patients  were  of  that  attack.  have  or  had  never  G e n t r y and  been Haney  to  patients  as  than  those  a  with  previously  2 of  known  the  h e l p f u l to  regarding played  the harm  reaction  Only  was  and  the  p a r t i c i p a n t s had  information  may  who  less anxious  the  heart  that  symptoms.  found  to  i t with  be  behavioral  information  process  to  associated  coronary  majority  said  rehabilitation  staff  have  h i s t o r y . Furthermore,  had  responded  the  presence  may  During  situation is stressful  infarction,  explained,  subjects them.  the role  in  appraisal  illness. A  the  that  s i t u a t i o n may  emotional  prior cardiac  of  the  were a l l f i r s t  experiencing  Possibly,  assume  signs  have  a p p r a i s a l . According  treated  myocardial  may  support  the  vital  anxieties.  plausible explanation  (1975) s t u d i e d  the  of  people  One  or  of  equipment.  threat  previously  in  to  and  patients  feedback  s e c u r i t y from  participants  a  moreover,  the  and  influenced Folkman  fears  unreasonable of  The  some  monitoring  second  situation,  situational may  c h a r a c t e r i s t i c , the  have a l s o  contributed  to  ambiguity  the  lack  of  of  significant unaware that  person  will  where  be u s e d  first  crisis fact  have  Consequently, patients  attack not  cues  perceive  fear  this  explain second  much w o r s e their Others  threat  further  harm  At  initial The  precarious appraisal.  or t h r e a t .  (1983) p o i n t  out, a  As  heart  b u t when p a t i e n t s  t h e most  In benefit  important  emotions  some  do  earlier  this  increase  interview,  i n benefit  time.  change  Since  have  and were e n c o u r a g e d begun t o p l a n  I f the patients  i t may  emotions.  During  been.  that  on  Some f o c u s e d  by t h e i r  their  perceived  the  optimism,  some p a r t i c i p a n t s c o m m e n t e d  the s i t u a t i o n could  had a l r e a d y  appraisal  over  of the s i t u a t i o n allows  progress  programs.  their  had s u b s i d e d .  symptoms a s w o r s e n i n g ,  study,  ambiguity  their  here.  are relieved.  was a n i n c r e a s e  also  ambiguity  reassuring  i n a less  and u n c e r t a i n t y ,  their  harm,  over  reported  their  even i n  i n the s i t u a t i o n d i d not lead  and Q u i n t - B e n o l i e l  anxieties  the  present  to anticipate  causes  In  influenced  degree of  be t h e c a s e  p a r t i c i p a n t s were  t h e p a r t i c i p a n t s were may  McCorkle  signalling  by a l l o w i n g  Initially  situation,  (1984) remark,  a r e cues threat  a high  i n t e r p r e t a t i o n s . S u c h may  and symptoms  position  the  there  I f a person i s  in a stressful  and Folkman  interview,  that  Involved  t o reduce  alternative  emotions.  u n l i k e l y experience  As L a z a r u s  situations  the  i n threat  of the r i s k s  threat.  can  change  how on  test results.  rehabilitation they  have  progressed, positive  their  added,  that  may  emotions  While intensity changing  as  likely  possible.  the  there of  have  at  the  was  increase  decreased  s i t u a t i o n may  (outcome) emotions  did  not  appraised  differently  the  demands  post  Lazarus  period,  significance  of  likely  to  In  present  such  a  These the  for  such  second  may  increase  in  emotions,  slightly.  explain  harm  change the  The  over  time.  situation is  depending  the  stressful  s i t u a t i o n for  his/her  of  and  threat  heart  attack,  patients  fear be  of  of  challenge.  r e s i d u a l symptoms  possible  although  event a  continues  negative  damage has  carries with  further  heart  obtained  at  some p a t i e n t s  unresolved.  the  issues  Patients  i t  attack  reflected in their Data  that  on  reassess  person  remark  why  the  to  the  although  remained  only  (1984),  further  m o s t p a t i e n t s , many o f  illness  reassuring  the  interview.  that  such  d i f f e r e n t stages,  situation,  as  information  during  threatening  threats  revealed  a  remind  life  threats  the  i n terms  Following  the  at  and  the  significantly  Folkman  imposed. They  Impact  well-being  and  Lazarus  in benefit  the  to  to  that  interview.  of  According  them  F o l k m a n and  contributed  harm e m o t i o n s  nature  remind  Therefore,  second  an  to  s i t u a t i o n evolves  ambiguity decreases.  interpretations benefit  was  outcomes were  (1985) s t a t e is  gain  are  outcomes. occurred, other or  death.  harm e m o t i o n s the  had  second  made  related reported  at  testing  progress, to  their  symptoms  increasing  both  i n numbers and s e v e r i t y , a s w e l l a s  concerns r e l a t e d lifestyle. returned these  t o ongoing  Furthermore, a l l except  one c a n h a r d l y  s t a g e was o v e r  L a z a r u s and F o l k m a n situations, cognitive that  or t h a t  (1984)  i t i s almost  continue  t h e e v e n t was  remark  processes associated  to stress  points  reconstruction before  to c r i s i s  may  emotional  last  B a s e d on  the post concluded.  to d i f f e r e n t i a t e the  w i t h each s t a g e .  would  change  theory,  Damage  of t h r e a t  the post  explain over  that  will  infarct  why harm time.  I n some  a period of  up t o a y e a r  stability  had n o t  in real-life  i t elements  emotions d i d not s i g n i f i c a n t l y according  that  the person during  s t a g e . The p r e c e e d i n g  level.  say that  impossible  happened c a r r i e s w i t h  cases,  one s u b j e c t  to their pre-infarct a c t i v i t y  observations,  impact  t e s t s and c h a n g e s i n  following  c a n be r e a c h e d  trauma,  (Wiklund  et a l . ,  1985) . Methodological of  s i g n i f i c a n t changes The  related the  p r o b l e m s may  absence  i n emotions  harm and t h r e a t alpha  the lack  time. i n e m o t i o n s may be  At the f i r s t  interview,  c o e f f i c i e n t f o r t h e harm e m o t i o n interview,  f o r the threat  must t h e r e f o r e  explain  t h e low i n t e r n a l c o n s i s t e n c y  scales.  was 0 . 5 8 . A t t h e s e c o n d coefficient  over  of s i g n i f i c a n t changes  t o problems with  reliability  further  the r e l i a b i l i t y  emotion s c a l e  be i n t e r p r e t e d  cautiously.  of  the scale alpha  was 0 . 4 4 . R e s u l t s  The  small  sample  size  may  the  non-significant results.  not  to p a r t i c i p a t e  in  the  who  may  explanation  Since  data  in interpreting  Another  influential  s u c h as  the  lack  results  i n emotion a p p r a i s a l s c o u l d  in  this  study  was  nursing  staff  judged a b l e  were  identified  refused  T h o s e who  differently; of  thus,  those  Another changes used.  not  because  the  Some o f  the  the  changes  i n e m o t i o n s may  the  weak s t a t i s t i c a l  of  not  significant  a myocardial  the  person  r e a c t i o n phase  at  (Wiklund  participation  patients  the  were t o o  emotionally  responded  have b e e n skewed  lack  stress. of  significant  test  used,  test  was  detected.  changes can not  but  significant  also  change  in eight  According  i s merely at  et a l . , 1985).  reflect  to the  weeks  crisis end  of  Further  needed  to determine  at  months  following a myocardial  twelve  in  have been s i g n i f i c a n t ;  have been  time  the  questionnaire  measurements a r e s i x or  be  significant  that  have  infarction. this  must  that a nonparametric  E m o t i o n a p p r a i s a l s may  following theory,  may  f i n d i n g s may  of  reality.  they  f o r the be  because  Absence  be  d i s p l a y i n g unusual  i n e m o t i o n s may  variance  Some p a t i e n t s , however,  s a m p l e may  explanation  of  to complete  refused  a wider  these  Only those  approached.  to p a r t i c i p a t e  distraught.  terms  and  causing  findings.  f o r the  voluntary.  in  some s u b j e c t s e l e c t e d  have p r o v i d e d  sample. T h e r e f o r e ,  considered  be  whether  changes  occur  infarction.  Possibly,  a s one p a t i e n t  emotion a p p r a i s a l s stressful  will  that  in  The  In  to prevent never  coping  before  of the e i g h t  were u s e d  social  strategy, reported second  i n coping  b u t one scare  i n t h e use  for confrontive, strategies. of  coping  a t the second  increased  was t h e most  a t each  reappraisal  a l l types  frequently  t h e Item mean s c o r e s support  strategies.  and p o s i t i v e  that  be  accepting  was n o t e d  revealed less  will  was n o t e d  support,  with moderately high  slightly. indicated  frquently  to moderately  period,  At the that  used low l e v e l s  a t b o t h t i m e s . P o s i t i v e r e a p p r a i s a l was t h e  most  times, with high  social  f o r d i s t a n c i n g which  seeking  of coping  and p l a n f u l p r o b l e m - s o l v i n g  Item mean s c o r e s  period,  I can  psychological  variability  Less v a r i a b i l i t y  initial  in a  attack,  of each s t r a t e g y  escape-avoidance  self-controlling  strategies  "Sure,  heart  types  changes  mean s c o r e s  seeking  responsibility, strategies.  a second  change  strategies  considerable  of d i s t a n c i n g ,  attack:  change... t h i s  addressing  comparing  period,  except  significantly  interview,  there".  frequency  discussed  time  will  a l w a y s be  Changes  may n e v e r  a t the second  s i t u a t i o n such a heart  change something thing  stated  frequently item  t o moderate  responsibility  used  mean s c o r e s levels.  decreased  type  of s t r a t e g y  decreasing  Scores  on  from  a t both moderately  accepting  f r o m m o d e r a t e t o m o d e r a t e l y low  levels. the  D i s t a n c i n g was  second  increased levels. at  the  both  time.  Scores  slightly  Scores Initial  t h e most u s e d  on  from  period  higher the both  low  s c o r e a t the  least  used  moderate  but  type  of s t r a t e g y scale  to moderately  remained  scale  high  were  moderately  higher  elevated at  low  levels.  The  levels  at both  times, with a  initial  period.  from  escape-avoidance slightly  Confrontive coping,  of c o p i n g , r e f l e c t e d  times, with only a s l i g h t  at  only  problem-solving scores decreased  moderate t o m o d e r a t e l y indicated  the d i s t a n c i n g  the s e l f - c o n t r o l l i n g  times. P l a n f u l  scale  on  type  decrease  low  levels  a t the  at  second  period. The  study demonstrates  range  of c o p i n g s t r a t e g i e s  their  h e a r t a t t a c k . At  although  MI,  five  a l l patients  a l l patients  used  and  the e i g h t  confrontive  coping strategies,  strategies  are just  a t each  may  stage  experimenting one  time,  strategies.  a wide  the  and  That  eight  types  weeks p o s t of  coping  used  9 4 . 4 % of p a t i e n t s a variety  they respond  encounter;  situation  MI,  available  at eight  t h e y used  to  and/or  of s t r a t e g i e s (Folkman  of  more  8 8 . 9 % of p a t i e n t s  with a v a r i e t y  a s p e c t of the  were u s e d  available  mean t h a t o f an  days p o s t  Similarly,  but a t t h i s  aspects  seven  ( 1 0 0 % ) used  strategies,  escape-avoidance  s u b j e c t s used  to d e a l w i t h the s t r e s s e s  of c o p i n g s t r a t e g i e s .  coping  the  some forms o f s t r a t e g i e s  frequently, types  that  used of  different  that  they  t o manage  & Lazarus,  1985) . The  results  appraisal  theory which  situations,  people  emotion-focused the  present  support, and  forms  positive  seeking  of coping.  