"Applied Science, Faculty of"@en . "Nursing, School of"@en . "DSpace"@en . "UBCV"@en . "Gauchie, Patricia"@en . "2010-03-29T19:40:11Z"@en . "1982"@en . "Master of Science in Nursing - MSN"@en . "University of British Columbia"@en . "This exploratory study examined the phenomenon of loss as expressed by the spouses of myocardial infarction patients. The purpose\r\nof the study was to describe the thoughts, feelings, actions and observable behaviours of the spouses from the initial impact of illness to six weeks post myocardial infarction and to develop a framework, based on the literature, which related the concept of loss to the experience of spouses of M.I. patients.\r\nThe study was conducted with a convenience sample of 12 spouses, ten women and two men, whose partners had experienced their first myocardial infarction. Using a semi-structured interview guide with open-ended questions, the investigator interviewed each subject four times over a six week period; from the initial impact of illness to approximately six weeks post myocardial infarction. Each interview covered three content areas: thoughts, feelings and actions. Broad open-ended questions were used to elicit data on the spouses thoughts, feelings and actions. During the interview the investigator observed the verbal (type, quality, characteristics of speech, focus of conversation) and non-verbal (activity, eye contact, body language, appearance) behaviours of the spouses.\r\nAn empirical inductive approach was used as the methodology for this study. Data coding and analysis were approached using the constant comparative method, an inductive method of discovering grounded theory developed by Glaser and Strauss (1967). The findings\r\n\r\nrevealed that the spouses experienced behaviours in response to loss that were common and formed a pattern through time. Three distinct phases were identified: Phase I The Event and Initial Spousal Response; Phase II Reaction to the Event; Phase III Impact of the Event. The phases were described further in light of the constructs formulated from the literature review: (1) Reactions to Loss; (2) The Elements of Loss; (3) The Meaning of Loss.\r\nThis study was designed to provide insight into understanding the event of a myocardial infarction within the context of the phenomenon of loss. The findings supported the use of a loss framework for assessing the reactions of spouses who are threatened with the death of their partner. Nurses are in a critical position to assist spouses experiencing loss. Implications and recommendations for nursing education,\r\npractice and research were delineated in light of the conclusions of the present study."@en . "https://circle.library.ubc.ca/rest/handle/2429/22906?expand=metadata"@en . "LOSS AS EXPERIENCED BY SPOUSES OF MYOCARDIAL INFARCTION PATIENTS by PATRICIA MARIE GAUCHIE B . S c , The U n i v e r s i t y o f A l b e r t a , 1972 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF THE FACULTY OF GRADUATE STUDIES SCHOOL OF NURSING We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA September 1982 C ) P a t r i c i a M. Gauchie, 1982 MASTER OF SCIENCE i n In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l l m e n t o f the r e q u i r e -ments f o r an advanced degree a t the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head o f my depart-ment or by h i s or her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department o f /\(cxJ>Srn The U n i v e r s i t y o f B r i t i s h Columbia Vancouver, B. C. Y6T 1W5 ABSTRACT i 1 i LOSS AS EXPERIENCED BY SPOUSES OF MYOCARDIAL INFARCTION PATIENTS This e x p l o r a t o r y study examined the phenomenon of l o s s as expressed by the spouses of myocardial i n f a r c t i o n p a t i e n t s . The pur-pose of the study was t o d e s c r i b e the thoughts, f e e l i n g s , a c t i o n s and observable behaviours of the spouses from the i n i t i a l impact of i l l n e s s to s i x weeks post myocardial i n f a r c t i o n and to develop a framework, based on the l i t e r a t u r e , which r e l a t e d the concept of l o s s to the experience of spouses of M.I. p a t i e n t s . The study was conducted with a convenience sample of 12 spouses, ten women and two men, whose partne r s had experienced t h e i r f i r s t myocardial i n f a r c t i o n . Using a s e m i - s t r u c t u r e d i n t e r v i e w guide with open-ended q u e s t i o n s , the i n v e s t i g a t o r i n t e r v i e w e d each s u b j e c t f o u r times over a s i x week p e r i o d ; from the i n i t i a l impact of i l l n e s s to approximately s i x weeks post myocardial i n f a r c t i o n . Each i n t e r v i e w covered three content areas: thoughts, f e e l i n g s and a c t i o n s . Broad open-ended questions were used to e l i c i t data on the spouses thoughts, f e e l i n g s and a c t i o n s . During the i n t e r v i e w the i n v e s t i g a t o r observed the verbal (type, q u a l i t y , c h a r a c t e r i s t i c s o f speech, focus o f conversation) and non-verbal ( a c t i v i t y , eye c o n t a c t , body language, appearance) behaviours of the spouses. An e m p i r i c a l i n d u c t i v e approach was used as the methodology f o r t h i s study. Data coding and a n a l y s i s were approached using the constant comparative method, an i n d u c t i v e method of d i s c o v e r i n g grounded theory developed by Glaser and Strauss (1967). The f i n d i n g s i v revealed t h a t the spouses experienced behaviours i n response to l o s s that were common and formed a p a t t e r n through time. Three d i s t i n c t phases were i d e n t i f i e d : Phase I The Event and I n i t i a l Spousal Response; Phase II Reaction to the Event; Phase III Impact of the Event. The phases were d e s c r i b e d f u r t h e r i n l i g h t of the c o n s t r u c t s formulated from the l i t e r a t u r e review: (1) Reactions to Loss; (2) The Elements of Loss; (3) The Meaning of Loss. T h i s study was designed to provide i n s i g h t i n t o understanding the event of a myocardial i n f a r c t i o n w i t h i n the context of the phenomenon of l o s s . The f i n d i n g s supported the use of a l o s s framework f o r a s s e s s i n g the r e a c t i o n s of spouses who are threatened with the death of t h e i r p a r t n e r . Nurses are i n a c r i t i c a l p o s i t i o n to a s s i s t spouses experiencing l o s s . I m p l i c a t i o n s and recommendations f o r nursing educa-t i o n , p r a c t i c e and research were d e l i n e a t e d i n l i g h t of the c o n c l u s i o n s of the present study. TABLE OF CONTENTS v Page ABSTRACT I i i TABLE OF CONTENTS v LIST OF TABLES i x LIST OF FIGURES x ACKNOWLEDGEMENTS x i CHAPTER 1 Int r o d u c t i o n 1 Background of the Study 1 S i g n i f i c a n c e of the Study 1 Statement of the Problem 2 Assumptions 3 L i m i t a t i o n s 3 D e f i n i t i o n o f Terms 4 CHAPTER 2 Review of the Related L i t e r a t u r e 6 Reactions to Loss 6 The Elements of Loss 16 The Meaning of Loss 17 Nursing Studies Related to Loss 19 Reactions to Loss by Spouses o f Myocardial I n f a r c t i o n P a t i e n t s 22 Summary 28 TABLE OF CONTENTS (Continued) v i Page CHAPTER 3 Methodology 30 I n t r o d u c t i o n : An Overview 30 The Research S e t t i n g 32 Sample S e l e c t i o n 32 Data C o l l e c t i o n 34 Data Coding and A n a l y s i s 40 R e l i a b i l i t y and V a l i d i t y Issues 41 CHAPTER 4 F i n d i n g s o f the Study 44 PHASE I The Event and I n i t i a l Spousal Response 44 PHASE I\u00E2\u0080\u0094T h o u g h t s 45 PHASE I - - F e e l i n g s 52 PHASE I \u00E2\u0080\u0094 A c t i o n s 56 PHASE II Reaction to the Event 62 PHASE I I \u00E2\u0080\u0094 Thoughts 62 PHASE I I - - F e e l i n g s 69 PHASE I I \u00E2\u0080\u0094 A c t i o n s 71 PHASE III Impact o f the Event 75 PHASE I I I \u00E2\u0080\u0094 T h o u g h t s (Group A F i n d i n g s ) 75 PHASE I I I \u00E2\u0080\u0094 F e e l i n g s 78 PHASE I I I \u00E2\u0080\u0094 A c t i o n s 82 PHASE III (Group B F i n d i n g s ) 84 PHASE I I I \u00E2\u0080\u0094 T h o u g h t 85 TABLE OF CONTENTS (Continued) v i i Page PHASE 111--Feelings 88 PHASE I I I \u00E2\u0080\u0094 A c t i o n s 89 Summary 93 CHAPTER 5 D i s c u s s i o n 94 PHASE I The Event and I n i t i a l Spousal Response 94 PHASE II Reaction to the Event 104 PHASE I I I Impact of the Event (Group A) 108 PHASE III Impact of the Event (Group B) 115 Summary 118 CHAPTER 6 Summary, Con c l u s i o n s , Im p l i c a t i o n s and Recommendations . . . . 119 Overview o f the Study 119 A Loss Framework 122 Impl i c a t i o n s 124 Recommendations 129 BIBLIOGRAPHY 130 APPENDICES Appendix A: Consent Form 135 Appendix B: Information Relted to Cardiac Research Study . . 137 Appendix C: Data C o l l e c t i o n Tool 139 TABLE OF CONTENTS (Continued) v i i i Page Appendix D: Sample o f Data Coding and A n a l y s i s Procedure . . 141 Appendix E: Overview of the Fi n d i n g s 143 Appendix F: Overview of the I n t e r p r e t a t i o n of the Findi n g s . 145 LIST OF TABLES i x Page Table 1 Age and Sex of P a t i e n t s and Spouses 35 2 Number of Days a f t e r Myocardial I n f a r c t i o n t h a t Interview Took Place 38 LIST OF FIGURES x Page Figure 1 The Meaning of Loss 109 2 A Loss Framework f o r Spouses o f Myocardial I n f a r c t i o n P a t i e n t s 125 ACKNOWLEDGEMENTS xi I wish to express my s i n c e r e a p p r e c i a t i o n to my t h e s i s a d v i s o r s , Rose Murakami (Chairperson) and Carol J i l l i n g s f o r t h e i r w i l l i n g and h e l p f u l guidance i n the development of t h i s t h e s i s . Thanks are a l s o due to the head nurses, s t a f f members and p a t i e n t s on the u n i t s where the study was conducted f o r being so understanding and h e l p f u l . A s p e c i a l thanks i s extended to the spouses who shared t h e i r personal experiences. T h e i r p a r t i c i p a t i o n was most a p p r e c i a t e d . The support o f the f o l l o w i n g i n d i v i d u a l s i s g r e a t f u l l y acknowl-edged: Michael Doyle and Barbara Wright f o r t h e i r expert a s s i s t a n c e with the p r e p a r a t i o n of t h i s manuscript; and, f i n a l l y my c l o s e f r i e n d s and f a m i l y who have continued to o f f e r encouragement i n the p u r s u i t o f my academic g o a l s . CHAPTER 1 INTRODUCTION Background o f the Study Nurses i n t h e i r p r a c t i c e are c o n t i n u a l l y c a r i n g f o r p a t i e n t s and f a m i l y members who have f a c e d some degree of l o s s ranging from a minor d i s r u p t i o n t o the death o f a l o v e d one. T h i s study used a phenomeno-l o g i c a l approach t o examine l o s s as expressed by the spouses of myo-c a r d i a l i n f a r c t i o n (M.I.) p a t i e n t s . Because of the importance of the p a t i e n t ' s r e l a t i o n s h i p t o a spouse, the need t o examine f u r t h e r the impact o f the p a t i e n t ' s i l l n e s s upon M.I. spouses p r o v i d e d the impetus f o r t h i s study. S i g n i f i c a n c e o f the Study Nurses have many o p p o r t u n i t i e s t o help persons a n t i c i p a t i n g , or alread y e x p e r i e n c i n g l o s s ( C a r l s o n , 1978). Studies have shown t h a t a myocardial i n f a r c t i o n has c o n s i d e r a b l e i n f l u e n c e on the spouse, u s u a l l y the w i f e , and her r e a c t i o n s , c a p a c i t i e s and a t t i t u d e s are g e n e r a l l y c r i t i c a l t o the p a t i e n t ' s r e h a b i l i t a t i o n (Gulledge, 1975). L i t t l e r esearch was found, however, which r e l a t e d the phenomenon of l o s s to spouses of myocardial i n f a r c t i o n p a t i e n t s . A need to i d e n -t i f y r e a c t i o n s t h a t spouses e x p e r i e n c e d i n response to l o s s was ev i d e n t . T h i s knowledge may a s s i s t the nurse i n p r o v i d i n g spouses with the necessary guidance and support with subsequent b e n e f i c i a l e f f e c t on the p a t i e n t . 2 Statement of the Problem Loss was d e s c r i b e d as \"a s t a t e o f being deprived of or of being without something one has had\" ( P e r e t z , 1970, p. 4 ) . While d i f f e r e n c e s i n the magnitude of l o s s may change the q u a l i t y of the subsequent emotional r e a c t i o n s , there was c o n s i d e r a b l e evidence to suggest s i m i l a r i t i e s i n the recovery process f o l l o w i n g major l o s s e s (Bowlby, 1961; Engel, 1962; Fink, 1967; Kubler-Ross, 1969, Parkes, 1972; Shontz, 1975). F u r t h e r , a number of a d d i t i o n a l s t u d i e s have v e r i f i e d t h a t spouses of myocardial i n f a r c t i o n p a t i e n t s r e a c t s i g n i f i c a n t l y t o t h e i r p a r t -ner's i l l n e s s , as evidenced by a n x i e t y , g u i l t , d e p r e s s i o n , h o s t i l i t y and o v e r p r o t e c t i v e behaviour (Adsett and Bruhn, 1968; Royle, 1973; Crawshaw, 1974; L a r t e r , 1976). T h e r e f o r e , f o r the nurse p r a c t i t i o n e r , more knowledge was r e q u i r e d of spousal behaviour i n order to b e t t e r understand the phenomena o f l o s s , and thus care more e f f e c t i v e l y f o r heart attack p a t i e n t s . Within the context of t h i s problem statement, the purpose of t h i s study was: - to e l i c i t d e s c r i p t i o n s from spouses o f M.I. p a t i e n t s o f t h e i r r e a c t i o n s i n response to l o s s from the i n i t i a l impact of i l l n e s s to s i x weeks post myocardial i n f a r c t i o n . - to observe spousal r e a c t i o n s i n response to l o s s from the i n i t i a l impact of i l l n e s s to s i x weeks post myocardial i n f a r c t i o n ; - to develop a framework, based on l i t e r a t u r e , which r e l a t e d the concept of l o s s to the experience of spouses of M.I. p a t i e n t s ; 3 - to make recommendations f o r change i n nursing education, p r a c t i c e and research drawn from the study. Assumptions I t i s assumed t h a t the husband-wife dyad i s s i g n i f i c a n t and t h a t l o s s experienced by one person i n the r e l a t i o n s h i p has c o n s i d e r a b l e impact on the p a r t n e r (Lindemann, 1944; M a r r i s , 1958; Parkes, 1969). Spouses o f h e a r t a t t a c k p a t i e n t s share common needs and concerns i n response to t h e i r p a r t n e r ' s i l l n e s s ( A dsett and Bruhn, 1968; Royle, 1973; Skelton and Dominian, 1973; L a r t e r , 1976; Mayou, F o s t e r and Williamson, 1978). The spouse's r e a c t i o n s , c a p a c i t i e s and a t t i t u d e s are g e n e r a l l y c r i t i c a l i n the M.I. p a t i e n t ' s r e h a b i l i t a t i o n . I t i s a l s o assumed M.I. spouses experience s i m i l a r r e a c t i o n s to l o s s . These g e n e r a l i z a t i o n s about a phenomenon can provide nurses with knowledge and d i r e c t i o n f o r p r a c t i c e . However, adequate r e c o g n i t i o n of i n d i v i d u a l d i f f e r e n c e s among spouses i n response t o a l o s s event such as a heart attack were acknowledged. L i m i t a t i o n s The emphasis of the study was on q u a l i t a t i v e data r a t h e r than on r e l a t i o n s h i p s between v a r i a b l e s . The purpose was to d i s c o v e r and d e s c r i b e l o s s as experienced by spouses of M.I. p a t i e n t s r a t h e r than prove or d i s p r o v e a given hypothesis. The s e l e c t e d sample was l i m i t e d to spouses whose partners had experienced t h e i r f i r s t myocardial i n f a r c t i o n . A convenient 4 non-random sample of twelve spouses was s e l e c t e d . No attempts were made a t r e p r e s e n t a t i v e n e s s i n the s t a t i s t i c a l sense. D e f i n i t i o n of Terms The f o l l o w i n g terms are o p e r a t i o n a l l y d e f i n e d i n the d i s c u s s i o n o f the data presented. Reactions The thoughts, f e e l i n g s and a c t i o n s as d e s c r i b e d by the spouses of myocardial i n f a r c t i o n p a t i e n t s . Observable behaviours The responses o f the spouses as observed by the i n v e s t i g a t o r during the i n t e r v i e w . These responses are c a t e g o r i z e d as verbal (type, q u a l i t y and c h a r a c t e r i s t i c s of speech, focus of conversation) and nonverbal (e.g. a c t i v i t y , eye c o n t a c t , body language and appearance). Loss The d e p r i v a t i o n of any o b j e c t , person, possession or i d e a l t h a t was c o n s i d e r e d v a l u a b l e and had an investment of s e l f . Loss was considered a c t u a l , p o t e n t i a l or symbolic ( P r a n u l i s , 1972). Loss could be t o t a l , p a r t i a l , permanent, temporary, p r e d i c t a b l e , u n p r e d i c t a b l e , sudden or gradual ( P e r e t z , 1970). Loss was understood as having an o b j e c t i v e q u a l i t y r e l a t e d to an event and a s u b j e c t i v e q u a l i t y r e l a t e d to the meaning given a l o s s event by an i n d i v i d u a l . G r i e f The p s y c h o l o g i c a l , emotional and somatic responses experienced f o l l o w i n g the p e r c e p t i o n of l o s s . Reactions i n c l u d e f e e l i n g s of shock 5 and d i s b e l i e f , h e l p l e s s n e s s , hopelessness, a n x i e t y , sadness, g u i l t , d e s p a i r , anger and aggression (Lindemann, 1944; Engel, 1962; Kubler-Ross, 1969; Parkes, 1972). Somatic symptoms i n c l u d e dyspnea, deep s i g h i n g , lumps or t i g h t s e n sation i n the t h r o a t , weakness, f e e l i n g s o f emptiness, exhaustion, decreased a p p e t i t e and insomnia (Lindemann, 1944; P e r e t z , 1970). I n i t i a l impact of i l l n e s s The f i r s t n i n e t y - s i x hours of the p a t i e n t ' s myocardial i n f a r c t i o n . This time represents the acute phase of the p a t i e n t ' s i l l n e s s and occurs during the h o s p i t a l i z a t i o n p e r i o d i n the coronary care u n i t (Roberts, 1978). P a t i e n t with an uncomplicated myocardial i n f a r c t i o n A p a t i e n t admitted to the coronary care u n i t with a d i a g n o s i s of myocardial i n f a r c t i o n who responds favourably to the p r e s c r i b e d coronary regime. The p a t i e n t maintains a s t a b l e p h y s i o l o g i c a l status and does not develop c a r d i a c f a i l u r e , thromboemoblism, extension o f i n f a r c t i o n , shock or c a r d i a c rupture. 6 CHAPTER 2 REVIEW OF THE RELATED LITERATURE A review of the l i t e r a t u r e r e v e a l e d few d i s c u s s i o n s of the concept o f l o s s as experienced by the spouses o f myocardial p a t i e n t s . There were numerous e m p i r i c a l and t h e o r e t i c a l - even c o n t r o v e r s i a l - s t u d i e s of l o s s from an emotional, p s y c h o l o g i c a l and p h y s i o l o g i c a l p e r s p e c t i v e . This chapter w i l l examine the concept of l o s s as found i n the l i t e r a -t u r e and w i l l o u t l i n e a framework f o r understanding the phenomenon of l o s s . The purpose of t h i s t h e o r e t i c a l background i s to provide the i n t e l l e c t u a l c o n text f o r the conduct of t h i s study. Loss has been s t u d i e d e x t e n s i v e l y from a behavioural viewpoint: much of the l o s s research has emerged from c l i n i c a l p s y c h o a n a l y s i s and has been developed by p s y c h i a t r i s t s and s o c i a l p s y c h i a t r i s t s (Freud, 1917; Lindemann, 1944; M a r r i s , 1955; Bowlby, 1961; Engel, 1962; Parkes, 1969; Kubler-Ross, 1969). In the l a s t two decades f u r t h e r research and theory have been developed f o c u s i n g on some of the concepts c e n t r a l to l o s s ( M a r r i s , 1958; Parkes, 1965; A v e r i l l , 1968; Lipowski, 1969; P e r e t z , 1970; Schoenberg, 1970). More r e c e n t l y nurse researchers have s t u d i e d the impact of i l l n e s s on the spouse (Hampe, 1975; Vachon, 1977; Dracup and Breu, 1978). Reactions to Loss A person may experience g r i e f and mourning r e g a r d l e s s of the degree of l o s s or i t s i m p l i c a t i o n (Freud, 1917; Bowlby, 1961; 7 Lipowski, 1969). To understand l o s s i t i s h e l p f u l to c o n s i d e r the behavioural response to l o s s , which o f t e n takes the form of a g r i e f r e a c t i o n . The l i t e r a t u r e r e v e a l e d d i f f e r e n c e s i n the use of the word g r i e f and r e l a t e d terms. G r i e f , g r i e v i n g , mourning, g r i e f work, and bereave-ment were a p p l i e d i n t e r c h a n g e a b l y : however, t h e o r i s t s commonly c a t e g o r i z e g r i e f and i t s r e l a t e d terms i n t o three major components: the p s y c h o l o g i c a l processes, the emotional responses and the somatic symptoms experienced at the time of l o s s . The h i s t o r i c a l development of l o s s began with the psychodynamic aspects of l o s s and g r i e f . In 1917, Freud f i r s t p u b l i s h e d Mourning and Melancholia which viewed mourning as a r e g u l a r c h a r a c t e r i s t i c f o l l o w i n g the l o s s o f a l o v e d one. Freud f e l t t h a t mourning was a process t h a t normally continued to a p r e d i c t a b l e outcome. The process of mourning was a continuum o f mental f e a t u r e s t h a t were symptomatic to every per-son who g r i e v e d . These f e a t u r e s were p a i n f u l d e j e c t i o n , abrogation of i n t e r e s t i n the o u t s i d e world, l o s s of the c a p a c i t y to l o v e , and i n h i -b i t i o n of a l l - a c t i v i t y . Freud f e l t , however, t h a t i f c e r t a i n f a c t o r s were present i n the c h a r a c t e r s t r u c t u r e of the g r i e v i n g person, the process of mourning could turn i n t o the p a t h o l o g i c a l s t a t e of melancholia. He i d e n t i f i e d three f a c t o r s t h a t i n f l u e n c e d t h i s type of outcome: l o s s of s e l f -esteem, strong dependency needs and ambivalence toward the l o s t o b j e c t . According to Freud, the development of melancholia i s not an exagger-ated g r i e v i n g process; r a t h e r i t i s a phenomenon which a r i s e s because of in h e r e n t t r a i t s i n the i n d i v i d u a l . 8 Stemming from Freud's attempts to l i n k mourning and m e l a n c h o l i a , w r i t e r s have s t u d i e d the e f f e c t s of bereavement i n a d u l t l i f e as well as the e f f e c t s of s e p a r a t i n g c h i l d r e n from t h e i r mothers. Lindemann (1944) p u b l i s h e d one of the most d e f i n i t i v e papers on g r i e f which d e s c r i b e d the c h a r a c t e r i s t i c s i g n s o f g r i e f based on an American study of 101 bereaved. He d e s c r i b e d acute g r i e f as a d e f i n i t e syndrome with p s y c h o l o g i c a l and somatic symptoms i n c l u d i n g somatic d i s t r e s s , preoccupation with the image of the deceased, g u i l t , h o s t i l e r e a c t i o n s , l o s s of h a b i t u a l p a t t e r n s of conduct, and with some frequency, the appearance of t r a i t s o f the deceased. Lindemann found t h a t persons i n acute g r i e f demonstrated q u i t e a uniform p i c t u r e and s t a t e d : Common to a l l i s the f o l l o w i n g syndrome: sensations of somatic d i s t r e s s o c c u r r i n g i n waves l a s t i n g twenty minutes to an hour a t a time, a f e e l i n g o f t i g h t n e s s i n the t h r o a t , choking with a shortness of breath, need f o r s i g h i n g , an empty f e e l i n g i n the abdomen, lack of muscular power, and an i n t e n s e s u b j e c t i v e d i s t r e s s d e s c r i b e d as t e n s i o n or mental pain (Lindemann, 1944, p. 141). Lindemann found i n d i v i d u a l s moved through a course of normal g r i e f r e a c t i o n s . He d e s c r i b e d t h i s process as g r i e f work, namely emanci-p a t i o n from the bondage to the deceased, readjustment to the e n v i r o n -ment i n which the deceased i s m i s s i n g , and the formation of new r e l a t i o n s h i p s . He found duration of the g r i e f r e a c t i o n depended upon the success with which a person completed the g r i e f work. Lindemann was the f i r s t to d e s c r i b e the concept of a n t i c i p a t o r y g r i e f . In h i s study of f a m i l i e s o f servicemen who had departed f o r 9 war, he found t h a t these i n d i v i d u a l s threatened with the l o s s of a l o v e d one experienced genuine g r i e f r e a c t i o n s which he l a b e l l e d as a n t i c i p a t o r y g r i e f . Lindemann suggested t h a t i n d i v i d u a l s who experienced a n t i c i p a t o r y g r i e f moved through the same process of g r i e f work as those who experienced g r i e f a f t e r an a c t u a l l o s s . The p a t i e n t i s so concerned with her adjustment a f t e r the p o t e n t i a l death o f f a t h e r or son t h a t she goes through a l l the phases of g r i e f d e p r e s s i o n , heightened preoccupation with the departed, a review of a l l the forms o f death which might be-f a l l him and a n t i c i p a t i o n of the modes o f readjustment which might be n e c e s s i t a t e d by i t . (Lindemann, 1944, p. 147). The r e a c t i o n s observed i n Lindemann's (1944) study were s i m i l a r to those d e s c r i b e d i n bereaved i n d i v i d u a l s . Most of the r e a c t i o n s were a s s o c i a t e d with d e p r e s s i o n , somatic symptoms o f exhaustion, l a c k of energy, s i g h i n g , r e s p i r a t i o n s , and d i g e s t i v e symptoms. Other f e e l i n g s of anger, i r r i t a b i l i t y , g u i l t and r e s t l e s s n e s s were rep o r t e d . Lindemann noted t h a t heightened preoccupation with the deceased was experienced by the bereaved as well as those a n t i c i p a t i n g the l o s s of a l o v e d one. This need f o r i n t e n s e preoccupation was f i r s t d i s c u s s e d by Freud (1917). He i n d i c a t e d that i t was a method which enabled the i n d i v i d u a l to e v e n t u a l l y give up the l o s t person. Werner (1970), i n a study of f a t a l l y i l l c h i l d r e n , observed t h a t the parents had an i n s a t i a b l e need to know e v e r y t h i n g about t h e i r c h i l d ' s c o n d i -t i o n . T h is search f o r i n f o r m a t i o n became an a l l consuming preoccupa-t i o n . The c h i l d became a constant focus i n t h e i r l i v e s and l i t t l e i n t e r e s t was shown f o r other a c t i v i t i e s . Reviewing the forms of death t h a t might b e f a l l the i n d i v i d u a l was 10 the t h i r d c h a r a c t e r i s t i c d e s c r i b e d by Lindemann. This r e a c t i o n i s s i m i l a r to t h a t experienced i n an actual l o s s , where the bereaved reviewed the events l e a d i n g up to and surrounding the death o f a l o v e d one ( M a r r i s , 1958; Parkes, 1972). Although Lindemann s t r e s s e d the s i m i l a r i t i e s between the r e a c t i o n s o f the bereaved and the r e a c t i o n s of those a n t i c i p a t i n g a l o s s , an important d i f f e r e n c e was mentioned by A l d r i c h (1975). Conventional g r i e f g e n e r a l l y d i s s i p a t e s with time, whereas a n t i c i p a t o r y g r i e f w i l l o f t e n i n t e n s i f y as the expected l o s s comes c l o s e r . Several authors have s t u d i e d the meaning of l o s s to i n d i v i d u a l s at v a r i o u s stages of the l i f e c y c l e from i n f a n c y to senescence (Anthony, 1940; P i a g e t , 1952; R o c h l i n , 1959; Nagy, 1959; Bowlby, 1961; Gesson, 1968; Burnside, 1969). John Bowlby (1961) r e f e r r e d to mourning as the p s y c h o l o g i c a l processes t h a t f o l l o w a l o s s of a s i g n i f i c a n t or valued o b j e c t , or t h a t f o l l o w the r e a l i z a t i o n t h a t such a l o s s may occur. The working through of these processes u s u a l l y leads to a g i v i n g up of the l o s t o b j e c t . He has s p e l l e d out i n great d e t a i l the way i n which young c h i l d r e n respond to the l o s s of a mother or mother s u b s t i t u t e . Bowlby b e l i e v e d t h a t the ego i s developed before the age of one y e a r and, t h e r e f o r e , the c h i l d i s capable of mourning at an e a r l y age. In drawing a d i r e c t r e l a t i o n s h i p between sepa r a t i o n l o s s and g r i e f , Bowlby argued t h a t c h i l d r e n and a d u l t s show s i m i l a r responses to the e x p e r i -ence o f l o s s whether act u a l or a n t i c i p a t e d . Some w r i t e r s have d e s c r i b e d phases or stages t h a t f o l l o w the death of a l o v e d one or major l i f e - t h r e a t e n i n g event ( M a r r i s , 1958; Engel, 1962; F i n k , 1967; Parkes, 1969; Kubler-Ross, 1969; Shontz, 1975). 11 Despite the t h e o r e t i c a l and d e s c r i p t i v e d i f f e r e n c e s between the v a r i o u s approaches, these w r i t e r s appeared to have many thoughts i n common about the nature o f g r i e f . They d e s c r i b e d the same elements although they gave d i f f e r e n t \" l a b e l s \" to the phases or stages. T h e i r g r i e f t h e o r i e s have provided a framework f o r understanding the phenomenon of l o s s . M a r r i s (1958) d e s c r i b e d g r i e v i n g or g r i e f work as the psycholog-i c a l sequence or process r e q u i r e d to a d j u s t to l o s s . The process i s evoked when a b i l i t i e s are threatened. M a r r i s conducted a systematic study o f the e f f e c t of bereavement on seventy-two London widows, ranging i n age from 25 t o 56. The widows complained o f d e t e r i o r a t i o n i n h e a l t h , insomnia, l o s s o f c o n t a c t with r e a l i t y , o b s e s s i v e memories and a sense of t h e i r dead husband's presence. M a r r i s d e s c r i b e d the widows' p r e v a i l i n g mood as a p a t h e t i c . He i d e n t i f i e d a c h a r a c t e r i s t i -c a l l y ambivalent response i n the behaviour of the bereaved where the women withdrew from people and t r i e d to escape from a l l reminders of the l o s s y e t i n the same breath seemed d e s p e r a t e l y l o n e l y and com-p l a i n e d i f people avoided them. The widows c u l t i v a t e d memories o f the dead, d e s i r i n g people to nurture those memories, y e t r e b u f f e d t h a t sympathy when i t was o f f e r e d . They i n s i s t e d t h a t t h e i r l i f e was mean-i n g l e s s now t h a t they had l o s t t h e i r husbands, however, they h u r r i e d back to t h e i r jobs while c a r i n g f o r t h e i r c h i l d r e n and homes with p r a c t i c a l e f f i c i e n c y . According to M a r r i s , i t i s d i f f i c u l t f o r others to know how to .. a s s i s t the new widows: sympathy aggravates the d i s t r e s s ; e x h o r t a t i o n s to be p r a c t i c a l and look to the f u t u r e seem g l i b and i n s e n s i t i v e ; s o l i c i t o u s n e s s seems o f f i c i o u s . Nothing seems r i g h t , causing f r i e n d s and f a m i l y to withdraw f u r t h e r . C l o s e l y l i n k e d to the works of Lindemann and Marris are the documented s t u d i e s o f g r i e f i n a d u l t l i f e by C o l i n Murray Parkes, (1965, 1972). Parkes has d e s c r i b e d g r i e f r e a c t i o n s i n d e t a i l , and has attempted to measure bereavement r e a c t i o n s using i n d i c a t o r s such as r a t e s of p h y s i c a l and mental i l l n e s s along with m o r t a l i t y s t a t i s t i c s . In 1959, f o l l o w i n g h i s d i s s e r t a t i o n on morbid g r i e f r e a c t i o n s , Parkes (1965) began a systematic i n v e s t i g a t i o n of 115 bereaved p s y c h i a t r i c p a t i e n t s whose i l l n e s s had developed w i t h i n s i x months a f t e r the death of a c l o s e f a m i l y member. He compared the r e a c t i o n s o f the bereaved to t y p i c a l g r i e f r e a c t i o n s as d e s c r i b e d by Marris (1958) i n h i s London widow study. Parkes found t h a t h i s p a t i e n t s had symptoms t h a t d i f f e r e d , i n i n t e n s i t y and d u r a t i o n which l e d him to c l a s s i f y g r i e f i n t o c a t e g o r i e s : t y p i c a l g r i e f , c h r o n i c g r i e f , i n h i b i t e d g r i e f and delayed g r i e f . Subsequently, Parkes (1971) undertook a l o n g i t u d i n a l study of the t y p i c a l g r i e f r e a c t i o n s o f London widows to the death o f t h e i r husbands. Parkes d e s c r i b e d the components of t y p i c a l g r i e f as alarm, s e a r c h i n g , m i t i g a t i o n , anger, g u i l t and g a i n i n g a new i d e n t i t y . During the alarm phase, the widows repor t e d r e s t l e s s n e s s and i n c r e a s e d muscle t e n s i o n , episodes of f e e l i n g panicky, i r r i t a b i l i t y , insomnia, l o s s o f a p p e t i t e , stomach upsets, and headaches. F o l l o w i n g the alarm phase, the widows experienced acute and e p i s o d i c \"pangs\" which were episodes of severe anxiety and p s y c h o l o g i c a l pain. Parkes termed t h i s phase s e a r c h i n g , and found i t occurred w i t h i n a few hours or days of bereave-ment and u s u a l l y reached a peak of s e v e r i t y w i t h i n f i v e to fourteen days. The widows s t r o n g l y missed t h e i r husbands, and would sob or c r y aloud f o r them, o f t e n preoccupied with thoughts of the l o s t person. Parkes f e l t the widows experienced p i n i n g , \"... the s u b j e c t i v e and emotional component of the urge t o search f o r a l o s t o b j e c t \" (Parkes, 1972, p. 40). The t h i r d phase d e s c r i b e d i s m i t i g a t i o n , which many o f the widows achieved by m a i n t a i n i n g a f e e l i n g or impression t h a t the bereaved person i s nearby, although he may not be seen or heard. The widows f e l t the p a i n was l e s s e n e d i f they had a c l e a r sense o f the continued presence of the deceased and became preoccupied with the thoughts of him. An o p p o s i t e r e a c t i o n was observed with other widows, who chose to m i t i g a t e the pain by d e n i a l . They t r i e d to b e l i e v e t h a t the l o s s had not o c c u r r e d and attempted to a v o i d people and s i t u a t i o n s t h a t would remind them o f the l o s s . Parkes found t h a t most widows expressed anger at some time during the f i r s t y e a r of bereavement. Sometimes the anger was d i r e c t e d towards the h o s p i t a l s t a f f o f t e n i t was expressed over a wide v a r i e t y of matters, many of them q u i t e t r i v i a l . He found r e p o r t s o f anger tended to be at a height during the f i r s t month, and to be reported only i n t e r m i t t e n t l y t h e r e a f t e r . Parkes termed the l a s t component of g r i e f \" g a i n i n g a new iden-t i t y , \" and r e p o r t e d the widows g r a d u a l l y learned a new r e p e r t o i r e of problem-solving s k i l l s i n order to cope with the u