reappraisal,  were  used  were used  positive  Two  distancing  plausible  in stressful  of seeking  frequently;  strategies  being  used  the most.  why  social  support  d e s c r i b e s t h e e f f o r t s t o seek The  patients,  and c o n s e q u e n t l y  coping  seeking  i n new  knowledge  i s one  situations  were  to.Cohen and L a z a r u s o f t h e most  where  sought  about  the problem,  could  be d o n e  about i t .  MI  people  i t existed,  (1979),  b a s i c forms have  i n f o r m a t i o n a s a way whether  first  l i m i t e d knowledge r e g a r d i n g  of  little  or i n ambiguous s i t u a t i o n s . Perhaps  participants  reason  the n o v e l t y and the  of the s i t u a t i o n . A l lp a r t i c i p a n t s  information  Seeking  emotional,  first  ambiguity  had  seeking  f r e q u e n t l y used.  support.  to situational factors:  time,  more  used  could explain were  i l l n e s s e s . According  social  s e l f - c o n t r o l l i n g and  strategies  their  social  seeking  support  relates  p e r i o d of  the most. At the second  were  and t a n g i b l e  and  accepting responsibility  social  informational  stress  problem-focused  strategies  reasons  the  At the i n i t i a l  reappraisal,  s o c i a l support  frequently,  most  support  that  use both  the strategies  strategies  distancing,  study  hypothesizes  typically  study,  distancing  support  of the present  the  t o f i n d o u t more  and  i f so  what  Seeking because  explain  care the  why s e e k i n g  available  positive  help  create  positive  (1982; state  that  maintain the  may o v e r l a p coping. that  that  denying In  right  outlook  individualized  the patients to perceive problems.  These  of  coping  accepting  have  a concomittant  (Degre-Coustry  &  and Folkman  resources  also help  i fpeople In this  such  problem-solving  reflect  the fact  way, s o c i a l  as a heart  & Folkman,  strategies.  that while  people receive  support  types  of  o f d i s t a n c i n g , i t may b e  the participants  planful  (1984)  believe they  t o be be e m o t i o n a l l y d e t a c h e d (Lazarus  theme  Grevisse  Lazarus  i n t h e case  situations  study,  used  forms  i n f l u e n c e the use of other  i t s occurrence this  widely  while  Additionally,  wish  were  meaning,  i s needed.  o r may  where  could  r e a p p r a i s a l and d i s t a n c i n g  e t a l . (1986).  i n stressful  patients  strategies  strategies.  t h e use of s o c i a l  support  observation  a l s o e x p l a i n why p e o p l e  and s e l f - c o n t r o l  a positive  available.  Positive  t o put things  Folkman  used  d i s t a n c i n g , s e l f - c o n t r o l l i n g and  responsibility  common t h e m e s .  been  as relevant t o their  could  reappraisal,  wanting  support  allowed  resources  responsibility of  period this  social  may h a v e  argument  accepting  a l s o have  i n a c a r i n g environment  was g i v e n  This  might  of the resources  at the i n i t i a l  Being  share  support  of the nature  Especially  used.  social  attack, without  1984).  made m o d e r a t e . u s e o f This  some a s p e c t s  choice  may  o f t h e MI  situation others used  were amenable  were  some  perceived  forms  frequently  of  than  self-control, consistent  positive the  both  situations,  the  of  of  coping  health contexts  least  Situational  r e a p p r a i s a l and  used  and  of  use  to  situational  and  life-threatening  situation  difficult  the  to  use  escape-avoidance efforts  contained  explanation et  or  at  factors  such  to  myocardial  as  a  envlromental  confrontive  coping,  may  patient's coping  limit  a  they  remark  patients  experiencing high  the  i n the  case  present  Methodological  times.  e x p l a i n the reason  in  the  Another  and  that hospital  of  It  risk-taking  Christman  distress  D i s c u s s i n g the  levels  refers  a  factors.  strategies,  lack  a t t a c k , made  included and  coping.  strategies  both  heart  aggressive  Infarction.  remark  stressful  dealing with  a l . (1988) s t u d i e d u n c e r t a i n t y , c o p i n g  following  They  first  in confrontive coping.  is related  Lazarus'  in  may  The  denial efforts  scale,  distancing is  used  strategies  Perhaps  less  emotion-focused  strategies.  factors.  patients  as  confrontive coping  coping  coping  such  study.  are  favor  environmental  these  the  F o l k m a n and  community sample  forms  That  strategies  coping  f i n d i n g s of  Escape-avoidance were  problem-solving,  unchangeable.  emotion-focused  with  while  as  rational  problem-solving  (1980) m i d d l e - a g e d that  to  use  environments  especially  stress.  of  This  may  in be  study.  problems  may  f u r t h e r e x p l a i n the  lack  of use of e s c a p e - a v o i d a n c e  coping  strategies.  participants  gave a s c o r e  they  c o n t a i n e d two d i f f e r e n t  thought  escape-avoidance "wish  coping scale  the s i t u a t i o n  with",  problems  smoking, like  particular  Results stressful  changes  revealed  decreased: planful social  coping  positive  of t h e s e  emotion-  i n a sample  F o l k m a n and L a z a r u s  coping  strategies  of  used  of coping  the s i t u a t i o n  have  coping  Semantic  Examining  strategies significantly  (emotion-focused), and s e e k i n g  and p r o b l e m - f o c u s e d ) . that  that  assessed  No  changes i n  was c o m p a r a b l e  However,  to that  i n t h e m i d t e r m exam  (1985) n o t e d  by s t u d e n t s  o f a m i d t e r m exam: t h e s e decreased  theory.  (problem-focused),  MI p a r t i c i p a n t s .  strategies  by e a t i n g ,  the r e c o g n i t i o n of  and c o p i n g  types  study,  stresses  over  i s t h e c l a i m o f L a z a r u s and  i n the l i t e r a t u r e  strategies  be  items:  c o p i n g c h a n g e s as a  reappraisal  (mixed  found  The  or m e d i c a t i o n s " .  forms o f c o p i n g  problem-solving  s t u d y was  that  appraisal  three  support  which  strategies.  i n the eight  that  better  may have a f f e c t e d  u n f o l d s . Such  Folkman's s t r e s s ,  feel  u s i n g drugs  demonstrate  event  actions.  w o u l d go away o r somehow  these  coping  items  c o n t a i n s two s u c h  and " t r y t o make m y s e l f  drinking,  the  o f "0" on c o p i n g  Many  similar  changes i n  to deal with the three  significantly  over  forms o f c o p i n g time  as t h e t h r e a t  decreased.  In t h e p r e s e n t  study,  positive  reappraisal  decreased  significantly that  some  forms  emphasizing coping  over  time.  of emotion-focused  the positive,  i f they  a r e used  Impede p r o b l e m - f o c u s e d something  contextual which  elements  I n t u r n have  problem-solving According explanation strategies done the  event  may  t o focus  half  (68%) of s t r a t e g i e s  energy generating  category by  Only  people  used  activities  11% of coping  coping  coping  that  of s e l f - c o n t r o l ,  h e a l t h p r o f e s s i o n a l s were  such  found  were  nature.  that  were  environmental i n the  42% o f methods  of that  et  as engaging i n  and d e c r e a s i n g  although  Miller  b y 480 c a r d i a c  p a t i e n t s used  strategies  when  used  situation.  activities,  c a n be  Conversely,  o f whom w e r e MI p a t i e n t s . T h e y  to problem-solving  stressors.  nothing  problem-solving  strategies  one p o s s i b l e  problem-solving  that  on t h e t r o u b l i n g  These  strategies.  (1985),  i n planful feel  available  planful  support  as changeable,  as p l a n f u l  that  positive reappraisal  the troubled situation.  such  majority  related  social  people  (1985) s t u d i e d c o p i n g  patients, the  be t h a t  would  of coping.  i n f l u e n c e d the use of  and seeking  that  options  forms  promoted  f o r the decrease  strategies,  al.  have  as  as resources, the  or coping  particular  may  i s appraised  them  such  argue  problem-focused  I t may b e  t o Folkman and Lazarus  t o change  allow  activities.  (1985)  such  t o manage e m o t i o n s  of the s i t u a t i o n ,  i t , may a f f e c t  coping,  can f a c i l i t a t e  i n the environment  exigencies within  Folkman and Lazarus  advised  In the  present  study,  although  problem-focused Initial  coping  p e r i o d than  participants  had  other  forms of c o p i n g  were  used,  were u s e d more f r e q u e n t l y a t  a t the  appraised  the  second  p e r i o d . P o s s i b l y , the  the  situation  MI  as  being  under  control. T h e r e was seeking the that  social  second the  changes  between t h e  with  the  post  MI  use  first  of  and  (1984) e x p l a i n  be  demands o f t h e  immediate  determined situation,  i t makes  by  the  and  the  logical  period, patients  h e a l t h p r o f e s s i o n a l s who  plausible changes  escape-avoidance, responsibility  emotional  explanations  offered tangible  support)  to  may  be  would  use  of s i g n i f i c a n t  measurement t o o l s .  responsibility coefficients  At  both  problem-solving coping  below  and  of coping,  accepting  related  to  methodological  earlier.  p r e v i o u s l y mentioned  planful  lack  in distancing, confrontive  strategies  absence  f o r the  self-controlling  problems r e f e r r e d  coping,  may  i n the  strategies.  significant  strategies  Folkman  strategies  (information, advice,  Other  with  and  demands. T h e r e f o r e ,  i n the  coping  The  strategies  of c o p i n g  i n these  interacting  such  support  available,  sense t h a t  support  decrease  periods. Lazarus  use  resources  also a significant  had  .60.  low  changes may  be  i n the related  types to  problems  testings confrontive and  accepting  reliability  Additionally,  alpha  at the  of  initial  period, low  s e l f - c o n t r o l l i n g and d i s t a n c i n g  reliability.  Results  must  therefore  coping be  a l s o had  interpreted  cautiously. The  lack  o f change  some q u e s t i o n s strategies. earlier, nature the  regarding  the v a l i d i t y  In a d d i t i o n  the lack  Regardless  coping  of the nature  coping  This  mentioned  P e r h a p s some o f  themselves  was n o t a c c u r a t e l y  of the items,  are not t y p i c a l  study's  patterns,  problems  scales.  a v a i l a b l e d i d not lend  some f o r m s o f c o p i n g coping.  raises  of the coping  t o the semantic  o f t h e i t e m s on t h e c o p i n g  strategies  strategies  o f s i g n i f i c a n t r e s u l t s may be due t o t h e  u s e d , and t h e r e f o r e  of  I n some c o p i n g  further  measured.  i t may a l s o  be  o f MI p a t i e n t s '  r e s u l t s may r e p r e s e n t  although  t o be  research  MI  that ways  patients'  i n t h i s area i s  necessary. Another the  explanation  nonparametr1c  f o r t h e r e s u l t s may be r e l a t e d t o  t e s t u s e d . Some o f t h e f i n d i n g s  been s i g n i f i c a n t ; but because used, s i g n i f i c a n t changes have been d e t e c t e d . different prove  o f t h e weak s t a t i s t i c a l  i n some f o r m s o f c o p i n g  The o p p o s i t e  statistical  may  may a l s o  be t r u e .  have test  may n o t With  t e s t s , some s i g n i f i c a n t r e s u l t s  may  otherwise.  Relationships  between C o g n i t i v e  Appraisal  and C o p i n g  Strategies In  t h i s study,  between t h e f o u r  s i g n i f i c a n t c o r r e l a t i o n s were  types  o f e m o t i o n a p p r a i s a l s and  found  particular  forms  period,  threat  the  of  use  emotions  planful  were  initial  related  coping.  emotions  and  planful  at  early  related  different benefit  use  of  confrontive  and  to  the  use  of  responsibility  types  period.  strategies  and  not  emotions  positive  at  points  both  were  were  in  time.  positively related  one  related  to  the  strategies,  accepting  type  of  coping,  any  of  the  to  at  reappraisal  emotions  s e l f - c o n t r o l l i n g and  was  strategies  s o c i a l support  Only  accepting  appraisal  assessed. The  stress,  explain coping  the  appraisal  relationships  strategies  (1984) s t a t e  that  used how  by a  and  MI  choice  of  appraisal,  and  coping  theory  cognitive  strategies, the  appraisal Folkman,  but  relationships types 1984).  and  not  a  emotions  the  Additionally,  no  of  Folkman  situation The  and  between p a r t i c u l a r forms  and  and  stress,  relationship  make s p e c i f i c  particular  to  appraisal  strategies.  predicts of  helps  Lazarus  appraises  coping  appraisal i t does  theory  patients.  person  the  between  coping  between c o g n i t i v e  influences  about  confrontive,  and  to  Harm  Benefit  were  seeking  strategies.  escape-avoidance,  to  MI  only  strategies.  problem-solving  emotions  post  positively related  s o c i a l support  strategies  Initially,  the  immediate  Similarly, challenge  seeking  to  were  the  problem-solving  period.  to  In  positively related  responsibility the  of  coping predictions emotion  coping  research  was  (Lazarus found  &  which  106 systematically appraisal At found  of  the  emotions initial  between  coping.  assessed  related  and  coping  period, a  McNett's  to  from  other  indicate  that  although  associated  coping  was  Therefore,  the  with  other  Furthermore, i s best the  research and  understood  and  by  and  the  the  coping  the  amenable coping  period  of  to  be  by to  short  delay  the  patients* admission  to  study  et  seem t o  as  the  well  between  the  forms  the A threat  may  be  patients  problem-solving  available. onset  hospital  as  available.  situation,  between  that  relationship  strategies  rational  i n some  situations Folkman  the  relationship  resources  the  were a l r e a d y engaged  seemed  (1984) s t a t e  resources  problem-solving  threatened  this  environment  and  planful  1979;  examining  emotions  of  coping  Folkman  f o r the  I t as  illness  findings.  explanation  appraised  However,  i n these  of  possible  although  significantly  & Lazarus,  results  Lazarus  person  options  because  functionally  with  a l s o used  al,  congruent  problem-solving  (r_ = 0 . 2 3 ) .  coping  was  health-related situations,  Cohen  that,  of  emotion-focused  1970-1971;  1986).  relationship  planful  coping  (Llpowski,  coping  and  s t u d i e s of  more w i t h  problem-solving  between  significant  (1987) s t u d y  emotion-focused  between c o g n i t i v e  strategies.  s u b j e c t s , t h r e a t a p p r a i s a l was  findings  coping  relationship  t h r e a t emotions  In the  disabled  the  of  Additionally, symptoms  suggests of  that  and  they  problem-solving.  be  According decide  to  G e n t r y and  to admit  committed coping,  Haney  themselves  than are  s u c h as  those  to  who  Folkman  patients  h o s p i t a l are r e l y on  (1984)  already  other  forms  further  factors explain  are that  the  coping  s t r a t e g i e s . They a l s o  threat  result  in emotion-focused  coping,  while  levels  r e s u l t i n problem-focused  coping.  In  experienced  emotions. Therefore,  individual's  significantly  Lazarus in  and  this  i n the  explain  be  the  use  threat  related  with  harm e m o t i o n s with  of  an  of  experienced  threat  c o r r e l a t i o n . According  harm and  i n some ways. MI  were  planful  problem-solving  t h i s study,  level  decisions.  (1984), d i f f e r e n t threats In  the  activities.  Interfere  period,  of  study,  a moderate  harm e m o t i o n s . L e v e l  Folkman  may  initial  moderate  explain  problem-solving may  of  planful  that  threat  of  levels  strategies. Participants also  harm a p p r a i s a l s .  appraisals  be  Lazarus of  use  high  may  positively correlated  factor  help  of  the  l e v e l s of  t o make r a t i o n a l  the  l e v e l s of  determining also  at  that  e m o t i o n s and  I t may  l e v e l s of  and  problem-solving moderate  use  ability  Similarly,  may  coping.  high  state  this observation  promotes the  Conversely,  influence  moderate  between t h r e a t  problem-focused threat  of  level  a p e r s o n e x p e r i e n c e s may  correlation  more  important,  threat  participants  who  denial.  Although environmental and  ( 1 9 7 5 ) , MI  as  a  coping to  are  involved  threat patients  may  have  been  using  manage s i m i l a r  planful problem-solving aspects  Harm e m o t i o n s accepting  were  an  accepts  responsibility  I n d i v i d u a l who  the s i t u a t i o n .  accepting coping.  positively  point  responsibility  One  could  it  would  further say that  likely  during have  t h e use  context  and  accepting  at the  week  responsibility  interventions  based  information  the  second.  period,  that  the with  a  acquired  allows  the  appraisals?  i n t e r v e n t i o n s might w h i c h may  to benefit emotions.  (1986) on  at  the s i t u a t i o n  of the s i t u a t i o n  medical  Hartman  accepting  harm e m o t i o n s  t h e c o r r e l a t i o n s of harm e m o t i o n s  and  were  i n f l u e n c e the r e a p p r a i s a l s , or i s  of p a t i e n t s ' perceptions  Burgess  way  problem-solving  i s why  the eight  new  In t h i s  to  strategies.  however,  i n the p a r t i c i p a n t s ' b e l i e f s  Influenced  of  and  t o do  harm e m o t i o n s  reassessed  Would  et a l .  knows what  b e n e f i t emotions  t o make d i f f e r e n t  Nursing  study  that  time period  the changed  change  also  correlates with  perspective.  this  patients  this  e x p l a i n why  but with  assume  different during  form of coping  question,  coping  period,  patients  uses  related to problem-solving  interesting  initial  may  with  t o Folkman  or blame They  correlated  According  r e s p o n s i b i t y promotes  This  An  situation.  significantly  responsibility.  (1986),  change  of the  strategies to  of the c a r d i a c  studied  t h e way  the e f f e c t  explain have  this  in turn  with In  their  crisis, of  nursing  i n d i v i d u a l s process  information. victims heart  Over a t h r e e  altered their  attack,  month p e r i o d ,  beliefs  and t h e i r  Instead  themselves,  people accepted  disease. offered  The  of b l a m i n g  researchers  heart  was  attack  happened", attack  be  In  a  study,  than  interventions  people  that  reframe believed  could  "how  which  the  have  can the  heart  patients  were  the e i g h t  interventions  i n harm  involved week may  and b e n e f i t  time have  appraisals  L a z a r u s and F o l k m a n o f harm  in  (1984)  and b e n e f i t  with  remark  c a n change  as  unfolds. period,  both  e m o t i o n s were  c o r r e l a t e d with  describes  appraisals  significantly  planful  that  the p a t i e n t s  simultaneously.  However,  of  and  coping.  r i s k - t a k i n g and a g g r e s s i v e  r a t i o n a l problem-solving  contradictory  outcome  confrontive  t h e s i t u a t i o n ; whereas  includes  coping  change  the i n i t i a l  positively  alter  thing  MI  these  appraisals  and b e n e f i t  coping  other  i f the p a t i e n t  programs d u r i n g  this  outcome  situation  harm  most  to self-blame.  At  that  helped  "the worst  As a r e s u l t ,  influenced  that  their  useful?".  rehabilitation  respect  sources  t h e a l t e r n a t i v e would be  this  period.  of  responsibility for their  alternative beliefs F o r example,  attack  t o resume p r e - i l l n e s s  believe  information.  heart  about the causes  ability  activities.  most  Confrontive  e f f o r t s to  problem-solving  efforts.  I t seems  would use b o t h according  forms of  t o Folkman e t  al.  (1986),  be  on o c c a s i o n s  an adaptive  patients  may  different of  form have  facets  the threats,  mutually other  of coping.  used  both  forms  contradictory  correlates  coping  way, c o n f r o n t i v e actions  coping  the study  Folkman  might  with  and  unsatisfactory encounters.  present  study  the  MI  and  negative various  emotions  in  a  o f harm.  In  facilitated  study,  with s a t i s f a c t o r y obtained  both  the patients No  i n the  emotions, the  found  to  deal  significant types  a t the second i s that,  period,  positive  tried  the four  given  of  measurement the  increase  the patients  may  situation.  a t the second  c o r r e l a t i o n was  adults,  problem-solving  as h o l d i n g  between  appraised  appropriate  at the i n i t i a l  of the s i t u a t i o n .  and b e n e f i t  the present  planful  Results  coping  this  appraisal.  that  explanation  positively  significant  the sources  or that  obtained  possible  challenge  have more In  demands  forms of used  perceived  and c o n f r o n t i v e  One  both  either  outcomes,  were  or adaptive  were a s s o c i a t e d  suggest  s i t u a t i o n was  correlations  time.  coping  Because the  patients  that  confrontive  be  MI  have  and  may  e t a l . , 1986).  benefit  found  on t h e n a t u r e  of coping  that  t h e MI  t o manage  of the community-residing  e t a l . (1986)  study  Depending  more m a t u r e  to control  associated  In  with  of coping  the investigator believes  confrontive  may  in this  forms  (Folkman  reflect  coping  Here,  of the s i t u a t i o n .  facilitative  coping,  confrontive  measurement  between  benefit  time,  emotions  and s e l f - c o n t r o l l i n g  Degre-Coustry an  adaptive  to  control  and G r e v i s s e form  emotional  objectively  reorganize  the  restrictions.  is  accompanied  association coping right  or t r y i n g At  seeking  social  emotions support  was  were  personal  may  appraisals. appraisals 1984).  appraisals over  study,  sense,  since  measurement  one's time,  life". a  significant  correlated with  related  seeking  i n ambiguous  occur  factors  when a n  a r e more  challenge  about  will  likely  requires substantial  personal  to influence  (Lazurus  &  Folkman,  challenge  has a sense  occur  earlier.  and b e n e f i t  (1984) s t a t e t h a t  individual  in relation  explained  to beliefs  situations.  and Folkman  social  reappraisal coping.  influenced challenge  Person-factors  and  challenge  o f t h e c o r r e l a t e s c a n be made  factors  of  to put things  Additionally,  say that  situation  forms  coping.  positive  account  This  support  significantly  to  self-controlling  both  of "wanting  the troubled person-environment  further  into  b e n e f i t emotions  have  Lazarus  taking  responsibility.  and environmental  Personal control  lives,  In this  themes  and w i t h  represents  patients t r y  between  Interpretations to  case,  found  coping,  to  self-control  In this  to reorganize  the f i r s t  relationship  their  logical  similar  According  r e a c t i o n s . T h e y make p l a n s  by a c c e p t i n g  makes  share  (1982),  of behavior.  their  imposed  coping.  of  relationship. only  efforts.  control They  i fthe  According  to  Llpowski of  (1970-1971),  illness.  Patients  more m a t u r e advice,  present the  forms  making  (Llpowski,  Social  these  support  people  have  will  receive social  & Cassem, t h a t MI  possibilities presence  participants  In the  patients  relationships  perceived  believed  were  found  support  i f they  when  (1979),  coping.  alternatives  t o implement  believe  support  and  how  their  They  i t i s needed.  social  of the  relationships,  1984).  may  social  with respect to  morale  they  situation.  perception of  in social  for effective  of workable  Information  1978).  the harmful  or  professional  and t h a t t h e y  assessed  a better  Cohen and L a z a r u s  t o use e f f e c t i v e  as seeking  (Lazarus and Folkman,  that  acceptance  i s d e f i n e d as the nature  place  are subjectively  reflect  and s e e k i n g  Hackett  t o manage  taking  supportiveness  the  plans  as c o n t r o l l a b l e ,  reason  interactions  to  such  be d u e t o t h e p a r t i c i p a n t s '  support.  