n f a m i l i a r tasks f a c i n g them. Widows repor t e d t h e i r r o l e s changing to i n c l u d e p r i n c i p a l wage earner, f a m i l y a d m i n i s t r a t o r and d i s c i p l i n a r i a n of the c h i l d r e n . At times the widows i d e n t i f i e d c l o s e l y with t h e i r former husbands, f o r 14 t h i s seemed to f a c i l i t a t e the r o l e changes and i n some way allowed them to keep a hold on t h e i r l o s t husbands. This coping mechanism, however, was only i n t e r m i t t e n t l y e f f e c t i v e . Episodes of comfortable c l o s e n e s s were followed by periods of g r i e v i n g and l o n e l i n e s s . The widows g r a d u a l l y found t h e i r new i d e n t i t y emerging from the a l t e r e d l i f e s i t u a t i o n s which they had to f a c e , and new f r i e n d s and workers provided the r o l e models. Several widows remarked t h a t t a l k i n g t o other widows was most h e l p f u l because they shared a common experience. Although many o f the bereavement s t u d i e s concentrated on the l o s s of a loved one, Marc F r i e d (1963) examined the concept of l o s s from a d i f f e r e n t p e r s p e c t i v e when he s t u d i e d the r e a c t i o n s of 789 Boston s i urn-dwellers who were moved from the west end of Boston under an urban renewal scheme. The f a m i l i e s were interviewed before the compulsory rehousing took place and again two years l a t e r . In h i s paper e n t i t l e d \" G r i e v i n g f o r a Lost Home\", F r i e d has drawn a c o n c i s e comparison between bereavement and the d e s t r u c t i o n of a neighbourhood and d i s p e r s a l of i t s r e s i d e n t s . He s t a t e d t h a t the m a j o r i t y gave evidence of f a i r l y severe g r i e f r e a c t i o n s . Intense p i n i n g f o r the l o s t home along with p s y c h o l o g i c a l , s o c i a l and somatic d i s t r e s s and o u t b u r s t s o f anger were t y p i c a l and there was a tendency to i d e a l i z e the o l d environment and to d e n i g r a t e the new. F o l l o w i n g F r i e d ' s work, Parkes (1972) and M a r r i s (1975) have expanded the research on g r i e f by conducting s t u d i e s to determine the r e a c t i o n s to s i g n i f i c a n t l o s s e s , other than the death of a loved one. Parkes i n t e r v i e w e d t h i r t y - s e v e n men and nine women under the age of 70, a t one and t h i r t e e n months a f t e r e x p e r i e n c i n g the l o s s of. an arm or a 15 l e g . He found t h a t the g r i e f a t the l o s s o f a loved person resembled the r e a c t i o n s f e l t by the amputees: It does seem t h a t the psychosocial t r a n s i -t i o n from being an i n t a c t person to being an amputee i s a p a i n f u l and time consuming p r o c e s s , which i s i n many ways s i m i l a r t o the t r a n s i t i o n from a married person to widow or widower (Parkes, 1972, p. 189). In a review a r t i c l e , M arris (1975) d i s c u s s e d h i s v a r i o u s s t u d i e s d e a l i n g with such d i v e r s e themes as the e f f e c t s o f bereavement on London widows, slum c l e a r a n c e i n America and N i g e r i a , students' e x p e r i -ence of u n i v e r s i t y education and American experiments i n s o c i a l reform. In each study the i n d i v i d u a l s were faced with a c r u c i a l t r a n s i t i o n . M a r r i s found the concept o f g r i e v i n g a p p l i c a b l e to many s i t u a t i o n s of change other than the death of a loved one. Whenever i n d i v i d u a l s experienced l o s s , even though they might d e s i r e change, t h e i r r e a c t i o n s expressed i n t e r n a l c o n f l i c t . The nature o f t h i s c o n f l i c t was fundamentally s i m i l a r to the working out o f g r i e f . The a n x i e t i e s o f change centered upon the s t r u g g l e to defend or to recover a meaningful p a t t e r n o f r e l a t i o n s h i p . Marris concluded t h a t \"the impulse to defend the p r e d i c t a b i l i t y o f l i f e i s a fundamental and u n i v e r s a l p r i n c i p a l o f human psychology\" ( M a r r i s , 1975, p. 3). Studies of the r e a c t i o n to l o s s by death o f a loved person have thrown c o n s i d e r a b l e l i g h t on the nature o f g r i e f and the process of adjustment which normally f o l l o w s a major bereavement. The t r a n s i t i o n begins with denial or numbness through a b i t t e r p i n i n g and f r u s t r a t e d search f o r the l o s t person. T h i s i s succeeded by depression and apathy when the bereaved person f i n a l l y g i v e s up the d e s i r e o f r e c o v e r i n g the l o s t person or o b j e c t . Next, a f i n a l phase of r e o r g a n i z a t i o n when new 16 plans and assumptions about the world and the s e l f are b u i l t up. The Elements of Loss Loss was c h a r a c t e r i z e d as a gradual p r e d i c t a b l e event and as a sudden traumatic experience. Loss, whether i n the past, present or f u t u r e , c o u l d be f e l t as a c t u a l , symbolic, or a n t i c i p a t e d (Lindemann, 1944; Schoenberg, 1970; Peretz, 1970; C a r l s o n , 1970). Loss was a l s o conceived as two events o c c u r r i n g simultaneously. To the observer t h e r e was a s p e c i f i c o b j e c t i v e or r e a l event t h a t s i g n a l e d an actual or p o t e n t i a l l o s s ; t o the i n d i v i d u a l e x p e r i e n c i n g the l o s s the event was a very s u b j e c t i v e one ( P e r e t z , 1970). In a narrow co n t e x t , l o s s was c a t e g o r i z e d as b i o l o g i c a l . B i o l o g -i c a l l o s s i n c l u d e d l o s s o f f u n c t i o n , p a r t or whole, and ranged from temporary a l t e r a t i o n of a system's f u n c t i o n to complete removal or l o s s of t h a t system. Psychosocial l o s s occurred i n c o n j u n c t i o n with b i o l o g -i c a l l o s s or, i n some cases, independently y e t both were e q u a l l y s i g n i f i c a n t (Parkes, 1972; Shontz, 1975; Roberts, 1978). I l l n e s s , l o s s of a limb or death, are concrete and observable whereas l o s s can a l s o take a more a b s t r a c t form and perhaps only be known to the i n d i v i d u a l . Loss of h e a l t h , f o r example, may l e a d to l o s s of a job as breadwinner r e s u l t i n g i n r e a l or a n t i c i p a t e d l o s s o f r e s p e c t from others ( P r a n u l i s , 1972). Peretz (1970) i d e n t i f i e d a b s t r a c t l o s s as l o s s of p o s i t i v e s e l f meaning the l o s s of a t t r a c t i v e -ness, p r i d e , esteem, independence and c o n t r o l . M a r r i s (1958) c i t e d the l o s s of freedom, happiness, hope, dreams, c e r t a i n t y , and p r e d i c t a b i l i t y as a b s t r a c t i n nature. Lipowski (1969) v o i c e d the same thoughts. He s a i d l o s s r e f e r r e d not j u s t to body pa r t s and f u n c t i o n s a c t u a l l y l o s t , but a l s o to d e p r i v a t i o n s of p e r s o n a l l y s i g n i f i c a n t needs and v a l u e s . The l a t t e r , he continued, were r e l a t e d c h i e f l y to s e l f - e s t e e m , s e c u r i t y and s a t i s f a c t i o n . P r a n u l i s (1972) viewed t h i s combination of concrete and a b s t r a c t l o s s with a broader f o c u s . She f e l t i n d i v i d u a l s were a s s a i l e d with l o s s on several l e v e l s a t d i f f e r e n t p o i n t s i n time. Peretz s t a t e d , with an even broader p e r s p e c t i v e , t h a t \"Each l o s s c a r r i e s with i t the t h r e a t of a d d i t i o n a l or f u t u r e l o s s e s \" ( P e r e t z , 1970, p. 4 ) . The Meaning of Loss Unlike the s t u d i e s d i s c u s s e d i n the previous s e c t i o n , a substan-t i a l number of w r i t i n g s were found t h a t presented l e s s d e f i n i t i v e opinions and t h e o r i e s r e l a t e d to l o s s . Although t h e o r i s t s v a r i e d i n t h e i r d e f i n i t i o n s o f l o s s , there was agreement t h a t an element, o b j e c t or event must be endowed with some s i g n i f i c a n t meaning i n order to be p e r c e i v e d as a l o s s . F u r t h e r d i s c u s s i o n on g r i e f , mourning, s e p a r a t i o n and other r e l a t e d concepts has c o n t r i b u t e d to the development of the theory of \" o b j e c t r e l a t i o n s \" which r e l a t e s mental i l l n e s s to the development of u n s a t i s f a c t o r y modes o f coping with l o s s throughout the course o f the l i f e s p a n (Lewin, 1935; E r i k s o n , 1959; Bowlby, 1961). Peretz (1970) used the term \" o b j e c t l o s s \" to r e f e r to the l o s s of an o b j e c t which has s p e c i a l value and emotional meaning to a person. Peretz conceived o b j e c t r e l a t i o n s h i p s as the r e l a t i o n s between an i n d i v i d u a l and the 18 t h i n g s i n h i s environment which have emotional s i g n i f i c a n c e i n c l u d i n g r e l a t i o n s between the i n d i v i d u a l and other persons, the i n d i v i d u a l and h i m s e l f , and the i n d i v i d u a l and inanimate o b j e c t s ( P e r e t z , 1970, p. 7). Moreover, l o s s was any s i t u a t i o n e i t h e r a c t u a l or p o t e n t i a l i n . which a valued o b j e c t was rendered i n a c c e s s i b l e to an i n d i v i d u a l or a l t e r e d i n such a way t h a t i t no longer had the q u a l i t i e s t h a t were valued. The l o s s o f a valued o b j e c t was con s i d e r e d to be the event preceding the s u b j e c t i v e s t a t e s of g r i e f and the p s y c h o l o g i c a l processes of g r i e v i n g (Peretz, 1970; C a r l s o n , 1970). Only the i n d i v i d u a l e x p e r i e n c i n g l o s s can know i t s f u l l meaning, although an observer may be able to d e f i n e some o f the o b j e c t i v e char-a c t e r i s t i c s of a l o s s . There was a tendency to a s s i g n g e n e r a l i z e d meaning to o b j e c t i v e d e s c r i p t i o n s of l o s s even though the e x p e r i e n c i n g person might d e f i n e the events q u i t e d i f f e r e n t l y ( C a r l s o n , 1978). According to Lipowski (1969) an i n d i v i d u a l ' s emotional and behav-i o u r a l response to l o s s was d i r e c t l y r e l a t e d to h i s p e r c e p t i o n of the event: The process of e v a l u a t i o n r e s u l t i n g i n meaning begins with the f i r s t p e r c e p t i o n of a p a t h o l o g i c a l process or i n j u r y and continues unabated throughout the course of i l l n e s s and i t s sequelae. The meaning i s the core of the person's p s y c h o l o g i c a l response to h i s d i s e a s e . I t i s of c r u c i a l importance f o r h i s emotional and behavioural response (Lipowski, 1969, p. 1198). A v e r i l l (1968) noted t h a t the nature and meaning of any l o s s experience was a f u n c t i o n of the p e c u l i a r h i s t o r y and present circumstances o f each i n d i v i d u a l as well as c u l t u r a l and b i o l o g i c a l determinants. 19 Writers have continued to i d e n t i f y f a c t o r s t h a t may i n f l u e n c e an i n d i v i d u a l ' s p e r c e p t i o n of l o s s . Age, r e l i g i o n , m a r i t a l s t a t u s , personal goals and v a l u e s , previous l o s s e s and e x t e r n a l support systems were some of the v a r i a b l e s noted i n the l i t e r a t u r e (Freud, 1917; Lindemann, 1944; M a r r i s , 1965; Parkes, 1974). Parkes (1974) viewed l o s s as causing d i s r u p t i o n i n the s t r u c t u r i n g and p r e d i c t a b i l i t y o f one's view of the world. \" G r i e f work\" was the process of r e - e s t a b l i s h i n g the congruence of present i n t e r n a l percep-t i o n s with the e x t e r n a l r e a l i t i e s of the l o s s . C a r l s o n (1978) d e f i n e d l o s s to r e f l e c t the importance of an i n d i -v i d u a l ' s goals i n one's p e r c e p t i o n of l o s s . The thwarting of d e s i r e s , hopes or goals seemed to be i n h e r e n t i n most l o s s events or e x p e r i -ences. Loss was an i n t e r r u p t i o n i n goal achievement - a change i n the i n d i v i d u a l ' s s i t u a t i o n t h a t reduced the p r o b a b i l i t y of a c h i e v i n g i m p l i c i t or e x p l i c i t g o a l s . As a r e s u l t , the meaning of l o s s was experienced uniquely by each i n d i v i d u a l depending upon the value placed upon the o b j e c t . Nursing Studies Related to Loss as Experienced by Spouses Since the e a r l y 1970's, nurse researchers have conducted c l i n i c a l s t u d i e s e x p l o r i n g the impact o f i l l n e s s on spouses as well as develop-i n g and implementing n u r s i n g i n t e r v e n t i o n s which help spouses cope with l o s s . These s t u d i e s o f f e r e d a new p e r s p e c t i v e to l o s s research which h i g h l i g h t e d the needs and concerns of spouses. Hampe (1975) focused on the g r i e v i n g spouses o f c h r o n i c a l l y ill oncology p a t i e n t s . From a comprehensive l i t e r a t u r e search o f l o s s and g r i e f Hampe i d e n t i f i e d e i g h t needs of the g r i e v i n g spouses which were c l a s s i f i e d under two headings. In the f i r s t category were those needs centered on the spouses' r e l a t i o n s with the dying person. The need t o f e e l h e l p f u l to the il l p a r t n e r , to be assured of the comfort o f the dying person, and to be kept informed o f the dying person's c o n d i t i o n and impending death were found. The second category o f needs r e l a t e d to the needs of the g r i e v i n g spouse: to v e n t i l a t e emotions, to r e c e i v e comfort and support from f a m i l y members, and to r e c e i v e acceptance, support and comfort from the h e a l t h p r o f e s s i o n a l s . The m a j o r i t y of spouses i n t e r v i e w e d by Hampe i d e n t i f i e d a l l e i g h t needs drawn from the l i t e r a t u r e . Hampe found t h a t although these needs were o f t e n recognized, they were inadequately met by nurses. Dracup and Breu (1978) used Hampe's e i g h t i d e n t i f i e d needs to design and implement a s p e c i f i c nursing care plan to meet the needs of g r i e v i n g spouses o f c r i t i c a l l y i l l c a r d i o v a s c u l a r p a t i e n t s . The researchers i n t e r v i e w e d twenty-six men and women to o b t a i n b a s e - l i n e data and found t h a t the e i g h t needs i d e n t i f i e d by Hampe were a l s o rep o r t e d by t h i s p o p u l a t i o n . Using the b a s e - l i n e data and t h e o r e t i c a l knowledge of l o s s and g r i e f , they designed and implemented s p e c i f i c nursing i n t e r v e n t i o n s f o r one-half of the sample. The remaining t h i r -teen spouses r e c e i v e d the usual nursing i n t e r v e n t i o n s , which were unstructured and i n c o n s i s t e n t at times. The researchers found the needs of the spouses i n the experimental group were met more c o n s i s t -e n t l y and completely. These f i n d i n g s were a t t r i b u t e d to the success o f the s t a n d a r d i z e d n u r s i n g care plan intended f o r the g r i e v i n g spouses of c a r d i o v a s c u l a r p a t i e n t s . 21 Vachon (1977) explored the problems of g r i e f and bereavement of wives of t e r m i n a l l y i l l cancer p a t i e n t s . Seventy-three women whose husbands had d i e d o f cancer a t the age of s i x t y - s e v e n or l e s s were in t e r v i e w e d f i v e times over a twenty-four month p e r i o d f o l l o w i n g bereavement. Vachon c a t e g o r i z e d the women i n t o two groups depending on how they viewed the i l l n e s s . One group saw t h e i r husbands' f i n a l i l l n e s s as terminal l e a d i n g slowly but i n e x o r a b l y to death. Other women viewed t h e i r husbands' i l l n e s s as p r i m a r i l y c h r o n i c wherein death was not a n t i c i p a t e d and came as a shock. In both groups, the widows reported the s t r e s s of l i v i n g with cancer was f a r worse than the s t r e s s of widowhood. During the f i n a l i l l n e s s there were many patterns of emotional r e a c t i o n s r e p o r t e d by the cancer widows. Widows reported great a n x i e t y over how much to d i s c u s s with t h e i r husbands about the i l l n e s s and i t s outcome. Widows reported f e e l i n g g u i l t y f o r wishing t h e i r husbands would d i e so as to end the s u f f e r i n g f o r a l l concerned. As w e l l , anger was d i r e c t e d towards husbands and h e a l t h p r o f e s s i o n a l s . Some l i m i t a t i o n s were noted with these s t u d i e s . The research focused mainly on spouses o f cancer p a t i e n t s . There was a need to explore the r e a c t i o n s of spouses i n many d i f f e r e n t i l l n e s s s i t u a t i o n s . More q u a l i t a t i v e data needs to be obtained about the immediate time-period t h a t f o l l o w s the l o s s event. The spouses' d e s c r i p t i o n s i n Vachon's study were obtained up to two years a f t e r the death of t h e i r husbands. R e t r o s p e c t i v e data have l i m i t a t i o n s i n terms of v a l i d i t y when one can not a c t u a l l y observe and d e s c r i b e the r e a c t i o n s a t the time of the l o s s . 22 Reactions to Loss by Spouses of Myocardial I n f a r c t i o n P a t i e n t s During the l a s t ten y e a r s , several i n v e s t i g a t o r s have s t u d i e d the spouses of myocardial p a t i e n t s i n more d e t a i l . T h i s research was p r e c i p i t a t e d by a growing awareness t h a t a heart attack has a s i g n i f i -cant impact upon the spouse. In response to the r e c o g n i t i o n t h a t some myocardial i n f a r c t i o n p a t i e n t s have s p e c i a l p s y c h o l o g i c a l adjustment d i f f i c u l t i e s , Adsett and Bruhn (1968) i n s t i t u t e d a short-term psychotherapy program f o r post-myocardial i n f a r c t i o n p a t i e n t s and t h e i r wives. The researchers found the myocardial i n f a r c t i o n p a t i e n t s were predominantly concerned with the l o s s of s e l f - e s t e e m whereas the spouses were concerned with g u i l t f e e l i n g s . They questioned what they might have done to c o n t r i b u t e to t h e i r p a r t n e r s ' h e a r t a t t a c k . Many of the wives f e l t i n h i b i t e d about expressing t h e i r f e e l i n g s s i n c e the heart a t t a c k . They f e l t g u i l t y about past negative or aggressive f e e l -ings and behaviours towards t h e i r p a r t n e r s . The women saw themselves as feeders and p r o t e c t o r s of t h e i r husbands and behaved i n an o v e r l y p r o t e c t i v e , non-demanding manner. Adsett and Bruhn found the wives to be anxious regarding the u n c e r t a i n f u t u r e while showing as much or more -depressive f e e l i n g s as t h e i r husbands. Although the spouses' r e a c t i o n s during the acute phase of t h e i r partner's i l l n e s s were not reported i n d e t a i l , r e a c t i o n s of c o n s i d e r a b l e anxiety and depression were d e s c r i b e d by the spouses one y e a r or more a f t e r t h e i r husbands' i l l n e s s . The r e s u l t s of the study showed t h a t both the p a t i e n t s and spouses appeared to achieve an improved ps y c h o s o c i a l adaptation but the c l i n i c a l f o l l o w -up was too b r i e f to evaluate the long-term e f f e c t s . The study was f u r t h e r l i m i t e d by the small sample and the s e l e c -t i o n of p a t i e n t s already demonstrating p s y c h o l o g i c a l maladjustment to the h e a r t a t t a c k . One rese a r c h e r who focused more on the acute as well c o n v a l e s c e n t phases o f a myocardial i n f a r c t i o n was Royle (1973). She st u d i e d what myocardial i n f a r c t i o n p a t i e n t s and t h e i r spouses under-stood and f e l t about the i l l n e s s and the treatment p r e s c r i b e d . Royle found t h a t d u r i n g the acute phase the p a t i e n t s and t h e i r spouses showed an awareness of the di a g n o s i s but t h e i r a b i l i t i e s to accept t h i s were i n f l u e n c e d by f e e l i n g s o f f e a r , anger, and d e n i a l . Although p a t i e n t s and spouses showed a t t i t u d e s of acceptance during the convalescent p e r i o d a t home, a c o n t i n u i n g element of f e a r was f e l t . Spouses repo r t e d anxiety i n regard to t h e i r own a b i l i t y to f o l l o w the p r e s c r i b e d d i e t a r y measures. A major source o f apprehension f o r the p a t i e n t s was the l i m i t a t i o n i n p h y s i c a l a c t i v i t y . Royle found t h a t the needs o f the p a t i e n t s and spouses f o r r e l e -vant i n f o r m a t i o n about heart d i s e a s e , h o s p i t a l environment, therapy, as well p r e p a r a t i o n f o r t r a n s f e r and discharge were not adequately i d e n t i -f i e d or met during t h e i r h o s p i t a l i z a t i o n or i n i t i a l p e r i o d a t home. P a t i e n t s and spouses repo r t e d r e c e i v i n g v a r i a t i o n s i n s p e c i f i c i t y o f i n s t r u c t i o n s . Medication i n f o r m a t i o n was c l e a r and s p e c i f i c , d i e t a r y r e s t r i c t i o n s were d e s c r i b e d i n general terms but accompanied by p r i n t e d i n s t r u c t i o n sheets. I n s t r u c t i o n s about p h y s i c a l a c t i v i t y were very vague. Royle concluded t h a t nurses need to a s s i s t p a t i e n t s and t h e i r spouses to adapt t o h e a r t d i s e a s e by i d e n t i f y i n g and meeting p a t i e n t and spousal l e a r n i n g needs at a l l the stages o f i l l n e s s and recovery. 24 This c o n c l u s i o n i s r e s t r i c t e d i n scope s i n c e none of the spouses were int e r v i e w e d during the h o s p i t a l i z a t i o n phase o f t h e i r p a r t n e r s ' i l l n e s s . A d e s c r i p t i v e study examining the r e a c t i o n s of wives of myocardial i n f a r c t i o n p a t i e n t s from the e a r l y h o s p i t a l i z a t i o n phase to one year post-myocardial' i n f a r c t i o n was conducted by Skelton and Dominian (1973). The s u b j e c t s s t u d i e d were a r e p r e s e n t a t i v e sample of s i x t y - f i v e wives. T h e i r husbands were consecutive p a t i e n t admissions to a coronary care u n i t with t h e i r f i r s t myocardial i n f a r c t i o n . Interviews were conducted a t l e a s t twice d u r i n g the husband's stay i n h o s p i t a l , then at t h r e e , s i x , and twelve months follow-up. Wives reacted to the i n i t i a l impact of the husband's i l l n e s s with c o n s i d e r a b l e d i s t r e s s . The suddenness of the i l l n e s s l e f t them with a sense of numbness and panic; many s t r e s s e d a f e e l i n g of u n r e a l i t y at t h i s time. G r i e f r e a c t i o n s and psychosomatic symptoms were common dur-ing t h i s p e r i o d of i n i t i a l impact. The women experienced f e e l i n g s o f l o s s , depression and anxiety and f r e q u e n t l y complained of s l e e p and a p p e t i t e d i s t u r b a n c e s . Psychosomatic symptoms were f e l t which the wives r e l a t e d to t h e i r husbands' i l l n e s s and reported as heart symptoms: chest p a i n s , t i g h t n e s s across the c h e s t , p a l p i t a t i o n s , f a i n t i n g and nausea. Many wives found the e a r l y convalescent p e r i o d - before the hus-bands' r e t u r n to work - very s t r e s s f u l . Spouses s u f f e r e d from f e e l i n g s of great a n x i e t y , d e p r e s s i o n , t e n s i o n and sleep d i s t u r b a n c e . They r e l a t e d t h e i r d i s t r e s s to t h e i r sense o f l o s s , f e a r of recurrence and the problems caused by the husbands' r e a c t i o n s a f t e r r e t u r n i n g home. 25 The women f e l t g u i l t y and f e a r f u l of l o s i n g t h e i r husbands and thus behaved i n an o v e r - p r o t e c t i v e manner. They reported t h e i r husbands as being more dependent and i r r i t a b l e . Skelton and Domini an d e s c r i b e d the t e n s i o n these f a c t o r s caused: T h i s combination of dependency and i r r i t a -b i l i t y r e s u l t e d i n f e e l i n g s o f t e n s i o n sometimes h o s t i l i t y i n the e a r l y weeks. If the wives showed concern they were accused of being o v e r p r o t e c t i v e and smothering but i f they showed l e s s concern they were f e l t to be unsympathetic. When they showed sympathy some husbands became more h e l p l e s s and demanding but i f they responded by firmness then they f e l t g u i l t y (Skelton and Dominian, 1973, p. 102). At one y e a r p o s t - i n f a r c t i o n , over o n e - t h i r d of the sample had made s a t i s f a c t o r y adjustment. The wives reported t h a t t h e i r own mood, a t t i t u d e and r e l a t i o n s with t h e i r husbands were s i m i l a r to t h e i r pre-i l l n e s s experience. A f u r t h e r o n e - t h i r d of the spouses were reasonably adjusted and s t i l l f e l t there were changes i n t h e i r f e e l i n g s and way o f l i f e causing some anxiety and apprehension. Less than o n e - t h i r d rep o r t e d c o n s i d e r a b l e d e p r e s s i o n , anxiety and sleep d i s o r d e r s a f t e r one y e a r . This poor adjustment caused a p p r e c i a b l e d i s t r e s s , both to them-s e l v e s and to t h e i r f a m i l i e s . Skelton and Dominian succeeded i n gathering a wealth of d e s c r i p -t i v e data concerning spouses r e a c t i o n s to t h e i r p a r t n e r s ' heart a t t a c k . Some l i m i t a t i o n s were noted. The study sample was e x c l u s i v e l y female. L i t t l e r esearch was found which examined male spousal r e a c t i o n s to t h e i r partners' heart a t t a c k . F u r t h e r , data were gathered from e a r l y h o s p i t a l i z a t i o n to one y e a r post-discharge y e t the time span of \" e a r l y discharge\" from h o s p i t a l was not s t u d i e d u n t i l three months p o s t - d i s c h a r g e . The r e s e a r c h e r s d i d not use a t h e o r e t i c a l framework r e l a t i n g to l o s s research or l o s s theory. L a r t e r (1976) examined the a t t i t u d e s of \"M.I. Wives\" toward the changes brought on by the husband's i l l n e s s . L a r t e r found many worries plagued the women. Concern regarding the p a r t n e r ' s o v e r e x e r t i o n , f e a r of recurrence and p o s s i b l e death were v o i c e d . The women f e l t they would u n i n t e n t i o n a l l y p r e c i p i t a t e the husband's death. They worried about the e f f e c t of sexual i n t e r c o u r s e and a l s o about t h e i r own h e a l t h . L a r t e r found t h a t expressions of anxiety were demonstrated i n a number of m a n i f e s t a t i o n s : worry over a n t i c i p a t e d problems, i r r i t a -b i l i t y , p a l p i t a t i o n s , shortness of breath, insomnia, worry over t r i v i a , headaches, c r y i n g e a s i l y and stomach upsets. The wives rep o r t e d t h a t the two areas o f t h e i r l i v e s most a f f e c t e d by t h e i r husbands' heart a t t a c k s were communication and sex r e l a t i o n s . The research examined the wives' r e a c t i o n s anywhere from one to t h i r t y - f i v e months a f t e r the occurrence o f t h e i r husbands' i l l n e s s through means o f a s t r u c t u r e d q u e s t i o n n a i r e by telephone or m a i l . The l e n g t h of time a f t e r the heart attack and the means of data c o l l e c t i o n may l i m i t the u s e f u l n e s s of t h i s study. More r e c e n t l y , research has been done by Mayou, F o s t e r and Williamson (1978). S i m i l a r to the study done by Skelton and Domini an, the researchers d e s c r i b e d spousal r e a c t i o n to t h e i r husband's myo-c a r d i a l i n f a r c t i o n from the i n i t i a l h o s p i t a l i z a t i o n to one year post-d i s c h a r g e . The i n f l u e n c e of wives i n determining the q u a l i t y o f outcome f o r a l l concerned was a l s o examined. Eighty-two wives whose husbands had s u f f e r e d t h e i r f i r s t h eart attack were i n t e r v i e w e d d u r i n g h o s p i t a l i z a t i o n , a t two months and one yea r p o s t - d i s c h a r g e . The semi-s t r u c t u r e d i n t e r v i e w s were conducted i n the s u b j e c t s ' home and tape recorded. The wives were seen s e p a r a t e l y from t h e i r husbands who were a l s o i n t e r v i e w e d i n regard to t h e i r a t t i t u d e s . During t h e i r husbands' h o s p i t a l i z a t i o n , the wives r e p o r t e d being moderately or s e v e r e l y d i s t r e s s e d . Crying and dist u r b a n c e s o f sleep and a p p e t i t e were common reported systoms but some women d e s c r i b e d f e e l i n g s o f numbness, u n r e a l i t y and a tendency t o c l i n g t o other people. During the f i r s t few weeks a f t e r the p a t i e n t s ' d i s c h a r g e , 80 percent o f the wives repo r t e d a n x i e t y , d e p r e s s i o n , f a t i g u e , i r r i t a -b i l i t y , poor c o n c e n t r a t i o n and insomnia. The re s e a r c h e r s found the spouses' complaints were as common and as severe as the p a t i e n t s ' r e p o r t s . At one year p o s t - i n f a r c t i o n , wives s t i l l showed c o n s i d e r a b l e p s y c h o l o g i c a l d i f f i c u l t i e s but were l e s s i r r i t a b l e than t h e i r husbands. F o r t y percent of wives complained of i l l h e a l t h a yea r a f t e r t h e i r husbands' i n f a r c t i o n . P r a c t i c a l problems faced by the wives while t h e i r husbands were i n the h o s p i t a l i n c l u d e d coping with v i s i t s to the h o s p i t a l , accommodating t h e i r time to the h o s p i t a l r o u t i n e , d i f f i c u l t y i n t r a n s p o r t a t i o n , e x t r a household chores and added r e s p o n s i b i l i t i e s e s p e c i a l l y with c h i l d c a r e . The women found the p r a c t i c a l and emotional support of f r i e n d s and r e l a t i v e s a great a s s i s t a n c e p a r t i c u l a r l y d u r i n g t h i s h o s p i t a l i z a t i o n p e r i o d . The re s e a r c h e r s found t h a t the wives had great i n f l u e n c e i n the p a t i e n t s ' readjustment during convalescence and t h a t the wives' a t t i t u d e s and behaviour were important determinants o f the ra t e and 28 e x t e n t of the p a t i e n t s ' recovery. T h i s research was s i m i l a r to Skelton and Dominian's work both i n i t s c o n t r i b u t i o n and l i m i t a t i o n s . These r e s u l t s emphasize the c o n s i d -e r a b l e i n f l u e n c e a myocardial i n f a r c t i o n has on the spouse. A truism i n the l i t e r a t u r e was t h a t the p a t i e n t may recover from h i s coronary but t h a t h i s wife may not. Summary I n v e s t i g a t o r s and w r i t e r s have used numerous methods and p o i n t s of view i n t h e i r attempts to understand l o s s . In the past century the study of l o s s has broadened from a f a i r l y narrow p s y c h o l o g i c a l or behavioural focus to encompass a more phenomenological p e r s p e c t i v e . Many s t u d i e s have focused on g r i e f r e a c t i o n s f o l l o w i n g a major l o s s and r e v e a l e d commonalities i n i n d i v i d u a l s ' behavioural responses to l o s s . (Freud, 1917; Lindemann, 1944; M a r r i s , 1958; Bowlby, 1961; Parkes, 1965). In a d d i t i o n to these s t u d i e s f u r t h e r research and theory have been developed f o c u s i n g on some of the concepts c e n t r a l to l o s s with p a r t i c u l a r emphasis on c h a r a c t e r i s t i c s o f l o s s and the i n d i v i d u a l s ' p e r c e p t i o n of the l o s s event ( A v e r i l l , 1968; Lipowski, 1969; Peretz, 1970; Schoenberg, 1970). More r e c e n t l y nurse researchers have s t u d i e d the impact of i l l n e s s on the spouse (Hampe, 1975; Vachon, 1977; Dracup and Breu, 1978). These s t u d i e s have y i e l d e d v a l u a b l e i n f o r m a t i o n on l o s s as experienced by spouses and o f f e r e d a new p e r s p e c t i v e to l o s s r e s e a r c h . Although the concept of l o s s has been well d e s c r i b e d i n the l i t e r -a ture there has been l i t t l e research done to r e l a t e l o s s to spouses of 29 myocardial i n f a r c t i o n p a t i e n t s . Several r e s e a r c h e r s have documented the r e a c t i o n s t h a t spouses of myocardial i n f a r c t i o n p a t i e n t s e x p e r i -enced i n response to t h e i r p a r t n e r s ' i l l n e s s ( A d s e t t , Bruhn, 1968; Royle, 1973; S k e l t o n , 1973; L a r t e r , 1976; Mayou, F o s t e r and Williamson, 1978). The spouses' r e a c t i o n s were not s p e c i f i c a l l y r e l a t e d to a l o s s framework, but the emotional and somatic responses d e s c r i b e d by the i n v e s t i g a t o r s r e f l e c t e d a remarkable resemblance to the g r i e f reac-t i o n s , as reported i n the l o s s s t u d i e s . From the evidence o f t h i s l i t e r a t u r e review i t seems reasonable to expect t h a t f u r t h e r d e t a i l e d d e s c r i p t i o n s of spousal r e a c t i o n s to the p a r t n e r s ' heart a t t a c k w i l l c o n s t i t u t e a useful and meaningful a d d i t i o n to understanding to the event of a myocardial i n f a r c t i o n w i t h i n the context of the phenomenon o f l o s s . Nurses need to e x p l o r e spouses' r e a c t i o n s beginning with a concep-t u a l grasp of l o s s then moving on to examine the problem from a new and d i f f e r e n t f o c a l p o i n t . Drawing from the l o s s l i t e r a t u r e the i n v e s t i g a t o r o u t l i n e d three main c o n s t r u c t s which d e c r i b e d the author's t h e o r e t i c a l or conceptual way of viewing l o s s . These c o n s t r u c t s were i d e n t i f i e d as (1) r e a c t i o n s to l o s s ; (2) elements of l o s s ; (3) meaning o f l o s s . This framework o f f e r e d a p e r s p e c t i v e on l o s s as experienced by spouses of myocardial i n f a r c t i o n p a t i e n t s i n t h a t i t provided a p i c t u r e o f the s i t u a t i o n w i t h i n which the problem under study was viewed. 