they  likely  i t i s possible  do s o m e t h i n g Another  also  of coping,  positive  study,  strategies  a r e more  1970-1971;  situation  could  coping  explain that  they  According  enhances the  Therefore, the  f o r coping  more m a t u r e  encouraged  forms of  coping. The by  fact  positive  reappraisal people Folkman  that seeking  reappraisal  social  appears  describes efforts  a r e more  likely  support  logical.  accompanied  Since  positive  to create positive  t o use e f f e c t i v e  e t a l . (1986) suggest  was  forms  that positive  meaning,  of coping.  reappraisal  facilitates positive of  problem-focused  reappraisal  a situation  effective.  reduce In  on  formulations believes  now  of  the  case  planful may  favorable  the and  that Ml  i n the  the  coping  had  present  have p r o d u c e d  that  reappraisal  problem-solving  o u t c o m e s may  stress, the  the  recognized  coping  Indicators  of  of  ( L a z a r u s and situational ambiguity,  that  been  study.  The  strategies  positive  have  to  results.  influenced  were  understanding  of  these  participants'  relevant  to  probably  influenced  words, t h e  In  to  the  are  and a  these  t h i s study,  i d e n t i f i e d as the  contextual  benefit  extent  to  emotions  well-being  major novelty,  the  perception  the  may  to  or  have  control  altered and  These b e l i e f s appeared  to  made i n t h a t  w h i c h harm,  e m o t i o n s were e x p e r i e n c e d .  participants'  are  the  participants' appraisals the  is  s i t u a t i o n and  factors  respect  illness.  the  It  the  person's  a v a i l a b l e . The  their  experiencing  through a s p e c i f i c pattern.  b e l i e f s with  for  theory's  investigator  in patients  c h a n g i n g demands o f resources  and  process  1984).  environmental  challenge  r e s u l t s , the  i s Important  factors  coping  situational factors  Folkman,  responsibility  and  emotion a p p r a i s a l s ,  what  the  appraisal  study's  i s determined  determinants  the  indicate  out  reappraisal.  Based  first  be  threat  these  positive  a  use  harm and  turn,  also  They p o i n t  i n which problem-focused  Such may  participants'  could  coping.  b e l i e f s regulated  the  they  threat, In  other  levels  of  emotions.  These  experienced illness. coping of  and  i s one  of  hold  true  to  challenge.  The  of  Folkman  consider  mature  types  the  and  forms  the  research  in this  area  Methodological significant related  to  earlier.  Five  Indicated  problems  low  had  a  Additionally, distancing  reliability at  the  as  indicated did  Folkman  and  by  help  two  first  threat  MI  MI.  patients  Further  explain  the  tools  appraisal At  lack  both  reliability  the  initial  confrontive .60.  scale  and  alpha  period,  reliability  be  planful  self-controlling  low  appraisal  may  scales  times,  and  of  reported  c o e f f i c i e n t below  period,  low  that  emotions  measurement  alpha  at  (1984)  r e s u l t s suggest  responsibility  Indicated  and  of  plausible explanation  initial  Similarly,  scale  coefficients,  scales  same  productive.  may  with  accepting  coping  coefficients. appraisal  be  level  moderate  set  weeks p o s t  internal consistency.  problem-solving coping  might  problems  coping  The  to  and  s t r a t e g i e s used eight  the  that  harm, b e n e f i t  a  ( i n t e n s i t y ) of  c o r r e l a t i o n s . One the  of  with  coping.  s e v e n d a y s and  explain  that  low  of  at  to  that  what L a z a r u s  the  their  f a c t o r s . The  of  levels  coping  and  stress  of  further  emotions  were a s s o c i a t e d  determined five  (1984)  determining  for  the  phases  multidetermined  the  reflective  reflect  in early  results revealed  emotions  correlates  emotions  patients  s t r a t e g i e s are  appears  the  MI  Lazarus  threat  levels  by  l e v e l s of  harm  alpha at  the  second  period.  Therefore,  the  results  must  be c a u t i o u s l y  interpreted. The  findings  validity  of p a r t i c u l a r  discussed  and  measure t h e  to the  reasons,  study  coping  use  with  the  additional  sample  may  be  related  Different  use  to  the  strategies previously  of a nonparametrlc  relationships.  been o b t a i n e d  larger  of t h e  to  correlations  of p a r a m e t r i c  research should  test  be  may  have  test.  For  these  carried  out  with  a  size.  Summary In t h i s described  chapter,  i n terms of the  educational  and  Scores appraisals  levels  both  least the in  participants'  on  the  four types  were d i s c u s s e d .  benefit  t h a t most s u b j e c t s e x p e r i e n c e d  e m o t i o n s were t h e  Initially,  appraisal  frequent  most  a t the  type,  at both  i s a s s o c i a t e d with appraisal  an  degree  frequent  benefit while  second  emotion a p p r a i s a l s suggests  positive  to  of t h r e a t , harm, c h a l l e n g e and  four emotion types  moderate times. of  low  Only  appraisal  type  e m o t i o n s were  harm e m o t i o n s  optimistic  found  stressful,  outlook  five  the  were  trend  that, although  are  to  variability.  p e r i o d . The  i n p a t i e n t s who  been  marital,  emotion  frequent  MI  age,  have  of  Interviews.  least  first  data  emotions r e v e a l e d a higher  Challenge at  characteristics  illness-related  obtained  of the  benefit  sample  o c c u p a t i o n a l s t a t u s . In a d d i t i o n  demographic data,  indicated  the  and  to seven  days  a  and to  eight the  weeks p o s t  MI.  S i t u a t i o n a l factors that  p a r t i c i p a n t s ' lack  of  demands o f a c h r o n i c  illness  changeability  MI  the  of  the  as  harm, t h r e a t ,  time  period.  with  only  noted  i n the  Challenge  a slight  i n the  lack  of  four  challenge  benefit  the  perceived  have c o n t r i b u t e d  experience,  and  personal  to  at  having a  stress appraisals  eight  the  moderate  and  first  week  l e a s t change change  was  threat levels.  The  participants MI  is a  contextual  in f i r s t  appraisal  stressful  factors  MI  patients  in  the  that  subjects  have  studied.  The  study's  wide r a n g e their  MI.  results indicated  of  coping  On  both  a v a i l a b l e types  except period.  distancing  s t r a t e g i e s t o manage t h e  occasions, of  coping.  were u s e d  O v e r a l l , the  most p a t i e n t s  coping  moderately  low  for distancing  and  which r e v e a l e d  both  levels,  interviews,  coping  scales  confrontive At  the  at  score  coping  stresses  used  A l l forms of  used  less frequently  to moderately high  times.  i n an  i n emotions  that  eight  emotions  B o t h harm and  remained  suggests  stages  of  whereas a g r e a t e r  experienced  influence  significant  emotions r e v e a l e d  changes  that  no  benefit  emotions.  but  significant  types  and  increase;  emotions decreased  of  as  s i t u a t i o n may  c h a n g e s were o b s e r v e d ,  c h a n g e s were n o t e d  a  well  the  results. Although  of  knowledge r e g a r d i n g  related  the  reported  except low  scores  s t r a t e g i e s of  the  at  second  both  seeking  social  support,  were t h e and  most  positive  reappraisal  f r e q u e n t l y used;  confrontive coping  and  whereas  were t h e  least  d i s t a n c i n g coping escape-avoidance  used  types  of  coping. The  results  findings  are  c o n s i s t e n t with  1979;  (Cohen & L a z a r u s ,  previous  research  1980).  Folkman & L a z a r u s ,  These r e s e a r c h e r s e x p l a i n t h a t a l t h o u g h h e a l t h - r e l a t e d situations  favor emotion-focused  emotion-focused this and  study,  and  coping  participants  were  aspects  of  reflected  of the  of  supports  social  determine seven  these  the  the  illness, aspect.  situational  and  coping  the  coping  may  forms of c o p i n g  of c o p i n g  related  factors  nature  related  of t h e  acute  variables.  as  use  Ml  MI.  More  The  care  helped  patient at  the  use  of  reappraisal In t u r n ,  of c o p i n g  demands o f t h e may  these  strategies  Conversely,  setting  five  specifically,  positive meaning.  to the  which  supportiveness  first  activities.  of  coping  forms of c o p i n g  have a f f e c t e d  such  the  to problem-solving  situational the  promoted  forms  options available  e i g h t weeks p o s t  In  with  patients'  perceived  p a t t e r n of a  contextual factors  used.  or v a r i o u s MI  of  emotion-focused  to deal  The  or a c t i v e  forms  are  forms of  d i s t a n c i n g to create p o s i t i v e  types  and  one  both  coping  possibly  situation,  d a y s and  particular and  their  mature  i n f l u e n c e d by  ambiguity  drew on  coping,  t o manage j u s t  patterns  to  problem-focused  problem-focused  different  coping,  have  other illness  Inhibited  the  escape-avoidance  Examining the coping  positive  seeking  research similar  social  findings changes  Influenced  the  The  i n the  indicated types  strategies.  initial  relationship  the  was  problem-solving positively  planful  and  found  coping: the  found:  The types  and  positive  available used,  recovery.  with  relationships various  coping  significant  and  accepting  with  coping.  responsibility,  seeking  seeking  social  support  relationships forms  support  significant  accepting  two  Similarly,  social  Significant  e m o t i o n s and  planful  significantly  confrontive coping.  emotions s i g n i c a n t l y and  reported  situational  Harm e m o t i o n s were  p e r i o d , o n l y two  the  of  previous  which  patients  period, a  between b e n e f i t  self-controlling  in  o f e m o t i o n s and  correlated  reappraisal  benefit  support  resources MI  significantly  between t h r e a t e m o t i o n s and  coping.  c o n f r o n t i v e and  second  changes  of  problem-solving  1985)  significant  emotions c o r r e l a t e d  positive  were  found  problem-solving  challenge  The  phases  between p a r t i c u l a r At  results  strategies  early  results  The  e i g h t forms  strategies planful  environmental  coping  i n the  & Lazarus,  in coping.  w e l l as  primarily  support.  confrontive coping.  time  reappraisal,  (Folkman  demands as  and  over  revealed that three coping  decreased: and  changes  and  of  coping.  correlations  correlated  At  were  with  responsibility.  a s s o c i a t i o n s of the  v a r i o u s f o r m s of c o p i n g  assessed suggest  emotion that a  heart  attack  Is a p p r a i s e d  patients  who  are  post  The  study's  MI.  patients' factors  may  of MI. of and  a  first  MI  at  coping  coping  The  patients five  to  strategies  the  of  c o n v e n i e n c e method  in  a sample  that  of  first  patients.  were c o n d u c t e d  was  only  recovery process demands o f  reliability  In The  and  validity  of  the  of  stresses  weeks  to  post  maintain  form hope  activities. i n some a r e a s may  of  sampling  small may  the  early  sample  have  of  the  participants* is s t i l l  of  the  very  two  appraisal  scales  reported  .60.  The  measure c h a n g e s and have a f f e c t e d  the  strategies  MI  may  of  basic.  problems.  c o p i n g may  coping  understanding  caused  c o e f f i c i e n t s below  size  population  e m o t i o n s and stages  be  resulted  have a l s o  coping  emotions.  