30 CHAPTER 3 METHODOLOGY In t r o d u c t i o n : An Overview The e m p i r i c a l i n d u c t i v e approach was used as the methodology f o r t h i s study. In order t o understand l o s s as experienced by spouses of M.I. p a t i e n t s , d e t a i l e d data o f a q u a l i t a t i v e nature were d e s i r e d . The l i t e r a t u r e provided a s c a r c i t y o f in f o r m a t i o n on the phenomenon of l o s s as experienced by spouses o f M.I. p a t i e n t s . More q u a l i t a t i v e data were r e q u i r e d so t h a t t h i s phenomena c o u l d be d e s c r i b e d , analyzed and co n c e p t u a l i z e d i n more depth. A non-experimental e x p l o r a t o r y design i s a method o f cho i c e when the purpose i s . to i n c r e a s e understanding o f human behaviour. In f a c t , d i s c o v e r y o f unexpected f i n d i n g s may r e s u l t from t h i s approach because the researcher uses the p e r s p e c t i v e s o f h i s s u b j e c t s on the phenomenon, not h i s own preconceived notions as o p e r a t i o n a l i z e d by r i g i d research techniques ( F i l s t e a d , 1970). D e s c r i p t i v e , e x p l o r a t o r y and fo r m u l a t i v e s t u d i e s l i t e r a l l y look f o r ways to c a t e g o r i z e , c l a s s i f y or concept-u a l i z e s i t u a t i o n s . P a r t i c i p a n t and n o n - p a r t i c i p a n t observations are the predominant primary data c o l l e c t i o n procedures. D i e r s s t a t e d , \"... the notion o f r i c h n e s s guides the data c o l l e c t i o n methods. P a r t i c i p a n t o b s e r v a t i o n , where the i n v e s t i g a t o r becomes p a r t of the events themselves, provides some dimensions t h a t can e n r i c h the concepts s i n c e i n f o r m a t i o n on the p a r t i c i p a n t s ' own f e e l i n g s become a v a i l a b l e \" ( D i e r s , 1979, p. 112). 31 The research technique used i n t h i s study was the constant compar-a t i v e method, an i n d u c t i v e method of d i s c o v e r i n g grounded theory d e v e l -oped by Glaser and Strauss i n 1967. This method i n i t s s i m p l e s t terms i s a process of moving from the data t o the concept. The i n t e n t i s t o c o n c e p t u a l i z e a given event or s i t u a t i o n as opposed to d e s c r i b i n g i t . Di e r s (1979) de s c r i b e s t h i s method as a p s y c h o l o g i c a l t h i n k i n g process, one of d i s c r i m i n a t i o n , d e f i n i t i o n and c l a s s i f i c a t i o n o f t e n c a l l e d i n f e r e n c e . The constant comparative method simply s t r u c t u r e s t h i s conceptual process with a l l i t s steps so t h a t one can see c l e a r l y how the concepts have been developed and thus make judgements about concept val i d i t y . Comparative a n a l y s i s emphasizes theory as a on-going process. The stages of development i n v o l v e s e q u e n t i a l f o r m u l a t i o n , t e s t i n g and redevelopment of p r o p o s i t i o n s u n t i l a theory i s generated. I t may then be operational!'zed f o r l a t e r t e s t i n g i n q u a n t i t a t i v e r e s e a r c h . Four stages are i n c l u d e d i n the constant comparative method: (a) comparing i n c i d e n t s a p p l i c a b l e to each category, (b) i n t e g r a t i n g c a t e g o r i e s and t h e i r p r o p e r t i e s , (c) d e l i n e a t i n g the theory, and (d) w r i t i n g the theory. The elements of theory t h a t are generated by comparative a n a l y s i s are the conceptual c a t e g o r i e s with t h e i r conceptual p r o p e r t i e s and the g e n e r a l i z e d r e l a t i o n s among the c a t e g o r i e s with t h e i r proper-t i e s . These f o r m a l i z e d steps i n the research process r e s u l t i n the development of a theory, which i s an a b s t r a c t i o n grounded i n data with s p e c i f i c d e f i n i t i o n s . I d e a l l y with the Glaser and Strauss method data are c o l l e c t e d , coded and analyzed so t h a t a l l concepts and t h e i r p r o p e r t i e s are \" s a t u r a t e d \" . This c o n s t a n t comparative a n a l y s i s and t h e o r e t i c a l sampling i m p l i e s an i n f i n i t e time investment. Time c o n s t r a i n t s i n t h i s study were a l i m i t a t i o n . The Research S e t t i n g The i n v e s t i g a t i o n was conducted at a l a r g e m e t r o p o l i t a n h o s p i t a l . The i n t e n s i v e care-coronary care u n i t c o n s i s t e d of twenty beds. The p a t i e n t s admitted with a d i a g n o s i s of acute myocardial i n f a r c t i o n were t r e a t e d i n the u n i t . If t h e i r recovery was s t a b l e and uncomplicated they were t r a n s f e r r e d i n three to f i v e days to an intermediate coronary c a r e u n i t . The i n t e r m e d i a t e u n i t had 25 beds comprised of 15 bed c a r d i a c surgery area and ten beds f o r myocardial i n f a r c t i o n p a t i e n t s . The p a t i e n t s convalesced on t h i s u n i t u n t i l t h e i r discharge on a p p r o x i -mately day twelve to day f o u r t e e n . Sample S e l e c t i o n A convenience non-random sample of twelve spouses were s e l e c t e d from 12 c o n s e c u t i v e p a t i e n t admissions and formed the s u b j e c t s of t h i s study. P a t i e n t s s e l e c t e d f o r the study were r e q u i r e d to meet the f o l l o w i n g c r i t e r i a : (a) the p a t i e n t was admitted to the coronary u n i t of a l a r g e Vancouver h o s p i t a l with the d i a g n o s i s o f an acute myocardial i n f a r c t i o n , (b) the p a t i e n t had experienced h i s / h e r f i r s t myocardial i n f a r c t i o n , (c) the p a t i e n t met the coronary care u n i t ' s c r i t e r i o n of an uncomplicated myocardial i n f a r c t i o n , and (d) the p a t i e n t ' s age i s between 40 and 69 y e a r s . Spouses s e l e c t e d f o r the study were r e q u i r e d to meet the f o l l o w i n g c r i t e r i a : (a) the s u b j e c t was l e g a l l y married and r e s i d e d with the p a t i e n t , (b) the s u b j e c t was g e o g r a p h i c a l l y l o c a t e d so t h a t follow-up v i s i t s are p r a c t i c a l , (c) the s u b j e c t was able to speak and understand E n g l i s h , and (d) the s u b j e c t ' s age was between 30 and 75 y e a r s . Both males and females were i n c l u d e d i n the sample. Based on the s e l e c t i o n c r i t e r i a a sample was obtained w i t h i n a four-month p e r i o d . Because of time c o n s t r a i n t s the c r i t e r i a were modi f i e d f o r two patient-spouse s e l e c t i o n s . The f i r s t exception was a p a t i e n t with a r e c e n t c a r d i o v a s c u l a r h i s t o r y who was diagnosed with a t r i p l e vessel d i s e a s e . The l a s t p a t i e n t and spouse s e l e c t e d d i d not hold a l e g a l m a r i t a l s t a t u s but had been l i v i n g common-law f o r two y e a r s . These m o d i f i c a t i o n s i n sample s e l e c t i o n were not considered s i g n i f i c a n t with r e s p e c t to the homogeneity o f the t o t a l sample. None of the spouses asked to terminate t h e i r p a r t i c i p a t i o n but i t was necessary to omit two of the s u b j e c t s from the study. In one case the s u b j e c t had a b r e a s t lump diagnosed and underwent a r a d i c a l mastectomy. In the second i n s t a n c e a male s u b j e c t was dropped because h i s wife had major c a r d i a c surgery w i t h i n a month of her i n i t i a l heart a t t a c k . The data from the f i r s t two i n t e r v i e w s o f these spouses were i n c l u d e d i n the f i n d i n g s as the circumstances t h a t a l t e r e d t h e i r s i t u a t i o n s d i d not occur u n t i l a f t e r the date of the second i n t e r v i e w . The procedure f o r o b t a i n i n g the sample i n v o l v e d three s t e p s . A p r e l i m i n a r y s o r t was done by the head nurse i n c o n s u l t a t i o n with the 34 c a r d i o l o g i s t s . The i n v e s t i g a t o r then reviewed the p a t i e n t s ' c h a r t i n d e t a i l and b r i e f l y d i s c u s s e d the study with the p a t i e n t to determine p a t i e n t and spouse e l i g i b i l i t y . A l l p a r t i c i p a n t s were given a f u l l e x p lanation o f the study both v e r b a l l y and i n an explanatory l e t t e r p r i o r to o b t a i n i n g t h e i r consent f o r i n c l u s i o n i n the study sample. An exp l a n a t i o n o f the study was given a t the same time, whenever p o s s i b l e , to both p a t i e n t and spouse. Once i n t e n t to p a r t i c i p a t e was e s t a b l i s h e d , w r i t t e n consents were obtained p r i o r to the commencement of the i n t e r v i e w . Two spouses r e f u s e d to p a r t i c i p a t e i n the study. The women f e l t they d i d not have enough \" c o n t r o l \" to deal with the in t e r v i e w s due to t h e i r \"upset f e e l i n g s a t t h i s time\". Demographic data s p e c i f i c to age and sex of the p a t i e n t s and spouses are shown i n Table 1. The sample c o n s i s t e d of 12 s u b j e c t s , 10 women and 2 men. The ages of the p a t i e n t s ranged from 51 to 69 ye a r s with a mean age of 57.9 y e a r s . The ages of the spouses ranged from 34 to 65 years with a mean age of 54.9 y e a r s . Of the 12 s u b j e c t s , 4 women and 1 man were working a t the time o f t h e i r p a r t n e r ' s heart a t t a c k . Of the 12 p a t i e n t s , 7 men and 1 woman were employed at the time o f t h e i r i l l n e s s . There were 4 r e t i r e d c o u p l e s . Three o f the 12 couples had c h i l d r e n r e s i d i n g at home. Data C o l l e c t i o n In t h i s study, data c o l l e c t i o n commenced with the process o f ob s e r v a t i o n . S p e c i f i c a l l y , p a r t i c i p a n t o b s e r v a t i o n was u t i l i z e d as the data c o l l e c t i o n procedure. Subjects were p u r p o s e f u l l y i n t e r v i e w e d 35 Table 1 Age and Sex of P a t i e n t s and Spouses P a t i e n t Age Sex Spouse Age Sex 1 55 F 1 55 M 2 52 . M 2 53 F 3 57 M 3 55 F 4 69 M 4 65 F 5 67 M 5 65 F 6 < 57 F 6 56 M 7 63 M 7 62 F 8 60 M 8 58 F 9 55 M 9 55 F 10 51 M 10 45 F 11 60 M 11 56 F 12 49 M 12 34 F with the i n t e n t o f g a t h e r i n g \" r i c h data\" regarding t h e i r r e a c t i o n s to l o s s from the i n i t i a l impact o f t h e i r p a r t n e r s ' i l l n e s s to s i x weeks post-myocardial i n f a r c t i o n . A data c o l l e c t i o n t o o l was developed to provide a c o n s i s t e n t organized approach with the i n t e r v i e w procedure. The i n i t i a l p a r t o f the instrument i n c l u d e d demographic data, the i n i t i a l s , age and sex of the spouse and the p a t i e n t ' s age and number o f days post M.I. The content areas of thoughts, f e e l i n g s , a c t i o n s and observable behaviours were addressed i n the t o o l . Observable behaviours were examined i n terms of verbal (type, q u a l i t y , c h a r a c t e r i s t i c s o f speech, focus o f conversation) and non-verbal ( a c t i v i t y , eye c o n t a c t , body language, appearance). Four broad open-ended questions were used to e l i c i t data on the spouses thoughts, f e e l i n g s and a c t i o n s . A copy of the data c o l l e c t i o n t o o l i s provided i n Appendix C. Since the purpose of the study was to explore the r e a c t i o n s o f spouses o f heart attack p a t i e n t s the i n t e r v i e w guide proved to be an e f f e c t i v e t o o l . The semi s t r u c t u r e d i n t e r v i e w provided enough d i r e c t i o n so t h a t s p e c i f i c content areas were covered i n each i n t e r v i e w , thus data c o u l d be compared from one i n t e r v i e w to another. At the same time there was f l e x i b i l i t y i n s t r u c t u r e a l l o w i n g f o r s h i f t i n sequence or t o p i c s i n keeping with the moods or needs of the spouses. A l l the interviewees' responses were audio taped. The subjects were assured t h e i r r e p l i e s would be kept i n s t r i c t confidence and t h e i r anonymity respected. None of the subjects objected to the t a p i n g . The i n v e s t i g a t o r i n i t i a t e d c o n t a c t with a few minutes of s o c i a l t a l k i n order to develop rapport and ease any apparent t e n s i o n . The i n v e s t i g a t o r was concerned t h a t the impact o f t h i s c r i t i c a l i l l n e s s would c r e a t e too g r e a t a s t r a i n f o r the spouses and they would be r e l u c t a n t to d i s c u s s t h e i r r e a c t i o n s so soon a f t e r the event. In f a c t , the opposite was found. The spouses were indeed w i l l i n g respondents. Many o f the s u b j e c t s expressed s u r p r i s e and p l e a s u r e t h a t they were being recognized and t h a t t h e i r r e a c t i o n s were con s i d e r e d of some importance. The res e a r c h e r approached the i n t e r v i e w i n an informal s u p p o r t i v e manner. The s u b j e c t s were encouraged t o f r e e l y d i s c u s s t h e i r r e a c t i o n s , with the assurance t h a t there was no r i g h t or wrong answer. Four i n t e r v i e w s were conducted with each s u b j e c t i n the study. The spouses were int e r v i e w e d from day three to day f i f t y - t w o of t h e i r partner's heart a t t a c k . This p e r i o d covered the time of the i n i t i a l impact of i l l n e s s to approximately s i x weeks post myocardial i n f a r c -t i o n . At the time of the l a s t i n t e r v i e w a l l p a t i e n t s had been discharged f o r a t l e a s t three to fo u r weeks. (See Table 2) The f i r s t i n t e r v i e w was scheduled w i t h i n n i n e t y - s i x hours of the hea r t attack and the second i n t e r v i e w f o l l o w e d during week two of the p a t i e n t ' s h o s p i t a l i z a t i o n . These two i n t e r v i e w s were arranged to c o i n -c i d e with the spouses' normal h o s p i t a l v i s i t i n g schedule. The researcher chose the s e t t i n g of a p r i v a t e o f f i c e to conduct the i n t e r -views. The t h i r d and f o u r t h i n t e r v i e w s were scheduled f o r one and three weeks post discharge of the p a t i e n t . During t h i s post h o s p i t a l i -z a t i o n p e r i o d the res e a r c h e r interviewed the spouses p r i v a t e l y i n the f a m i l i a r and comfortable s e t t i n g of t h e i r own homes. The i n t e r v i e w s ranged from 12 to 75 minutes with an average time of 35 minutes. 38 Table 2 Number of Days A f t e r Myocardial I n f a r c t i o n That Interview Took Place Number of Days F i r s t Second T h i r d Fourth S u b j e c t I n t e r v i e w Interview Interview Interview 1 6 17 26 43 2 3 15 27 40 3 3 11 21 34 4 5 11 24 38 5 3 9 26 40 6 6 12 26 46 7 3 14 31 52 8 3 8 28 43 9 6 11 22 42 10 4 9 27 43 11 4 10 23 37 12 4 10 19 33 39 During the i n t e r v i e w s the i n v e s t i g a t o r observed the verbal and non-verbal behaviours o f the spouses. Notes of these o b s e r v a t i o n s were made i n p r i v a t e immediately a f t e r each i n t e r v i e w . The f o r t y - e i g h t semi s t r u c t u r e d i n t e r v i e w s y i e l d e d an abundance of data. A f t e r conducting an i n t e r v i e w with each s u b j e c t the i n v e s t i g a t o r l i s t e n e d to the tape to get a general o v e r a l l impression o f the m a t e r i a l . Nota-t i o n s were made of any ideas and themes. The i n v e s t i g a t o r used t h i s time to j o t down spontaneous ideas t h a t came to mind while l i s t e n i n g to the tapes. Notes from the spouses' observable behaviours were r e f e r r e d to c o n j o i n t l y with the audio tapes, thus p r o v i d i n g an accurate impres-s i o n of the i n t e r v i e w . In f a c t , the data c o l l e c t i o n phase was not i s o l a t e d from the data p r o c e s s i n g and a n a l y s i s . The researcher had many a b s t r a c t thoughts about the events observed and recorded. G l a s e r and Strauss advocate the w r i t i n g o f \" a n a l y t i c memos\" at s p e c i f i e d i n t e r v a l s throughout the data c o l l e c t i o n p e r i o d . Summaries of one's developing thoughts about the data from which concepts begin t o emerge or d i r e c t i o n s f o r f u t u r e data c o l l e c t i o n s t a r t to form ( G l a s e r and S t r a u s s , 1967). The data c o l l e c t i o n p e r i o d took approximately f i v e months t o complete. I d e a l l y i n the grounded theory approach, data c o l l e c t i o n i s s a i d to end when the f a c t o r s or c a t e g o r i e s are \" s a t u r a t e d \" , when new data no longer reveal new dimensions ( G l a s e r and S t r a u s s , 1967). This was not p o s s i b l e i n t h i s study due to the time c o n s t r a i n t s o f the researcher. With t h i s approach there are i n f i n i t e p o s s i b i l i t i e s f o r developing new concepts as more data become a v a i l a b l e . Even with the 40 volume of data c o l l e c t e d i n t h i s study only a f i n i t e aspect of the phenomenon or s i t u a t i o n were examined. Data Coding and A n a l y s i s F o l l o w i n g the data c o l l e c t i o n phase of the study the audiotapes were t r a n s c r i b e d and the raw data was examined, s o r t e d and coded i n t o as many c a t e g o r i e s as p o s s i b l e . In order to systematize the coding process each item of data was a l l o t t e d a c o l o u r . For example, spouses commented on t h e i r p h y s i c a l disturbances e.g. headaches, l o s s o f a p p e t i t e , insomnia, e t c . This raw data were then coded with a y e l l o w dot. I n i t i a l category c o n s t r u c t i o n was a simple process of c o l l e c t i n g a l l the data with the same c o l o u r (e.g. the y e l l o w d o t s ) . To f a c i l i -t a t e data c o m p i l a t i o n data were entered on r e f e r e n c e c a r d s . Three numbers were noted a f t e r each item of data, i n d i c a t i n g the respondent, the number of the i n t e r v i e w and the exact page number of the t r a n -s c r i b e d data. The c o l o u r o f the category was marked i n the upper right-h a n d corner of the c a r d . The i n v e s t i g a t o r then proceeded to d e f i n e and d e s c r i b e the c a t e -g o r i e s . These beginning s e t o f c a t e g o r i e s were a p p l i e d to the data. Often the same data were used to generate the category to check f o r \" f i t \" or c o n s i s t e n c y . The c a t e g o r i e s were reworked over and over u n t i l the concepts and t h e i r p r o p e r t i e s became c l e a r e r . The d e s c r i p t i o n s of the c a t e g o r i e s were a l s o t r a n s c r i b e d onto r e f e r e n c e c a r d s . The c o l o u r coding system was used to q u a n t i f y the data. The frequency of s p e c i f i c c a t e g o r i e s was noted by simply counting c o l o u r s . The q u a l i t a t i v e and q u a n t i t a t i v e data obtained were t r a n s c r i b e d onto a l a r g e matrix with each respondent r e p r e s e n t i n g a row and each category r e p r e s e n t i n g a column. The c o l o u r s of the category and i t s d e f i n i t i o n s were entered i n the columns and the frequency of the category entered i n each respondents row. The i n v e s t i g a t o r continued to examine the data, comparing and c o n t r a s t i n g c a t e g o r i e s with a purpose o f t h r e a d i n g the concepts and p r o p e r t i e s together i n t o some meaningful p a t t e r n . As the process evolved, more and more data were encompassed meanin g f u l l y under l a r g e r a b s t r a c t concepts. To f u r t h e r c l a r i f y the process of data coding and a n a l y s i s an example has been i n c l u d e d i n Appendix D. This overview i l l u s t r a t e s the a p p l i c a t i o n of the G l a s e r and Strauss method of constant comparative a n a l y s i s . Diers (1979) d e f i n e d t h i s method i n i t s s i m p l e s t terms as a process of d i s c r i m i n a t i o n , d e f i n i t i o n and c l a s s i f i -c a t i o n . R e l i a b i l i t y and V a l i d i t y Issues The s e l e c t e d methodology r a i s e s several i s s u e s r e l a t e d to r e l i a -b i l i t y and v a l i d i t y . D i e r s (1979, p. 112) s t a t e d t h a t the usual concerns about r e l i a b i l i t y and v a l i d i t y of the instruments used i n the study do not apply with t h i s study design. There i s more concern f o r the r e l i a b i l i t y of the sources of data and or the r e c o r d e r ...\" t h a t i s the concern whether the sources of data represent well the developing concepts and whether the person r e c o r d i n g the data gets i t a l l down\". To t e s t the v a l i d i t y of the data g a t h e r i n g instrument two subjects were interviewed i n a p i l o t study. The data gathered from t h i s p i l o t were adequate f o r the purpose o f the study. To ensure r e l i a b i l i t y of 42 the f i n d i n g s a data g a t h e r i n g instrument was u t i l i z e d and a l l i n t e r v i e w s were audiotaped. In a d d i t i o n , immediately f o l l o w i n g the i n t e r v i e w the i n v e s t i g a t o r made notes o f the spouses' observable behaviours i n order t o maintain accurate r e c a l l . The problem o f poor or s e l e c t i v e memory was minimized by i n t e r v i e w i n g the su b j e c t s on fo u r separate o c c a s i o n s , i n a s h o r t span o f time, from the i n i t i a l impact o f the i l l n e s s to s i x weeks a f t e r the heart a t t a c k . The concern t h a t the respondents would h e s i t a t e to d i s c l o s e t h e i r r e a c t i o n s because of the s e n s i t i v e nature o f the study d i d not m a t e r i a l i z e . The spouses were i n f a c t w i l l i n g respondents and f r e e l y d i s c u s s e d t h e i r thoughts and f e e l i n g s . S e l l i t z , Wrightsman and Cook (1976) pointed out t h a t the most important f a c t o r i n determining the frequency and v a l i d i t y o f response i s the s a l i e n c e o f the i n t e r v i e w t o p i c . With p a r t i c i p a n t o b s e r v a t i o n the i n v e s t i g a t o r ' s personal e x p e r i -ences and bia s e s can be a t h r e a t to the o b j e c t i v i t y o f the study. Di e r s (1979) s t a t e d t h a t the c r e a t i v e use of personal i n s i g h t s can g r e a t l y e n r i c h t h i s type o f study as long as proper p r e c a u t i o n s are taken to balance those kinds of data with other data which might d i s c o n f i r m one's own impressions. The i n v e s t i g a t o r was aware o f her personal b i a s e s and u t i l i z e d the t h e s i s committee as o b j e c t i v e resources to \" t e s t \" personal impressions. A s t a n d a r d i z e d procedure was used f o r data c o l l e c t i o n , coding and a n a l y s i s . This systematic approach provided a degree o f r e l i a b i l i t y to the study. To ensure f u r t h e r r e l i a b i l i t y o f data coding and a n a l y s i s a procedure f o r i n t e r r a t e r r e l i a b i l i t y was undertaken. The i n v e s t i g a t o r d e f i n e d the s i x t e e n c a t e g o r i e s i d e n t i f i e d i n the study. Those c a t e g o r i e s comprised the phases and the three elements of thoughts, f e e l i n g s and a c t i o n s f o r each phase. Four examples of i l l u s t r a t i v e data were chosen t o r e p r e s e n t each o f the c a t e g o r i e s . A t a b l e o f random numbers was used to determine which of the data would be s e l e c t e d f o r the r e l i a b i l i t y check. Of the s i x t y - f o u r pieces of data, twenty-eight were chosen. Two nurses with v a r i e d t e a c h i n g , c l i n i c a l and a d m i n i s t r a t i v e experiences were s e l e c t e d as r a t e r s . Using the d e f i n e d c a t e g o r i e s and the twenty-eight items of data the r a t e r s were asked to make two d e c i s i o n s . F i r s t l y , they had to s o r t each item of data i n t o one of the three phases. The second s o r t e n t a i l e d coding each item of data i n t o one of the three main elements comprising each category, thoughts, f e e l i n g s or a c t i o n s . In the f i r s t s o r t the percentage of agreement was 85.7. The r a t e r s found t h a t i n most i n s t a n c e s the phases were c l e a r l y d e s c r i b e d but there was some o v e r l a p p i n g , p a r t i c u l a r l y with the spouses' thoughts and f e e l i n g s . The second s o r t r e s u l t e d i n a 82.1 and 85.7 percentage of agreement f o r the two r a t e r s . Again the g r e a t e s t d i f f i c u l t y was i n d i f f e r e n t i a t i n g whether the item of data was d e s c r i b i n g a thought or a f e e l i n g . C o n s i d e r i n g the high l e v e l o f agreement, however, i t appeared t h a t the c a t e g o r i e s guided the r a t e r s i n coding the m a j o r i t y of the data c o r r e c t l y . 44 CHAPTER 4 FINDINGS OF THE STUDY Based on the methodology d e s c r i b e d i n Chapter I I I data were obtained from subjects who were spouses o f myocardial i n f a r c t i o n p a t i e n t s . Using an i n t e r v i e w guide with open-ended questions the researcher asked spouses what t h e i r thoughts, f e e l i n g s and a c t i o n s were i n response to t h e i r p a r t n e r s ' heart a t t a c k . In a d d i t i o n to the verbal data obtained, the spouses' behaviours were observed during each i n t e r v i e w . Common verbal and observed spousal behaviours were i d e n t i f i e d during the six-week p e r i o d of i n v e s t i g a t i o n . Three d i s t i n c t phases o f behaviour over the time of the study were found. Appendix E shows the r e l a t i o n s h i p o f the f i n d i n g s to the three phases of spousal r e a c t i o n to l o s s . PHASE I The Event and I n i t i a l Spousal Response This phase covered the h o s p i t a l i z a t i o n p e r i o d of the p a t i e n t from the t h i r d to the seventeenth day post-myocardial i n f a r c t i o n . The r e a c t i o n s t h a t the spouses experienced were d e s c r i b e d or observed during the f i r s t and second i n t e r v i e w . The i n t e r v i e w s corresponded with the acute (coronary care u n i t ) and convalescent (postcoronary care u n i t ) h o s p i t a l i z a t i o n o f the p a t i e n t . The f i n d i n g s from both i n t e r v i e w s were subsumed under one phase. 45 PHASE I \u00E2\u0080\u0094 T h o u g h t s F o u r c a t e g o r i e s were i d e n t i f i e d t h a t d e s c r i b e d what t h e s u b j e c t s were d o i n g i n a c o g n i t i v e s e n s e . They were t e r m e d r e v i e w i n g , a n t i c i -p a t i n g , c o m p a r i n g and r e d e f i n i n g . The o r d e r o f t h e c a t e g o r i e s as r e p o r t e d does n o t n e c e s s a r i l y i m p l y t h e s u b j e c t s p r o g r e s s e d w i t h a s equence o f t h o u g h t s . However , a d e g r e e o f o r d e r i s e v i d e n c e d w i t h some o f t h e c a t e g o r i e s and i s r e p o r t e d as s u c h . R e v i e w i n g Of t h e t w e l v e s u b j e c t s , t e n i n i t i a t e d t h e f i r s t i n t e r v i e w w i t h a s p o n t a n e o u s b l o w - b y - b l o w d e s c r i p t i o n o f \"how i t h a p p e n e d \" . They moved f r o m a p o s t t o a p r e s e n t t i m e f r a m e and were a b l e t o r e c a l l v i v i d l y t h e i r p a r t n e r s ' symptoms and r e a c t i o n s and t h e n d e t a i l t h e i r own r e a c t i o n s t o t h e s i t u a t i o n s . In r e c a l l i n g t h e i n c i d e n t , s e ven s u b j e c t s d i s c u s s e d t h e i r s u r p r i s e a t s u c h an u n e x p e c t e d e v e n t . Two e x p r e s s e d g u i l t f e e l i n g s . They f e l t i g n o r a n t i n n o t r e c o g n i z i n g t h e symptoms o f a h e a r t a t t a c k and t h o u g h t t h e i r p a s s i v e r o l e i n t h e i n c i d e n t had i n some way i n h i b i t e d t h e s e e k -i n g o f m e d i c a l a t t e n t i o n . A n t i c i p a t i n g Many o f t h e s u b j e c t s ' t h o u g h t s f o c u s e d on t h e a n t i c i p a t e d l o s s o f t h e i r p a r t n e r s . They q u e s t i o n e d many t h i n g s , t h e r e a s o n o r c a u s e o f t h e i l l n e s s - \"why t h i s h a p p e n e d \" and i s s u e s r e l a t e d t o c o m p l i c a t i o n s , r e c u r r e n c e o f t h e h e a r t a t t a c k and t h e q u a l i t y o f a d j u s t m e n t . D u r i n g 46 the f i r s t i n t e r v i e w the s u b j e c t s ' g r e a t e s t f e a r was t h a t o f another heart a t t a c k , because they p e r c e i v e d the i n t e n s i v e care p e r i o d to be a c r i t i c a l and u n c e r t a i n time. One woman summed up her f e a r s : Well my thoughts are p r e t t y well e v e r y t h i n g how bad i s i t , how well w i l l h i s recovery b e \u00E2\u0080\u0094 I mean anything can happen y e t . Fears of recurrence were commonly r e p o r t e d : I am f r i g h t e n e d of another occurrence, t h a t p a r t , t h a t ' s one of the major concerns ... so I worry about when he gets home, and i f he gets home even ... I would always be s o r t o f f r i g h t e n e d a f t e r you have him home, th a t i t would occur again. As the p a t i e n t s progressed i n an uneventful recovery and were t r a n s f e r r e d to the convalescent ward, the s u b j e c t s began to focus l e s s on the f e a r o f r e c u r r e n c e . The questions a t t h i s time centered more on how well t h e i r partners would a d j u s t , both i n the h o s p i t a l and at home. Many s u b j e c t s a n t i c i p a t e d t h e i r partners would not cooperate: So I worry about how I am going to hold him back. Oh I can do i t you know, but I don't want to get i n t o any arguments. A l o t goes through your mind and you t h i n k , w e l l , w i l l he be a l r i g h t when he gets home? I'm worried about (my husband). He's so stubborn. He s a i d he was j u s t w a i t i n g t i l l the nurses weren't watching him so c l o s e l y and then he was going to sneak a walk i n the h a l l s . As the p a t i e n t moved c l o s e r to discharge the m a j o r i t y of s u b j e c t s began to d i s c u s s i n d e t a i l the changes they a n t i c i p a t e d i n r o l e s and r e s p o n s i b i l i t i e s . These changes were perc e i v e d as a f f e c t i n g themselves and t h e i r r e l a t i o n s h i p . The s u b j e c t s a n t i c i p a t e d t h a t the i l l n e s s would a f f e c t t h e i r own l i v e s even more so than i t d i d t h e i r p a r t n e r s . A comment by one woman summed up t h i s a n t i c i p a t i o n : 47 I t has q u i t e a b i t of e f f e c t on me. I t h i n k more so than my husband. For me there are more important ways of doing t h i n g s , than r e a l l y f o r him. Because with him, i f he takes i t easy and doesn't do anything, well with me, I have to plan our s o c i a l l i f e d i f f e r e n t l y and I have to l e a r n to cook d i f f e r e n t l y , and I have to compromise more to h i s way now. Many s u b j e c t s spoke about f i n a n c e s . Only two s u b j e c t s expressed f i n a n c i a l concerns. The m a j o r i t y f e l t f i n a n c i a l matters would not pose a problem i n t h e i r l i v e s . Retirement seemed to play a s i g n i f i c a n t f a c t o r i n f i v e of the s u b j e c t s ' responses. One woman s t a t e d : I don't t h i n k our l i f e s t y l e w i l l change t h a t much. We are r e t i r e d so we can come and go and do as we want. Maybe we don't have as much as some, but we have enough. In the f i r s t i n t e r v i e w one h a l f of the sample asked general questions r e l a t e d to t h e i r i n f o r m a t i o n needs: \"What I want to know i s how do we approach t h i s t h i n g ? \" \"How do I handle him?\" As the p a t i e n t moved c l o s e r to discharge ten s u b j e c t s i d e n t i f i e d s p e c i f i c i n f o r m a t i o n needs. A l l s u b j e c t s wanted to know the medical plans \"I want to know the do's and don'ts, otherwise he could be doing something and I don't know i f i t ' s r i g h t or wrong.\" \"I want to know a l l about h i s heart so I can do the r i g h t t h i n g f o r him and me.\" In the second i n t e r v i e w , ten s u b j e c t s organized t h e i r plans f o r approaching the convalescent p e r i o d . T h e i r thoughts d e a l t with the p h y s i c a l and p s y c h o l o g i c a l plans f o r t h e i r p a r t n e r s . In a n t i c i p a t i o n of what was to come, the s u b j e c t s r e d e f i n e d t h e i r r o l e s to i n c l u d e the new r e s p o n s i b i l i t i e s of c o n t r o l l e r and p r o t e c t o r . One young s u b j e c t saw the n e c e s s i t y of changing r o l e s and r e s p o n s i b i l i t i e s , y e t r e a l i z e d the d i f f i c u l t y i n c a r r y i n g these tasks f o r e v e r : I t ' s s trange to me to see him l i k e t h i s (dependent). I t makes me f e e l , well I don't mind. I was always t r e a t e d l i k e the weak one, but I can handle i t p e r f e c t l y w e l l , but I wouldn't want i t to go on f o r -e ver. I t would be too much. Comparing In the f i r s t i n t e r v i e w eleven s u b j e c t s sought a frame o f r e f e r e n c e . They compared t h i s l o s s with o t h e r l o s s e s they had experienced o r t h a t o t h e r people had e x p e r i e n c e d . In t h i s way they seemed to make some sense o f t h e i r l o s s , d e a l i n g with i t i n some f a m i l i a r c o n c r e t e r e f e r e n c e . I had q u i t e an experience with t h i s bad a c c i d e n t so t h i s time I wasn't as confused about i t a l l . He broke h i s femur'in s e v e r a l p l a c e s i n a c a r a c c i d e n t f o u r y e a r s ago. He was i n the General about f o u r months t h i n g s don't seem as bad as they d i d back then. L i k e I say I've been through so much, t h r e e s u f f e r i n g s deaths r e c e n t l y , so i f he's going t o go l e t him go quick. I don't know whether I've hardened because o f t h i s , but I'm prepared. I can cope, I can cope. One woman seemed t o search a c t i v e l y f o r a r e f e r e n c e p o i n t : I saw the s p e c i a l i s t , and he s a i d i t was a s l i g h t a t t a c k , but there are people who have had even s l i g h t e r ones than my husband, but then t h e r e are the people l i k e the r e s t o f h i s f a m i l y who are very bad. The need t o d i s c u s s a frame o f r e f e r e n c e was l e s s i n the second i n t e r v i e w i n which only two o f the s u b j e c t s repeated t h e i r comments. .49 R e d e f i n i n g During t h i s phase the su b j e c t s ' thoughts r e f l e c t e d a time f o r r e d e f i n i t i o n o f s e l f , p a r t n e r , marriage and philosophy o f l i f e . The t o p i c s were d i s c u s s e d b r i e f l y i n the f i r s t meeting, and then d e s c r i b e d i n more d e t a i l by the m a j o r i t y o f su b j e c t s i n the second i n t e r v i e w . The threatened l o s s o f a partner p r e c i p i t a t e d many thoughts of marriage and r e l a t i o n s h i p s . Of the twelve s u b j e c t s e i g h t took stock o f t h e i r marriage, r e f l e c t i n g on the strengths and l i m i t a t i o n s o f t h e i r p a r t n e r s h i p : Our l i f e has been one t h a t you know, there has been no need to f e e l g u i l t y over any lac k t h a t e i t h e r one of us may have done, or may not have done. (My wife) and I have been p r e t t y c l o s e , w e l l , s i n c e we have been about nine years o l d , i t ' s l i k e a p a r t o f y o u r s e l f , \u00E2\u0080\u0094 p r e t t y much what she f e e l s I f e e l . It was a r e v a l u a t i o n time a l s o to almost l o s e aloved one makes t h a t person even more c h e r i s h e d . One man, vo i c e choked with emotion e x p l a i n e d i t t h i s way: Li k e I guess everyone probably f e e l s the same way about t h e i r spouse, l i k e she i s the only one. You know you don't r e a l i z e how much one means to the o t h e r , u n t i l a c r i s i s comes. Another woman expressed s i m i l a r thoughts: It ' s a funny t h i n g you know, while he's healthy you do get annoyed with each other and you think you might be able to do without each o t h e r , but you can't do without one another. I can't wait f o r him to come home! 50 Many of the s u b j e c t s r e f l e c t e d on what they b e l i e v e d , and how they were approaching the s i t u a t i o n . They were aware of the u n c e r t a i n t i e s but t r i e d to accept and make the best o f i t : I t ' s kind o f hard to t e l l r i g h t now what to do. I'm j u s t t a k i n g i t as i t comes, and I ' l l judge i t ... No I don't think you can ever f e e l c o n f i d e n t nothing could happen, you j u s t hope f o r the best i f you know there i s no s o l u t i o n you have to wait and see what happens. A f a t a l i s t i c approach to l i f e was voic e d by f i v e o f the s u b j e c t s . One woman simply s t a t e d : \"I'm not a c o l d person, but when your time i s up, i t ' s up\". Another s u b j e c t quoted an o l d saying: \"You know there i s an o l d S c o t t i s h s a y i n g , what's 'fore you won't go past you\". This f a t a l i s m seemed to comfort the s u b j e c t s i n some way, as i f t h i s s i t u a -t i o n was no longer i n t h e i r l o c u s o f c o n t r o l and so there was no p o i n t i n worrying. One s u b j e c t s a i d : \"Both (my husband) and I are f a t a -l i s t s , what's going to be i s going to be, and there's sweet boo we can do about i t . \" The heart attack p r e c i p i t a t e d a l o t o f t h i n k i n g about l i f e and death i s s u e s f o r one spouse: \"(My wife) i s n ' t worried now, nor am I, I think you r e a l i z e now, well and t r u l y , you are mortal.