a more m a t u r e  Measurements of  to  affects  choice  may  tests  e m o t i o n s and  the  participants  Illness  in turn  eight  representative  during  their  alpha  nonparametric  reflect  MI  contextual  with  p r o b l e m s . The  where t h e  tools  scales  not  the  challenge  to deal  significant results  and  coping  use  used  methodological  Measurement  and  MI  weeks  that  the  s e v e n d a y s and  to  the  benefit  problem-solving  lack  MI  suggest of  first  eight  t h e i r b e l i e f s which  related the  further  understanding  which enables  initiate  s e v e n d a y s and  e m o t i o n s seem t o d e t e r m i n e  strategies  The  or  harm, t h r e a t ,  l e v e l s of  coping  to  results  influence  of  m o d e r a t e l y s t r e s s f u l by  five  perception  appraisal The  at  as  use  Five  of  relationships  the be  results. questionable.  Perhaps p a r t i c u l a r coping MI  patients*  therefore The  ways o f  coping  was  strategies  coping, not  basis  between c o g n i t i v e strategies  used  for  and  t i m e by  of MI  not  be  typical used,  of  and  measured.  coping  explaining  appraisal  over  could  accurately  stress, appraisal  theoretical  or  were n o t  theory provided  c h a n g e s and  e m o t i o n s and patients.  a  relationships coping  CHAPTER  FIVE  Summary, C o n c l u s i o n s , and  Implications  Recommendations  Introduction This  s t u d y was d e s i g n e d  cognitive  a p p r a i s a l and c o p i n g  myocardial  infarction  the  initial  the  variables  period  investigated strategies chapter  patients  and e i g h t  o£ t h r e a t , for their  patients  presents  conclusions, and  to describe  s t r a t e g i e s used by a t two p o i n t s  weeks l a t e r .  harm, c h a l l e n g e  used d u r i n g  implications  i n time, i n  Additionally, and b e n e f i t  r e l a t i o n s h i p s to the  an o v e r v i e w  recommendations  and compare t h e  coping  the recovery  of the study,  f o r theory  were  process.  followed  and n u r s i n g  This  by  practice  f o r research.  Summary A review relate  of l i t e r a t u r e  to patients'  suggests  that  processes  appraisals  o f an e v e n t  and c o p i n g  s t r a t e g i e s used i n  emotional  reactions  stressful  situations.  No r e s e a r c h  has been  help  found  c o m p r e h e n s i v e l y measures emotion a p p r a i s a l s patients  recovering  change over  been m e a s u r e d , r e s e a r c h patients  experienced  anxiety  have  found  and d e p r e s s i o n  which  appraisals  emotion a p p r a i s a l s  findings  explain  made by  f r o m a MI, and how t h e s e  time. Although  which  have n o t  that  most MI  in early  convalescence.  According  coping  negative  theory,  indicators studies with  o f harm and  suggest  the  (Lazarus  and  described the  particular  various coping  Investigated  how  Furthermore,  no  systematically and  coping  illness.  of  e m o t i o n s and  emotions  While  no  o f hope  benefit appraisals findings  s t u d i e s were change  found over  found  relationship  study  relationships coping  was  designed  have  during  which  time.  which  between  p a t i e n t s at various stages this  and  p a t i e n t s used  r e s e a r c h s t u d i e s were the  are  Additionally,  research  strategies  assessed  the  these  and  is also associated  forms o f c o p i n g  stages,  Therefore,  c h a n g e s and  attack  1984).  coping  In MI  as  o f c h a l l e n g e and  Folkman,  appraisal  threat appraisals.  of p o s i t i v e  reflective  stress,  emotions such  that a heart  occurrence  confidence  to the  of  have emotions  their  to assess  the  between c o g n i t i v e a p p r a i s a l  strategies  MI  p a t i e n t s used  over  time . This was  hospitals met  the  fifth  and  the  i n the  i n western  sampling  investigator  then  correlational  i n i t i a l l y conducted  four who  descriptive  criteria  days  c r i t i c a l care  comprised  1985),  the  the  p o s t MI  while  Emotion A p p r a i s a l S c a l e  Revised  the  participants  i n e i g h t weeks. T h e y c o m p l e t e d  Included  longitudinal  Ways o f C o p i n g  study  f a c i l i t i e s of  C a n a d a . Twenty-one MI  i n t e r v i e w e d the seventh  and  patients  sample.  between i n the  The  the  CCU,  and  a q u e s t i o n n a i r e which (Folkman  Checklist  &  Lazarus,  (Lazarus  &  Folkman,  1984),  were a n a l y s e d The  using  at least were  with  school  retired  and  62.3 y e a r s .  tests. The  Eighty  and  29% were  data  16 m a l e s .  education.  (52%);  comprised  one  85% had  The m a j o r i t y  of  employed i n the  cardiac  of confirmed  h i s t o r y , except  a h i s t o r y of hypertension.  week  Increased  i n number  period  of the study.  subjects  experienced  symptoms;  while  second  period.  breath  and  were a l s o patients  reported  patients  Interview  chest  various  such  eight  81% of  pain,  of  over  problems half  frequent  were a s y m p t o m a t i c  9%  shortness  medical  Interviews,  symptoms  at the  as l o n e l i n e s s ,  during  of the  symptom.  at the  first  their  of p a t i e n t s reported  whereas 42% complained  reported  the  period,  symptoms  f a t i g u e as t h e most  Initially,  a t the second  patients  At both  had d e v e l o p e d  pain;  who  psychological  and s e v e r i t y d u r i n g  r e l a t e d to other  ( 1 9 % ) who  convalescence.  P h y s i c a l and  In a d d i t i o n to chest  reported.  patients  some p h y s i c a l o r p s y c h o l o g i c a l  95% reported  and p a i n  MI  f o r two p a t i e n t s  At the i n i t i a l  f a t i g u e , symptoms  tearfulness  pain  a high  s a m p l e was  no p r i o r  symptoms  The  The  force. The  the  sheet.  o f t h e p a r t i c i p a n t s were m a r r i e d ,  participants  had  of 5 females  f o r t h e p a r t i c i p a n t s was  attained  work  information  d e s c r i p t i v e and n o n p a r a m e t r i c  sample c o n s i s t e d  mean a g e percent  as w e l l as an  of mild  mild  to severe  chest  i n t e r v i e w . A d d i t i o n a l l y , 19% of shortness  of breath  a s a new  symptom.  Thirty-three other  health  or  hypertension. admitted  to  22  majority  length  d a y s . The  length  attack At  four and  that  interviews,  of  by  the  least that  only  were  symptoms from  of  3 to  15  from  (M.  6  to  participants  10%  knowledge  patients  at  of  the  of  heart  lack  results  c h a n g e s were f o u n d  while  second may  to  of  only  i n the  benefit  perceived  four  and  emotions  Challenge type  at  results  influenced  both least the suggest by  changeability  knowledge r e g a r d i n g  i n the  emotions  harm e m o t i o n s were The  no  the  challenge  e m o t i o n s were t h e  period.  a  l e v e l s of  harm,  appraisal  i n d i c a t e d changes,  harm, c h a l l e n g e  low  threat,  have b e e n  the  experienced  variability.  benefit  f a c t o r s of  s i t u a t i o n and  but  of  type, the  of  frequent  emotion a p p r a i s a l s  threat,  a MI,  MI  types  patients  Initially,  frequent  While  the  majority  some v a r i a b i l i t y  most  appraisal  situational  the  the  degree  e m o t i o n s were t h e  frequent  (76%)  ranged  emotions, w i t h moderate  a higher  interviews.  and  h o s p i t a l i z a t i o n ranged  such previous  b e n e f i t . T h e r e was  revealed  i n CCU  suffered  emotion a p p r a i s a l s  experienced  MI  of  diabetes  participants as  having  helpful.  both  wide r a n g e  stay  reported  s u c h as  same day  days. Although  stated  was  patients  of  the  of  known someone who  patients  of  problems  h o s p i t a l on  (H = 12.3)  had  medical  The  a p p e a r e d . The =6.8)  percent  the  the of  illness.  significant  emotion a p p r a i s a l s  b e n e f i t . Threat  the  of  emotions  decreased  s l i g h t l y over  Similarly, 5.6).  (_ = 4 . 1 , _ = 3 . 7 ) .  harm  emotions  s l i g h t l y decreased  Challenge  emotions  increased very  _ = 6 . 3 ) . The emotions,  The  g r e a t e s t c h a n g e was  which  significant  lack  patients  slightly  observed  M  (_ =  =  6.1,  in benefit  i n c r e a s e d b u t t h e i n c r e a s e was  of s i g n i f i c a n t experienced  a stressful  contextual  (M = 6.4,  not  (_ = 3 . 3 , _ = 5 . 3 ) .  participants is  time  who  suggests  experience,  factors  change  i n emotions  that having  and t h a t p e r s o n a l  influence stress  are five  a  first  MI  and  appraisals in first  t o s e v e n days and e i g h t weeks  MI  post  MI. The  participants  manage t h e demands was  noted  social  support,  of t h e i r  distancing, Planful  confrontive coping  participants All  used  frequently  Certain periods.  The  escape-avoidance  revealed  less  types  Increased  strategies  of seeking  frequently  used.  accepting  were  a t both  used  times.  less  distancing  slightly. were  and p o s i t i v e  and  v a r i a b i l i t y . Most  i n t e r v i e w , except  strategies  distancing  seeking  self-controlling  of coping  of coping  to  variability  reappraisal,  problem-solving,  a t the second  which  strategies  MI. C o n s i d e r a b l e  the eight types  eight available  coping  various coping  In t h e use of p o s i t i v e  responsibility. and  used  s t r o n g l y i n evidence  reappraisal  At the f i r s t  social were  at  both  support, t h e most  interview, seeking  social  126 support  was  the most  moderately times of  the  (H = 10.7,  second  d e c r e a s i n g from  availability novelty  and  Influenced seeking  of the  the  social  distancing share The  and  both  trend (Cohen  related are  to both  used,  was  type  type.  decreased  from  Scores  on  most  of  positive  that  have  increasing  strategy  relating  situation  well  support.  affected  the  reappraisal  since  of  positive  creating  In use  these  found  levels  in health-related emotion-focused  ( H = 8.3,  Scores moderate  on  research  situations  accepting  of strategies  planful used  from This  studies which  strategies  problem-solving coping c o p i n g may  be  the  responsibility  to moderately  self-controlling  turn,  7.1).  & L a z a r u s , 1980)  and  the  were m o d e r a t e l y  in earlier  Folkman  as  meaning.  problem-solving decreased low  the  have  of a c c e p t i n g r e s p o n s i b i l i t y , self-controlling  levels  to  may  was  with  h i g h to moderate  seeking social  s u p p o r t may  and  the  type  reappraisal  of  factors  both  used  scores  Positive  used  reported at  the  with  although emotion-focused  preferred  4.6).  use  & L a z a r u s , 1979; that  9.4).  a m b i g u i t y of  to moderately  Indicated  levels  period,  Situational  times. Planful  reflects  low  with  e n v i r o n m e n t a l r e s o u r c e s , as  strategies  moderate  strategy,  moderately  common t h e m e s  problem-solving at  second  frequently  10.3).  of  Distancing  (H = 8.91,  most  (M. = 1 1 . 4 8 ,  all  7.1).  at the  slightly  scores  type  high to moderately  strategy  only  used  low  remained  levels  (H =  moderately  6.0,  elevated  at both  responsibility  times  and  use  least  indicated  low  Confrontive  (_  4.4).  = 4.7,  and  The  confrontive  may  have  least  times  coping.  times  (_  used  results  common influenced  have p r e v e n t e d  the  were  Escape-avoidance  = 7.7,  strategy  suggest  6.3). at both  decrease  that  times  over  time  situational  illness  patients  and  from  hospital using  strategies. c h a n g e s were n o t e d  In t h r e e  reappraisal  (_  coping:  positive  planful  problem-solving coping  seeking  social  results  previous coping.  support  are c o n s i s t e n t  The  results well  influenced  the e a r l y At  phases  the  relationship  as the  problem-solving  suggest  (_ (_  = -1.92, p. = = -2.74, p_ =  that  environmental  found  of  = -2.15, p_ =  w i t h Folkman which  forms  .055),  similar in  (1985)  changes i n  situational  resources available  coping strategies  MI  and  .01).  & Lazarus'  changes  .03),  patients  used  may in  of r e c o v e r y .  initial was  coping  coping  research findings  demands a s have  at both  t o t h e demands o f t h e  Significant  The  may  scores with only a s l i g h t  related  environment these  strategies  c o p i n g , the  low  Accepting  which share  things right  s c o r e s at both  indicated  8.7).  problem-solving.  used  escape-avoidance  factors  t o put  of r a t i o n a l  The  = 9.9,  self-controlling  themes o f w a n t i n g the  (_  Interview, a s i g n i f i c a n t  found coping  between t h r e a t (rho =  .49,  p_ =  positive  emotions  and  . 0 3 ) . Harm  planful emotions  were  significantly  coping  scales:  accepting planful  positively correlated  confrontive  problem-solving  challenge  positive  emotions  coping  (rho  =  (rho  .73,  p_ =  p_ =  .04).  =  .45,  coping  r e s p o n s i b i l i t y coping  Significant  =  and  .42,  coping  p_ =  .06),  seeking  and  positive  =  .05)  and  seeking  p. = At  the  second and  between distancing  reappraisal emotions  coping  coping  (rho  were  confrontive  coping  coping  benefit  (rho  (rho  =  emotions with  two  =  .50,  p_ =  r e s p o n s i b i l i t y coping  (rho  =  .42,  p_ =  findings of  suggest  first  patients  Therefore,  of  levels  experienced  by  in turn emotions  i n the of  mediates  the  types  coping.  patients'  the  affect are  early  emotions  patients,  determines  that  particular contextual  levels  of  and  .03).  s o c i a l support  positively correlated  Moderate  which  found  s o c i a l support  interview,  b e l i e f s which  MI  .00),  p_ =  (rho  understanding their  .47,  s e l f - c o n t r o l l i n g coping  accepting The  .03),  .01) .  significantly scales:  scales:  p_ =  p_ =  scales:  Similarly, benefit coping  three  .49,  .62,  were  coping  .00),  =  = =  three  two  .54,  (rho  and  with  p_ =  (rho  correlations  correlated .44,  (rho  with  and  choice  association  levels  appraised stages  of  represent i t is this  of  coping  between  as  of  .04). or  emotions.  stressful  their the  and  influence  Illness.  stress  l e v e l of  strategies  emotion  .02),  perception  factors  the  coping  stress or  appraisals  and  by  Conclusions Because nature  of  of  the  be  however, t h e  the  appraisals  to  although a heart of  reduce  of  the  convenience  findings  of  this  its limitations,  suggest  a  some  to  first  MI  a  first  moderate  general  MI,  challenge  levels  emotions  eight  in  with  weeks p o s t - i n f a r c t .  threatening,  commitments may  appraisals,  an  patients  emotions suggests  is l i f e  of  experienced.  is associated  a positive appraisal  attack  favorable  of  benefit  challenge  b e l i e f s and  help  maintain  that  the the  personal individual  hope, and  thereby  stress.  Situational novelty,  the  benefit  factors  resources  appraisals.  patients  experience  Information  The  or  associated  that  ambiguity,  s i t u a t i o n as  a  harm  l e v e l s of new  ambiguous  with  the  the  the  affect threat,  moderate  suggest  which a l l o w s  a mediating  may  is lacking,  threat  Ambiguity  r e l a t i n g to  c h a n g i n g demands o f  environmental  reduce  and  and  low  s e v e n d a y s and  predominance  make more  Despite  e a r l y stages  challenge  outlook  five  factors  the  findings  predominate with  optimistic  This  study's  i t is stressful,  are  s i z e and  procedure,  generalized.  i n the  harm, t h r e a t ,  who  sample  directions.  Overall,  While  small  sampling  study cannot  t r e n d s and  the  heart  maintenance to  of  where to  attack.  hope may  the  as  emotions  s i t u a t i o n s appear  first  f a c t o r which c o n t r i b u t e s  well  and  threat  situations  the  also  increasing  be  levels  o£  benefit  emotions. Moderate  emotions which p e r s i s t and to  demands stress  imposed  various first  early  coping  MI.  and  facets  strategies  patients.  of  their  and  the  strategies  and  nature  may  p a t i e n t s from  escape-avoidance Significant  of t h e  and  which  to  both  are suggest  t o manage  particular  aspect.  social  support,  t o be  social  illness  used  positive  the  and  most  support  which  meaning  and  by  the  resources  such  may  promotes  such  hospital  using strategies  as the  environment as  confrontive coping.  changes noted  planful  problem-solving  suggest  that contextual factors  availability  related  d i s t a n c i n g . Conversely,  threatening prevent  try  to create p o s i t i v e  reappraisal  used  of s t r a t e g i e s  one  continue  findings  of e n v i r o n m e n t a l  of s e e k i n g  MI  MI.  coping,  or  threats  e x i g e n c i e s of a  ambiguous s i t u a t i o n s  influence  use  the  of s t r a t e g i e s  illness  just  harm  patients  t o manage t h e  of s e e k i n g  supportIveness  positive  of r e c o v e r y ,  d i s t a n c i n g appear  New  by  months p o s t  a variety  perceived  coping  two  stage  of  t h a t the  forms o f c o p i n g . The  use  strategies and  suggest  early  types  to deal with  reappraisal  time  problem-focused  of mature  patients will  different  MI  stages  P a t i e n t s use  reflective  The  are  strategies  emotion-focused  that  i n the  p a t i e n t s who  In the  over  levels  coping  of e n v i r o n m e n t a l  in positive  reappraisal,  and  social  seeking  related  resources  to and  support  the the  changing  situational use  demands may  i n the  Threats  early  and  continue  demands  results  moderate planful  levels  imposed  Moderate various  to  low  suggest  stage  a t two  strategies  o f c h a l l e n g e and related  to seeking  self-controlling  turn  t h a t MI  factors  be  the  phases  of  the  their  and  determinants  and to  elicit support,  that  positive  of  strategies  types  coping.  The  p e r c e p t i o n of  beliefs  experienced  of c o p i n g  use  accepting  over  of emotions. L e v e l s of  stress  MI.  problems.  social  for effective  patients'  affect  influence levels  which r e f l e c t to  p a t i e n t s to choose posslblities  MI  to  designed  benefit  MI  contextual  the  likely  manage s i t u a t i o n a l  emotions enable  suggest  by  months p o s t  most  These a s s o c i a t i o n s s u g g e s t  findings  MI.  patients experiencing  responsibility.  which enhance the  patients  accepting responsibility  m e a n i n g and  reappraisal,  early  t h r e a t are  a l l coping  levels  strategies  following a  are  t h a t MI  of harm and  forms o f c o p i n g  positive  i n the  p a t i e n t s who  coping,  positive  coping  of r e c o v e r y  problem-solving,  confrontive create  stages  to s t r e s s  The  affect  by MI  strategies  time  which  in  emotions  p a t i e n t s appear used  in  early  they  would  recovery.  Implications While suggest if  the  this  study's  implications findings  here  results  f o r both are  are  tentative,  n u r s i n g t h e o r y and  confirmed  practice  i n subsequent s t u d i e s .  During  a critical  who a r e i n v o l v e d supportive patients. fear,  that  such as a c a r d i a c event,  in cardiac rehabilitation  and e d u c a t i o n a l A c a r d i a c event  anxiety  feelings  illness  and anger  role  o f hope and c o n f i d e n c e .  event  benefit. illness  This  useful  negative  regarding  their  framework w i t h  interventions  suggests of the and a  w o r d s , MI p a t i e n t s c a n a p p r a i s e and/or  such  the p o s i t i v e  response  t h e impact  from a p o s i t i v e v i e w p o i n t ,  stress-producing  MI  emotions  a s a t h r e a t , a harm, a c h a l l e n g e  In other  patients  negative  but i t a l s o generates  patients c o g n i t i v e l y appraise  cardiac  p r o g r a m s have a  i n working with  generates  nurses  their  i n a more  way. The a p p r a i s a l s made by illness  which  specifically  provides  to design  nurses with  effective  a  nursing  r e l a t e d t o t e a c h i n g and  support. An  integral  necessary their  emotional  response  that  components  intervention appraisal  i s important  illness,  Additionally,  should  allow  assisting  Nursing patients  them t o f o c u s  on t h e  type of  p a t i e n t s make more o p t i m i s t i c  illness.  to help  and h e l p  to the c a r d i a c c r i s i s .  of the event. This  can help  of t h e i r  i s the r e c o g n i t i o n of  a r e d i r e c t e d toward  the a p p r a i s a l l e v e l  positive  it  o f t h e a s s e s s m e n t and i n t e r v e n t i o n s  t o meet p a t i e n t s ' n e e d s  Interventions at  part  In working with  them s e e how t h e y  MI p a t i e n t s ,  perceive  their  them make a l t e r n a t i v e a p p r a i s a l s .  nursing  i n t e r v e n t i o n s should  a s s i s t the  patient and  t o manage t h e t h r e a t e n i n g a s p e c t s o£ t h e i l l n e s s  subsequently create a less Secondly,  process.  coping with a cardiac  MI p a t i e n t s  use a v a r i e t y  related  to both  coping.  The MI c r i s i s  emotion-focused  understand  the d i f f e r e n t  a combination  informational  s u p p o r t may be a n i m p o r t a n t Offering  environments Timely  emotional  to express that  their  often  source  should  by a l a c k  also  long-term  of knowledge  strategies  or minimize  their  may  It various of  i s important appraisals  foster  that  interventions  encouraging  i n those acute  patients  from  care  doing so.  f e a r s and a n x i e t i e s of the i l l n e s s .  Nurses  learn  that  t h e y c a n do  the n e g a t i v e e f f e c t s of a sense  nurses  MI p a t i e n t s  coping strategies  i n the  i n t e r m s o f s h o r t - and  something t o a l t e r this  used  assess the various  o u t c o m e s . When p a t i e n t s  illness  need t o  and t a n g i b l e  means  feelings  restrict  help patients  problem-solving  of coping  of s t r e n g t h i n times of  support  information can a l l e v i a t e  generated  nursing  particular  process.  use o f e m o t i o n a l ,  patients  with  coping strategies  this  strategies  problem-focused  N u r s e s w o r k i n g w i t h MI p a t i e n t s  they can f a c i l i t a t e  crisis.  i s a complex  of coping  and  r e c o v e r y p r o c e s s , and how t h r o u g h  The  event  presents the patient  demands o r t a s k s w h i c h r e q u i r e strategies.  s t r e s s - p r o d u c i n g response.  o f hope and  understand  make  and u l t i m a t e l y  control.  how t h e  influence  the choice  o u t c o m e s . MI  patients  facing  threat  strategies coping.  such as e s c a p e - a v o i d a n c e  N u r s e s need  controlling implement patient need  harm and t h r e a t  supportive  t o take  The  their  coping  Interventions  certain  illness.  determine threat,  The framework  challenge  forms of c o p i n g  that  to allow the  related  can both  and b e n e f i t  theory  cognitive  nurses to the  facilitate  isa  useful  a p p r a i s a l and  use i n t h e e a r l y phases o f is clinically  of emotional  used  factors  and c o p i n g  MI p a t i e n t s  the type  play i n  strategies.  which t o a s s e s s  strategies  they  forms o f c o p i n g . A d d i t i o n a l l y ,  stress, appraisal  framework w i t h coping  nursing  into account  various  confrontive  e m o t i o n s , and need t o  and h o s p i t a l e n v i r o n m e n t  hinder  and  f o r a time,  t o be aware o f t h e r o l e  t o use such  illness or  a n d harm may c h o o s e , a t l e a s t  reactions  appraisals,  to counteract  relevant to related  t o harm,  and t o I d e n t i f y  or enhance  their  effects .  Recommendations  The  that  cannot  the study  warrant  replicated The time  Further  Research  r e s u l t s o f t h i s s t u d y a r e i n c o n c l u s i v e and  therefore small,  for  periods  findings  Although  indicated  additional research.  