\" The r e d e f i n i t i o n o f s e l f and pa r t n e r was d i s c u s s e d by a l l twelve s u b j e c t s . They de s c r i b e d t h e i r partners' p e r s o n a l i t y c h a r a c t e r i s t i c s , and how they viewed t h e i r p a r t n e r s ' r e a c t i o n s to the i l l n e s s a t t h i s time. Many of the sub j e c t s saw t h e i r partners as very independent and e n e r g e t i c , and a n t i c i p a t e d they would have d i f f i c u l t y a c c e p t i n g the r e s t r i c t e d a c t i v i t y : He's very a c t i v e , he can't s i t down and r e l a x , he's got to be doing something, t h a t ' s what bothers me, because i t ' s going 51 to be very hard f o r him to slow down. He'll have to slow down, but w i l l he be able to? The m a j o r i t y o f the s u b j e c t s d e s c r i b e d t h e i r p a r t n e r s ' e a r l y r e a c t i o n s as non-accepting, \"I don't think i t has r e a l l y r e g i s t e r e d y e t , what has happened, not y e t \" . By the second i n t e r v i e w the s u b j e c t s f e l t t h e i r p a r t n e r s were more ac c e p t i n g and c o o p e r a t i v e with the medical regime: I t h i n k he's r e a l i z i n g t h a t h e ' l l have to take i t easy, and there are l o t s o f th i n g s h e ' l l have to f o r g e t about. I think I r e a l i z e d more from the beginning than he d i d , he thought once he's out o f the h o s p i t a l he'd be r i g h t back to where he l e f t o f f . Now he's beginning to r e a l i z e t h a t i t j u s t won't be t h a t way anyhow. Accompanying t h i s i n c r e a s e d r e a l i z a t i o n , s u b j e c t s r e p o r t e d partner r e a c t i o n s o f c o n f u s i o n , d e p r e s s i o n , worry, f r i g h t and dependence. The subje c t s ' thoughts turned inward as they r e f l e c t e d on t h e i r p e r s o n a l -i t i e s and how they p e r c e i v e d themselves i n t h i s s i t u a t i o n as a r e s u l t of t h i s l o s s . Some of the p e r s o n a l i t y c h a r a c t e r i s t i c s d e s c r i b e d were: \"I'm not a rel a x e d person -- I am a l o n e r \" , \"I'm an o p t i m i s t , I'm not a whining woman, I'm a p o s i t i v e t h i n k e r \" , \"I can't take a l o t , I'm weaker than my husband\". G e n e r a l l y , the working s u b j e c t s saw themselves as more independ-ent, while the women who d i d not work or were c a r i n g f o r c h i l d r e n a t home viewed themselves as f i n a n c i a l l y or emotionally more dependent on t h e i r p a r t n e r s . Several subjects worried about t h e i r v u l n e r a b i l i t y and r e a l i z e d how tenuous t h e i r emotional and f i n a n c i a l p o s i t i o n s were. One spouse 52 s t a t e d \"I f i n d I'm preoccupied with myself\" and another r e p o r t e d f e e l i n g s o r r y f o r h e r s e l f , but not showing i t . The m a j o r i t y of spouses viewed t h i s time as a g a t h e r i n g o f s t r e n g t h and doing the best they c o u l d , f o r they recognized the need to be strong and independent. One s u b j e c t d e s c r i b e d how i t f e l t to be strong a t a time l i k e t h i s : Well sometimes i t ' s harder on the person at home. I'm sure i n a l o t o f cases i t c o u l d be very bad. You have to be a w f u l l y strong y o u r s e l f even though you are the person t h a t i s w e l l . PHASE I \u00E2\u0080\u0094 F e e l i n g s During the i n t e r v i e w s s u b j e c t s were asked to d e s c r i b e t h e i r f e e l i n g s i n response to t h e i r p artners' heart a t t a c k . Subjects d e s c r i b e d mood s t a t e s and p h y s i c a l or h e a l t h d i s t u r b a n c e s as f e e l i n g s . Mood Statements of shock and d i s b e l i e f were reported by e i g h t of the s u b j e c t s during the i n i t i a l i n t e r v i e w . No matter how much you think you are prepared f o r t h i n g s you are r e a l l y not. I never thought about a heart a t t a c k . It ' s taken me by s u r p r i s e , when someone has never been s i c k before i t h i t s you p r e t t y hard, i t j u s t seems to happen, and i t ' s t h e r e , i t ' s hard. Many of these comments were di s c u s s e d i n r e t r o s p e c t , f o r by the f o u r t h or f i f t h day the s u r p r i s e element had receded, and the heart attack had become more o f a r e a l i t y . However, one s u b j e c t s t i l l f e l t shocked over the s i t u a t i o n : I t doesn't seem l i k e i t i s r e a l l y happen-i n g , once I r e l a x t h i s w i l l h i t me, I haven't had time y e t . I t f i n a l l y \" h i t \" one woman the day o f the f i r s t i n t e r v i e w : I t was a shock. I t d i d n ' t h i t me u n t i l t h i s morning. I t ' s the f u n n i e s t t h i n g , i t d i d a l l o w me to get r i d o f t e n s i o n and t e a r s , I've had no t e a r s up t i l l now. Another woman d e s c r i b e d the f e e l i n g o f a delayed r e a c t i o n : People do tend to underestimate the s e r i o u s n e s s o f the problem ( h e a r t a t t a c k ) . I t r e a l l y was a r e v e l a t i o n t o me to r e a l i z e how s e r i o u s i t was. I t seems to come more with time. I d i d n ' t grab how s e r i o u s i t was a t the be g i n n i n g . I t ' s j u s t an osmosis t h i n g . The m a j o r i t y o f s u b j e c t s r e p o r t e d f e e l i n g upset, and found the time i n the i n t e n s i v e care u n i t the most d i f f i c u l t . Although i t was a s t r e s s f u l time, the s u b j e c t s were a b l e t o d e s c r i b e t h e i r f e e l i n g s c l e a r l y . Often they c o u l d not f i n d the r i g h t word to d e s c r i b e t h e i r f e e l i n g s t a t e , y e t t h e i r comments and nonverbal behaviours c l e a r l y pointed to the sorrow they f e l t . One woman, s t r u g g l i n g to remain composed, expressed these f e e l i n g s : You do get upset, o f yeah s u r e , ah, I don't t h i n k angry or depressed but you j u s t ah, I don't know, i t ' s r e a l l y hard to say what you r e a l l y f e e l , you know. You j u s t f e e l s o r r y t h a t t h i n g s have to happen t h i s way you k n o w \u00E2\u0080\u0094 i t ' s a hard t i me. Subjects a l s o r e p o r t e d f e e l i n g s o f d e s p a i r , d e p r e s s i o n , g u i l t , c o n f u s i o n , and anger. Three f e e l i n g s were i d e n t i f i e d by one woman: 54 Despair more than anything. Anger t h a t I hadn't been ther e when i t happened, and g r a t i t u d e t h a t i t had not happened on the way to work, during rush hour t r a f f i c . The s u b j e c t s , r e g a r d l e s s o f t h e i r sex, d e s c r i b e d the i n t e n s i t y o f t h e i r f e e l i n g s . One man commented: I d i d n ' t think I c o u l d get emotional, but the f i r s t day I r e a l l y broke down. You know i t s o r t of gets automatic, the I l o v e you, and honey, and a l l of t h a t s t u f f , but then t h i s was something e l s e , walking out, a f t e r v i s i t i n g hours, and I'd look back, and my God i t ' s a hard t h i n g to do, to walk away. As the p a t i e n t s progressed i n an uneventful recovery the m a j o r i t y of s u b j e c t s r e p o r t e d f e e l i n g more p o s i t i v e and o p t i m i s t i c : W e l l , I'd say I was 75 percent b e t t e r than l a s t week. Everything p o i n t s to her recovery, so I've changed my mood too as f a r as t h a t goes. Well I f e e l calmer, the t h i n g s you have to c o n s i d e r are more under your c o n t r o l , or a t l e a s t I think so, and I suppose t h a t ' s the important t h i n g , but i t ' s c e r e t a i n l y a shaker at f i r s t . The optimism, however, was guarded as they r e a l i z e d the s i t u a t i o n was. s t i l l p r e c a r i o u s : \"Well anything can happen y e t . \" \"I'm okay as long as i t doesn't happen again.\" \"As long as he watches i t , e v e r y t h i n g w i l l be a l r i g h t . \" P h y s i c a l Disturbances Every s u b j e c t reported h e a l t h concerns. I n t e r f e r e n c e s with sleep and a p p e t i t e were most common. Subjects reported f e e l i n g general f a t i g u e and i r r i t a b i l i t y . I have t r o u b l e s l e e p i n g at n i g h t . It gets hard then, e v e r y t h i n g seems to go through your mind and you know you c a n ' t s l e e p . I've gone o f f my food, i f i t weren't f o r (my son) I wouldn't even bother cooking, I have to cook f o r him. Most of the s u b j e c t s spent several hours, day and n i g h t at t h e i r p a r t n e r s ' bedside. One woman maintained a f i v e - d a y v i g i l i n the i n t e n s i v e care u n i t . She d e s c r i b e d her f e e l i n g s : I d i d n ' t l e a v e h i s s i d e . I was a f r a i d he was going to d i e . I t ' s h o r r i b l e watching the monitor through the n i g h t , I t was h o r r i b l e ! I c o u l d ' t e a t , I c o u l d n ' t swallow anything, I c o u l d n ' t s l e e p . One young s u b j e c t d e s c r i b e d her f a t i g u e : I t ' s been a heavy, t h i n k i n g week. I've been ver y , very t i r e d . Short p e r i o d s o f t i r e d , where I haven't been hard l y able to keep my eyes open ... I'm e a t i n g one meal at nigh t t h a t ' s a l l . By the second i n t e r v i e w sleep and a p p e t i t e d i s t u r b a n c e s had decreased but r e p o r t s of i n c r e a s e d f a t i g u e and i r r i t a b i l i t y were more common. Several s u b j e c t s r e p o r t e d being \"on edge\" with f r i e n d s or f a m i l y . Subjects with c h i l d r e n l i v i n g a t home seemed to experience more t e n s i o n and i r r i t a b i l i t y : I get upset q u i t e e a s i l y . Things have to be j u s t so, or e l s e I get upset. I'm more i r r i t a b l e , e s p e c i a l l y with the young one ... I c a n ' t be bothered with s o c i a l c o n t a c t s , they ask too many questions and get on my nerves. Related to p h y s i c a l d i s t u r b a n c e s were comments of heightened concern f o r ones' own h e a l t h . Four s u b j e c t s ' r e f l e c t i o n s on t h e i r own 56 h e a l t h , and the n e c e s s i t y o f keeping healthy f o r t h e i r p a r t n e r s ' sake were voic e d by fo u r o f the samples: I o f t e n think now, when I get a pain i t probably wouldn't be something s e r i o u s , but i t c o u l d happen ... I'm making sure nothing i s happening to me because I should be keeping myself i n good c o n d i t i o n so I ' l l be able to look a f t e r her. Yes, you have to look a f t e r your own h e a l t h . You can't look a f t e r him then. He c o u l d lean on me a b i t , he's not as f i t as I am. PHASE I \u00E2\u0080\u0094 A c t i o n s During the i n t e r v i e w s s u b j e c t s d e s c r i b e d t h e i r behaviour patterns s i n c e t h e i r p a r t n e r s ' heart a t t a c k . The rese a r c h e r a l s o observed the su b j e c t s ' a c t i o n s a t t h i s time. V e r b a l i z e d Behaviours Ten s u b j e c t s reported d i f f e r e n t p a tterns of behaviours during the f i r s t week of h o s p i t a l i z a t i o n . T h e i r a c t i v i t i e s were very p a t i e n t focused, c e n t e r i n g around h o s p i t a l v i s i t s and communicating the c r i t i c a l s i t u a t i o n to f r i e n d s and f a m i l y . The spouses coped as best they c o u l d , o f t e n by keeping busy and r e f u s i n g to thi n k o f themselves or beyond the immediate s i t u a t i o n . One woman exp l a i n e d her behaviours during t h i s c r i t i c a l p e r i o d : You don't have time to break down i n the e a r l y stage, you're too concerned, you're very i n t e n s e and a l l your thoughts are t r a i n e d to hoping h e ' l l get b e t t e r and behave h i m s e l f and not be naughty. And 57 r e a l l y , you don't th i n k o f anything e l s e , and even i f you've got the time, which I d i d n ' t , even i n the c a r , I made sure I had the r a d i o on, so I d i d n ' t t h i n k and a t home you do the washing o r c l e a n the house, change the t u r t l e bowl, feed the c a t , t a l k t o the k i d s and then you are so exhausted you go to bed and sleep and wake up i n the morning and s t a r t again. Another woman saw her behaviours as q u i t e d i f f e r e n t now t h a t her husband was i l l . She re p o r t e d : I've been c l e a n i n g my house thoroughly. I have to keep busy. Normally when he i s home I watch T.V. or read, but I work, I come to the h o s p i t a l , and then there are a few phone c a l l s a t n i g h t and then I go to bed. I go to bed much e a r l i e r . In the second week o f h o s p i t a l i z a t i o n a l l twelve s u b j e c t s r e p o r t e d t h e i r r o u t i n e s as becoming more h e c t i c . Three-quarters o f the s u b j e c t s d i d not d r i v e , so the c o n t i n u a l commuting and t r a v e l arrangements, plu s the added r e s p o n s i b i l i t i e s , d e c i s i o n making and concerns seemed to r e s u l t i n g r e a t e r f a t i g u e with l i t t l e time to s e l f . One woman with three teenage daughters d e s c r i b e d her day: I'm up a t 5:30, the twins have been a b i g help, so I l i k e to make them a good break-f a s t , then I stay up to t i d y the house, and we have a b i g garden so t h a t ' s a l o t of work ... I le a v e home at ten f o r the h o s p i t a l ( f o r t y m i l e s away) I t r y and eat a t the h o s p i t a l and I'm t i r e d when I get home a t night--I'm i n bed a t midnight but I don't sleep w e l l . The actual changes i n d a i l y r o u t i n e s , r e g a r d l e s s o f the q u a n t i t y or q u a l i t y were perc e i v e d s t r e s s f u l by the s u b j e c t s . One man expressed h i s s i t u a t i o n : There's an i n a b i l i t y to s t a r t anything you j u s t do what you can to get by. You keep 58 the place c l e a n , eat pr o p e r l y and get down to the h o s p i t a l and t h a t ' s a f u l l - t i m e job and you don't sleep t h a t w e l l . Although r o u t i n e s were considered h e c t i c , one h a l f o f the group repor t e d l o n e l i n e s s : \"I've become a l i t t l e l o n e l y a t home i n the evenings, i t ' s p r e t t y l o n e l y and the evenings are the worst.\" \" I t ' s d i f f e r e n t now by m y s e l f \u00E2\u0080\u0094 I never go anywhere, i t ' s no fun going anywhere by y o u r s e l f . \" Despite the f a c t t h a t the sub j e c t s g r i e v e d f o r t h e i r p a r t n e r s ' presence, they were not i n t e r e s t e d i n s o c i a l i z i n g with o t h e r s . They seemed too f a t i g u e d and preoccupied with t h e i r own thoughts to i n i t i a t e c o n t a c t s , or l i s t e n to other people's c o n v e r s a t i o n s . The emotional and ph y s i c a l f a t i g u e the spouses f e l t r e s u l t e d i n an a p a t h e t i c approach to t h e i r normal r o u t i n e s . One man who d e s c r i b e d h i m s e l f as a hockey a d d i c t r e p o r t e d : Well, t h i n g s went on the b l i n k . I wasn't i n t e r e s t e d i n the T.V. or the e l e c t i o n s t h a t were on. I could have cared l e s s what was going on. I have no f e e l i n g to play c r i b or bridge or p o o l , which I l i k e doing. Nothing i n t e r e s t s me, I j u s t want to be l e f t alone. I come home at ni g h t and j u s t s i t down and s t a r e i n t o space. The t o p i c o f h e l p f u l others was d i s c u s s e d by eleven s u b j e c t s and f i v e f e l t f r i e n d s and fami l y were not h e l p f u l during t h i s time. \"I would j u s t as soon have q u i e t now, because you do have t h i n g s to think about.\" \"I can't be bothered with s o c i a l c o n t a c t s , they ask so many questions.\" Often \" h e l p f u l others\" were misguided i n t h e i r attempts to comfort: 59 My s i s t e r t r i e s to minimize e v e r y t h i n g and t h i s i s not r e a l l y a-- well she says i t ' s going to be okay I know t h i s person had t h i s and t h a t , and they are a l l okay, but well t h i s i s d i f f e r e n t i f i t h i t s y o u r s e l f . People are phoning. I f i n d i t t i r i n g i f they t a l k very l o n g . I'm not a telephone person. I t ' s mostly the men who phone and they go on and on. They know every Tom, Dick and Harry t h a t ever had a heart a t t a c k and the r e s u l t s o f i t and I'm not i n t e r e s t e d i n i t ! G e n e r a l l y speaking, f r i e n d s and f a m i l y were sought f o r s o l a c e , and the d o c t o r s and nurses were seen as h e l p f u l f o r i n f o r m a t i o n by s i x o f the sample. Nurses met both o f these needs f o r some s u b j e c t s . One 45 ye a r o l d woman expressed her views towards the nurses. The nurses were wonderful. They were so calm, so you were calm. They were t r u t h f u l and t o l d you e v e r y t h i n g . You c o u l d ask them anything. They brought me c o f f e e a l l the time, I have not gone home y e t ; I've s l e p t i n the c h a i r s i n c e Monday ( f i v e days ago). They (nurses) t r i e d t o get me to go, but they never f o r c e d me. For some spouses the i n v e s t i g a t o r was the only suppport person they had. At the t e r m i n a t i o n o f the f i r s t i n t e r v i e w a 56 ye a r o l d man spoke a p p r e c i a t i v e l y : Thank you f o r l e t t i n g me speak. I t gave me a chance t o l e t my f e e l i n g s out and a i r my concerns, because you know, you can't do i t i n f r o n t o f your p a r t n e r , you t r y and keep p o s i t i v e and keep the homefront going. Another s u b j e c t confirmed the i n a b i l i t y t o c o n f i d e i n her l o v e d one: I t ' s n i c e to t a l k to you, i t gets i t out and i t ' s n i c e and informal here. You know even with my husband and c h i l d r e n I s t i l l keep up a f r o n t and everyone i s han d l i n g i t ( i l l n e s s ) i n t h e i r own way. 60 Keeping up a f r o n t , no matter what the personal c o s t , was a behaviour seven s u b j e c t s d e s c r i b e d . There seemed to be a l t e r e d communications between husbands and wives, almost akin to a co n s p i r a c y of s i l e n c e . For whatever the reason, sharing of f e e l i n g s and concerns was not pe r c e i v e d as a p p r o p r i a t e . One 34 yea r o l d woman de s c r i b e d her communication p a t t e r n s with her husband: We w i l l both be very c a r e f u l r i g h t now of what we'll l e t the other person know. Like he asked me i f I had eaten, and I say of course I've eaten because I don't want him to worry about me because i t ' s not a p r i o r i t y r i g h t now. Observed Behaviours The i n v e s t i g a t o r recorded her observations o f the su b j e c t s ' behaviours during the in t e r v i e w s and compared these observations with the behaviours v e r b a l i z e d by the s u b j e c t s . As i n d i c a t e d e a r l i e r i n the f i n d i n g s , the su b j e c t s viewed the f i r s t week as s t r e s s f u l and t h i s p e r c e p t i o n was evidenced i n t h e i r observed behaviours. Of the 12 s u b j e c t s , f i v e spouses acted as i f they were under great s t r e s s . Two women openly wept during the f i r s t i n t e r -view and the three others v i s i b l y fought f o r emotional c o n t r o l . These f i v e s u b j e c t s were a l l adequately groomed. T h e i r h a i r , make-up and c l o t h i n g were neat and t i d y i n appearance but t h e i r faces looked very drawn and pale with dark c i r c l e s under t h e i r eyes. They t a l k e d with long pauses and s i g h s . T h e i r v o i c e s lacked i n f l e c t i o n and were s o f t o r trembling at times. These spouses r a r e l y smiled or used body gestures f o r emphasis. They gave the i n v e s t i g a t o r o c c a s i o n a l eye c o n t a c t and were noted to glance f r e q u e n t l y down at t h e i r hands or l a p s . 61 Another f i v e spouses saw t h i s time as s t r e s s f u l but they r e p o r t e d being upset more i n r e t r o s p e c t f o r they f e l t the worst was over. Although these s u b j e c t s looked f a t i g u e d and concerned they were able to d i s c u s s t h e i r r e a c t i o n s with l e s s emotional d i f f i c u l t y than the former f i v e . Sighs and long pauses were l e s s f r equent i n t h e i r c o n v e r s a t i o n s . They smiled o c c a s i o n a l l y and gestured with t h e i r hands. Of the 12 s u b j e c t s , the remaining two spouses d i d not present the same behaviours. The behaviours reported and observed by these two women i n d i c a t e d calm and optimism. These s u b j e c t s were responsive and eager to t a l k . They smiled o f t e n , used frequent eye c o n t a c t and gestured a p p r o p r i a t e l y with nods and a c t i v e f a c i a l e x p r e s s i o n s . These su b j e c t s seemed very much i n c o n t r o l of t h e i r emotions. The observable behaviours demonstrated by these two women were congruent with t h e i r r eported behaviours but not congruent with the remaining ten s u b j e c t s . There are several f a c t o r s t h a t c o u l d c o n t r i b u t e to the d i f f e r e n c e s i n the spouses' behaviours and t h i s w i l l be d i s c u s s e d i n the next chapter but an i n t e r e s t i n g c o r r e l a t i o n was found between the time of the f i r s t i n t e r v i e w and the type, frequency and i n t e n s i t y of behaviours. The s u b j e c t s i n t e r v i e w e d from day two to day f o u r of the partners' i l l n e s s p e r c e i v e d t h i s time as very s t r e s s f u l and t h e i r behaviour r e f l e c t e d t h i s p e r c e p t i o n . The time of the f i r s t i n t e r v i e w f o r the remaining s u b j e c t s v a r i e d from day three to day s i x and t h e i r r eported s t r e s s was more i n r e t r o s p e c t which concurred with the behaviours observed by the i n v e s t i g a t o r . 62 At the time of the second i n t e r v i e w a l l p a t i e n t s were c o n v a l e s c i n g i n the post coronary u n i t and the subjects seemed to be l e s s upset and more o p t i m i s t i c about the i l l n e s s . T h e i r r e p o r t e d h e c t i c r o u t i n e s were r e f l e c t e d i n i n c r e a s e d symptoms of f a t i g u e observed by the i n v e s t i -g a t o r. They smiled more f r e q u e n t l y and t h e i r speech showed more i n f l e c t i o n . Eye c o n t a c t was frequent and d i r e c t e d at the i n v e s t i g a t o r . Nods, hand gestures and l e a n i n g forward were common behaviours noted. PHASE II Reaction to the Event The second phase has been termed r e a c t i o n to the event. This phase corresponded to the t h i r d i n t e r v i e w with the s u b j e c t s and covered the i n i t i a l post discharge p e r i o d o f the p a t i e n t . The time frame o f t h i s phase v a r i e d f o r each s u b j e c t the range was from day s i x to day f f o u r t e e n , the average being nine days post d i s c h a r g e . PHASE I I \u00E2\u0080\u0094 Thoughts Three thought c a t e g o r i e s have been i d e n t i f i e d i n t h i s phase and l a b e l l e d a s s e s s i n g , implementing and r e d e f i n i n g . Assessi ng At the time of the t h i r d i n t e r v i e w , the study sample c o n s i s t e d of ten s u b j e c t s . A l l ten assessed t h e i r p artners' p h y s i c a l and emotional h e a l t h i n some d e t a i l . During the f i r s t week many of the spouses des c r i b e d t h i s time as d i f f i c u l t or scary. It was termed by one spouse as \" l i k e walking on eggs f o r the f i r s t w h i l e \" . The 6 3 assessment, e s p e c i a l l y during the f i r s t few days a t home, tended to occupy many of the su b j e c t s ' thoughts: I watch him too much, I watch h i s breath-i n g , I ask 1000 times a day, are you a l r i g h t ? Well l a s t week was the hardest, I was up a l o t , I was up t h r e e , f o u r o r f i v e times a n i g h t , going i n and l o o k i n g at him, I wasn't g e t t i n g any s l e e p . By the end of the f i r s t week and the beginning o f the second week \"things were s t a r t i n g to get back to normal\". The s u b j e c t s continued to assess t h e i r partners' p h y s i c a l and emotional s t a t e , y e t i n a more r e l a x e d manner. During the h o s p i t a l i z a t i o n phase, the s u b j e c t s were very concerned t h a t t h e i r partners would not cooperate and would exceed t h e i r l i m i t a t i o n s . They a n t i c i p a t e d the worst i n terms o f the adjustment. At the time of t h i r d i n t e r v i e w however, the p a t i e n t s were i n f a c t cooperating s a t i s f a c t o r i l y and the s u b j e c t s f e l t encouraged. The m a j o r i t y spoke p o s i t i v e l y about t h e i r partners' recovery. In d i s c u s s i n g t h e i r p a r t n e r s ' adjustments several areas were examined: Well, t h i n g s are f i n e , they are g e t t i n g back to normal (my husband) i s a d j u s t i n g well to h i s d i e t , he doesn't mind i t - - h e i s well on h i s way to normal a c t i v i t y ... He goes shopping every day, he walks around and does t h i n g s around the house-- there has been an improvement. Not a l l the subjects viewed t h e i r p a r t n e r s ' recovery as p o s i t i v e . A husband's r e a c t i o n was de s c r i b e d by one woman i n t h i s manner: Well i t was so bad and you c o u l d see t h a t i t was a mental t h i n g . To suggest anything wouldn't do any good; he never spoke, he was r e a l q u i e t . I t was a l l up here ( p o i n t s to her head). I suggested t h i n g s but he wasn't keen on doing anything! 64 In an e a r l i e r i n t e r v i e w , one young su b j e c t feared t h a t her en e r g e t i c \"hyper\" husband would soon become bored and i r r i t a b l e a t home. Her f e a r s were soon r e a l i z e d : Well he's bored, not scared, j u s t bored. I can see he's dying to d r i v e . I enjoy having him here except he's cranky. I thin k he's g e t t i n g stronger and as he gets s t r o n g e r , he gets worse to handle. In terms o f a s s e s s i n g the changes i n t h e i r l i v e s one h a l f o f the su b j e c t s f e l t a l l those changes t h a t were a n t i c i p a t e d e i t h e r d i d not occur or were not as bad as they had f e a r e d . One woman who had a n t i c i p a t e d a l o t o f o f e x t r a work with cooking and shopping was pleased t o f i n d out her concerns were not a c t u a l i z e d : I t h i n k t h i n g s are going to work out f i n e . Things a r e n ' t t h a t much d i f f e r e n t so there i s n ' t t h a t much of an upset. We have a few l i t t l e changes from our r o u t i n e but i t ' s nothing d r a s t i c l i k e I thought i t would be. One woman who c a l l e d h e r s e l f a \"worrier\" had f e a r e d many changes would occur as a r e s u l t o f her husband's i l l n e s s . In d i s c u s s i n g her thoughts one week a f t e r her pa r t n e r ' s d i s c h a r g e , she no longer held these concerns and she e x p l a i n e d her new t h i n k i n g i n t h i s way: Well you know when i t happens you don't know what r e a l l y to expect and o f course you always th i n k of the worst, but i t ' s good to f i n d out t h a t i t ' s not as bad--so there are not too many changes; not r i g h t now, not r e a l l y \u00E2\u0080\u0094 s u r e our s o c i a l l i f e w i l l have to change to a c e r t a i n extent but i t doesn't r e a l l y bother me t h a t much. In t h i s e a r l y post discharge p e r i o d , one h a l f o f the sample reported s i g n i f i c a n t changes i n t h e i r l i v e s . Many of the changes 65 r e v o l v e d around a s h i f t i n r o l e s and r e s p o n s i b i l i t i e s . With two teenagers a t home one woman found her l i f e had many changes: Yeah, i t ' s q u i t e d i f f e r e n t because I can ' t do the th i n g s I use to do. I can't get the vacuum out or have an empty house, to dust f u r n i t u r e . I have to plan around every-t h i n g . My lunches are d i f f e r e n t , my dinner and b r e a k f a s t s are d i f f e r e n t . I have someone asking f o r c o f f e e or tea every hour. Implementing The mental planning and o r g a n i z i n g done by the s u b j e c t s during the h o s p i t a l i z a t i o n time expanded i n t h i s , post discharge p e r i o d to implementation. The approaches or r o l e s the s u b j e c t s had a n t i c i p a t e d they would f u l f i l l were now s p e c i f i c a l l y d e f i n e d and acted out. A l l su b j e c t s d e f i n e d t h e i r r o l e s i n d e t a i l . T h e i r comments r e v e a l e d t h e i r p erceptions o f how they attempted to c o n t r o l the s i t u a t i o n . In a l l areas the spouses acted very much l i k e \"watchdogs\" they l i m i t e d v i s i t o r s , monitored t h e i r p a r t n e r ' s p h y s i c a l a c t i v i t y , prepared the c o r r e c t d i e t and r e f r a i n e d from engaging i n any emotional i s s u e s . One man commented on h i s new r o l e . Well you wonder i f a disagreement, minor or major, i s something you have to watch and how c a r e f u l am I going to have to be--yeah I watch i n p r a c t i c a l t h i n g s , l i k e you know, f o r people to come and v i s i t , t h a t ' s a l l r i g h t ... And I say to her don't f o r g e t your p i l l s and you don't want to leave the house f o r too lo n g , you scoot over to the sto r e knowing t h a t r e a l l y nothing i s going to happen, but you s t i l l p a r c e l out your time. 66 Several s u b j e c t s hovered around t h e i r p a r t n e r s d u r i n g the f i r s t week, f e a r f u l of l e t t i n g them out of t h e i r s i g h t . As t h e i r partners recuperated, t h e i r own a n x i e t i e s lessened and they slackened t h e i r p r o t e c t o r r o l e somewhat. Fear of not f u l f i l l i n g her new r o l e and thus somehow harming her husband caused a good deal o f g u i l t i n one s u b j e c t . Anxiously she expressed her concerns: I w i l l d e f i n i t e l y do my p a r t . I've got to organize v i s i t o r s b e t t e r so they don't come a l l a t once. I t ' s my f a u l t completely i f he has another one, I have to organize b e t t e r ... I don't want to do anything to rouse him. I am concerned he c o u l d have another heart a t t a c k . We don't sleep together now, I am r e s t l e s s and I don't want to d i s t u r b him r i g h t now ... Well, i f he gains weight i t ' s my f a u l t , i f I don't give him the r i g h t foods low i n c h o l e s -t e r o l t h a t w i l l be my f a u l t . Although the s u b j e c t s were concerned and wanted to do the r i g h t t h i n g s , changes i n r o l e s and r e s p o n s i b i l i t i e s were not p r i o r i t i e s with a l l the group. Three of the sample were working women and t h e i r comments r e f l e c t e d the value placed on t h e i r r o l e a l s o : \"At work I am very busy and I don't have much time to worry about him.\" One woman who took her h o l i d a y s to be with her husband was d e l i g h t e d to r e t u r n to work: \"I'm not f u s s i n g and worrying as much now t h a t I'm back a t work.\" Another s u b j e c t who had spent long hours i n meal p r e p a r a t i o n f o r her husband's r e t u r n home f e l t she would do anything f o r her husband, but she was not going to be a s l a v e , and she was \"paying the b i l l s too!