using  lack  be g e n e r a l i z e d .  a larger  t h e sample was  some g e n e r a l  This  study  trends  s h o u l d be  sample.  o f s i g n i f i c a n t r e s u l t s may be r e l a t e d choosen  f o r a s s e s s m e n t . The p r e s e n t  to the  study  assessed early  stages  Illness along be  e m o t i o n a p p r a i s a l s and c o p i n g of the i l l n e s s .  The demands o f a c h r o n i c  may p l a y a more o r l e s s  i n the course  experienced.  cognitive  of t h i s  Follow-up  appraisal  the p a t t e r n of r e s u l t s  periods  r e m a i n s t h e same o v e r  designs  would  responses  stages  rehabilitation patients  may  lead  are  data  trauma, such  types  suggest  to  determine  a t the  Repeated  measure  processes.  t h a t MI  patients' While  recovery,  bypass g r a f t  designs  would  into  surgery.  a complicated  others  time.  also  Since  appear  processes  factors  which  which  patients  Comparative  measurements o f  i n MI p a t i e n t s e x p e r i e n c i n g  related  recovery. to the nature  of the  t o I n f l u e n c e e m o t i o n s and c o p i n g  the context  element, a d d i t i o n a l  face  Assuming the  strategies  subgroups.  o r an u n c o m p l i c a t e d  Environmental setting  further  p r o d u c e more a c c u r a t e  e m o t i o n s and c o p i n g  some  a s a p r o g r e s s i o n i n symptoms  o f e m o t i o n s and c o p i n g  be d i v i d e d  of the  and t h e s e q u e n c e o f  a p p r o p r i a t e f o r t h e demands o r s t r e s s o r s ,  should  initial  understanding  is idiosyncratic.  an u n e v e n t f u l  to coronary  divergent  time.  a more e x p l i c i t  process  experience  additional  obtained  r e a c t i o n s and c o p i n g  Illness-related  further  when demands b e g i n t o  a r e needed  t o a MI s i t u a t i o n ,  i n emotional  role  s t u d i e s on measurements o f  whether  usual  important  illness,  and c o p i n g  provide  only during the  of the s i t u a t i o n  measurements s h o u l d  is a  over  critical  be o b t a i n e d  i n the  same s e t t i n g . determining  Future  Investigations should  the f a c t o r s w i t h i n  more s y s t e m a t i c a l l y . The f i r s t in  CCU and t h e s e c o n d  focus  on  the h o s p i t a l environment measurement c o u l d  i n a subacute  unit prior  be t a k e n  to hospital  discharge. In many ways t h i s research  should  variables The  Influence validity  influenced inflated  before  i s only  how c u l t u r a l  of the measuring  the f i n d i n g s of t h i s  should  a beginning.  to their  illness.  t o o l s may have  study.  the r e s u l t s .  They might  have  The Ways o f C o p i n g  be r e v i s e d , and t h o s e  items which  m u l t i p l e a c t i o n s and t h o u g h t s s h o u l d administering  Further  and e d u c a t i o n a l  p a t i e n t s ' response  or u n d e r s c o r e d  checklist contain  explore  study  the q u e s t i o n n a i r e  perhaps  be r e f i n e d  i n future  research.  REFERENCES Burckhardt, chronically i l l . 543-550.  C.S. ( 1 9 8 7 ) . Coping s t r a t e g i e s of N u r s i n g C l i n i c s of N o r t h A m e r i c a ,  the 22 ( 3 ) ,  B u r i s h , T. & B r a d l e y , L . ( 1 9 8 3 ) . C o p i n g w i t h c h r o n i c d i s e a s e . R e s e a r c h and a p p l i c a t i o n s . San F r a n c i s c o : Academic P r e s s , Inc. B u r g e s s , W.A. & Hartman, C.R. p e r c e p t i o n s of the c a r d i a c c r i s e s . N u r s i n g , 5_, 4 5 - 7 1 .  (1986). Patients American J o u r n a l of  B u r n s , N. & G r o v e , S.K. ( 1 9 8 7 ) . The p r a c t i c e o f n u r s i n g r e s e a r c h : c o n d u c t , c r i t i q u e and u t i l i z a t i o n . P h i l a d e l p h i a : W.B. S a u n d e r s Co. C a n a d a . ( 1 9 8 5 ) . Canada y e a r S u p p l y and S e r v i c e s C a n a d a .  book. O t t a w a : M i n i s t r y  of  Cassem, N.H. & H a c k e t t , T.P. ( 1 9 7 1 ) . P s y c h i a t r i c c o n s u l t a t i o n i n a c o r o n a r y c a r e u n i t . A n n a l s of I n t e r n a l M e d i c i n e , 75. ( 9 ) , 9 - 1 4 . Cassem, N.H. & H a c k e t t , T.P. ( 1 9 7 3 ) . P s y c h o l o g i c a l r e h a b i l i t a t i o n of 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 i n a c u t e p h a s e . H e a r t a n d L u n g . 2. ( 3 ) , 3 8 2 - 3 8 8 . Cassem, N.H. & H a c k e t t , T.P. a s p e c t s of m y o c a r d i a l i n f a r c t i o n . A m e r c U , £1 ( 4 ) , 711-721.  (1977). Psychological M e d i c a l C l i n i c s of North  Cassem, N.H. & H a c k e t t , T.P. ( 1 9 7 9 ) . P s y c h o l o g i c a l I n t e r v e n t i o n In m y o c a r d i a l i n f a r c t i o n . In W.D. G e n t r y and R.B. W i l l i a m s ( E d s . ) . P s y c h o l o g i c a l a s p e c t s of m y o c a r d i a l i n f a r c t i o n and c o r o n a r y c a r e ( 2 n d ed.) (pp. 1 4 9 - 1 6 1 ) . S t . L o u i s : C.V. Mosby Co. C h r i s t m a n , N . J . , M c C o n n e l l , E.A., P f e i f f e r , C, W e b s t e r , K.K., Scchmitt & Ries, J . ( 1 9 8 8 ) . Uncertainty, c o p i n g , and d i s t r e s 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 r a n s i t i o n f r o m h o s p i t a l t o home. R e s e a r c h I n N u r s i n g & H e a l t h , 11, 71-82. Cohen, F. & L a z a r u s , R. ( 1 9 7 9 ) . C o p i n g w i t h t h e s t r e s s e s o f i l l n e s s . In G.C. S t o n e , F. Cohen, N.E. A d l e r . H e a l t h p s y c h o l o g y - A handbook, ( p p . 2 1 7 - 2 5 4 ) . San Francisco: Jossey-Brass P u b l i s h e r s . Cook, R.L. ( 1 9 7 9 ) . myocardial i n f a r c t i o n .  P s y c h o l o g i c a l responses to H e a r t & L u n g , 8. ( 1 ) , 1 3 0 - 1 3 5 .  D e g r 6 - C o u s t r y , C. & G r < W i s s e , M. (1982). P s y c h o l o g i c a l problems In r e h a b i l i t a t i o n a f t e r m y o c a r d i a l i n f a r c t i o n : n o n - i n s t i t u t i o n a l approach. Advances i n C a r d i o l o g y , 2__, 126-131. F o l k m a n , S. & L a z a r u s , R.S. (1980). An a n a l y s i s o f c o p i n g i n a m i d d l e - a g e d community s a m p l e . J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r , 21 , 219-239. F o l k m a n , S. & L a z a r u s , R. (1985). I f i t c h a n g e s i t must be a p r o c e s s : s t u d y o f e m o t i o n and c o p i n g d u r i n g three stages of a c o l l e g e examination. J o u r n a l of P e r s o n a l i t y and S o c i a l P s y c h o l o g y . 45. ( 1 ) , 150-170. F o l k m a n , S., L a z a r u s , R.S., G r u e n , R . J . , & D e L o n g i s , A., (1986). A p p r a i s a l , c o p i n g , h e a l t h s t a t u s , and p s y c h o l o g i c a l symptoms. J o u r n a l o f P e r s o n a l i t y and S o c i a l P s y c h o l o g y . 5_p_ ( 3 ) , 571-579. F o l k m a n , S., L a z a r u s , R.S., D u n k e l - S c h e t t e r , C, D e L o n g e s , A., & G r e e n , R . J . (1986). Dynamics o f a s t r e s s f u l e n c o u n t e r : c o g n i t i v e a p p r a i s a l , c o p i n g , and e n c o u n t e r o u t c o m e s . J o u r n a l o f P e r s o n a l i t y and S o c i a l P s y c h o l o g y . 5_ ( 5 ) , 992-1003. G a r r i t y , T . F . (1975). M o r b i d i t y , m o r t a l i t y , and r e h a b i l i t a t i o n . I n .W.D. G e n t r y and R.B. W i l l i a m s ( E d s . ) . Psychological  coronary  care,  aspects  of  myocardial  Infarction  and  ( p p . 124-133). S t . L o u i s : C.V. Mosby Co.  G e n t r y , W.D. & Haney, T. (1975). E m o t i o n a l and behavioral r e a c t i o n s to acute myocardial i n f a r c t i o n .  & Lung, 1  Heart  ( 5 ) , 738-745.  G r a n g e r , J.W. (1974). F u l l r e c o v e r y from m y o c a r d i a l i n f a r c t i o n : p s y c h o s o c i a l f a c t o r s . H e a r t & Lung, 2 ( 4 ) ,  (pp. 600-610).  G u l l e d g e , A.D. (1979). P s y c h o l o g i c a l a f t e r maths o f m y o c a r d i a l i n f a r c t i o n . I n W.D. G e n t r y and R.B. W i l l i a m s ( E d s . ) . P s y c h o l o g i c a l a s p e c t s o f m y o c a r d i a l i n f a r c t i o n and c o r o n a r y c a r e (2nd e d . ), (pp 113-130). S t . L o u i s : C.V. Mosby Co. H a c k e t t , T.P. & Cassem, N.H. (1978). P s y c h o l o g i c a l a s p e c t s of r e h a b i l i t a t i o n a f t e r m y o c a r d i a l i n f a r c t i o n . In N.K. Wenger and H.K. H e l l e r s t e i n ( E d s . ) . R e h a b i l i t a t i o n o f t h e c o r o n a r y p a t i e n t , ( p p . 243-253). New Y o r k : J o h n W i l e y & Sons. H i j e c k , T.W. (1984). The h e a l t h b e l i e f model and c a r d i a c r e h a b i l i t a t i o n . Nursing C l i n i c s of North America,  11  (3), 449-457.  139  H i l t o n , B.A. ( 1 9 8 7 ) . C o p i n g w i t h t h e u n c e r t a i n t i e s o f b r e a s t c a n c e r : a p p r a i s a l and c o p i n g s t r a t e g i e s . Ann A r b o r , MI: U n i v e r s i t y M i c r o f i l m s I n t e r n a t i o n a l , No. 8 7 - 0 0 , 2 0 5 . J e n k i n s , C D . ( 1 9 7 5 ) . C o p i n g w i t h 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 . I n W.D. G e n t r y and R.B. W i l l i a m s (Eds.), P s y c h o l o g i c a l a s p e c t s of m y o c a r d i a l i n f a r c t i o n and c o r o n a r y c a r e , (pp 5 - 2 3 ) . S t . L o u i s : C.V. Mosby Co. L a z a r u s , R. ( 1 9 8 0 ) . E m o t i o n s : A c o g n i t i v e p h e n o m e n o l o g l c a l a n a l y s i s , i n R. P l u t c h i k a n d H. K e l l e r m a n  (Eds.), E m o t i o n , Theory, R e s e a r c h and E x p e r i e n c e , (pp. 189-207)  New  York: Academic  Press.  L a z a r u s , R. ( 1 9 8 4 ) . The t r i v i a l i z a t i o n o f d i s t r e s s . In B.L. Hammonds a n d C . J . S c h e i r e r ( E d s . ) . P s y c h o l o g y and H e a l t h , ( p p . 1 2 5 - 1 4 4 ) . W a s h i n g t o n , DC: A m e r i c a n Psychological Association.  and  L a z a r u s , R. & F o l k m a n , S. ( 1 9 8 4 ) . S t r e s s , c o p i n g . New Y o r k : S p r i n g e r P u b l i s h i n g Co.  appraisal  Llpowski, Z.J. (1970-1,971). P h y s i c a l i l l n e s s , the I n d i v i d u a l and t h e c o p i n g p r o c e s s e s . International Journal o f P s y c h i a t r y i n M e d i c i n e , 1, 9 1 - 1 0 2 . M e d d i n , J . & B r e l j e , M. ( 1 9 8 3 ) . U n e x p e c t e d p o s i t i v e e f f e c t s o f m y o c a r d i a l i n f a r c t i o n on c o u p l e s . H e a l t h and S o c i a l Work. S p r i n g . 8_ ( 2 ) , 4 3 - 4 6 . M c C o r k l e , R. & Q u i n t - B e n o l i e l , J . ( 1 9 8 3 ) . Symptom d i s t r e s s , c u r r e n t c o n c e r n s a n d mood d i s t u r b a n c e a f t e r d i a g n o s i s o f l i f e - t h r e a t e n i n g d i s e a s e . S o c i a l S c i e n c e and Medicine. H (7), 431-438. M c N e t t , S. ( 1 9 8 7 ) . S o c i a l s u p p o r t , effectiveness in functionally disabled. 16_  ( 2),  t h r e a t , and N u r s i n g Reseach,  98-103.  M i l l e r , P., G a r r e t t , M.J. M c M a t t o n , M., J o h n s o n , N.L. & W l k o f f , R. ( 1 9 8 5 ) . C o p i n g methods and s o c i e t a l a d j u s t m e n t s o f c a r d i o v a s c u l a r c l i e n t s . H e a l t h V a l u e s , 9_ (4),  10-13.  M i l l e r , B.F. & Keane, C.B. ( 1 9 8 7 ) . E n c y c l o p e d i a d i c t i o n a r y o f m e d i c i n e , n u r s i n g , and a l l i e d h e a l t h . e d . ) . P h i l a d e l p h i a : W.B. S a u n d e r s Co.  and (4th  Monat, A. & L a z a r u s , R. ( 1 9 8 5 ) , S t r e s s a n d c o p i n g : some c u r r e n t i s s u e s and c o n t r a v e r s i e s . I n A. Monat a n d R. L a z a r u s ( E d s . ) , s t r e s s a n d c o p i n g ; a n a n t h o l o g y . New Y o r k : Columbia U n i v e r s i t y P r e s s .  