\" She commented: 67 I think t h a t ' s where the d i f f e r e n c e l i e s between one woman's r e a c t i o n and another. If you are working a l l day you have to cope with e v e r y t h i n g , but i f you're not working you s i t home and fuss and mope and do a l l the l i t t l e t h i n g s f o r him you want to do. Redefining At t h i s time the m a j o r i t y o f the sub j e c t s continued to r e d e f i n e t h e i r p h i l o s o p h i c a l b e l i e f s i n l i g h t o f t h e i r l o s s e s . They seemed to att a c h meaning to more concrete signs t h a t l i f e was r e t u r n i n g to normal. T h e i r comments r e f l e c t e d a more p o s i t i v e and a c c e p t i n g a t t i t u d e . In drawing an analogy from one's r e a c t i o n s to death a s u b j e c t summed up these i d e a s : Well you know t h i s t h i n g (heart attack) i s l i k e what happens when someone d i e s , there i s so much confusion and change and you wonder, w e l l , should I do t h i s or w i l l I now have to do t h a t , and everything i s kind of up i n the a i r , but a f t e r a few weeks or months, t h i n g s s e t t l e down and l i f e goes on. It has t o , whatever i s going to happen w i l l happen, there i s no p o i n t worrying about a l l those t h i n g s . Only a couple o f s u b j e c t s spoke about the f u t u r e i n terms of a n t i c i p a t i n g what to expect or how to pla n . The m a j o r i t y o f the group thought from day to day and t r i e d to be as p o s i t i v e as they c o u l d : W e l l , I thi n k there's no sense i n planning the f u t u r e because you never know. You don't know the score from one day to the next r e a l l y . At f i r s t t h a t upset me, but i t doesn't now because I know you can't change i t , so you j u s t make the best o f the day. 68 The s u b j e c t s ' thoughts r e v e a l e d a more e g o c e n t r i c focus during t h i s time. Many su b j e c t s continued to look a t themselves i n t h i s s i t u a t i o n and comment on how they were a f f e c t e d by the l o s s . The spouses saw themselves as \"holding down the f o r t \" and t h i s r e s p o n s i -b i l i t y r e s u l t e d i n some negative f e e l i n g s . Some g r i e v e d f o r t h e i r own time and independence. A few f e l t t h a t 24 hour r e s p o n s i b i l i t y f o r t h e i r husbands was too much and they wanted t h e i r own space. In an animated c o n v e r s a t i o n one of the subjects d e s c r i b e d how \" s t i r c r azy\" she f e l t : The f i r s t week was t e r r i b l e . I co u l d n ' t get out a t a l l . My neighbour was my p s y c h o l o g i s t . I ran up there one day and s a i d , have you got anything to do, j i g s a w s , anything. I'm going out of my mind! In c o n j u n c t i o n with a d e s i r e f o r more f r e e time, f o u r s u b j e c t s reported f e e l i n g overwhelmed. The a l t e r e d r o l e s and e x t r a r e s p o n s i b i l i t i e s kept them very busy. These four worked hard without any s i g n i f i c a n t r e c o g n i t i o n o f t h e i r e f f o r t s . The resentment was now s t a r t i n g to s u r f a c e : Well having him around there's nothing worse than having him s i t t i n g around a l l day. Your r o u t i n e i s o f f - - y o u r ' r e going back and forwards running errands. Men are not good p a t i e n t s . He won't do anything. I s c u r r y around and do the housework; he watches T.V. A r e a l concern f o r o n e s u b j e c t was the l o s s o f a w e l l - e s t a b l i s h e d r o u t i n e a t home whereby her husband would prepare the evening t e a . The i l l n e s s d i s r u p t e d t h i s s p e c i a l r e l a x i n g time f o r her. She repo r t e d : 69 Well of course when he was s i c k I s t a r t e d doing i t (pr e p a r i n g evening t e a ) . Well God I was nuts to s t a r t doing t h a t again. He's a l o t stronger now and he can do i t but he's got t h a t he'd j u s t l i k e to s i t t h e r e and l e t me do i t and t h i s has got to me. Maybe i t ' s cause I'm t i r e d , i t wouldn't r e a l l y i r r i t a t e t h a t much but I haven't even had my shower y e t ! PHASE I I \u00E2\u0080\u0094 F e e l i n g s Mood T h i s time was c h a r a c t e r i z e d by a general mood o f g r a t e f u l n e s s . Of the ten s u b j e c t s , seven reported f e e l i n g b e t t e r . This o p t i m i s t i c mood apparently evolved from the d e f i n i t e signs o f t h e i r partners' recovery. Because t h e i r p a r t n e r s had \"made it\"--were so c o o p e r a t i v e and ac c e p t i n g of t h e i r r e s t r i c t i o n s \u00E2\u0080\u0094 t h e s u b j e c t s f e l t they indeed had something to be thankful f o r . One s u b j e c t was d e l i g h t e d to f i n d many of her f e a r s were unfounded and her mood r e f l e c t e d the p o s i t i v e turn i n events: Well t h i n g s are going b e t t e r than I expected--I'm f e e l i n g p r e t t y p o s i t i v e cause he's doing p r e t t y good\u00E2\u0080\u0094I'm f e e l i n g more re l a x e d and th i n g s are s t a r t i n g to get back to normal ... So I can sleep now, and i t helps t h a t he's home, and he's t a k i n g i t (hea r t attack) the way he i s . In commenting on t h e i r mood s t a t e , four women d i s c u s s e d t h e i r f e e l i n g s of ambivalence. Three of the sub j e c t s reported t h i s ambivalence had a f f e c t e d t h e i r mood i n t h a t they f e l t \"lower or more i r r i t a b l e . \" The women were pleased and g r a t e f u l f o r t h e i r husbands' recovery, y e t at the same time they d e s i r e d r e c o g n i t i o n and thanks f o r t h e i r e f f o r t s and more f r e e time to themselves. The sub j e c t s f e l t 70 g u i l t y about t h i s need and they f r e q u e n t l y berated or admonished themselves f o r being so s e l f i s h . These f e e l i n g s are i l l u s t r a t e d by t h i s s u b j e c t s ' comments: Well I f e e l exhausted, cranky and i r r i t a b l e at times. I'm up e a r l y I do a l l t h i s and t h a t and he doesn't seem to a p p r e c i a t e i t . I get down sometimes. You know he seems so well you sometimes f o r g e t he i s s i c k \u00E2\u0080\u0094 i t ' s j u s t t h a t somedays I t h i n k t h a t I get l e f t behind. Sometimes I wonder about my f e e l i n g s I t h i n k , you are s e l f i s h , and I f e e l bad, but i t ' s j u s t t h a t you have f e e l i n g s and you have your own l i f e too, but i t ' s j u s t t h a t what I f e e l you can't take out on you husband so. P h y s i c a l Disturbances A c o r r e l a t i o n was found between mood s t a t e and p h y s i c a l or h e a l t h s t a t u s . In the sample, s i x subjects reported f e e l i n g calmer and more p o s i t i v e as a p p e t i t e and sleep patterns returned to normal. Four su b j e c t s reported f e e l i n g s t r e s s e d , with complaints of s l e e p , a p p e t i t e and stomach d i s t u r b a n c e s . One woman, who p r e v i o u s l y had appeared very p o s i t i v e and calm without any h e a l t h d i s t u r b a n c e s , now experienced a \"delayed r e a c t i o n \" . She d e s c r i b e d how her f e e l i n g s had a f f e c t e d her h e a l t h : I was r e a l l y s i c k t h a t f i r s t week when he came home. I had t e r r i b l e headaches. I t h i n k the h e a r t attack h i t me stronger than I r e a l i z e d . My head was so bad I c o u l d h a r d l y see and my neck, apparently the veins were a l l swollen up and i t was r e a l l y r o t t e n . It s t a r t e d the day before he came home and I went to see the doctor and he put me on some medication. The doctor thought i t was a l l the s t r e s s . 71 Increased f a t i g u e was r e p o r t e d by the m a j o r i t y during t h i s time. Though t h e i r mood and sleep p a t t e r n s may have improved the changes i n r o l e s and r e s p o n s i b i l i t i e s along with the ever present worries o f r e l a p s e c o n t r i b u t e d to the growing f a t i g u e . PHASE 11--Actions V e r b a l i z e d Behaviours During the f i r s t week of t h e i r partner's discharge the m a j o r i t y o f s u b j e c t s r e p o r t e d behaviours which seemed to be assessment-oriented. They watched t h e i r partners c o n s t a n t l y , checking to see i f they were i n any d i s t r e s s . T h e i r new p r o t e c t o r r o l e , i n c o n j u n c t i o n with the e x t r a domestic, s o c i a l and f i n a n c i a l r e s p o n s i b i l i t i e s meant a very busy schedule. The freedom from h o s p i t a l v i s i t s , however, allowed more time f o r some of the new r o u t i n e s at home. As the week progressed and recovery seemed more assured, many s u b j e c t s reported t h i n g s were now s t a r t i n g to get to normal. As one woman s t a t e d , \" I t ' s b e t t e r to have him home than when he was i n the h o s p i t a l ; before I had no time f o r anything e l s e and now I can watch him b e t t e r . \" Four of the s u b j e c t s f e l t t h e i r r o l e s and r e s p o n s i b i l i t i e s were g r e a t l y a l t e r e d , and they d i d not see t h e i r l i v e s as r e t u r n i n g to normal. These women g r i e v e d f o r t h e i r own time and independence, they f e l t t h e i r \"24 hour duty\" allowed f o r l i t t l e p r i v a t e time. Concerns regarding d i e t and a c t i v i t y and medication were voic e d by the m a j o r i t y . The i n f o r m a t i o n g u i d e l i n e s provided by the h o s p i t a l were perceived as h e l p f u l . Yet questions regarding these t o p i c s i n d i c a t e d a need f o r v a l i d a t i o n and reassurance r a t h e r than f o r 72 i n f o r m a t i o n . Two s u b j e c t s d i d focus a good deal on d i e t as evidenced by t h e i r lengthy d i s c u s s i o n s . These women had researched low c h o l e s t e r o l d i e t s i n d e t a i l and had spent hours i n meal planning and pr e p a r a t i o n . The t o p i c o f h e l p f u l others was int r o d u c e d again i n t h i s phase by seven s u b j e c t s . Friends and fa m i l y were u s u a l l y seen as h e l p f u l : they o f f e r e d encouragement and s p e l l e d o f f the boredom f o r the c o n v a l e s c i n g p a r t n e r s . One h a l f o f the group who had f a m i l y c o n t a c t spoke p o s i -t i v e l y of the a s s i s t a n c e they r e c e i v e d . Family and c l o s e f r i e n d s i n p a r t i c u l a r were seen as h e l p f u l \"as long as they don't overdue i t \" i n terms of t i r i n g the p a r t n e r s . Two subjects mentioned t h e i r f r u s t r a t i o n with t h e i r well-meaning f r i e n d s who i n s i s t e d on imparting a l l t h e i r knowledge about heart a t t a c k s . One woman coped by l e a v i n g her phone o f f the hook. A few su b j e c t s had c o n t a c t with t h e i r general p r a c t i t i o n e r s during t h e i r p artners' check-up v i s i t s . These subjects s t a t e d the v i s i t s were h e l p f u l i n terms of inf o r m a t i o n o f f e r e d and v a l i d a t i o n o f t h e i r partner's progress i n recovery. However, only one su b j e c t approached her doctor to d i s c u s s f e e l i n g s o r concerns. The f i n d i n g s r e f l e c t e d a decrease i n communication between seven of the couples. The t o p i c o f the heart attack was r a r e l y d i s c u s s e d between the cou p l e s , e s p e c i a l l y a f t e r the f i r s t week a t home. Often the impetus f o r d i s c u s s i o n arose when f r i e n d s and f a m i l y v i s i t e d . As one spouse s t a t e d , \" I t ' s only when v i s i t o r s come t h a t we t a l k about i t , otherwise we never mention i t . \" 73 Four o f the s u b j e c t s expressed concerns t h a t t h e i r p a r t n e r s d i d not know or app r e c i a t e how t i r e d and s t r e s s e d they f e l t . These women f e l t i n a quandary because they wanted a p p r e c i a t i o n and sympathy, y e t they d i d not wish to draw a t t e n t i o n to t h e i r needs and f e e l i n g s f o r f e a r o f causing another heart a t t a c k . One woman expressed her c o n f l i c t : Well (my husband) i s not a t a l k e r , he keeps ev e r y t h i n g to h i m s e l f - - I get down sometimes and he doesn't seem to r e a l i z e ! I don't know why. I'm j u s t keeping my f e e l i n g s i n s i d e . I ' l l never say anything to him. I j u s t go and lo c k myself i n the bathroom ... I f i n d I'm ea t i n g too much. I ' l l have to stop, maybe i t ' s a p a r t o f t h i s s t r e s s , I don't know. The communication patterns o f the remaining three couples c o u l d be de s c r i b e d as open i n t h a t they shared t h e i r f e e l i n g s and concerns and seemed to be aware of each other's needs. Two o f the su b j e c t s s e t down some \"ground r u l e s \" with t h e i r husbands without f e a r o f r e p r i s a l s . Both women took a f i r m stance on r e f u s i n g to buy c i g a r e t t e s f o r t h e i r house-bound husbands. This was an area with p o t e n t i a l c o n f l i c t but they were able to r e s o l v e the i s s u e by d i s c u s s i n g i t with t h e i r p a r t n e r s . Observed Behaviours The behaviours of the sub j e c t s as observed by the i n v e s t i g a t o r during the t h i r d i n t e r v i e w were found to be congruent with the re p o r t e d behaviours. The o v e r a l l mood o f g r a t e f u l n e s s and a i r o f optimism were r e f l e c t e d i n most of the subj e c t s ' a c t i o n s . T h e i r speech and hand gestures were animated, t h e i r faces were b r i g h t and they smiled 74 f r e q u e n t l y . The s u b j e c t s were well groomed while t h e i r posture was more r e l a x e d . ' There was an absence o f nervous tapping, f i d g e t i n g or tremors seen i n the e a r l i e r i n t e r v i e w s . Good eye c o n t a c t was main-t a i n e d throughout the i n t e r v i e w . During the t h i r d i n t e r v i e w p e r i o d , three of the s u b j e c t s behaved s i m i l a r l y to the r e s t of the group although t h e i r a c t i o n s were somewhat more subdued. These women were f r i e n d l y and t a l k a t i v e , however, the tone of t h e i r speech was s o f t e r and lower with more frequent s i g h s . They looked f a t i g u e d , with l i n e d and drawn faces while t h e i r body posture was slouched. Good eye c o n t a c t was u s u a l l y e v i d e n t and occa-s i o n a l smiles were noted. One change i n behaviour from the previous i n t e r v i e w s was the i n c r e a s e i n the number o f s o c i a l overtures shown towards the i n v e s t i -gator. These s o c i a l gestures v a r i e d from o f f e r s o f tea and c o f f e e to t o u r s o f t h e i r homes and i n v i t a t i o n s extended to d i n n e r o r other s o c i a l events. This s o c i a l theme was a l s o r e f l e c t e d i n the i n c r e a s e in \" s o c i a l c h a t t e r \" i n the s u b j e c t s ' c o n v e r s a t i o n s . In comparison with previous v i s i t s , a g r e a t e r p r o p o r t i o n of the t h i r d i n t e r v i e w s was comprised o f d i s c u s s i o n s of f a m i l y t o p i c s , s o c i a l a c t i v i t i e s , hobbies and i n t e r e s t s . For the f i r s t time, several of the s u b j e c t s i n d i c a t e d i n t e r e s t i n the i n v e s t i g a t o r ' s s i t u a t i o n beyond the i n t e r v i e w s e t t i n g by q u e s t i o n i n g her hobbies, c a r e e r goals and f a m i l y l i f e . 75 PHASE III Impact o f the Event The l a s t i n t e r v i e w covered the e a r l y c o n v a l e s c e n t p e r i o d of the p a t i e n t , v a r y i n g from day 20 to day 38 post d i s c h a r g e , with an average of approximately 28 days. The f i n d i n g s of the f o u r t h i n t e r v i e w r e v e a l e d two more d i s t i n c t p a t t e r n s i n the thoughts, f e e l i n g s and a c t i o n s of the ten s u b j e c t s . Up to t h i s p o i n t the s u b j e c t s had shared many of the same f e e l i n g s and concerns as r e f l e c t e d i n t h e i r r e p o r t e d and observed r e c t i o n s . The f i n d i n g s were separated i n t o Group A and Group B to i l l u s t r a t e the d i f f e r e n c e s i n the s u b j e c t s ' responses. Group A comprised seven women, the m a j o r i t y o f the sample. Group B were the remaining three s u b j e c t s , one man and two women. PHASE I I I \u00E2\u0080\u0094 T h o u g h t s (Group A Findings) The thought c a t e g o r i e s i d e n t i f i e d i n phase three were a s s e s s i n g and r e d e f i n i n g . Assessing The s u b j e c t s continued to assess t h e i r p a r t n e r s ' p h y s i c a l and emotional h e a l t h . G e n e r a l l y the subjects d i d not view the recovery as p o s i t i v e l y as i n phase two. As the convalescence lengthened, many o f the husbands were g e t t i n g bored and f r u s t r a t e d with t h e i r i n a c t i v i t y . Some p a t i e n t s tended to overdo i t and experienced subsequent p a i n . One s u b j e c t was so f r u s t r a t e d with her partner because he never d i s c l o s e d 76 how he was f e e l i n g . She feared he was o v e r a c t i v e : I think about him a l o t ; i f he was honest with you and he'd t e l l you j u s t how he f e e l s then i t would make i t e a s i e r , and when they don't t e l l you, you have to guess and then i t makes i t harder, and sometimes he can hide i t (pain) p r e t t y good too. The s u b j e c t d i s c u s s e d concerns t h a t loomed i n the near f u t u r e : f e a r s of t h e i r partners' d r i v i n g and r e t u r n i n g to work. This d i s c u s -s i o n o f t e n l e d i n t o the o v e r a l l f e a r o f r e c u r r e n c e , a worry t h a t had not been s t r o n g l y v o i c e d s i n c e the e a r l y h o s p i t a l i z a t i o n p e r i o d : Well I don't think he should go back to work, i t ' s too h e a v y \u00E2\u0080\u0094 w e l l not f o r a few months\u00E2\u0080\u0094but then i f i t means h e ' l l be cut o f f h i s pension, then h e ' l l have t o . A pension i s important, but he should take l i g h t j o b s \u00E2\u0080\u0094 b u t I wonder i f h e ' l l have another one, of course he's been c a r e f u l and he hasn't had any more p a i n s , he has been good a l l along. I worry about another heart a t t a c k , e s p e c i a l l y when he goes back to work. I'm not r e a l l y a w o r r i e r , but when he goes back to work with t h a t company he always does more than h i s j o b \u00E2\u0080\u0094 i t ' s so h e c t i c , a l o t of deadlines and (my husband) f l a r e s up so e a s i l y i n work s i t u a t i o n s . Even i f the p a t i e n t ' s recovery was u n e v e n t f u l , the women d i d not view t h i s time as p o s i t i v e f o r the s t r e s s of having t h e i r husbands \"around a l l the time\" as well as the e x t r a demands placed on them added a l o t of pressure. A l l seven s u b j e c t s assessed the changes i n t h e i r l i v e s . The changes d e s c r i b e d a few weeks e a r l i e r had grown to occupy many of the s u b j e c t s ' thoughts. 77 R e d e f i n i n g Many o f the s u b j e c t s thoughts were e g o c e n t r i c i n f o c u s . The women viewed the l o s s from t h e i r p e r s p e c t i v e . They d i s c u s s e d how they saw themselves i n t h i s s i t u a t i o n as a r e s u l t o f the l o s s . They continued to speak o f t h e i r p r o t e c t o r r o l e s and e x t r a r e s p o n s i b i l i t i e s , but a l s o began to v e r b a l i z e how many o f t h e i r thoughts were focused on them-s e l v e s . The time had come f o r them to take a hard look a t t h e i r l i v e s and t h e i r f u t u r e . One woman expressed these thoughts w e l l : W e l l , t h i s l a s t week I've become very very s e i f - c e n t e r e d - - I r e a l l y became greedy--no not greedy, j u s t over concerned, over compensating f o r myself--I was a b s o l u t e l y at the end o f my rope, I c o u l d n ' t take i t . I've been t h i n k i n g , I'm young and I've got a long f u t u r e ahead o f me and i t ' s r e a l l y something t o thi n k about. I f I thought (my husband) would be i n c a p a c i t a t e d or unable t o g e t back i n t o the main stream i t would r e a l l y i n v o l v e a l o t , and the k i d s \u00E2\u0080\u0094 a n d we have a l o t o f f i n a n c i a l problems. The d i s r u p t i o n o f a normal l i f e meant e x t r a worry and \u00E2\u0080\u00A2 r e s p o n s i b i l i t y f o r many o f the s u b j e c t s : I t takes a l o t more e f f o r t , you have to thin k more about every thing--you r e a l l y have more to worry about, l i k e b efore you d i d n ' t worry, you j u s t knew e v e r y t h i n g would go by p l a n , and not i t ' s a l l \u00E2\u0080\u0094 w e l l i t ' s a l l stopped. I t ' s l i k e grand c e n t r a l s t a t i o n h e r e \u00E2\u0080\u0094 I ' m b u r i e d with r e s p o n s i -b i l i t i e s , i t ' s hard 'cause I've never had a l l these b e f o r e . I don't mind because I know I can do i t , but i t gets t o y o u \u00E2\u0080\u0094 i t adds up, a l l the r e s p o n s i b i l i t i e s . Several s u b j e c t s mentioned t h a t the changes i n t h e i r r o u t i n e s were patterned a f t e r t h e i r husbands' wishes. They conceded to t h e i r 78 partners f o r f e a r o f i n i t i a t i n g an argument and p o s s i b l y another heart a t t a c k : He wants to do the things he can't do but then he doesn't want to do some of my work, even simple t h i n g s , y e t you don't want to have a row so. My house today i s so d i r t y , i t looks l i k e a hu r r i c a n e h i t i t , y e t I can't touch i t . (My husband) wants to do the p a i n t i n g outside--and i t ' s j u s t not worth the argu-ment to say, look I want to do the housework, but i t ' s very important t o me because I am a very fussy housekeeper. PHASE I I I - - F e e l i n g s Mood The upward swing i n mood found i n the e a r l y post discharge p e r i o d was no longer apparent i n t h i s group. A general slump i n mood l e v e l was re p o r t e d . The impact o f the i l l n e s s r e a l l y seemed to have \" h i t home\". F e e l i n g s o f dep r e s s i o n , resentment and g u i l t were most commonly re p o r t e d . Several o f the s u b j e c t s d i s c u s s e d t h e i r depression openly. One woman spoke q u i e t l y : Well he i s okay, no problems there but I th i n k my mood i s lower compared to how i t used to be. I am q u i t e normal, but I am nervous person though. Although the a l t e r a t i o n i n mood was n o t i c e a b l e with a l l the group s u b j e c t s the i n t e n s i t y o f depression was most remarkable i n the two youngest women. Both of them had adolescent c h i l d r e n at home f i n a n c i a l concerns and other r e s p o n s i b i l i t i e s . One 34 o l d woman d e s c r i b e d her mood since our l a s t v i s i t : Well the l a s t couple of weeks r e a l l y turned around. I became very deeply depressed. Small t h i n g s kept bothering me, I got stuck with a l l the work, the house, the garden, e v e r y t h i n g . I have been r e a l l y very t e a r y - - I become p h y s i c a l l y very i l l . The doctor gave me some a n t i d e p r e s s a n t s , they are j u s t s t a r t i n g to work ... Things are, p i c k i n g up a b i t , they c o u l d n ' t have got any worse. T h i s same woman had spent a g r e a t deal o f time r e f l e c t i n g on her thoughts and f e e l i n g s . She expressed her home and f a m i l y r e s p o n s i b i l i t i e s and her r o l e i n t h i s s i t u a t i o n : I don't have time to be s i c k , you have no time to break down--you have to be the p i v o t p o i n t f o r everyone, so the more people i n v o l v e d the more d i f f i c u l t i t becomes. The younger the f a m i l y i s , then i t becomes even more important. Many woman g r i e v e d f o r t h e i r own time and space. So many demands had been p l a c e d on them t h a t they f e l t \" b u r i e d \" . The e x t r a demands combined with the l a c k o f r e c o g n i t i o n f o r t h e i r e f f o r t s were reported as major concerns. One s u b j e c t reported f e e l i n g \" l e f t behind\", c o n t i n u i n g she s t a t e d : Well I don't begrudge doing anything f o r anyone, but I don't have any time. Anyway, maybe i t ' s j u s t the way I'm t h i n k i n g , but I f e e l nobody cares t h a t I don't have any time, and nobody knows how I f e e l . The m a j o r i t y of the group spoke o f t h e i r d e s i r e f o r time to themselves. This time was d i f f i c u l t to come by. Even i f they \"freed-up\" t h e i r time and r e s p o n i b i l i t i e s they had t h e i r p a r t n e r s to contend with: I am one of these people who l i k e s time to myself, I don't know what I do with i t , but I can't r e a l l y get along without having 80 t h a t time. R i g h t now I c a n ' t go i n t o town by m y s e l f - - h e ' l 1 say, oh I ' l l go with you, and I don't want him to!--and he won't understand t h a t I don't want him to come. The resentment r e p o r t e d i n the e a r l y d i s c h a r g e . p e r i o d was pronounced a few weeks l a t e r . Four s u b j e c t s v e r b a l i z e d resentment over the lack of f r e e time. The e x t r a r e s p o n s i b i l i t i e s : cooking, c l e a n i n g , c a r i n g f o r husband, c h i l d r e n , e n t e r t a i n i n g v i s i t o r s , a l l compounded t h i s f e e l i n g . One s u b j e c t e x p l a i n e d e m o t i o n a l l y why she f e l t so angered and r e s e n t f u l : I have had dozens and dozens o f v i s i t o r s i n my home these l a s t few weeks. I t o l d them (the l a t e s t v i s i t o r s ) I can't take any more of t h i s , no more people v i s i t i n g . (My husband) i s very s u r p r i s e d t o hear me say t h i s . Men c a n ' t r e a l l y understand a l l o f t h i s because they r e a l l y have no r e a l i t y on the s u b j e c t a t a l l ! They don't know what's i n v o l v e d i n the cooking, c l e a n i n g , laundry, t o w e l s , bathrooms. R e a l l y ! They think the magic f a i r y does i t a l l , and when a l l y our v i s i t o r s are here you s t i l l have to do a l l the cooking, c l e a n i n g and keep doing t h i n g s , keep people f e d , keep them e n t e r t a i n e d . Along with a i r i n g t h e i r resentment the s u b j e c t s i n the same breath, admonished themselves f o r being so s e l f i s h and unkind. They wanted to express t h e i r need f o r more f r e e time and r e c o g n i t i o n and a t the same time to acknowledge t h e i r g r a t i t u d e f o r t h e i r husbands' h e a l t h and t h e i r good marriage. T h i s ambivalence s u r f a c e d with several e x p r e s s i o n s of g u i l t : No r e a l l y , I'm so g r a t e f u l he's home and he d i d n ' t have a worse he a r t a t t a c k . I t h i n k how s e l f i s h I am that I t h i n k of these t h i n g s when I should be so g r a t e f u l he's here. 81 You f e e l t h a t you are wanting a l l the a t t e n t i o n , and there's nothing wrong with you r e a l l y \u00E2\u0080\u0094 i t ' s j u s t t h a t I'm f e e l i n g s h o r t changed, and then I f e e l g u i l t y , I cou l d o f l o s t him, which I never wanted to d o \u00E2\u0080\u0094 a n d he's the best o f husbands and he provides and he's so good and he has s p o i l e d me t e r r i b l y - ^ b u t j u s t a n i c e k i n d word would be n i c e , and then you get to f e e l i n g bad because they ( f a m i l y ) are not unkind. The impact o f the i l l n e s s f i n a l l y h i t one s u b j e c t , a woman who had p r e v i o u s l y denied any concerns and had c o n s i s t e n t l y maintained a very l i g h t , cheery manner. She spoke of her experience: I had a delayed r e a c t i o n , i t dawned on me e x a c t l y j u s t what had h a p p e n e d \u00E2\u0080\u0094 i t dawned . on me t h a t i t was J u l y , my mind was a blank and t h i n g s h i t me a l l a t once. I was r e a l l y scared. I t was h o r r i f y i n g , w e l l , the thought t h a t God he co u l d have g o n e \u00E2\u0080\u0094 and I thought o f f i n a n c e s and what c o u l d I d o ? \u00E2\u0080\u0094 a n apartment--I c o u l d never look a f t e r t h i s house, I mowed the lawn f o r the f i r s t time i n my l i f e t h i s week because (my husband) used to do i t \u00E2\u0080\u0094 a n d a l l those t h i n g s h i t me j u s t 1 ike t h a t ! P h y s i c a l Disturbances The general emotional slump f e l t by the sub j e c t s c o i n c i d e d with r e p o r t s o f in c r e a s e d f a t i g u e and i r r i t a b i l i t y . This f a t i g u e ranged from \"being t i r e d \" to f e e l i n g i n c a p a c i t a t e d . In r e t r o s p e c t one s u b j e c t d e s c r i b e d her f a t i g u e , \"Gee i t ' s r e a l l y f r i g h t e n i n g , I j u s t d i d n ' t r e a l i z e how t i r e d I was, I was so sleepy a l l the time!\" Three women were the most s e r i o u s l y d i s t r a u g h t and repor t e d the g r e a t e s t number of p h y s i c a l symptoms: I became p h y s i c a l l y very i l l , i t was j u s t e v e r y t h i n g . It manifested i t s e l f i n my 82 back and kidneys and stomach--At f i r s t I thought I had a kidney i n f e c t i o n . These headaches keep bothering me, they are r i g h t a t the back o f my neck. I don't r e a l l y f e e l l i k e e a t i n g . I'm not s l e e p i n g much, I'm up every hour or so. PHASE 111--Actions V e r b a l i z e d Behaviours As the weeks progressed the subjects continued to f u l f i l l the p r o t e c t o r - c o n t r o l l e r r o l e as they had done i n the e a r l y phase. This r o l e d i d not occupy as much of t h e i r time f o r t h e i r husbands were c o n v a l e s c i n g w e l l . Along with t h i s r e c u p e r a t i o n came boredom and f r u s t r a t i o n f o r the p a t i e n t s , and so they looked to t h e i r spouses and f r i e n d s f o r entertainment. The changes i n r o l e s and added r e s p o n s i b i l i t i e s continued to keep many of the women very a c t i v e . As the weeks passed by the c o n t i n u a l energy r e q u i r e d to cook, c l e a n , organize f a m i l y and watch over husband began to show i t s f u l l impact. Organization o f the p a r t n e r s ' d i e t s t i l l occupied a l o t of time f o r two s u b j e c t s . The t o p i c o f h e l p f u l others was d i s c u s s e d again during t h i s p e r i o d . Due to t h e i r general f a t i g u e and slump i n mood several s u b j e c t s d i d not welcome v i s i t o r s a t t h i s time. A few c l o s e f r i e n d s and r e l a t i v e s were h e l p f u l i n r e l i e v i n g the p a t i e n t ' s boredom. Too many v i s i t o r s , however, were p e r c e i v e d by the s u b j e c t s as t i r i n g f o r both- p a t i e n t and subject and t h e r e f o r e not welcomed. Although the s u b j e c t s c o n f i d e d f r e e l y with the i n v e s t i g a t o r , they spoke of a general r e l u c t a n c e to d i s c u s s t h e i r f e e l i n g s with t h e i r 83 p a r t n e r s , f r i e n d s , f a m i l y or p h y s i c i a n s . Two women, both t e a r y and depressed d e s c r i b e d t h i s r e l u c t a n c e : I need someone to t a l k t o . I hate to go to my d o c t o r , i t makes me f e e l s t u p i d , 'cause t h e r e ' s nothing r e a l l y wrong, well (my husband) i s b e t t e r so--I hate t a l k i n g to a strange d o c t o r \u00E2\u0080\u0094 I ' d j u s t end up i n t e a r s , and I'd f e e l worse. I'm sure i t wouldn't upset the doctor but i t would upset me. W e l l , you c a n ' t t a l k t o your f r i e n d s or r e l a t i v e s about t h i s , even with your doctor you c a n ' t t a l k because he doesn't r e a l l y understand. There's nothing t h a t the d o c t o r can say t o the wives, n a t u r a l l y the d o c t o r i s more i n t e r e s t e d i n the p a t i e n t , but the e f f e c t i t has on the f a m i l y and the spouse i s tremendous, and the younger the f a m i l y the more traumatic because t h a t means more people i n v o l v e d and more f u t u r e t o t h i n k about. Many s u b j e c t s d e s c r i b e d a h e s i t a n c y to d i s c l o s e t h e i r thoughts and f e e l i n g s with t h e i r p a r t n e r s . Several f e l t t h e i r husbands c o u l d not o r would not understand. Some men are l i k e t h a t \u00E2\u0080\u0094 h e has n o t i c e d I'm g e t t i n g t i r e d but he j u s t doesn't do anything t o h e l p \u00E2\u0080\u0094 h e j u s t doesn't t h i n k . (My husband) can't r e l a t e to how I f e e l , he j u s t doesn't see i t . I don't know why. I c r i e d , he i s very s e n s i t i v e t o t h a t , but he s t i l l doesn't understand. Observed Behaviours The changes i n the group's mood were well r e f l e c t e d i n the s u b j e c t s non-verbal behaviours. The s u b j e c t s appeared q u i e t e r than i n the previous i n t e r v i e w . The o v e r a l l r e p o r t s o f f a t i g u e and d e p r e s s i o n were ev i d e n t i n t h e i r tone o f v o i c e and slouched body posture. These 84 s u b j e c t s sighed a l o t and r a r e l y smiled. A c t i v e hand movements, ta p p i n g , c l a s p i n g and unclasping of hands were noted with two s u b j e c t s . These movements were absent i n the previous i n t e r v i e w s . Three subjects who had looked f a t i g u e d two weeks e a r l i e r appeared more so a t t h i s time. T h e i r f a c e s were drawn with dark c i r c l e s under t h e i r eyes. A s u b j e c t , who reported being deeply depressed, spoke i n a s o f t monotone v o i c e and her posture was slouched. She looked drawn and wore no make-up. Her obvious depression was i n s t a r k c o n t r a s t to her previous appearances as a well groomed, e n e r g e t i c , a r t i c u l a t e woman. The s o c i a l theme e v i d e n t i n phase two was found to be subdued at t h i s time. Many s u b j e c t s made some type o f s o c i a l overture to the i n v e s t i g a t o r but the gestures were not as e f f u s i v e . PHASE III (Group B F i n d i n g s ) The thoughts, f e e l i n g s and a c t i o n s of the remaining three subjects v a r i e d s i g n i f i c a n t l y from Group A. Group B s u b j e c t s seemed b e t t e r a d j u s t e d . These subjects discussed t h e i r present s i t u a t i o n at length but a l s o moved beyond the present to a f u t u r e - o r i e n t a t i o n and spoke o p t i m i s t i c a l l y of the months and year to come. This group comprised three s u b j e c t s , two women and one man. The two women had f u l l - t i m e employment o u t s i d e t h e i r homes. The man, although r e t i r e d , supplemented h i s income through h i s a r t work. A l l three subjects had c h i l d r e n but none of them had f a m i l y members l i v i n g a t home. 85 PHASE 111--Thought The main thought c h a r a c t e r i s t i c s found i n t h i s group were a s s e s s i n g and p l a n n i n g . Assessing The assessment i n c l u d e d the checking of t h e i r partner's p h y s i c a l and mental he a l t h and as the weeks progressed these thoughts occupied l e s s o f the s u b j e c t s ' time. The assessment v a r i e d from the Group A s u b j e c t s i n t h a t i t expanded to i n c l u d e more of an \"us\" or p a r t n e r s h i p o r i e n t a t i o n . The s u b j e c t s examined, as a couple, the changes t h a t had occurred and were s t i l l to come. They planned r e a l i s t i c a l l y , y e t o p t i m i s t i c a l l y f o r the f u t u r e . One s u b j e c t d i s c u s s e d h i s thoughts about h i s wife's heart a t t a c k : Well I suppose i t ' s a veneer on almost e v e r y t h i n g . You t h i n k o f e v e r y t h i n g i n terms of i s i t too much, or are there too many v i s i t o r s and so o n \u00E2\u0080\u0094 b u t I f i n d as each day goes by (my wife's) s i t u a t i o n takes a l i t t l e l e s s o f my thoughts, so now I can think more i n terms of what I am going to f i n d over a t the s t o r e , r a t h e r than I must be away only twenty minutes. The time has sped by and she i s j u s t so much b e t t e r . Time dimmed the memory o f the heart a t t a c k , and l i f e began to r e t u r n to normal f o r these s u b j e c t s . The determination to l i v e a normal l i f e and \"push\" the heart a t t a c k from t h e i r l i v e s was f e l t by a l l s u b j e c t s . One woman explained t h i s f e e l i n g : I think l i f e i s g e t t i n g back to normal. The longer i t g e t s \u00E2\u0080\u0094 l i k e today i t ' s been s i x weeks s i n c e the heart attack and every week i t gets a l i t t l e b i t b e t t e r and we are pushing i t away. Because, f o r one t h i n g , you don't see anything, i f somebody would r e a l l y look down o r bad then you would have t h a t i n f r o n t o f y o u r eyes a l l the time, but t h i s way i s d i f f e r e n t . So we j u s t do t h i n g s and l i f e goes on. The heart a t t a c k brought many changes to the l i v e s o f these s u b j e c t s . Whatever the new l i m i t a t i o n s , the group seemed a b l e t o cope w e l l ; the changes were accepted m a t t e r - o f - f a c t l y . These s u b j e c t s looked on the b r i g h t s i d e o f the changes i n t h e i r l i v e s : Well I don't know, but I t h i n k t h a t e v e r y t h i n g goes f o r the b e t t e r ! He has changed completely he has been more t a l k a t i v e . Now he says i f something h u r t s or whatever, and he does t h i n g s around the house. Well sometimes a change can b r i n g a good r e a c t i o n t o o . I go f o r walks a l o t more than I used t o . He chases me out f o r walks. I t ' s good f o r both o f us.\u00E2\u0080\u0094I'm happy, I t h i n k we both d i d p r e t t y good! Planning Subjects planned r e a l i s t i c a l l y y e t o p t i m i s t i c a l l y f o r the f u t u r e . A heart attack can a c t as a c a t a l y s t i n a couple's l i v e s , b r i n g i n g welcomed change. One couple f i n a l l y decided to s e l l t h e i r home--something they had been \" s i t t i n g on\" f o r y e a r s . T h i s same spouse was d e l i g h t e d with the changes i n v o l v e d with the hea r t a t t a c k such as f r e s h a i r , e x e r c i s e and e x t r a time spent with h i s w i f e . He e x p l a i n e d h i s new s i t u a t i o n : Gosh I don't know how to say t h i s \u00E2\u0080\u0094 b u t a h \u00E2\u0080\u0094 a h e a r t a t t a c k can have a l o t o f b e n e f i t s too! ( l a u g h t e r ) - - i t f o r c e s you to go out and do the t h i n g s you've always wanted to do! A l l three s u b j e c t s took stock o f t h e i r s i t u a t i o n s . They r e f l e c t e d but d i d not dwell on t h e i r l o s s e s ; they viewed t h e i r l i f e and t h e i r 87 r e l a t i o n s h i p o p t i m i s t i c a l l y . R e a l i z i n g t h a t t h e i r time together was tenuous they seemed to look forward to the f u t u r e , determined to make the best o f i t . One woman portrayed t h i s frame o f mind with these words: Some people think about i t (he a r t attack) a l l the time, and well you can c r e a t e more t r o u b l e f o r y o u r s e l f . Sure e v e r y t h i n g looked so grey and dreary a t f i r s t but now i t ' s s t a r t i n g to look b e t t e r \u00E2\u0080\u0094 y o u have to say well i t ' s happened, now l e t ' s t r y and make the best o f i t . Well I know i t ' s hard to plan f o r the f u t u r e , but we are going with a good frame of mind f o r our vaca-t i o n \u00E2\u0080\u0094 a n d our daughter i s coming t o v i s i t i n October so ... . For one man, the heart attack p r e c i p i t a t e d a r e f l e c t i o n on h i s own m o r t a l i t y : Well I think i t (heart attack) c e r t a i n l y makes you r e a l i z e t h a t you are m o r t a l . You know, you don't go on t h i n k i n g you never reach the end. So (my wife's) heart attack has caused me to think a l o t \u00E2\u0080\u0094 b u t ah, maybe t h a t ' s a normal way to go and th a t ' s how acceptance b u i l d s . Acceptance i s d e s c r i b e d i n another s u b j e c t ' s thoughts. She seemed to s i z e up the past, present and f u t u r e r e a l i s t i c a l l y , y e t with an a i r of optimi sm: Well we are both i n t e l l i g e n t enough to r e a l i z e t h a t we are very l u c k y , and we have a l o t going f o r us. We have nothing to complain about; a f t e r a l l I'm f i f t y - s e v e n and (my husband) i s s i x t y and we've had l o t s o f good times i n our l i v e s . I t ' s not l i k e we are t h i r t y . And y e t we have a l o t of good times ahead, as long as we do the thi n g s t h a t we should, and maybe do a few d i f f e r e n t l y . And (my husband) l o v e s to p a i n t , and r e a l l y wants to get back p a i n t i n g so I t o l d him to get h i s easel up and get busy! 88 One s u b j e c t compared h i s s i t u a t i o n to other heart a t t a c k v i c t i m s . His comments spoke to a frame of r e f e r e n c e : Well we were walking t h i s morning, and you can see the f a s t walkers, and you can spot them and can say well he's one o f the c l u b ! (Heart a t t a c k v i c t i m . ) You know what I mean, very muscular men i n t h e i r f i f t i e s and walking to beat h e l l , and you t h i n k well they've been there too. And you see them h u s t l i n g around, and t h a t makes you f e e l more comfortable with the f u t u r e . PHASE I I I \u00E2\u0080\u0094 F e e l i n g s Mood In c o n t r a s t to the o f t e n depressed mood of Group A s u b j e c t s t h i s group rep o r t e d f e e l i n g calm, thankful and i n good s p i r i t s . These f e e l i n g s were r e f l e c t e d i n t h e i r c o n v e r s a t i o n s : Well I'm about 99 percent back to normal, I'm f e e l i n g good. Sure e v e r y t h i n g looked so grey and dreary at f i r s t , but now i t ' s s t a r t i n g to look b e t t e r . Well I'm f e e l i n g e a s i e r , every day i s another mark on the wall--I'm f e e l i n g p r e t t y well myself now. There's no concern a t l e a v i n g the house where as a t f i r s t you get scared r e a l l y to go out and then you kind o f run back every f i v e minutes to see i f she i s s t i l l a l i v e ; not now, now I'm more at ease. One woman, i n e a r l i e r i n t e r v i e w s , had expressed a l o t o f r e s e n t -ment and anger towards her husband. She f e l t he had p r e c i p i t a t e d h i s own heart a t t a c k . He had ignored her pleas to change h i s behaviour and subsequently had a heart a t t a c k . Her comments i n t h i s l a s t i n t e r v i e w seemed more i n s i g h t f u l . In examining her behaviour she had worked hard at a new approach, one she f e l t y i e l d e d a healthy compromise: 89 I guess maybe I s t i l l have t h a t b i t o f resentment, i f I allow i t t o be, but i f i t get busy and do something to occupy my time then I'm f i n e . You know i t can well up i n s i d e of you and i t does. I c o u l d n ' t p o s s i b l y s u r v i v e i f I d i d n ' t say something. I'm not going to be a mickey mouse with him j u s t cause he had a heart a t t a c k but at the same time I'm f a r b e t t e r than I used to be, simply because I don't want him to have another heart a t t a c k . And i f t h a t means t h a t f o r me, not saying a l o t w i l l h elp, then okay, and i t seems to be working out f i n e . Physical Disturbances The reported improved mood and general f e e l i n g of calm and optimism were a l s o r e f l e c t e d i n a improved s t a t e of p h y s i c a l h e a l t h . A l l three subjects reported f e e l i n g w e l l , t h e i r sleep and a p p e t i t e patterns were \"back to normal.\" The f a t i g u e and i r r i t a b i l i t y d e s c r i b e d by Group B were not reported by these s u b j e c t s . PHASE I I I - - A c t i o n s V e r b a l i z e d Behaviours The changes i n r o l e s and r e s p o n s i b i l i t i e s i n t h i s group were shared by both p a r t n e r s . Two s u b j e c t s , both working women, found t h e i r husbands assumed more of the domestic r o l e s during t h e i r convalescence. This had a dual b e n e f i t : i t a l l e v i a t e d the husbands' boredom and lessened the subjects' r e s p o n s i b i l i t i e s a f t e r work hours. One s u b j e c t spoke of the changes i n her husband's a t t i t u d e towards the housework: Well when I get home from work I'm t i r e d and I f a l l a s leep f o r awhile. Well he has 90 changed completely, he does t h i n g s around the house. So he i s a c t i v e , and he says why d i d you do t h a t , j u s t leave i t f o r me, so he keeps busy--I don't mind him doing the d i s h e s , i t ' s not l i k e b e f o r e , t h e r e was j u s t one person, and t h a t was me, you know. One e n e r g e t i c spouse had been moving f u r n i t u r e and c l e a n i n g c a r p e t s the day p r i o r to the i n t e r v i e w . She spoke s y m p a t h e t i c a l l y of her husband's f e e l i n g s : Well (my husband) f e e l s so badly t h a t he can't do anything f o r me. I s a i d don't f e e l bad about the c a r p e t s , there are other t h i n g s you can do. So he's been c l e a n i n g the s i l v e r and f i x i n g the meals and i t r e a l l y h e l p s . Switching r o l e s came e a s i l y to one o f the s u b j e c t s . He e x p l a i n e d how the couple's experiences had helped them cope with t h e i r present changes: Well i t ' s been p r e t t y easy. We don't r e a l l y have a l o t o f d e f i n e d r o l e s \u00E2\u0080\u0094 a n d we have been through t h i s i n a k i n d o f m i n i - s e r i e s before you know. Like i f (my wife) was l a i d up with anything, or i f I was l a i d up with anything i t was the same as i t i s now. We'd j u s t switch r o l e s , so there hasn't had to be any accommodation to another r o l e . No concerns were v o i c e d by t h i s group i n regards t o d i e t , medica-t i o n or a c t i v i t y . The s u b j e c t s were pleased with the convalescence and they d i d not f e e l t h e i r partners were \"overdoing i t \" . One p a t i e n t had alr e a d y returned to work part-time. This a c t i v i t y was welcomed by both p a t i e n t and s u b j e c t with no d i f f i c u l t i e s r e p o r t e d . Returning to work was a concern f o r one 53 year o l d s u b j e c t . She f e l t her husband, a l a b o u r e r , would no longer be able to handle the s h i f t work and p h y s i c a l r e s p o n s i b i l i t i e s . Her a t t i t u d e , however, was p o s i t i v e : 91 Well i t might not be so easy f o r (my husband) but we'll j u s t have to see how i t works out. I t ' s not the end of the world anyhow\u00E2\u0080\u0094I'm working so i t helps some. A l l three s u b j e c t s r e p o r t e d a f a i r l y q u i e t s o c i a l l i f e . An occa-s i o n a l v i s i t from f r i e n d or r e l a t i v e was welcomed but there was a general tendency not to reach out and i n i t i a t e a l o t o f s o c i a l c o n t a c t . Both p a r t i e s seemed to agree on the amount o f s o c i a l i z i n g to be done and were able to arrange an a p p r o p r i a t e schedule. Two s u b j e c t s expressed p o s i t i v e f e e l i n g s about t h e i r f a m i l y doc-t o r s . They found them h e l p f u l , p a r t i c u l a r l y i n o f f e r i n g i n f o r m a t i o n and v a l i d a t i n g t h e i r partners' p o s i t i v e recovery. One s u b j e c t mentioned how he found other h e a r t attack p a t i e n t s h e l p f u l and comforting. Yeah, there's an amazing number of people t h a t have been through i t (heart a t t a c k ) and you meet them and you r e a l i z e i t ' s not a l l t h a t bad, i t ' s s c a r y , but see, they are s t i l l going strong, so ... . The communication between the s u b j e c t s and t h e i r partners was reported to be \"good\" and i n some cases had improved s i n c e the h e a r t a t t a c k . The i l l n e s s had drawn these couples together; they seemed able to share t h e i r thoughts and concerns f r e e l y . This time was used to r e f l e c t on t h e i r r e l a t i o n s h i p and t h e i r c u r r e n t s i t u a t i o n . Many of t h e i r thoughts, f e e l i n g s and a c t i o n s had a team o r i e n t a t i o n : Well the heart attack i s i n our conversa-t i o n s , but we don't dwell on i t . This has been a s e r i o u s s i t u a t i o n and i t b r i n g s you c l o s e r together. I suppose c l o s e r i n the way t h a t there i s a complete dependence on one another. Well (my wife's) a t t i t u d e has been g r e a t . She knows e x a c t l y how much she can take, so i t ' s been p r e t t y well a 50/50. 92 d e c i s i o n . We haven't c o n s c i o u s l y s a i d well what do you t h i n k , i t j u s t happens. One s u b j e c t complained t h a t her husband used to work midnight s h i f t and t h i s had s t r a i n e d t h e i r r e l a t i o n s h i p . Since the heart attack she had n o t i c e d changes i n t h e i r r e l a t i o n s h i p and she spoke p o s i t i v e l y of t h i s time: Well he has changed completely. He has been more t a l k a t i v e . Before he would hardl y say anything, and now he t a l k s about h i s heart a t t a c k and what he has been doing. Now i t ' s b e t t e r , because when I come home he's awake, and we t a l k . Before the heart a t t a c k , I only saw him s l e e p i n g from the s h i f t work, so now i t ' s b e t t e r . Observed Behaviours The behaviours of the s u b j e c t s during t h i s l a s t i n t e r v i e w were congruent with t h e i r reported r e a c t i o n s . They seemed to enjoy the i n t e r v i e w . They were a l e r t and responsive, devoid of many o f the a n x i e t i e s and t e n s i o n noted i n the e a r l i e r group. The faces and body posture of the spouses appeared calm and r e l a x e d . T h i s contentment was a l s o r e f l e c t e d i n t h e i r eye c o n t a c t and v o i c e i n f l e c t i o n . The s u b j e c t s used t h e i r hands to gesture a p p r o p r i a t e l y or e l s e they held them i n t h e i r l a p s . One man, s i t t i n g n e s t l e d i n h i s f a v o u r i t e c h a i r , leaned back o c c a s i o n a l l y with h i s hands behind h i s head. He seemed d e l i g h t e d to have the opportunity to t a l k . In f a c t none of the subjects were in a hurry to terminate the c o n v e r s a t i o n . The f r i e n d l i n e s s and comfortable atmosphere were al s o r e f l e c t e d i n the number of s o c i a l overtures made 93 to the i n v e s t i g a t o r . This group was very s o c i a l and i n i t i a t e d o f f e r s o f t e a , lunch and d i s c u s s i o n s o f f a m i l y and other i n t e r e s t s . Summary The f i n d i n g s from these three phases r e v e a l e d a common pa t t e r n o f behaviours which spouses o f myocardial i n f a r c t i o n p a t i e n t s experienced i n response to l o s s . The p a t t e r n of behaviours comprised the thoughts, f e e l i n g s and a c t i o n s o f the s u b j e c t s from the i n i t i a l impact o f i l l n e s s to s i x weeks post myocardial i n f a r c t i o n . The data d e s c r i b e d the process spouses experienced from the i n i t i a l p e r c e p t i o n of the l o s s to the subsequent impact of the event. 94 CHAPTER 5 DISCUSSION Th i s study focused on the r e a c t i o n s t h a t spouses of myocardial i n f a r c t i o n p a t i e n t s experienced i n response to l o s s . The s u b j e c t s ' thoughts, f e e l i n g s and a c t i o n s were d e s c r i b e d i n Chapter IV. The * f i n d i n g s i n d i c a t e d t h a t the spouses experienced behaviours i n response to l o s s t h a t were common and formed a pa t t e r n through time. Three d i s t i n c t phases were i d e n t i f i e d : the event and i n i t i a l spousal response, r e a c t i o n to the event, and impact of the event. In order to understand the ongoing process o f l o s s experienced by the spouses, the f i n d i n g s were i n t e r p r e t e d i n l i g h t o f the three c o n s t r u c t s e l u c i d a t e d i n the l i t e r a t u r e review: the r e a c t i o n s to l o s s , the elements of l o s s , and the meaning of l o s s . The purpose of t h i s chapter was to i n t e g r a t e the f i n d i n g s with the l o s s l i t e r a t u r e and thus to develop an understanding of the phenomenon of l o s s f o r spouses of myocardial i n f a r c t i o n p a t i e n t s . An overview of the i n t e r p r e t a t i o n of the f i n d i n g s i s presented i n Appendix F. Phase I The Event and I n i t i a l Spousal Response Reactions to l o s s The thoughts, f e e l i n g s and a c t i o n s o f the s u b j e c t s i n t h i s study had a c l o s e resemblance to the c h a r a c t e r i s t i c s of a n t i c i p a t o r y g r i e f as i d e n t i f i e d by Lindemann (1944). Lindemann d e s c r i b e d acute g r i e f as a d e f i n i t e syndrome with p s y c h o l o g i c a l and somatic symptoms. He suggested t h a t i n d i v i d u a l s who experienced a n t i c i p a t o r y g r i e f moved 95 through the same process o f g r i e f work as those who had experienced g r i e f a f t e r an actual l o s s . Lindemann d e s c r i b e d g r i e f work as a heightened preoccupation with the departed, a review o f a l l forms o f death which might b e f a l l one, and an a n t i c i p a t i o n o f the modes o f readjustment which might be n e c e s s i t a t e d . The p e r i o d of \"heightened preoccupation\" was a \"very heavy t h i n k -ing time\" f o r the s u b j e c t s and several thoughts occupied t h e i r minds. They o f t e n questioned why the l o s s had occurred and attempted to appor-t i o n blame somewhere. Not only d i d they search f o r a cause, or reason, but they a l s o looked f o r some frame of r e f e r e n c e , a concrete comparison to help them understand and accept t h e i r l o s s . The s u b j e c t s ' c o g n i t i o n extended to i n c l u d e thoughts of t h e i r marriage and t h e i r l i v e s t ogether. In t a k i n g stock o f t h e i r l i v e s they o f t e n r e f l e c t e d on how much they loved and needed t h e i r p a r t n e r . This \"heightened preoccupa-t i o n with the departed\" was a l s o d e s c r i b e d by Parkes (1971) i n h i s London widow study where he termed the behaviour \" s e a r c h i n g \" . Lindemann a l s o noted t h a t the wives of s o l d i e r s who had departed f o r war reviewed the forms of death t h a t might b e f a l l t h e i r l o v e d ones. Bereaved persons o f t e n have a need to review the events l e a d i n g up to and surrounding the death of a loved one. F u l t o n and F u l t o n (1972) concluded t h a t f a m i l i e s faced with the terminal i l l n e s s o f one o f t h e i r members w i l l rehearse the death before i t o c c u r s . This rehearsal may i n c l u d e thoughts about when, as well as how, the p a t i e n t may d i e . Rehearsal of death i s an ominous phrase, y e t one t h a t a p t l y de s c r i b e d the s u b j e c t s ' thought processes o f reviewing and a n t i c i p a t i n g during t h i s c r i t i c a l time. A common behaviour noted i n t h i s study was 96 the \"blow-by-blow d e s c r i p t i o n \" or \"how i t happened\". This behaviour termed reviewing, seemed to allow the s u b j e c t s time to r e f l e c t and contemplate the extent o f t h e i r experiences and i n t e g r a t e the past events and f e e l i n g s , with the present. Working through the past memories may have a s s i s t e d the s u b j e c t s i n accepting the r e a l i t y o f the present and the t h r e a t of f u t u r e l o s s . The m a j o r i t y o f s u b j e c t s viewed death of the spouse as c l o s e . T h e i r g r e a t e s t f e a r s during the f i r s t week were of c o m p l i c a t i o n s and of recurrence of another h e a r t attack f o r t h e i r p a r t n e r . They p e r c e i v e d t h i s time as c r i t i c a l and u n c e r t a i n and thus would l i e awake at n i g h t , r e h e a r s i n g or a n t i c i p a t i n g the worst t h a t might b e f a l l t h e i r p a r t n e r s . The s u b j e c t s ' behaviours of a n t i c i p a t i n g can be i n t e r p r e t e d i n l i g h t of Lindemann's t h i r d c h a r a c t e r i s t i c termed \" a n t i c i p a t i n g the modes of readjustment\". I n i t i a l l y , the subjects questioned whether t h e i r l i v e s would change i n the f u t u r e , and they acknowledged the changes t h a t had occurred i n t h e i r d a i l y r o u t i n e s w i t h i n the l a s t few days. As the p a t i e n t moved c l o s e r to d i s c h a r g e , the s u b j e c t s a n t i c i -pated the changes t h a t would occur i n t h e i r l i v e s and the readjustment t h a t these changes n e c e s s i t a t e d . A l l o f the s u b j e c t s agreed t h a t t h e i r partners would have to change t h e i r l i v e s with regard to work, s o c i a l a c t i v i t y and d i e t . Three quarters o f the s u b j e c t s feared and prepared themselves f o r the worst i n terms of t h e i r p a r t n e r s ' p h y s i c a l and p s y c h o l o g i c a l adjustment. Of the twelve s u b j e c t s , nine spoke s p e c i f i -c a l l y about the a n t i c i p a t e d changes t h a t would a f f e c t them. Over one h a l f of these s u b j e c t s feared the worst. The thoughts of the modes o f readjustment r e l a t e d to the i l l n e s s , not to the death of t h e i r 97 p a r t n e r s . The spouses feared the worst i n terms o f changes and upset i n t h e i r normal r o u t i n e s but they d i d not d i s c u s s readjustment t h a t might be n e c e s s i t a t e d by the partner's death. Although f e a r o f death was c e r t a i n l y on t h e i r minds i t may have been too p a i n f u l to e n t e r t a i n f o r any l e n g t h o f time. When the thought o f death was d i s c u s s e d i t was in r e l a t i o n to f e e l i n g s of h e l p l e s s n e s s , l o n e l i n e s s and dep r e s s i o n . The r e p o r t e d mood s t a t e s and somatic d i s t u r b a n c e s d e s c r i b e d i n t h i s acute phase approximated several of the a n t i c i p a t o r y g r i e f a c t i o n s d e s c r i b e d by Lindemann. In a d d i t i o n to c o r r o b o r a t i n g Lindemann's J f i n d i n g s , the r e a c t i o n s o f the su b j e c t s during t h i s c r i t i c a l p e r i o d o f the partner's i l l n e s s are s i m i l a r to the r e a c t i o n s d e s c r i b e d by other w r i t e r s who have focused s p e c i f i c a l l y on the stages or phases t h a t f o l l o w a major a n t i c i p a t e d or actual l o s s (Bowlby, 1961; Engel, 1962; Fink, 1967; Kubler-Ross, 1969; Parkes, 1972; Shontz, 1975). The sub-j e c t s ' i n i t i a l responses to l o s s i n t h i s study m i r r o r e d the r e a c t i o n s d e s c r i b e d during the i n i t i a l phase o r stage o f a major l o s s . G r i e f r e a c t i o n s were well d e s c r i b e d by many authors (Parkes, 1971; Royle, 1973; Skelton and Dominian, 1973; L a r t e r , 1976; Mayou, Foster and Williamson, 1978). T h e i r d e s c r i p t i o n o f l o s s resembled the i n i t i a l r e a c t i o n s d e s c r i b e d by the subjects o f t h i s study. The f i n d i n g s r e p o r t e d by Skelton and Dominian (1973) and Mayou, Fos t e r and Williamson (1978) were of p a r t i c u l a r r e l e v a n c e . These w r i t e r s s t u d i e d a r e p r e s e n t a t i v e sample of wives o f myocardial i n f a r c -t i o n p a t i e n t s during the acute \" h o s p i t a l i z a t i o n p e r i o d . Common r e a c t i o n s noted by both r e s e a r c h e r s were sleep and a p p e t i t e d i s t u r b -ances, anxiety and t e n s i o n . Skelton and Dominian (1973) reported 98 f e e l i n g s of l o s s and depression as well as other psychosomatic i l l n e s s r e l a t e d to the p a t i e n t ' s heart a t t a c k . The study r e p o r t e d spouses having many d i f f e r e n t f e e l i n g s , how-ever, depression was not commonly de s c r i b e d by the s u b j e c t s i n Phase I. This f i n d i n g was i n t e r e s t i n g , f o r i t d i f f e r e d from Skelton and Dominian's study, where reported and observable behaviours of depression were noted. Mayou, Foster and Williamsons' (1978) f i n d i n g s , on the other hand, noted depression as a l a t e r r e a c t i o n e v i d e n t i n the i n t e r v i e w s two months a f t e r h o s p i t a l d i s c h a r g e . The f i n d i n g s o f t h i s study concurred with t h i s view. In terms o f a c t i o n s v e r b a l i z e d by the s u b j e c t s , a noteworthy d i f f e r e n c e was found between the i n v e s t i g a t o r ' s data and the f i n d i n g s of Mayou, e t a l . These researchers noted the s u b j e c t s had a tendency to c l i n g to other people. None o f the s u b j e c t s i n the present study d e s c r i b e d what could be reported as c l i n g i n g behaviour. Six subjects f e l t f a m i l y and f r i e n d s were h e l p f u l w i t h o u t apparent dependency on t h i s a s s i s t a n c e . F i v e o f the sample p r e f e r r e d to be alone and d i d not a p p r e c i a t e c o n t a c t at t h i s time as i t was a busy t h i n k i n g time and they d e s i r e d s o l i t u d e . There seemed to be a v a r i a t i o n i n the degree to which f r i e n d s , f a m i l y , doctors and nurses were repor t e d as h e l p f u l by the spouses. F u r t h e r , the spouses r a r e l y sought i n f o r m a t i o n from the i n v e s t i g a t o r . Although the m a j o r i t y o f s u b j e c t s i n d i c a t e d a need f o r i n f o r m a t i o n , i t appeared that the s t r u c t u r e d c a r d i a c teaching program met t h e i r needs during t h i s e a r l y phase. The p e r i o d . o f r e a c t i n g to the event was d e s c r i b e d as a l o n e l y time. The s u b j e c t s only wanted to be with t h e i r p a r t n e r s and o f t e n no 99 one e l s e c o u l d s u b s t i t u t e . As one spouse s t a t e d , \" I f I c a n ' t be with (my wife) then I'd j u s t r a t h e r be by myself.\" This behaviour i s s i m i l a r to t h a t d e s c r i b e d by Marris (1968) i n h i s study o f the e f f e c t o f bereavement on London widows. He found the bereaved o f t e n tend to devalue a l l r e l a t i o n s h i p s except the one which has been l o s t , so t h a t i n s t e a d of t u r n i n g to c h i l d r e n , f a m i l y or f r i e n d s the widow may become almost i n d i f f e r e n t to them. Although the myocardial i n f a r c t i o n spouses i n t h i s study seemed u n i n t e r e s t e d i n s o c i a l c o n t a c t they d i d , i n f a c t , yearn f o r a t t e n t i o n and support as evidenced by t h e i r eager w i l l i n g n e s s to t a l k to the i n v e s t i g a t o r . One woman de s c r i b e d the r e s e a r c h e r as a \" c a r i n g o u t s i d e r \" . Although the researcher was concerned about being i n t r u s i v e a t a time o f g r i e f , these i n d i v i d u a l s r e p o r t e d t h a t the research was very h e l p f u l . The subjects had a great need f o r v e n t i l a . t i o n . This need i s well documented i n the l i t e r a t u r e (Lindemann, 1944; Glaser and S t r a u s s , 1965; Parkes, 1971; Hampe, 1975). Dracup and Breu found a s i m i l a r r e a c t i o n i n i n t e r v i e w i n g spouses of c r i t i c a l l y i l l c a r d i o v a s c u l a r p a t i e n t s . They found the spouses expressed g r a t i t u d e f o r having the o p p o r t u n i t y to share t h e i r f e e l i n g s with an o b j e c t i v e , empathic person--a person o u t s i d e the f a m i l y u n i t \u00E2\u0080\u0094 i n which a l l of the members were sharing t h e i r anguish. The researchers b e l i e v e d the b e n e f i t s of a d d i t i o n a l support and an oppor-t u n i t y to v e n t i l a t e t h e i r r e a c t i o n s outweighed the r i s k of psycho-l o g i c a l trauma. Parkes (1971) found a s i m i l a r r e a c t i o n when he undertook a l o n g i t u d i n a l study of the r e a c t i o n s of London widows. Although the widows of t e n withdrew from s o c i a l c o n t a c t , they welcomed 100 the i n v e s t i g a t o r ' s study. I n i t i a l l y Parkes had some m i s g i v i n g s about the study, f o r he d i d not wish to i n t r u d e upon the widow's g r i e f and cause her unnecessary p a i n . He found, however, the o p p o s i t e : On the c o n t r a c t , the m a j o r i t y seemed g r a t e f u l f o r the o p p o r t u n i t y to t a l k f r e e l y about the d i s t u r b i n g problems and f e e l i n g s t h a t preoccupied them ... she seemed to f i n d the i n t e r v i e w t h e r a p e u t i c ... I had no sense o f i n t r u s i o n a f t e r the f i r s t few minutes o f the i n i t i a l c o n t a c t . (Parkes, 1971, p. 35.) The Elements of Loss Both the l i t e r a t u r e and t h i s study found t h a t an a n a l y s i s o f the l o s s process produced some common elements or c h a r a c t e r i s t i c s . From the comments and observed behaviours of the spouses i t was ev i d e n t t h a t the elements of l o s s were r e l a t e d to the per c e p t i o n o f the event i n time. The l o s s was a sudden, traumatic event s i n c e the heart attack was unexpected. The h e a r t a t t a c k had oc c u r r e d but was d e s c r i b e d by the spouses i n three separate time frames. They reviewed what had happened, d i s c u s s e d the l o s s i n terms o f the present consequences and a n t i c i p a t e d l o s s f o r the f u t u r e . In p a r t i c u l a r , the event had a strong f u t u r e and a n t i c i p a t o r y q u a l i t y . The su b j e c t s focused more on the threatened or a n t i c i p a t e d l o s s o f t h e i r p a r t n e r . I t was a c r i t i c a l time f o r the s u b j e c t s with the f e a r o f t h e i r partner's death looming as a formidable l o s s i n an un c e r t a i n f u t u r e . The heart attack a l s o p r e c i p i t a t e d the r e c a l l o f oth e r l o s s experienced i n the past which seemed to o f f e r a frame of reference f o r the spouses. 101 Loss was a l s o conceived as two events o c c u r r i n g simultaneously. From the o b j e c t i v e eye of the i n v e s t i g a t o r the heart a t t a c k was viewed as an observable concrete event: an actual l o s s t h a t had c l e a r l y a l t e r e d the b i o l o g i c a l f u n c t i o n i n g of the he a r t . For the spouse e x p e r i e n c i n g the same event the l o s s was a very s u b j e c t i v e one. The Meaning of Loss The f u l l r e a l i t y o f what had happened d i d not penetrate the consciousness o f the s u b j e c t s a t f i r s t . The r e a l i t y o f any c a t a -s t r o p h i c l o s s producing g r i e f i s g e n e r a l l y too overwhelming to pe r c e i v e a c c u r a t e l y and to i n t e g r a t e f u l l y . That which had occurred was incon-gruent with the r e a l i t y p r e v i o u s l y known to the su b j e c t s ( C a r l s o n , 1978). Most o f the s u b j e c t s d e s c r i b e d t h e i r f e e l i n g s o f shock and d i s b e l i e f while t h e i r r e a c t i o n s r e v e a l e d a gradual development of awareness as they began to understand and a t t a c h some meaning to the 1 oss. Although persons commonly go through the same stages or phases f o l l o w i n g a major l o s s , there are several d i f f e r e n c e s t h a t can occur i n t h i s passage. For example, an i n d i v i d u a l ' s \"timing\" may be d i f f e r e n t : one may move slowly o r r a p i d l y through phases, bypass a phase, or perhaps v a c i l l a t e between phases ( C a r l s o n , 1978; Roberts, 1978). Carlson developed t h i s p o i n t by saying t h a t g e n e r a l i z a t i o n s about personal experience and behaviour are useful only when one maintains a commitment to the understanding and acceptance o f i n d i v i d u a l v a r i a t i o n s ( C a r l s o n , 1978, p. 88). 102 Most of the spouses r e p o r t e d s i m i l a r behaviours during the i n i t i a l impact o f the i l l n e s s , however, two s u b j e c t s d i d not \" f i t \" the de s c r i b e d behaviours o f the group. Two women denied f e e l i n g any shock or numbness and r e p o r t e d f e e l i n g \" p r e t t y good and w e l l \" . T h e i r behaviours, as observed by the i n v e s t i g a t o r , were congruent with t h e i r r e p o r t e d f e e l i n g s t a t e s : they smiled f r e q u e n t l y , demonstrated good eye co n t a c t , and gestured a p p r o p r i a t e l y with nods and a c t i v e f a c i a l g e s t u r e s . They seemed res p o n s i v e and eager t o t a l k and d i s p l a y e d a mood of calm and optimism. One i n t e r p r e t a t i o n o f these r e a c t i o n s i s t h a t the spouses were a c t i v e l y denying t h e i r l o s s . For whatever reason, the l o s s was too p a i n f u l to encounter so the su b j e c t s used d e n i a l mechanisms to remove themselves e m o t i o n a l l y from the l o s s . This i n t e r p r e t a t i o n bears some v a l i d i t y , because i n the t h i r d and f o u r t h i n t e r v i e w , the su b j e c t s d i d r e p o r t the impact o f the he a r t a t t a c k as \" h i t t i n g them l a t e r \" and \"harder\" than they thought. The v i v i d d e s c r i p t i o n s o f t h e i r r e a c t i o n s a t t h i s time resembled the re p o r t e d r e a c t i o n s o f the other s u b j e c t s during phase one. The reasons f o r the d e n i a l , then r e s t e d on many f a c t o r s . These two women had s u f f e r e d r e c e n t major l o s s e s t h a t c o u l d have a f f e c t e d t h e i r r e a c t i o n s , a t t h i s time, to t h e i r p a r t n e r ' s h e a r t a t t a c k . One woman had almost \" l o s t \" her husband i n a s e r i o u s c a r ac c i d e n t . Although i t had been three y e a r s s i n c e the event, the woman co n s t a n t l y r e c a l l e d the i n c i d e n t i n d e t a i l and reassured h e r s e l f t h a t \" t h i s \" (heart a t t a c k ) was not as bad, and t h a t she was prepared t h i s time. S i m i l a r reassurance was echoed by the second woman, who had \"been through a number o f f a m i l y deaths r e c e n t l y \" . This experience 103 caused her to minimize the present event. She s t a t e d , \"I can cope, I can cope.