N l c h o l l s , E., N a i r , C , M a c W i l l i a m , L., Moen, J . & Mao, Y. ( 1 9 8 6 ) . C a r d l o - v a s c u l a r d i s e a s e In C a n a d a . ( C a t a l o g u e 8 2 - 5 4 4 ) O t t a w a : S t a t i s t i c s Canada, H e a l t h and W e l f a r e Canada P o l i t , D. & H u n g l e r , B. ( 1 9 8 3 ) . N u r s i n g r e s e a r c h p r i n c i p l e s and m e t h o d s . ( 2 n d e d . ) . P h i l a d e l p h i a : J.B. L i p p i n c o t t Co. P r a n u l i s , M.F. ( 1 9 7 5 ) . C o p i n g w i t h 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 . In W.D. G e n t r y and R.B. Williams ( E d s . ) , P s y c h o l o g i c a l a s p e c t s of m y o c a r d i a l i n f a r c t i o n and c o r o n a r y c a r e . (pp 6 5 - 7 5 ) . S t . L o u i s : C.V. Mosby Co. Rossi, sudden  (3),  L.  cardiac  (1985). death.  Nursing Nursing  care  f o r s u r v i v o r s of  clinics  of  North  America,  11  411-425.  S c a l z i , C.C. ( 1 9 7 3 ) . N u r s i n g management of b e h a v i o 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 & Lung. 1 ( 1 ) , 6 2 - 6 9 . Shine, K.J. ( 1 9 8 4 ) . A n x i e t y P s y c h o s o m a t i c s , 21 ( 1 8 ) , 2 7 - 3 1 .  in patients  Wenger, N.K. ( 1 9 7 8 ) . E a r l y ambulation a f t e r m y o c a r d i a l i n f a r c t i o n : r a t i o n a l e , program components, r e s u l t s . In N.K. Wenger and H.K. H e l l e r s t e i n (Eds.), R e h a b i l i t a t i o n of t h e c o r o n a r y p a t i e n t , ( p p . , 5 3 - 6 3 ) . York: John W i l e y & Sons.  and New  W i k l u n d , I . , Sanne, H., V e d i n , A. & W i l h e r m s s o n , C. ( 1 9 8 4 ) . S i c k - r o l e and a t t i t u d e t o w a r d s d i s e a s e and w o r k i n g l i f e two months 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 , Scandinavian Journal R e h a b i l i t a t i o n Medicine. L i , 57-64. W i k l u n d , I . , Sanne, H., V e d i n , A. & W i l h e r m s s o n , C. ( 1 9 8 5 ) . C o p 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 : a model w i t h a p p l i c a t i o n s , a l i t e r a t u r e review. I n t e r n a t i o n a l R e h a b i l i t a t i o n Medicine. 2 ( 4 ) , 167-175. W i s h n i e , H.A., H a c k e t t , T.P. & Cassem, N.H. (1971). P s y c h o l o g i c a l h a z a r d s of c o n v a l e s c e n c e f o l l o w i n g m y o c a r d i a l i n f a r c t i o n . J o u r n a l of A m e r i c a n M e d i c a l A s s o c i a t i o n , 2_5_ ( 8 ) , 1 2 9 2 - 1 2 9 6 .  141  A p p e n d i x A:  Emotion A p p r a i s a l  Scale  142 Emotion  Appraisal  Scale  1. As b e s t y o u c a n , t e l l us how y o u f e e l a b o u t y o u r h e a r t a t t a c k t o d a y . To do t h i s , p l e a s e c i r c l e f o r e a c h i t e m t h e number t h a t b e s t d e s c r i b e s t h e e x t e n t o f t h a t feeling. Not a t all 0  A little 1  Somewhat 2  Quite a bit 3  A  Great deal 4  a. t  anary  b,  lealous  0  1  2  3  4  c.  worried  0  1  2  3  4  d,  challenged  0  1  2  3  4  e.  exhilarated  0  1  2  3  4  t,  sad  0  1  2  3  4  q,  threatened  0  1  2  3  4  h,  disappointed  0  1  2  3  4  1,  secure  0  1  2  3  4  1 ,  harmed  0  1  2  3  4  k,  confident  0  1  2  3  4  1,  in  0  1  2  3  4  fearful  0  1  2  3  4  n.  pleased  0  1  2  3  4  0t  guilty  0  1  2  3  4  P,  hopeful  0  1  2  3  4  q,  disgusted  0  1  2  3  4  E,  eaaer  0  1  2  3  4  s.  frustrated  0  1  2  3  4  t,  embarrassed  0  1  2  3  4  Ut  anxious  0  1  2  3  4  y,  happy  0  1  2  3  4  w.  envious  0  1  2  3  4  Xt  relieved  0  1  2  3  4  V.  other  0  1  2  3  4  control  (Dlease  specify):  Appendix  B:  The  Revised  Ways of  Copi  The  Revised  Ways o f C o p i n g  Scale  F o r e a c h i t e m , p l e a s e i n d i c a t e , by c i r c l i n g t h e a p p r o p r i a t e number, t o what e x t e n t y o u a r e u s i n g t h e s e s t r a t e g i e s a t t h e p r e s e n t time t o d e a l w i t h your h e a r t attack s i t u a t i o n . Used somewhat  Used quite a bit  Use great a deal  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  0  I  I  3  Not used 1. 2.  3 .  4.  5.  6 .  7. 8. 9 . 10. 11. 12.  I j u s t c o n c e n t r a t e on what I have t o do n e x t — t h e next s t e D I t r y to analyze the problem i n order t o understand i t b e t t e r I t u r n t o work or substitute activity t o t a k e my mind o f f things I f e e l t h a t time w i l l make a d i f f e r e n c e — t h e o n l y t h i n g t o do is t o wait I b a r g a i n o r compromise to get something p o s i t i v e from t h e situation I do s o m e t h i n g w h i c h I don't t h i n k w i l l work, b u t a t l e a s t I am d o i n g s o m e t h i n g I t r y t o get the person responsible to change h i s o r h e r mind I t a l k t o someone t o f i n d o u t more a b o u t t h e situation I c r i t i c i z e or l e c t u r e myself I t r y n o t t o b u r n my bridges, but leave t h i n g s open somewhat I hope a m i r a c l e w i l l happen I go a l o n g w i t h f a t e ; sometimes I j u s t have bad l u c k  Used somewhat  Used quite a bit  0  1  2  3  0  1  2  3  0 o  1 1.  2 2  3 3  0  1  2  3  0  1  2  3  0  1  2  3  0  1  2  3  o  1  2  3  o  1  2  3  0  1  2  3  0  1  2  3  o  1  2  3  o  1  2  3  o  1  2  3  o  1  2  3  o  1  2  3  0  1  2  3  0  1  2  3  Not used 13. 14. 15.  IS,  17.  18.  19.  20. 21. 22. 23. 24.  25.  26. 27 .  28. 29 . 30.  31.  I go on as i f n o t h i n g has happened I t r y t o keep my f e e l i n a s to myself I look f o r the s i l v e r l i n i n g , so t o speak; I t r y t o l o o k on t h e b r i g h t s i d e of t h i n g s I s l e e p more t h a n u s u a l I express anger to the p e r s o n ( s ) who caused the problem I a c c e p t sympathy and u n d e r s t a n d i n g from someone I t e l l myself things t h a t h e l p me t o f e e l better I am i n s p i r e d t o do soraethina c r e a t i v e I t r y t o f o r g e t the whole t h i n g I'm g e t t i n g professional help I c h a n g e or grow as a p e r s o n i n a good way I w a i t t o s e e what w i l l happen b e f o r e doina anythinq I a p o l o g i z e or do s o m e t h i n g t o make up for i t I make a p l a n o f a c t i o n and f o l l o w i t I accept the next b e s t t h i n g t o what I want I l e t my f e e l i n g s o u t somehow I r e a l i z e I brought t h e p r o b l e m on m y s e l f I am c o m i n g o u t of t h e experience better t h a n when I went i n I t a l k t o someone who c o u l d do s o m e t h i n g c o n c r e t e about the problem  Used great a deal  Not used 32.  33.  34. 35.  36, 37.  38. 39 . 40. 41.  42. 43 . 44. 45. 46. 47 . 48 .  I g e t away from i t f o r a while; I t r y to rest or take a v a c a t i o n 0 I t r y t o make m y s e l f f e e l b e t t e r by e a t i n g , d r i n k i n g , smoking, u s i n g drugs or medication, etc. 0 I take a b i g chance or do s o m e t h i n g risky 0 I t r y not to act too h a s t i l y or f o l l o w my first hunch 0 I h a v e f o u n d new faith 0 I m a i n t a i n my p r i d e and keep a s t i f f upper l i p . 0 I r e d i s c o v e r what i s important i n l i f e 0 I change something so 0 t h i n a s w i l l t u r n out I avoid being with people i n general 0 I don't l e t i t get to me; I r e f u s e t o t h i n k t o o much a b o u t i t 0 I ask a r e l a t i v e or f r i e n d I r e s p e c t for advice 0 I keep o t h e r s from knowing how b a d t h i n a s a r e 0 I make l i g h t o f t h e situation; I refuse to aet too s e r i o u s about i t 0 I t a l k t o someone a b o u t how I am feelina 0 I s t a n d my g r o u n d a n d f i g h t f o r what I 0 want I t a k e i t o u t on o t h e r people 0 I d r a w o n my p a s t e x p e r i e n c e s ; I was i n a similar situation before 0  Used somewhat  Used quite a b i t  Used great a deal  1  2  3  1  2  3  1  2  3  1  2 2  3 3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  147  Not used 49.  50. 51.  52.  53. 54.  55.  56. 57.  58. 59.  60, 61. 62. 63 .  64.  I k n o w w h a t h a s t o be done, so I d o u b l e my e f f o r t s t o make t h i n g s work 0 I refuse to believe t h a t i t has happened 0 I make a p r o m i s e t o myself that things w i l l be d i f f e r e n t next time. 0 I h a v e come up w i t h a couple of d i f f e r e n t s o l u t i o n s to the problem Q I accept i t , since 0 n o t h i n a c a n be d o n e I t r y t o k e e p my f e e l i n g s from i n t e r fering with other t h i n c t s t o o much 0 I wish that I could change what has happened or how I feel 0 I change something about myself 0 I daydream or imagine a b e t t e r time or place t h a n t h e o n e I am i n 0 I wish that the s i t u a t i o n w o u l d go a w a y o r somehow 0 be o v e r w i t h I have f a n t a s i e s or w i s h e s a b o u t how things may t u r n o u t 0 I pray 0 I prepare myself for the worst 0 I g o o v e r i n my m i n d 0 what I w i l l s a y o r do I t h i n k a b o u t how a person I admire would handle t h i s s i t u a t i o n and use t h a t as a model 0 I t r y t o see t h i n g s from the other person's 0 p o i n t of view  Used somewhat  Used quite a bit  Used great a deal  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1  2  3  1 1  2 2  3 3  1  2  3  1  2  3  1  2  3  1  2  3  Not used 65.  Used quite a bit  Used great a deal  I r e m i n d m y s e l f how much worse t h i n g s CQuld  66. 67.  Used somewhat  be  Q  T i o a or e x e r c i s e I t r y something entirely different f r o m a n y o f t h e above (please describe) :  Q  0  1  2  1  1  2  2  1  1  3  Appendix  C:  Patient  In-Hospital Sheet  Information  150  Patient  In-Hospital  Information  Sheet  Age Sex Marital  Status:  Married Separated  Divorced Widowed  Single Occupation Education Date  of your  heart  Date o£ a d m i s s i o n Are  attack t o CCU  you e x p e r i e n c i n g Chest  pain  Shortness Fatigue Other  any of the f o l l o w i n g  of b r e a t h  symptoms?  Appendix  D:  Patient  At-Home Sheet  Information  152  Patient  Number  of days spent  Date o f d i s c h a r g e Are  At-Home  Sheet  i n CCU  from h o s p i t a l  you e x p e r i e n c i n g Chest  Information  any of t h e f o l l o w i n g  symptoms?  pain  Shortness  of b r e a t h  Fatigue Other Do y o u have a n y o t h e r  Do y o u know o t h e r  health  people  problems?  who have had a h e a r t  attack?  Appendix E:  Information-Consent Form  Letter  154 Patient  Information-Consent  My name i s P e g g y B e c h a r d . a student the  i n the Master  learning heart  i n Nursing  Columbia.  N u r s e and  Program a t  I am i n t e r e s t e d i n  how c a r d i a c p a t i e n t s p e r c e i v e  and cope w i t h  their  attacks. I am i n v i t i n g  will  I am a R e g i s t e r e d  of Science  U n i v e r s i t y of B r i t i s h  Form  be a s k e d  you t o p a r t i c i p a t e i n t h i s  t o complete  a questionnaire  fifth  and s e v e n t h d a y s a f t e r  eight  weeks  f o l l o w i n g your  questionnaire could  will  take  come t o y o u r  requires  your  heart  about  You  between t h e  heart  attack,  attack.  Each  and a g a i n  45 m i n u t e s t o c o m p l e t e . I  home when t h e s e c o n d  completion  study.  questionnaire  or any p l a c e  which  i s convenient  to  i s .no d i r e c t  b e n e f i t t o you, such  you. Although information stress  there  will  be u s e f u l t o n u r s e s  and c o p i n g  behaviors  that  nurses  need  t o know more a b o u t  only  in hospital, All  protect  can give  better  or n u r s i n g  nurses  will  recovery.  be c o n f i d e n t i a l . To  a c o d e number  instead  of your  on t h e q u e s t i o n n a i r e .  Your p a r t i c i p a t i o n medical  I believe that  t h e way c a r d i a c p a t i e n t s c o p e , n o t  you p r o v i d e  confidentiality, be u s e d  care.  understand  by c a r d i a c p a t i e n t s so  b u t a l s o a t home d u r i n g  information  name w i l l  used  to better  care  i n the study while  will  i n or a f t e r  not a f f e c t discharge  your from  

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