\" Although the s u b j e c t s looked i n t o the past and to the f u t u r e , many of t h e i r thoughts focused on the present. T h e i r p h i l o s o p h i c a l b e l i e f s r e f l e c t e d a here-and-now stance. I t may have been too uncomfortable f o r the s u b j e c t s to p r o j e c t i n t o the f u t u r e when i t was such an uncer-t a i n and u n p r e d i c t a b l e time. Many o f the s u b j e c t s spoke about hope. Hope has been i d e n t i f i e d as a need r e l a t e d to the process o f a n t i c i p a -t o r y g r i e f . T h is need has been s t u d i e d i n r e l a t i o n to the threatened l o s s experienced by s i g n i f i c a n t o thers o f c r i t i c a l or t e r m i n a l l y i l l p a t i e n t s (Friedman, Choi d o f f and Hamburg, 1963; Futterman, Hoffman and Sabshin, 1972; Hampe, 1975; Dracup and Breu, 1978). To f e e l there i s hope was found to be the most s i g n i f i c a n t need i d e n t i f i e d by r e l a t i v e s o f c r i t i c a l l y i l l p a t i e n t s during the i n t e n s i v e care phase o f h o s p i t a l -i z a t i o n (Moulter and Captain, 1979). Korner (1970) d i s c u s s e s the coping value o f hope. She says the more u n c e r t a i n man i s , the more he needs a cushion of defense a g a i n s t h i s f e a r s and a n x i e t i e s . Not a l l the s u b j e c t s were ho p e f u l . Some of them took what c o u l d be d e s c r i b e d as a f a t a l i s t i c approach during t h i s c r i t i c a l time. T h i s approach i s d i f f i c u l t to i n t e r p r e t . Are the s u b j e c t s preparing f o r the worst? Are they a b s o l v i n g themselves? Does f a t a l i s m have coping value? A f a t a l i s t i c approach does tend to take the r e s p o n s i b i l i t y and perhaps f e a r out of the event. The l o s s i s e s s e n t i a l l y out of one's l o c u s o f c o n t r o l . Two s u b j e c t s i n d i c a t e d these b e l i e f s were o f long standing and t h i s was how they approached l i f e i n g e n e r a l . An i n t e r -e s t i n g f i n d i n g was t h a t three s u b j e c t s who held f a t a l i s t i c values could 104 not f i n d a reason f o r t h e i r p a r t n e r ' s heart a t t a c k . They c o u l d not a f f i x blame, so to speak, on the p a t i e n t , on r i s k f a c t o r s , or on themselves. A c o n j e c t u r e , a t t h i s p o i n t , i s t h a t perhaps the s u b j e c t s a c t i v e l y searched f o r some ex p l a n a t i o n and \"found\" a metaphysical or superordinate s t r u c t u r e as r e s p o n s i b l e . Somehow i t was j u s t meant to be. Not only were the spouses' p e r c e p t i o n s important i n regards to t h e i r thoughts and f e e l i n g s but a l s o s i g n i f i c a n t with t h e i r a c t i o n s The need to seek out support, or i n f o r m a t i o n was c o n t i n g e n t on a \" c r i t -i c a l t iming f a c t o r \" . If the timing was not r i g h t f o r the s u b j e c t s , he or she would not seek support or information and d i d not p e r c e i v e i t as h e l p f u l . One s u b j e c t f e l t h i s f a m i l y was h e l p f u l i n the f i r s t few days, but once the i n i t i a l impact had h i t , he p r e f e r r e d to be by him-s e l f , as he had \"a l o t to t h i n k about\". Im summary, the f i n d i n g s i n d i c a t e d the s u b j e c t s responded to t h e i r own perceptions o f the l o s s , not the o v e r t r e a l i t y as observed by an \" o u t s i d e r \" . T h e i r thoughts, f e e l i n g s and a c t i o n s d e s c r i b e d a process they experienced as they attempted to understand and a t t a c h meaning to the l o s s . Phase II Reaction to the Event Reactions to l o s s The f i n d i n g s i n t h i s phase d e s c r i b e d a s h i f t i n the s u b j e c t s ' d e s c r i p t i o n s of t h e i r r e a c t i o n s to the l o s s event. In b r i e f , the heightened thought processes decreased while the s u b j e c t s ' a c t i o n s i n c r e a s e d . This was a busy time f o r the s u b j e c t s , y e t i t was a l s o c h a r a c t e r i z e d as a more c e r t a i n p e r i o d , one i n which the s u b j e c t s had more c o n t r o l o v e r t h e i r p a r t n e r s ' l i v e s . T h i s c o n t r o l i s well i l l u s t r a t e d i n Vachon's (1978) study o f widows of men with c h r o n i c c a r d i o v a s c u l a r d i s e a s e . Vachon found t h a t the wives f e l t they played an a c t i v e r o l e i n h e l p i n g t h e i r husbands during the time o f i l l n e s s , she s t a t e d : These women f e l t t h a t i f they f e d t h e i r husbands r i g h t , helped them a l l e v i a t e t h e i r s t r e s s , made them c u t down a c t i v i t i e s , t h a t they wouldn't d i e (Vachon, 1978, p. 56). In c o n t r a s t t o the e a r l i e r phase, the m a j o r i t y o f s u b j e c t s appeared b r i g h t , r e s p o n s i v e and vo i c e d g r a t e f u l n e s s and optimism f o r the f u t u r e . Although f o u r s u b j e c t s complained of sle e p and a p p e t i t e d i s t u r b a n c e s with i n c r e a s e d f a t i g u e , t h e i r a f f e c t remained p o s i t i v e and they r e p o r t e d a calmer, more p o s i t i v e mood s t a t e . The u p l i f t i n mood can be i n t e r p r e t e d i n l i g h t o f the f a c t t h a t many s u b j e c t s a n t i c i p a t e d the worst w h i l e t o t h e i r d e l i g h t many o f the changes d i d not occur o r were not as tr a u m a t i c as a n t i c i p a t e d . The s u b j e c t s ' mood s h i f t may a l s o have r e f l e c t e d the mood of t h e i r p a r t n e r s . They had \"made i t \" through the f i r s t week at home. Although t h i s time was d e s c r i b e d as very s t r e s s f u l t h i n g s were s t a r t i n g to improve. T h i s upswing i n mood i s not well r e p o r t e d i n the l o s s l i t e r a t u r e . However, the eu p h o r i c \"we have made i t \" f e e l i n g i s s i m i l a r t o the euphoric response observed by Kimball (1969). In a study o f the post o p e r a t i v e behaviour o f c a r d i a c surgery p a t i e n t s a euphoric response was noted during the l a t e r convalescent p e r i o d o f h o s p i t a l i z a t i o n when the 106 c r i t i c a l stages o f t h e i r surgery had passed. Kimball i d e n t i f i e d the behaviours as c o n f i d e n t , b r i g h t , responsive and \"glad to be a l i v e \" . The r e s e a r c h e r has a l s o n o t i c e d a s i m i l a r behaviour i n her nursing experience while c a r i n g f o r c r i t i c a l l y i l l p a t i e n t s . Many i n d i v i d u a l s who have recovered from a l i f e t h r e a t e n i n g event do r e f l e c t on how lucky they are to be a l i v e . An i n f e r e n c e was drawn t h a t i n d i v i d u a l s who are threatened with the l o s s o f t h e i r l i v e s , or t h e i r loved ones, experience a response s i m i l a r to t h a t d e s c r i b e d by the s u b j e c t s i n t h i s study. The subjects reported t h i s time to be very busy. T h e i r \"watchdog or p r o t e c t o r \" behaviours i n v o l v e d h e c t i c schedules o f o r g a n i z i n g the household, f a m i l y and v i s i t o r s as well as monitoring t h e i r partners' d i e t , medications and a c t i v i t i e s . Many o f the s u b j e c t s had gained i n f o r m a t i o n about t h e i r partners' p r e s c r i b e d d i e t , medications and l e v e l o f a c t i v i t y from the s t r u c t u r e d i n - h o s p i t a l c a r d i a c teaching program. Two su b j e c t s however, seemed rather anxious about the d i e t planning. Cooking the r i g h t meals was perc e i v e d as very important and these women spent hours i n reading about and preparing low c h o l e s t e r o l d i e t s . One i n t e r p r e t a t i o n o f t h i s behaviour was t h a t the spouses viewed d i e t p r e p a r a t i o n as a f a m i l i a r role--one they had enacted f o r many y e a r s \u00E2\u0080\u0094 t h e y c o u l d perform i t w e l l . I t enabled them to p r o t e c t t h e i r partners i n a concrete f a s h i o n . However, the two sub j e c t s r e c e i v e d the same d i e t information as the r e s t o f the group, and t h e i r husbands' d i e t s were not d i f f e r e n t from those o f the other p a t i e n t s . What c o u l d e x p l a i n t h e i r preoccupation and anxiety over d i e t ? In re-examining the data, the rese a r c h e r found these subjects v e r b a l i z e d a 107 l o t o f g u i l t . They p e r c e i v e d themselves, i n p a r t , as r e s p o n s i b l e f o r the partner's h e a r t a t t a c k . They had cooked \" a l l the wrong t h i n g s \" . Thus, these f e e l i n g s o f g u i l t might have played a s i g n i f i c a n t r o l e i n c o n t r i b u t i n g to t h e i r behaviour. The Elements o f Loss In phase one the l o s s event was viewed by the su b j e c t s with a f u t u r e and a n t i c i p a t o r y p e r s p e c t i v e . The time frame changed i n the e a r l y discharge p e r i o d to focus more on the present. The event now had a l i f e o f three weeks. It was no longer seen as sudden or u n p r e d i c t -a b l e . As one s u b j e c t r e p o r t e d : \"Well, i t ' s (the heart attack) now three weeks o l d you know\". The s u b j e c t s found t h a t t h e i r a n t i c i p a t e d f e a r s of. recurrence and poor partner adjustment had not m a t e r i a l i z e d . T h e i r p a r t n e r s were c o n v a l e s c i n g well and the present and f u t u r e looked o p t i m i s t i c . The heart attack now seemed f a i r l y p r e d i c t a b l e and w i t h i n c o n t r o l . I n i t i a l l y the i l l n e s s or threatened l o s s o f t h e i r partners had a concrete observable q u a l i t y . The s u b j e c t s began to view the l o s s w i t h i n a wider context; the i n i t i a l l o s s expanded to i n c l u d e secondary l o s s e s , many of which were a b s t r a c t i n nature. Subjects i d e n t i f i e d l o s s they had experienced i n terms of t h e i r r o l e s , r e l a t i o n s h i p s and self-esteem. The i n i t i a l threatened l o s s o f t h e i r p a r t n e r s ' l i v e s had not occurred, now other l o s s was being r e a l i z e d by the s u b j e c t s . 108 The Meaning of Loss The s u b j e c t s ' perceptions of l o s s broadened i n t h i s phase and now encompassed three areas; the p a t i e n t , the couple and the spouse. Through the s u b j e c t s ' eyes, t h i s phase can best be d e s c r i b e d as the c l o s u r e o f the c r i t i c a l time o f t h e i r p a r t n e r s ' i l l n e s s . The s u b j e c t s c o u l d now allow themselves time to \"take a deep breath\" and say \"we have made i t \" . In the same b r e a t h , the s u b j e c t s began to focus more i n t r o s p e c t i v e l y on t h e i r l o s s . Some women g r i e v e d f o r t h e i r own time and independence. The added r o l e s and r e s p o n s i b i l i t i e s , i n c l u d i n g a l a c k of r e c o g n i t i o n f o r t h e i r e f f o r t s , caused them great concern. T h e i r own l o s s was only beginning to be f e l t . The euphoric s p i r i t tended to counter or de-emphasize t h e i r concerns and they admonished themselves f o r being so s e l f i s h when they f e l t they should have been g r a t e f u l f o r t h e i r partners' h e a l t h . It was a d i f f i c u l t time f o r the s u b j e c t s , a time o f t r a n s i t i o n . The meaning o f l o s s as experienced by the s u b j e c t s i n t h i s e a r l y post discharge p e r i o d i s i l l u s t r a t e d i n Figure 1. The meaning of l o s s cannot be comprehended by t a k i n g a narrow p e r s p e c t i v e and f o c u s i n g on o n l y one aspect o r l e v e l o f a l o s s . The meaning of l o s s as experienced by the s u b j e c t s now encompassed three d i f f e r e n t l e v e l s . There i s an e v i d e n t need to view l o s s i n t h i s t o t a l i t y i n order to c o n c e p t u a l i z e the phenomenon of l o s s . Phase III Impact of the Event (Group A) Reactions to Loss Many of the s u b j e c t s ' thoughts were e g o c e n t r i c i n f o c u s . These 109 1. P a t i e n t Focus C l o s u r e of a n t i c i p a t e d l o s s ... \"He i s a l i v e and welI and hasn't had another heart a t t a c k \" . ... \"I'm watching him and l o o k i n g a f t e r him\". 2. Couple Focus Loss as i t a f f e c t s us ... \"We have made i t ... we're working t o g e t h e r \" . ... \"Yeah l o t s of changes f o r us\". 3. P e r s o n a l - s e l f Focus Beginning of actual l o s s \"I miss my own time\" ... \"I do a l l the work and get no thanks\". ... \"I have my own l i f e t oo!\". Figure 1. The Meaning o f Loss 110 women viewed the l o s s from t h e i r own p e r s p e c t i v e . They continued to speak of t h e i r p r o t e c t o r r o l e s and e x t r a r e s p o n s i b i l i t i e s but a l s o began to v e r b a l i z e how many o f t h e i r thoughts were focused on themselves. The time had come f o r them to take a hard look at t h e i r l i v e s and t h e i r f u t u r e . The s u b j e c t s ' f e e l i n g s were heightened i n t h i s phase, s i m i l a r to the i n t e n s i t y d e s c r i b e d i n Phase I. In c o n t r a s t to the shock, numb-ness, a n x i e t y and t e n s i o n r e p o r t e d i n i t i a l l y the s u b j e c t s d e s c r i b e d a range of emotions: anger, b i t t e r n e s s , resentment, g u i l t and s e l f -reproach with depression the most commonly reported f e e l i n g . The m u l t i p l i c i t y of f e e l i n g s r e p o r t e d by the s u b j e c t s i n t h i s study i s well corroborated i n the research f i n d i n g s (Adsett and Bruhn, 1968; Skelton and Dominian, 1973; Harding and M o r e f i e l d , 1976; L a r t e r , 1976; Mayou, Foster and Williamson, 1978). In t h i s phase ambivalence surfaced again but i t was now more in t e n s e . The s u b j e c t s were angry and r e s e n t f u l y e t they admonished themselves f o r being so s e l f i s h and unkind. They could not come to terms with what they f e l t and what \"others\" expected them to f e e l . Anger and resentment were turned inward with r e s u l t a n t g u i l t and depression. The ambivalence experienced by the s u b j e c t s was s i m i l a r to the secondary emotional r e a c t i o n s i d e n t i f i e d by Peretz (1970). He d e s c r i b e d these ambivalent r e a c t i o n s as c o n f l i c t between f e e l i n g s t h a t an i n d i v i d u a l a n t i c i p a t e d and accepted with those he d i d not expect and c o u l d not accept. The subjects had d i f f i c u l t y d e a l i n g with t h e i r resentment and anger. They resented the e x t r a workload and demands placed on t h e i r I l l time y e t they f e l t g u i l t y i f they expressed these f e e l i n g s . Even i f they f e l t abused they would not speak out f o r f e a r o f u p s e t t i n g t h e i r partners and perhaps p r e c i p i t a t i n g another heart a t t a c k . Many wives f e l t i t wasn't \" r i g h t \" to complain, a f t e r a l l , weren't they the healthy ones? As one woman s t a t e d : \" I t ' s catch-22, you are damned i f you do, and damned i f you don't.\" Poor communication, and l i t t l e evidence of sharing on a f e e l i n g l e v e l seemed to e x i s t between the p a t i e n t s and t h e i r spouses. This f i n d i n g was a l s o reported in recent s t u d i e s (Adsett and Bruhn, 1968; Harding and M o r e f i e l d , 1976; L a r t e r , 1976). The s u b j e c t s had an obvious need to v e n t i l a t e t h e i r f e e l i n g s . Although t h i s need was reported i n the r e c e n t r e s e a r c h (Hampe, 1975; Dracup and Breu, 1978; Moulter and Captain, 1979), i t was not always met by h e a l t h p r o f e s -s i o n a l s . At a time when the s u b j e c t s were most d i s t r a u g h t , they f e l t they had no one to turn to other than a few c l o s e f a m i l y or f r i e n d s . The s u b j e c t s p e r c e i v e d t h a t \"no one r e a l l y understood\". Due to the l i m i t a t i o n s of the study i t was d i f f i c u l t to c o n j e c t u r e why the s u b j e c t s i n such obvious need d i d not speak or reveal t h e i r f e e l i n g s . There could be many reasons why the spouses grew apart from t h e i r p a r t n e r s . Several r e p o r t e d not speaking out f o r f e a r of p r e c i p i -t a t i n g a heart a t t a c k ; others d e s i r e d to \" p r o t e c t \" t h e i r p a r t n e r s . Some sub j e c t s f e l t t h e i r f e e l i n g s were s o c i a l l y unacceptable and i t j u s t wasn't r i g h t to d i s c u s s them. Another i n t e r p r e t a t i o n was t h a t the p r i o r communication p a t t e r n s o f the couples were non.-sharing i n nature. The Elements o f Loss The nature of the l o s s experienced by the spouses continued to broaden i n t h i s phase as the i n i t i a l l o s s p r e c i p i t a t e d many secondary l o s s e s (e.g. l o s s of own time, independence, r o u t i n e s ) and threatened f u t u r e a d d i t i o n a l l o s s e s ( f e a r of p a r t n e r s ' d r i v i n g and r e t u r n i n g to work). Many of the s u b j e c t s r e a c t i o n s up to t h i s p o i n t were i n response to the threatened l o s s o f t h e i r p a r t n e r . This l o s s can be c h a r a c t e r -i z e d as o v e r t . It was concrete and e a s i l y r e c o g n i z a b l e , and as such, was more r e a d i l y understood and accepted by the s u b j e c t s e x p e r i e n c i n g the l o s s or to those o u t s i d e viewing the l o s s . The l o s s d e s c r i b e d by the s u b j e c t s i n phase two and more i n t h r e e , was a d i f f e r e n t c h a r a c t e r . I t spoke more to the l o s s of p e r s o n a l l y s i g n i f i c a n t needs and v a l u e s . This l o s s was more c o v e r t i n nature and was, t h e r e f o r e , not as e a s i l y i d e n t i f i e d or understood. Regardless of the c o v e r t nature of the l o s s , the g r i e f r e a c t i o n s experienced by the spouses a t t h i s time were very heightened, s i m i l a r to the i n t e n s i t y of f e e l i n g s d e s c r i b e d i n phase one. The Meaning of Loss T h i s phase was s i m i l a r to the acknowledgement stage d e s c r i b e d i n the l i t e r a t u r e (Bowlby, 1961; Engel, 1962; Kubler-Ross, 1969; Parkes, 1972). G l i c k , Weiss and Parkes (1974) described t h i s time as the g r i e v i n g phase. The i n d i v i d u a l was confronted with the d a i l y r e a l i t i e s of l o s s and the f u l l impact of the l o s s was now t r u l y f e l t . At t h i s time the i n i t i a l l o s s expanded to i n c l u d e numerous secondary l o s s e s . 113 While profound sadness and depression are dominant during t h i s phase, the i n d i v i d u a l may experience numerous f e e l i n g s and v a c i l l a t e between these s t a t e s . There are many v a r i a b l e s t h a t c o u l d have i n f l u e n c e d the spouses' perceptions a t t h i s time. Robinson (1974) s t a t e d t h a t past e x p e r i e n c e s , successes, f a i l u r e s , r e l a t i o n s h i p s and standards can mold a person's p e r c e p t i o n s and r e a c t i o n s t o t h e i r l o s s . In t h i s group a l l but one of the s u b j e c t s were non-working women. The meaning of the l o s s v a r i e d s i g n i f i c a n t l y f o r these women compared to the working women. The non-working women seemed p s y c h o l o g i c a l l y more dependent on t h e i r p a r t n e r s . Many o f t h e i r v a l u e s , b e l i e f s , and sense o f worth were apparently bound i n e x t r i c a b l y to t h e i r husbands. One co u l d i n f e r from these f i n d i n g s t h a t the degree t o which one's s e l f concept was t i e d o r mi r r o r e d to a loved one would have an a f f e c t on the l o s s experienced. An i n t e r e s t i n g p o i n t i s t h a t the one working woman i n the group had been coping well with her husband's i l l n e s s u n t i l the l a s t i n t e r -view. She d e s c r i b e d h e r s e l f a t t h a t time, as having a \"setback\", because of a very r e c e n t l o s s o f a c l o s e f a m i l y member. A f a c t o r t h a t can i n f l u e n c e an i n d i v i d u a l ' s c a p a c i t y t o adapt to a l o s s i s a concur-r e n t l o s s ( P e r e t z , 1970; Schoenberg, 1970). T h i s f a c t o r , then, could have i n f l u e n c e d t h i s s u b j e c t ' s r e a c t i o n s a t t h i s time. The s u b j e c t s g r i e v e d f o r t h e i r sense o f s e l f , t h e i r i n t e g r i t y , worth and the normalcy o f t h e i r l i v e s . Depression was most commonly repor t e d . Depression was f e l t most i n t e n s e l y by the two youngest s u b j e c t s . Both women had ad o l e s c e n t c h i l d r e n a t home. T h e i r r e s p o n s i -b i l i t i e s were e n d l e s s : home, garden, p e t s , a d o l e s c e n t s , v i s i t o r s and 114 s i c k husbands. As one woman e x p l a i n e d , \"you have to be the p i v o t p o i n t f o r everyone, so the more people i n v o l v e d , the more d i f f i c u l t i t becomes\". When one c o n s i d e r s the q u a l i t y and q u a n t i t y o f change t h a t the younger su b j e c t s experienced, i t i s not d i f f i c u l t to understand the s e v e r i t y o f t h e i r g r i e f r e a c t i o n s . Goldston (1962) confirmed t h i s view, and st a t e d t h a t the gre a t e r the changes and s h i f t s a f a m i l y was fo r c e d to make as a r e s u l t o f a heart a t t a c k , the g r e a t e r becomes the s t r e s s s i t u a t i o n w i t h i n the f a m i l y . The r e l a t i o n s h i p between age and s e v e r i t y o f g r i e f r e a c t i o n s found i n t h i s study was c o r r o b o r a t e d by Skelton e t a l . (1973). These re s e a r c h e r s found t h a t the severe g r i e f r e a c t i o n s were more common among younger w i v e s \u00E2\u0080\u0094 l e s s than 45 ye a r s of age--than among o l d e r wives. One cannot examine the spouse i n i s o l a t i o n . The r e a c t i o n s o f the p a t i e n t and the other f a m i l y members are s i g n i f i c a n t to c o n s i d e r . How the p a t i e n t p e r c e i v e d the l o s s would indeed a f f e c t the s u b j e c t . Because o f the commonalities i n the l o s s experience one c o u l d expect t h a t the p a t i e n t experienced s i m i l a r thoughts and f e e l i n g s . If the phenomenon of l o s s i s viewed as a process, however, the couples may have been at d i f f e r e n t phases at d i f f e r e n t times. The meaning of l o s s f o r each person guided t h e i r own l o s s journey. It was p o s s i b l e t h a t the l o s s experienced by both p a t i e n t and spouse was so intense and eg o c e n t r i c t h a t they were unable t o look o r f e e l beyond themselves. The data i n t h i s study corroborated the increased d i s t a n c e between the couples i n terms o f communication t h a t may have l i m i t e d s h a r i n g o f t h e i r thoughts and f e e l i n g s . 115 PHASE III Impact o f the Event (Group B) Reactions to Loss The r e a c t i o n s to l o s s of the remaining s u b j e c t s , two women and one man, were d i f f e r e n t and have been d e s c r i b e d s e p a r a t e l y as Group B. These s u b j e c t s i n c o n t r a s t to Group A were i n good s p i r i t s , content with t h e i r p a r t n e r s and themselves. T h i s contentment touched on a l l p a r t s of t h e i r l i v e s . They were pleased with t h e i r p a r t n e r s ' a d j u s t -ment and seemed g r a t e f u l f o r what they had accomplished and how they managed together as a team. The s u b j e c t s looked forward to the f u t u r e with optimism. Many of the r e a c t i o n s d e s c r i b e d by the s u b j e c t s i n t h i s phase are s i m i l a r to the acceptance and adaptation phase d e s c r i b e d i n the l i t e r a -t u r e when an i n d i v i d u a l copes s u c c e s s f u l l y with l o s s (Bowlby, 1961; Engel, 1962; Kubler-Ross, 1969; Parkes, 1972; Shontz, 1975). This phase i s c h a r a c t e r i z e d by a gradual move forward to organize one's l i f e and i n t e g r a t e the r e a l i t i e s o f l o s s . Often the i n d i v i d u a l experiences a decrease i n anxiety as hope takes the place of hopelessness. Instead of f o c u s i n g on what has been l o s t , a t t e n t i o n i s r e d i r e c t e d to the present and f u t u r e . The s u b j e c t s i n t h i s group seemed more accepting o f t h e i r l o s s . They viewed the b r i g h t e r more p o s i t i v e s i d e o f the changes t h a t had d i s r u p t e d t h e i r l i v e s . T h e i r comments were honest and r e a l i s t i c . L i f e had been very d i f f i c u l t f o r them and they were aware of some hard and u n c e r t a i n times ahead. Yet the o v e r a l l f e e l i n g was one o f \"we have made i t , as a couple\", and i t seemed these p o s i t i v e gains r e i n f o r c e d t h e i r adaptive behaviour. The l i f e - t h r e a t e n i n g nature o f the i l l n e s s 116 a l s o prompted a r e v a l u a t i o n o f the values and goals i n t h e i r r e l a t i o n s h i p . There was a r e a l i z a t i o n f o r these couples t h a t t h e i r time together was not u n l i m i t e d . Although i t may appear f o r t u i t o u s , t h i s group was aware o f the need f o r hard work. They a l s o knew t h e i r l i v e s would never r e t u r n to what they had before the heart a t t a c k . This p o i n t was emphasized by Carlson (1978). She s t a t e d t h a t acceptance and adaptation do not imply a 100 percent r e t u r n to the p r e - l o s s s t a t e . A person may never completely get over a major l o s s . Healthy adaptive behaviour may be, i n f a c t , p i c k i n g up the pieces and t r y i n g to make the best o f the s i t u a t i o n . The Elements of Loss O v e r t l y the l o s s had s i m i l a r c h a r a c t e r i s t i c s to those d e s c r i b e d by the subjects i n Group A. It was an event t h a t had s t a r t e d as a b i o l o g -i c a l l o s s and grown to i n c l u d e psychosocial l o s s f o r both the p a t i e n t and spouse. In c o n t r a s t with Group A s u b j e c t s , the time frame of l o s s was d i f f e r e n t f o r Group B s u b j e c t s . Group A s u b j e c t s focused very much on the present, overwhelmed with the l o s s of normalcy i n t h e i r l i v e s and they feared f u t u r e a d d i t i o n a l l o s s . For the Group B s u b j e c t s the l o s s at t h i s time was seen more i n r e t r o s p e c t . Time had pushed the l o s s away. It was seen as a past event, an event t h a t had changed t h e i r l i v e s f o r the p o s i t i v e . 117 The Meaning of Loss These s u b j e c t s d i d not appear to turn inward and view the l o s s from an e g o c e n t r i c f o c u s , and they d i d not seem to g r i e v e f o r l o s s o f s e l f . Many o f t h e i r comments r e f l e c t an \"us\" o r couple f o c u s . There are several f a c t o r s to c o n s i d e r t h a t c o u l d shed some l i g h t on why these i n d i v i d u a l s r e a c t e d so d i f f e r e n t l y to t h e i r l o s s . In c o n t r a s t to the dependence e v i d e n t i n the s u b j e c t s ' r e l a t i o n s h i p s i n Group A, the r e l a t i o n s h i p s o f Group B c o u l d be d e s c r i b e d as interdependent. The l a t t e r leaned on each o t h e r : the balance between the dependence and independence was comfortable. They shared t h e i r f e a r s and concerns and worked out the changes i n r o l e s and r e s p o n s i b i l i t i e s . T h e i r r o u t i n e s were d i s r u p t e d but they d i d not p e r c e i v e the changes as overwhelming. From an o b j e c t i v e viewpoint, t h e i r l i v e s were not d i s r u p t e d as g r e a t l y as those of some o f the Group A s u b j e c t s . Another f a c t o r to c o n s i d e r was t h a t these l a t t e r i n d i v i d u a l s were employed and were not home during the day to worry over t h e i r p a r t n e r s . Apparently they d i d not see themselves as dependent on t h e i r partners because v a l i d a t i o n o f t h e i r v a l u e s , worth and a b i l i t i e s was a l s o gained from t h e i r work. L a r t e r (1976) found that the degree of m a r i t a l accord was an important v a r i a b l e i n examining the impact o f i l l n e s s on wives o f myocardial i n f a r c t i o n p a t i e n t s . Although i t i s d i f f i c u l t to i n f e r from the present data, i t seems Group B couples had open and s h a r i n g communication p a t t e r n s . They f e l t t h a t the heart attack had acted as a c a t a l y s t and had improved t h e i r communication p a t t e r n s g r e a t l y . 118 Previous l i f e experiences can a s s i s t an i n d i v i d u a l i n d e a l i n g with a l o s s , by h e l p i n g to develop a r e p e r t o i r e of coping mechanisms which can be used i n f u t u r e adjustments. The male s u b j e c t i n t h i s group c e r t a i n l y agreed t h i s was the case with h i s l o s s . He f e l t he had coped well with the event because o f a previous \"experience\". He had been i n j u r e d during the war; h i s long and r e c u r r i n g i l l n e s s had caused him to be bed-bound f o r months a t a time. He f e l t both he and h i s wife had experienced many changes i n t h e i r l i v e s , and had always managed to come through i n the end. He approached t h i s r e c e n t l o s s with a p o s i t i v e a i r and some workable ways of coping. Summary The l o s s experienced by the spouses of myocardial i n f a r c t i o n p a t i e n t s was d e s c r i b e d i n t h i s chapter w i t h i n a phenomenological p e r s p e c t i v e . In each phase the nature of the l o s s experience was unique. The l o s s event, the per c e p t i o n s o f l o s s and the r e a c t i o n s to l o s s d e f i n e d the process i n which the s u b j e c t s d e a l t with l o s s . The i n i t i a l l o s s event expanded i n depth and breadth to impact s i g n i f i -c a n t l y on the spouse. The heart attack could now be viewed w i t h i n the t o t a l i t y of the phenomenon o f l o s s . 119 CHAPTER 6 SUMMARY, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS Th i s study was designed to provide i n s i g h t i n t o understanding the event o f a myocardial i n f a r c t i o n w i t h i n the c o n t e x t o f the phenomenon of l o s s . An overview o f the study i s presented i n t h i s chapter followed by the a r t i c u l a t i o n o f a framework, based on the l i t e r a t u r e and the f i n d i n g s , which r e l a t e s the concept o f l o s s to the experience of spouses o f myocardial i n f a r c t i o n p a t i e n t s . In a d d i t i o n , i m p l i c a -t i o n s and recommendations f o r nursing education, nursing p r a c t i c e and f u r t h e r research are d e l i n e a t e d . Overview of the Study T h i s e x p l o r a t o r y study examined the phenomenon of l o s s as expressed by the spouses o f myocardial i n f a r c t i o n p a t i e n t s . The pur-pose of the study was to d e s c r i b e the thoughts, f e e l i n g s , a c t i o n s and observable behaviours o f the spouses from the i n i t i a l impact o f i l l n e s s to s i x weeks post myocardial i n f a r c t i o n and to develop a framework, based on the l i t e r a t u r e , which r e l a t e d the concept o f l o s s to the experience o f spouses o f M.I. p a t i e n t s . The study was conducted with a convenience sample of 12 spouses, ten women and two men, whose partners had experienced t h e i r f i r s t myocardial i n f a r c t i o n . Using a semi-structured i n t e r v i e w guide with open-ended que s t i o n s , the i n v e s t i g a t o r interviewed each s u b j e c t , four times, from day three to day 52 o f the partner's h e a r t a t t a c k . This p e r i o d covered the time o f the i n i t i a l impact o f i l l n e s s to 120 approximately s i x weeks post myocardial i n f a r c t i o n . The f i r s t i n t e r -view was scheduled w i t h i n 96 hours o f the heart a t t a c k and the second i n t e r v i e w f o l l o w e d d u r i n g week two o f the p a t i e n t ' s h o s p i t a l i z a t i o n . The t h i r d and f o u r t h i n t e r v i e w s were scheduled f o r one and three weeks post discharge o f the p a t i e n t . The i n t e r v i e w s ranged from 12 to 75 minutes, with an average time of 35 minutes. Each i n t e r v i e w covered th r e e content areas: the thoughts, f e e l i n g s , a c t i o n s o f the spouses. Broad open-ended questions were used to e l i c i t data on the spouses' thoughts, f e e l i n g s and a c t i o n s . During the i n t e r v i e w the i n v e s t i g a t o r observed the verbal (type, q u a l i t y , c h a r a c t e r i s t i c s o f speech, focus of c o n v e r s a t i o n ) and non-verbal ( a c t i v i t y , eye c o n t a c t , body language, appearance) behaviours o f the spouses. An e m p i r i c a l i n d u c t i v e approach was used as the methodology f o r t h i s study. Data coding and a n a l y s i s were approached using the constant comparative method, an i n d u c t i v e method o f d i s c o v e r i n g grounded theory developed by Glaser and Strauss (1967). The f i n d i n g s rev e a l e d t h a t the spouses experienced behaviours i n response to l o s s t h a t were common and formed a p a t t e r n through time. Three d i s t i n c t phases were i d e n t i f i e d : Phase 1 the event and i n i t i a l spousal response; Phase 2 r e a c t i o n to the event; Phase 3 impact of the event. The phases were d e s c r i b e d f u r t h e r i n l i g h t o f the c o n s t r u c t s formu-l a t e d from the l i t e r a t u r e review: (1) the r e a c t i o n s to l o s s ; (2) the elements o f l o s s ; (3) the meaning o f l o s s . Phase I covered the h o s p i t a l i z a t i o n p e r i o d o f the p a t i e n t . T h i s phase was c h a r a c t e r i z e d by heightened thought processes. Many of the spouses' thoughts were p a t i e n t - o r i e n t e d and focused on the a n t i c i p a t e d 121 l o s s o f t h e i r p a r t n e r through c o m p l i c a t i o n s o r occurrence o f another heart a t t a c k . The s u b j e c t s perceived t h i s time as c r i t i c a l and uncer-t a i n while the r e a l i t y o f the l o s s was beginning to penetrate i n t o t h e i r awareness. T h e i r r e a c t i o n s d e s c r i b e d the process o f understand-ing and a t t a c h i n g meaning to the l o s s . The second phase covered the e a r l y discharge p e r i o d o f the p a t i e n t . This phase was c h a r a c t e r i z e d by decreased t h i n k i n g and i n c r e a s e d a c t i o n s r e l a t e d to p r o t e c t o r or c o n t r o l l e r a c t i v i t i e s . The present and f u t u r e were viewed with more p r e d i c t a b i l i t y and optimism. The s u b j e c t s began to view the l o s s w i t h i n a wider c o n t e x t as t h e i r p e r c e p t i o n s o f l o s s encompassed three areas; the p a t i e n t , the couple and the spouse. Since the threatened l o s s o f t h e i r p a r t n e r ' s l i v e s had not o c c u r r e d , o t h e r l o s s was now being r e a l i z e d by the s u b j e c t s i n terms o f r o l e s , r e l a t i o n s h i p s and self-esteem. Phase I I I d e s c r i b e d the impact o f the event f o r the spouses. Two d i s t i n c t p a t t e r n s o f behaviours were i d e n t i f i e d i n t h i s phase. Group A f i n d i n g s comprised one p a t t e r n o f r e a c t i o n s f o r seven o f the s u b j e c t s . D i f f e r e n t r e a c t i o n s were d e s c r i b e d by the remaining three s u b j e c t s i n the Group B f i n d i n g s . The nature o f the l o s s f o r the Group A s u b j e c t s continued to broaden to i n c l u d e many secondary l o s s e s f o r the spouses (e.g. l o s s o f time, independence, normalcy o f r o u t i n e s ) and the threatened f u t u r e a d d i t i o n a l l o s s e s ( f e a r o f p a r t n e r s d r i v i n g and r e t u r n i n g to work). The spouses viewed the l o s s from an e g o c e n t r i c f o c u s . Ambivalent f e e l i n g s were heightened i n t h i s phase. The s u b j e c t s f e l t angry and r e s e n t f u l over t h e i r personal l o s s experiences y e t expressed g u i l t and depression over t h e i r \" s e l f i s h , unkind\" 122 thoughts. In c o n t r a s t , the Group B s u b j e c t s d i d not seem to view the l o s s from an e g o c e n t r i c f o c u s . They were i n good s p i r i t s , content with t h e i r p a r t n e r s and themselves. Many of t h e i r r e a c t i o n s r e f l e c t e d an \"us\" or couple f o c u s . The l o s s was viewed as a past event, an event t h a t had changed t h e i r l i v e s f o r the p o s i t i v e . They looked forward t o the f u t u r e with optimism. A Loss Framework The f i n d i n g s i n t h i s study s t r o n g l y support the use of a l o s s framework f o r a s s e s s i n g the r e a c t i o n s o f spouses who are threatened with the death o f t h e i r p a r t n e r . From the l i t e r a t u r e and the research f i n d i n g s of t h i s study s e v e r a l c o n s t r u c t s were i d e n t i f i e d t h a t r e p r e s e n t e d the major s t r u c -t u r e s of a l o s s framework f o r spouses of myocardial i n f a r c t i o n p a t i e n t s . The process of l o s s f o r the spouses began with the i n i t i a l l o s s e v e n t \u00E2\u0080\u0094 t h e h e a r t a t t a c k . The i l l n e s s was a stimulus which p r e c i p -i t a t e d a s e r i e s o f events t h a t became p a r t o f the phenomenon of l o s s . From the i n i t i a l stimulus the spouses moved on to p e r c e i v e and to a t t a c h meaning to the l o s s . The elements o f l o s s d e s c r i b e d i n t h i s study shaped the nature of the l o s s e x p e r i e n c e . In a d d i t i o n , many i n d i v i d u a l v a r i a b l e s can be c o n s i d e r e d as i n f l u e n c i n g the s u b j e c t i v e meaning of l o s s f o r each spouse. Loss was a l s o d e s c r i b e d i n terms of the the behavioural responses t h a t f ollowed the p e r c e p t i o n o f the l o s s event. The thoughts, f e e l i n g s and a c t i o n s d e s c r i b e d by the spouses were the three main c a t e g o r i e s of behaviour corresponding to the p s y c h o l o g i c a l , emotional and 123 p h y s i o l o g i c a l d i s t u r b a n c e s found i n the l i t e r a t u r e . Often the spouses e x h i b i t e d a complex combination of a l l three c a t e g o r i e s o f r e a c t i o n s to l o s s . Another important c o n s t r u c t d e s c r i b e d i n the l i t e r a t u r e and i n t h i s study was the concept o f phases o f l o s s . In t h i s study, the spouses' behaviours were s i m i l a r to one another and formed a p a t t e r n through time. The p a t t e r n o f behaviours comprised t h r e e d i s t i n c t phases. Although the \" l a b e l l i n g \" of the phases i n t h i s study d i f f e r e d from t h a t o f the l i t e r a t u r e i t was evident t h a t the process or sequence of a d aptation was apparently the same. The three phases d e s c r i b e d the process i n which the spouses d e a l t with l o s s . The l o s s l i t e r a t u r e was h e a v i l y laden with the word \"process\". Authors have not d e f i n e d o r d e s c r i b e d t h i s process i n i d e n t i c a l terms. For a n a l y t i c a l purposes, w r i t e r s have taken apart the concept o f l o s s and given i t v a r i o u s l a b e l s , stages o r phases but they have neglected to put i t back together again. This \"Humpty Dumpty\" approach r e s u l t s i n a f r a c t u r e d concept o f l o s s , frozen i n time, and n e g l e c t f u l o f the actual experience of l o s s . Loss i s not a s e r i e s of a r r i v a l s but r a t h e r a journey. It i s a process t h a t i n d i v i d u a l s become p a r t of i n an attempt to r e s t r u c t u r e l i f e a f t e r a major d i s r u p t i o n . Process i m p l i e s c o n t i n u i t y or movement. It i s dynamic, purposeful and has an element of time. Based on the f i n d i n g s from t h i s study a framework of l o s s evolved based on a phenomenological p e r s p e c t i v e . Loss was seen as a process experienced from the i n i t i a l event or stimulus to the s u c c e s s f u l or unsuccessful r e s o l u t i o n of the l o s s . On one l e v e l l o s s was seen as the 124 i n i t i a l event t h a t p r e c i p i t a t e s the i n d i v i d u a l going through the p e r c e i v i n g and a t t a c h i n g o f meaning to l o s s . On another l e v e l , l o s s was the sequence o f g r i e f r e a c t i o n s experienced i n response to the l o s s event. These a c t i v i t i e s were viewed as interwoven or o v e r l a p p i n g , l i k e a matrix. The v e r t i c a l threads d e s c r i b e d the r e a c t i o n s i n response t o l o s s while the h o r i z o n t a l threads represented the meaning of l o s s f o r the spouse. A process o f l o s s paradigm was i n c l u d e d to i n d i c a t e the framework of l o s s f o r spouses o f myocardial i n f a r c t i o n p a t i e n t s (see Figure 2). Imp!ications Nursing P r a c t i c e Nurses are c o n t i n u a l l y i n t e r a c t i n g with p a t i e n t s and spouses who have experienced major l o s s e s . The nurse can perform a c r i t i c a l r o l e i n preventing or l e s s e n i n g the impact of l o s s . The r e s u l t s of t h i s study p o i n t s t r o n g l y to the importance o f a s s e s s i n g the actual and p o t e n t i a l l o s s e s o f the spouses i n understanding the i n d i v i d u a l ' s perception of the l o s s . Armed with t h i s knowledge, nurses are b e t t e r able to provide the necessary guidance and support to the spouses with subsequent b e n e f i c i a l e f f e c t on the p a t i e n t s . Although t h i s study d i d not focus on r e l a t i o n s h i p s between v a r i -a b l e s , many f a c t o r s emerged t h a t must be c o n s i d e r e d i n understanding the variance i n the spouses' r e a c t i o n s to l o s s . Not only must the nurses be knowledgeable about l o s s but an understanding of the f a c t o r s i n f l u e n c i n g the p e r c e p t i o n of l o s s and i t s s e v e r i t y i s imperative i f they are to perform t h e i r r o l e e f f e c t i v e l y . 125 I n d i v i d u a l i n f l u e n c i n g f a c t o r s (e.g. age, f a m i l y , I work s t a t u s , past l o s s experiences) Heart Attack a l o s s event-(stimulus) 7 -\u00C2\u00A3>perception a t t a c h meaning to l o s s A Reactions To Loss Phases ->(1) Thoughts (2) F e e l i n g s (3) Actions elements of l o s s (e.g. p a s t , p r e s e n t , f u t u r e , a c t u a l , a n t i c i p a t e d , c o n c r e t e a b s t r a c t ) r e s o l v e d \ ^ l o s s u n resolved l o s s THE PROCESS OF LOSS < : > Figure 2. A l o s s framework f o r spouses of myocardial i n f a r c t i o n p a t i e n t s . 126 This study suggested t h a t spouses may experience a n t i c i p a t o r y g r i e f soon a f t e r the i n i t i a l l o s s event. The r e a c t i o n s as d e s c r i b e d i n phase one provide i n s i g h t i n t o the v a r i o u s ways i n d i v i d u a l s experienced and d e s c r i b e d t h i s a n t i c i p a t o r y g r i e f r e a c t i o n . The nurse who can recognize a n t i c i p a t o r y g r i e f can b e t t e r assess the spouses' r e a c t i o n s and i n t e r v e n e to help these i n d i v i d u a l s cope with these f e e l i n g s . It has been suggested t h a t t a l k i n g about f e e l i n g s t h a t deal with such a c r i t i c a l area as a l i f e t h r e a t e n i n g i l l n e s s i s d i f f i c u l t and i n t r u s i v e f o r the i n d i v i d u a l e x p e r i e n c i n g the l o s s or t h r e a t o f l o s s . The r e s u l t s o f t h i s study do not support t h i s suggestion. A l l of the s u b j e c t s i n t h i s sample were w i l l i n g respondents, eager to t a l k about t h e i r concerns and touched t h a t someone cared enough to ask. This f i n d i n g had important i m p l i c a t i o n s f o r nurses because i t i n d i c a t e d t h a t spouses were approachable very e a r l y i n t h e i r l o s s experience and they need comfort and support as well as i n f o r m a t i o n . Nurses must be a v a i l a b l e to p a t i e n t s and t h e i r f a m i l i e s and must be able and w i l l i n g to l i s t e n i f the need a r i s e s . Spouses must be encouraged to d i s c u s s t h e i r concerns s i n c e they need v a l i d a t i o n t h a t t h e i r responses are normal r e a c t i o n s to t h e i r l o s s . The phases i d e n t i f i e d i n t h i s study d e s c r i b e d a common p a t t e r n o f r e a c t i o n s t h a t spouses o f myocardial i n f a r c t i o n p a t i e n t s experienced i n response to l o s s . These phases can serve as o r g a n i z i n g c e n t e r s f o r approaching problems and working towards need s a t i s f a c t i o n f o r spouses. The l o s s framework presented i n t h i s study o f f e r e d d i r e c t i o n f o r nursing p r a c t i c e . The r e a c t i o n s experienced by the spouses must be examined over a c o n s i d e r a b l e length of time. It i s not enough to 127 i n t e r v e n e once i n the h o s p i t a l o r make one home v i s i t . Nurses must meet r e g u l a r l y with p a t i e n t s and spouses throughout the course o f recovery. The f a m i l y members should be encouraged to v e n t i l a t e t h e i r thoughts and f e e l i n g s while the nurse must be a v a i l a b l e to l i s t e n . The study r e v e a l e d a p a t t e r n o f divergence i n the s h a r i n g o f thoughts and f e e l i n g s between some p a t i e n t s and t h e i r spouses. The nurse i s i n a p o s i t i o n to f a c i l i t a t e i n t e r a c t i o n between the c o u p l e . A c t i n g as a f a c i l i t a t o r the nurse can a s s i s t both the p a t i e n t ' s and the spouse's adjustment to t h e i r l o s s with r e s u l t a n t improved h e a l t h f o r a l l f a m i l y members. Nursing Education A l l l e v e l s of n u r s i n g education should i n c l u d e the a p p r o p r i a t e knowledge and s k i l l s r e l a t e d to a f a m i l y focus i n h e a l t h c a r e . Nursing education must prepare the nurse to assess the spouses' r e a c t i o n s i n response to l o s s and to help p a t i e n t s and spouses cope with t h e i r r e a c t i o n s . A l l nursing programs should i n c l u d e the concept of l o s s i n t h e i r c ore c u r r i c u l a . Included a l s o should be content r e l a t e d to f a m i l y dynamics, c r i s i s and r o l e t h e o r i e s , a d a p t a t i o n , change theory and i n t e r p e r s o n a l and communication theory. This knowledge and s k i l l w i l l provide the students with a general guide to a s s e s s i n g l o s s i n i n d i v i d u a l s , i n f a m i l i e s and i n t h e i r own experiences. As well as r e c o g n i z i n g the commonalities of l o s s , the nurse must be taught to understand and accept the i n d i v i d u a l i t y of any l o s s experience and plan nursing i n t e r v e n t i o n s a c c o r d i n g l y . 128 Nursing Research T h i s study has provided f u r t h e r knowledge of the common pat t e r n s of r e a c t i o n s t h a t spouses experience i n response to l o s s . To what extent are these phases or common pa t t e r n s of r e a c t i o n s present i n the population of spouses o f myocardial i n f a r c t i o n p a t i e n t s ? It i s necessary f o r these r e a c t i o n s to be examined to a g r e a t e r extent with a random s e l e c t i o n of spouses from a v a r i e t y o f s e t t i n g s . Further study i s a l s o r e q u i r e d to i d e n t i f y the commonalities and d i f f e r e n c e s between the sexes. This study was conducted during a s i x week time p e r i o d , f o l l o w i n g the p a t i e n t ' s d i a g n o s i s . A l o n g i t u d i n a l study examining the r e a c t i o n s experienced by p a t i e n t s and spouses would provide g r e a t e r i n s i g h t i n t o the l o s s experienced. T h i s study d i d not examine the p a t i e n t ' s r e a c t i o n s i n response to l o s s . Many questions are unanswered. Are the p a t i e n t s e x p e r i e n c i n g s i m i l a r r e a c t i o n s to l o s s ? Are t h e i r r e a c t i o n s c o n c u r r e n t with those o f t h e i r spouses? What accounts f o r the convergence and divergence i n the p a t i e n t and spouse's r e l a t i o n s h i p ? How does t h i s r e l a t e to the l o s s experienced? Further research i s needed t o e x p l o r e the l o s s - r e l a t e d v a r i a b l e s . The variance i n i n d i v i d u a l s ' r e a c t i o n s i n t h i s study are e v i d e n t and most remarkable. While t h i s study has added t o the body o f knowledge of l o s s t h a t spouses o f myocardial i n f a r c t i o n p a t i e n t s experienced i t has a l s o r a i s e d many questions about the phenomenon. In a d d i t i o n , nurse researchers must begin to study the e f f e c t s o f s e l e c t e d planned 129 n u r s i n g i n t e r v e n t i o n s on p a t i e n t s and spouses e x p e r i e n c i n g l o s s . Such research should e v e n t u a l l y l e a d to more e f f i c i e n t and e f f e c t i v e nursing c a r e . Recommendations On the b a s i s of the f i n d i n g s and i m p l i c a t i o n s of t h i s study i t i s recommended t h a t : 1. Nurse p r a c t i t i o n e r s assess the r e a c t i o n s t h a t spouses experience i n response to l o s s and provide the immediate guidance and support r e q u i r e d to f a c i l i t a t e the spouses' maximum adjustment to t h e i r l o s s . The p a t i e n t with a f a m i l y focus should be an i n t e g r a l p a r t o f nursing care i n a l l s e t t i n g s . 2. Nurse educators provide the nursing student with the appro-p r i a t e knowledge and s k i l l s r e q u i r e d to assess the actual and p o t e n t i a l l o s s e s o f spouses and to understand the i n d i v i d u a l ' s need f o r meaning during the l o s s process. This knowledge should i n c l u d e an under-standing o f the many v a r i a b l e s i n f l u e n c i n g the spouses' pe r c e p t i o n s of l o s s as well as the elements or c h a r a c t e r i s t i c s o f l o s s . 3. Future s t u d i e s with a l a r g e random sample o f spouses from a v a r i e t y o f s e t t i n g s be conducted to i n c r e a s e the g e n e r a l i z a b i l i t y of the r e s u l t s concerning the phenonmenon of l o s s . 4. Research be conducted to examine the d i f f e r e n c e s between the Group A and B f i n d i n g s with p a r t i c u l a r a t t e n t i o n to l o s s r e l a t e d v a r i a b l e s . 5. Spouses' and p a t i e n t s ' r e a c t i o n s to l o s s should be examined simultaneously i n l o n g i t u d i n a l s t u d i e s . BIBLIOGRAPHY 130 A d s e t t , A., & Bruhn, J . Short term group psychotherapy f o r post myocardial i n f a r c t i o n p a t i e n t s and t h e i r wives. 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C o l l e c t e d Papers, 1946, 4, 152-170. F r i e d , M. G r i e v i n g For a Lost Home i n The Environment of the Metropol Iis. E d i t e d by Schoenberg e t a l . New York: Columbia U n i v e r s i t y Press, 1972. Friedman, S.B., Chodoff, P., Mason, J.W., & Hamburg, D.A. Behavioural observations on parents a n t i c i p a t i n g the death of a c h i l d . P e d i a t r i c s , 1973, 32 ( 4 ) , 610-625. F u l t o n , R., & F u l t o n , J . A n t i c i p a t o r y g r i e f : a Psychosocial aspect o f terminal c a r e . In Psychosocial Aspects of Terminal Care. E d i t e d by Schoenberg e t a l l New York: Columbia U n i v e r s i t y Press, 1972. Futterman, E.H., Hoffman, I., & Sobshin, M. Parental A n t i c i p a t o r y Mourning. In Psychosocial Aspects of Terminal Care. E d i t e d by Schoenberg e t a l . New York: Columbia U n i v e r s i t y Press, 1972. G l a s e r , B., Strauss, A. 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Group i n t e r v e n t i o n f o r wives o f myocardial i n f a r c t i o n p a t i e n t s . Nursing C l i n i c s of North America, 1976, 11 ( 2 ) , 339-347. H o i s t i , 0. Content A n a l y s i s f o r the S o c i a l Sciences and Humanities. Don M i l l s , O n t a r i o : Addison Wesley, 1969. Kahn, R. & C o n n e l l , C. The Dynamics of Int e r v i e w i n g . New York: John Wiley and Sons, 1965. K e r l i n g e r , F. Foundations of Behavioural Research. 2nd ed. Toronto: Holt, Rinehart, and Winston, 1973. K i m b a l l , C P . P s y c h o l o g i c a l responses to the experience o f open heart surgery. American Journal of P s y c h i a t r y , 1969, 126 (3), 97-107. K l e i n , R. The impact of i l l n e s s upon the spouse. Journal Chronic D i s a b i l i t y , 1967, 20, 241-247. Korner, J.N. Hope as a method of coping. J . C o n s u l t i n g and C l i n i c a l Psychology, 1970, 34 (2), 2-3. Kubler-Ross, E. On Death and Dying. New York: The MacMillan Company, 1969. ~~ L a r t e r , M. M. I. Wives need you. R.N., 1976, ( 8 ) , 45-46. Lindemann, E. Symptomatology and management o f acute g r i e f . American Journal of P s y c h i a t r y , 1944, 101 ( 9 ) , 141-148. , Lipowski, Z.J. 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 the coping process. I n t e r n a t i o n a l Journal of P s y c h i a t r y In Medicine 1, 1970, 91-101. M a r r i s , P. Widows and T h e i r F a m i l i e s . London: Routeledge and Kegan Paul, 195\"8^ Mayou, R., F o s t e r , A. & Williamson, B. The p s y c h o l o g i c a l and s o c i a l e f f e c t s o f myocardial i n f a r c t i o n on wives. B r i t i s h Medical J o u r n a l , 1978, 6114 ( 3 ) , 699-701. Moos, R. Coping with P h y s i c a l I l l n e s s , New York: Plenum Medical Book, 1977. 133 Moulter, N. Needs o f r e l a t i v e s o f c r i t i c a l l y i l l p a t i e n t s . Heart and Lung, 1979, 8 ( 2 ) , 322-339. Nagy, M. The C h i l d ' s View of Death, In the Meaning of Death. E d i t e d by Herman F i e f e e . New York: McGraw Hi I I, Co. 1959. Parkes, CM. Bereavement: Studies o f G r i e f i n A d u l t L i f e . New York: Basic Books, 19/Z. Peretz, D. Development, O b j e c t - R e l a t i o n s h i p s and Loss i n Loss and G r i e f : P s y c h o l o g i c a l Management i n Medical P r a c t i c e . E d i t e d by Schoenberg e t a l . New York: Columbia U n i v e r s i t y Press, 1970, 3-9. P i a g e t , J . The Language and Thoughts of the C h i l d . London: Routledge, 1952. P r a n u l i s , M.F. Loss: a f a c t o r a f f e c t i n g the welfare of the coronary p a t i e n t . . Nursing C l i n i c s of North America, 1972, 7 (3), 445-455. Quint, J . D e l i n e a t i o n of q u a l i t a t i v e aspects of nursing c a r e . Nursing Research, 1962, 11 ( 4 ) , 205-206. Roberts, S. Behavioural Concepts and Nursing Throughout the L i f e Span. New Jersey\"! P r e n t i c e - H a l l Inc., 19/8. Robinson, L. L i a i s o n Nursing, P s y c h o l o g i c a l Approach to P a t i e n t Care. P h i l a d e l p h i a ! l-.A. Davis Co., 19/4. R o c h l i n , G. The l o s s complex. Journal of the American P s y o a n a l y t i c A s s o c i a t i o n , 1959, 7 (4), 299TJT5: Royle, J . Coronary p a t i e n t s and t h e i r f a m i l i e s r e c e i v e incomplete c a r e . Canadian Nurse, 1973, 69 (2), 21-25. Ruskin, H. MMPI comparison between p a t i e n t s with coronary h e a r t d i s e a s e and t h e i r spouses together with o t h e r demographic data. Scandinavian Journal of R e h a b i l i t a t i o n and Medicine, 1970, ( 2 ) , 99-104. Schmidt, L., & Hatton, C. The Concept of Loss i n F i v e Years Co-operation to Improve C u r r i c u l a i n Western Schools of Nursing Western I n t e r s t a t e Commission f o r Higher Education. E d i t e d by J . Smith Boulder: Colorado, 1972, 26-51. Schoenberg, B., Carr, A., P e r e t z , D. & Kutscher, A. Loss and G r i e f : P s y c h o l o g i c a l Management i n Medical P r a c t i c e . New York: Columbia U n i v e r s i t y Press, 1970. S e l l i t z , C , Cook, S.W., & Wrightsman, L.S. Research Methods i n S o c i a l R e l a t i o n s . (3rd Ed.) New York: Holt, Rinehart and Winston, 19/6. 134 Shontz, F.C. The Psy c h o l o g i c a l Aspects of Physical I l l n e s s and D i s a b i l i t y . New York: MacMiI Ian Co., 1975. ~~ S i l v a , M. Spouses need nurses too. Canadian Nurse, 1977, 73 (12). 39-41. Sk e l t o n , M., & Dominian, J . Ps y c h o l o g i c a l s t r e s s i n wives o f p a t i e n t s with myocardial i n f a r c t i o n . B r i t i s h Medical J o u r n a l , 1973, 2 ( 4 ) , 101-103. S t r i c k l e r , M., & La Sor, B. The concept o f l o s s i n c r i s i s i n t e r v e n t i o n . Mental Health Hygiene, 1970, 54 (2), 301-305. Toth, A., & Toth, S. Post-coronary p a t i e n t s r e c e i v e group therapy. H o s p i t a l Progress, 1977, (8), 72-75. Vachon, M.L.S. The f i n a l i l l n e s s i n cancer: the widow's p e r s p e c t i v e . CMA J o u r n a l , 1977, 117 (9), 1151-1154. W i l l i a m s , C , & Ri c e , D. The I.C.U. - s o c i a l work i n t e r v e n t i o n with f a m i l i e s o f the c r i t i c a l l y i l l p a t i e n t . S o c i a l Work i n Health Care, 1977, 2 (10), 391-398. Wu, R. Behaviour and I l l n e s s . Englewood C l i f f s , New J e r s e y : P r e n t i c e Hal 1 , 1973. Yokes, J . Family R e h a b i l i t a t i o n : an Adult with Myocardial I n f a r c t i o n , i n Family Health Care. E d i t e d by D. Hymovich. New York: McGraw-Hill, 1973. Appendix A: Consent Form 136 CONSENT FORM Consent to p a r t i c i p a t e i n Research Study conducted by P a t t i Gauchie, R.N. I, , agree to p a r t i c i p a t e i n the research study being conducted by P a t t i Gauchie. I understand that t h i s study deals with examining the f e e l i n g s and r e a c t i o n s that the spouse experiences when the partner has s u f f e r e d a heart a t t a c k . I understand t h a t my p a r t i c i p a t i o n w i l l i n v o l v e four i n t e r v i e w s of approximately one hour each and I have agreed to have these i n t e r v i e w s tape recorded. I understand that I w i l l remain anonymous and that the tapes of the in t e r v i e w w i l l be a v a i l a b l e only t o the i n v e s t i g a t o r and the members o f her t h e s i s committee. I a l s o understand that t h i s tape w i l l be erased when the i n v e s t i g a t o r ' s t h e s i s has been completed. I understand t h a t I am fr e e to withdraw from the study at any time, and that t h i s a c t i o n w i l l not j e o p a r d i z e the treatment of my spouse. Signed: Witnessed: Date: Appendix B: Information Related to Cardiac Research Study I 138 INFORMATION RELATED TO CARDIAC RESEARCH STUDY ' As p a r t o f t h e d a t a c o l l e c t i o n f o r my M a s t e r T h e s i s i n N u r s i n g , I am c o n d u c t i n g i n f o r m a l i n t e r v i e w s w i t h s p o u s e s whose p a r t n e r s a r e h e a r t a t t a c k p a t i e n t s b e i n g t r e a t e d i n t h e c o r o n a r y c a r e u n i t a t S t . P a u l ' s H o s p i t a l . My t h e s i s t o p i c d e a l s w i t h e x a m i n i n g t h e f e e l i n g s and r e a c t i o n s t h a t t h e spouse e x p e r i e n c e s when t h e p a r t n e r has s u f f e r e d a h e a r t a t t a c k . As a n u r s e , I have worked w i t h h e a r t a t t a c k p a t i e n t s and have been c o n c e r n e d w i t h h e l p i n g t h e s p o u s e s cope w i t h t h e s t r e s s o f t h e i l l n e s s . In n u r s i n g ' w e have n o t s t u d i e d t h e s p o u s e v e r y t h o r o u g h l y , so we have l i t t l e i n f o r m a t i o n t o g u i d e us i n p r o v i d i n g t h e a s s i s t a n c e s p o u s e s may r e q u i r e . I b e l i e v e t h a t my r e s e a r c h i s i m p o r t a n t i n g a t h e r i n g t h i s i n f o r m a t i o n . I hope t h a t you w i l l c o n s i d e r p a r t i c i p a t i n g i n t h i s s t u d y . I w o u l d l i k e t o c o n d u c t f o u r i n f o r m a l i n t e r v i e w s w i t h y o u , two d u r i n g t h e h o s p i t a l i z a t i o n p e r i o d o f y o u r p a r t n e r and t h e f i n a l two a t one and t h r e e weeks a f t e r h o s p i t a l d i s c h a r g e . The t i m e and l e n g t h o f t h e i n t e r v i e w s w o u l d be a r r a n g e d a t y o u r c o n v e n i e n c e . A l l i n t e r v i e w s w i l l be c o n f i d e n t i a l , y o u r c o n t r i b u t i o n s w i l l r e m a i n anonymous . You may w i t h d r a w f rom t h e s t u d y a t any t i m e . I w i l l g l a d l y s h a r e t h e r e s u l t s o f t h i s s t u d y upon c o m p l e t i o n o f my r e s e a r c h . I w i l l t e l e p h o n e you w i t h i n the week t o answer any f u r t h e r q u e s t i o n s you may have i n r e g a r d t o t h e s t u d y and t o d i s c u s s t h e p o s s i b i l i t y o f y o u r p a r t i c i p a t i o n . I w i s h t o s t r e s s t h a t r e f u s a l t o p a r t i c i p a t e i n t h i s s t u d y w i l l n o t j e o p a r d i z e c u r r e n t o r f u t u r e t r e a t m e n t o f y o u r p a r t n e r . I l o o k f o r w a r d t o t a l k i n g w i t h y o u . Thank y o u , P a t t i G a u c h i e , R .N . U . B . C . S choo l o f N u r s i n g Appendix C: Data C o l l e c t i o n Tool DATA COLLECTION TOOL Demograph i c D a t a : D a t e : Name o f Spouse ( i n i t i a l s ) Spouse s a g e : P a t i e n t ' s a g e : S p o u s e ' s s e x : I n t e r v i e w G u i d e : Number o f days p o s t M. I The i n t e r v i e w w i l l e x p l o r e t h e d e g r e e , f r e q u e n c y , i n t e n s i t y and d u r a t i o n o f s p e c i f i c p s y c h o l o g i c a l and s o m a t i c r e s p o n s e s . A r e a s t o be examined w i l l b e : 1. v e r b a l ( t y p e , . q u a l i t y c h a r a c t e r i s t i c s o f s p e e c h , f o c u s o f c o n v e r s a t i o n ; 2. n o n - v e r b a l ( a c t i v i t y , eye c o n t a c t , body l a n g u a g e , a p p e a r a n c e ) . Q u e s t i o n s ( b r o a d - o p e n e n d e d ) : 1. Can y o u t e l l me what y o u r t h o u g h t s have been i n r e l a t i o n t o y o u r s p o u s e ' s h e a r t a t t a c k s i n c e I l a s t saw you? 2. When y o u t h i n k a b o u t y o u r s p o u s e ' s h e a r t a t t a c k how do y o u f e e l ? 3. Can y o u d e s c r i b e y o u r b e h a v i o u r s i n c e y o u r s p o u s e ' s h e a r t a t t a c k ? 4. Is t h e r e a n y t h i n g e l s e t h a t y o u f e e l i s i m p o r t a n t t o m e n t i o n ? Appendix D: Sample of Data Coding and A n a l y s i s Procedure 142 SAMPLE OF DATA CODING AND ANALYSIS PROCEDURE DISCRIMINATION \u00E2\u0080\u00A2 STEP: Data s o r t e d and c o l o u r coded. Category I d e n t i f i e d and c o l o u r coded. Sample of I l l u s t r a t i v e Data (coded with a red dot) He Is not a person who t e l l s you he Is hurt so when t h i s happened \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 He had pains In h i s arms so I was wondering .... W e l l , how I t happened was s o r t of a s u r p r i s e .... W e l l , we were up at Sechelt in our new motor home .... Spouses g i v e a blow-by-blow d e s c r i p t i o n of the heart a t t a c k . I n v e s t i g a t o r uses i l l u s t r a t i v e data to name the category. HOW IT HAPPENED DEFINITION STEP: Category de f i n e d and d e s c r i b e d . Category reworked u n t i l p r o p e r t i e s and concepts become c l e a r e r . C h a r a c t e r i s t i c s or p r o p e r t i e s : HOW IT HAPPENED| > 1 4. 5. I n i t i a t e d the f i r s t i n t e r -view with a d e s c r i p t i o n of event; moved from past to present time frame; v i v i d l y r e c a l l e d t h e i r p a r t n e r ' s symptoms; d e t a i l e d t h e i r own r e a c t i o n s ; progressed from these thoughts t o question the reason or cause of I l l n e s s i . e . why i t happened. CLASSIFICATION i n t e r p r e t a t i o n in IIght of loss framework category of [REVIEWING| STEP: Category compared and c o n t r a s t e d t o other c a t e g o r i e s , threaded together. Larger a b s t r a c t concepts evolve. Concepts and p r o p e r t i e s are Compared and c o n t r a s t e d REVIEWING with comparing r e d e f i n i n g and a n t i c i p a t i n g Main themes emerge (a) p a t i e n t focus; (b) heightened thoughts (c) a n t i c i p a t e d loss of partner Phase I The Event and I n i t i a l Spousal Response A p p e n d i x E: O v e r v i e w o f t h e F i n d i n g s 144 APPENDIX E PHASES FINDINGS Phase I The Event and I n i t i a l Spousal Response 1. H o s p i t a l i z a t i o n p e r i o d of p a t i e n t . 2. Subjects Interviewed and observed twi c e (week one and two). Thoughts: ( t ) reviewing; (2) a n t i c i -p a t i n g ; (3) comparing; (4) r e d e f i n i n g . FeelInqs: (1) mood-shock/disbelief, upset with gradual c o n t r o l guarded optimism; (2) p h y s i c a l d i s t u r b a n c e s , loss of sleep and a p p e t i t e , increased f a t i g u e and I r r i t a b i l i t y . A c t i o n s : (1) verbal I z e d - h e c t i c schedules, loss of s o c i a l c ontact: (2) observed c r y i n g , long s i g h s , decreased eye co n t a c t , slouched posture, f a t i g u e d faces, few s m i l e s . Phase II - Reaction To The Event 1. E a r l y post discharge p e r i o d of the p a t i e n t . 2. Subjects interviewed and observed once (week t h r e e to f o u r ) . M E Phase I I Impact Of The Event Later post discharge p e r i o d of the p a t i e n t . Subjects Interviewed and observed once (week f i v e t o s i x ) . Two separate p a t t e r n s of r e a c t i o n s - Group A f i n d i n g s Group B f i n d i n g s Thoughts: (1) a s s e s s i n g ; (2) implement-ing; (3) r e d e f i n i n g . FeelInqs: (1) mood-gratefulness, optimism, beginning of g u i l t , r e s e n t -ment and ambivalence; (2) p h y s i c a l disturbances--improved a p p e t i t e and sl e e p . Increased f a t i g u e . A c t i o n s : (1) verbal Ized-watchdog, p r o t e c t o r behaviours, a l t e r e d r o l e s and r e s p o n s i b i l i t i e s ; (2) observed animated speech, Increased s m i l e s Increased eye c o n t a c t , s o c i a l o v e i \u00E2\u0080\u0094 \ t u r e s . Group A Thoughts: (1) a s s e s s i n g ; (2) r e d e f i n i n g Feel Ings: (1) mood - depression, g u i l t resentment; (2) p h y s i c a l disturbances increased f a t i g u e , loss of sleep and a p p e t i t e , headaches. A c t i o n s : ( I ) v e r b a l i z e d - loss of own. time, Increased changes i n r o l e s and r e s p o n s i b i l i t i e s , decreased communi-c a t i o n with p a r t n e r ; (2) observed increased s i g h i n g , monotone v o i c e s , slouched posture, no make-up, decreased eye conta c t and s o c i a l o v e r t u r e s . Group B Thoughts: (1) assessing; (2) p l a n n i n g . FeelInqs: (1) mood - calm, t h a n k f u l , p o s i t i v e , a c c e p t i n g ; (2) p h y s i c a l d i s t u r b a n c e s h a l t h back to normal. A c t i o n s : (1) v e r b a l i z e d - shared r o l e s and r e s p o n s i b i l i t i e s , communication with partner; (2) observed - a l e r t , r e sponsive, calm, r e l a x e d voice and body posture, increased eye co n t a c t and s o c i a l o v e r t u r e s . Appendix F: Overview of the I n t e r p r e t a t i of the F i n d i n g s 146. APPENDIX F 1n t e r p r e t a t l o n Major Themes . Phase 1 The Event and I n i t i a l - r e a c t i o n s s i m i l a r t o a n t i c i p a t o r y 1. heightened thought Spousal Response g r i e f r e a c t i o n s described by processes; Lindemann; 2. p a t i e n t focus; - loss i s sudden and traumatic and experienced in 3 time frames, 3. a n t i c i p a t e d loss past, present and f u t u r e ; of p a r t n e r . - f u l l r e a l i t y of loss has not penetrated, s u b j e c t s beginning t o p e r c e i v e and attach meaning t o l o s s . Phase 11 Reaction to the Event - c l o s u r e of a n t i c i p a t e d l o s s , 1. decreased thought p a t i e n t r e c o v e r i n g well and processes; s u b j e c t s p r o t e c t i n g and watching t h e i r p a r t n e r s ; 2. p a t i e n t and spouse focus; - couple focus - loss examined as i t a f f e c t s \"us\"; 3. euphoric f e e l I n g s . - personal s e l f focus - subjects express actual loss of s e l f (e.g. time, independence, r o u t i n e s ) . Phase 111 Impact to the Event 'Group A: 1. heightened thought - unresolved loss processes; - loss expands to focus on loss of spouses needs, v a l u e s , r o l e s , 2. e g o c e n t r i c focus; more covert a b s t r a c t loss experienced by s u b j e c t s . 3. hei ghtened - acknowledgement phase, the t r u e ambivalence and - Impact of the loss now f e l t with depress i o n . numerous secondary l o s s e s . Group B: 1. acceptance and - r e s o l v e d loss - acceptance and optimIsm; adaptation; - loss viewed from an us or couple 2. couple or us focus not from e g o c e n t r i c focus; p e r s p e c t i v e ; - loss seen as a past event, an event 3. fu t u r e o r i e n t e d . t h a t had changed t h e i r l i v e s f o r the p o s i t i v e ; - view f u t u r e with optimism. "@en . "Thesis/Dissertation"@en . "10.14288/1.0095124"@en . "eng"@en . "Nursing"@en . "Vancouver : University of British Columbia Library"@en . "University of British Columbia"@en . "For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use."@en . "Graduate"@en . "Loss as experienced by spouses of myocardial infarction patients"@en . "Text"@en . "http://hdl.handle.net/2429/22906"@en .