484814

research-article2013
WJN35810.1177/0193945913484814Western Journal of Nursing ResearchSon et al.

Article
Western Journal of Nursing Research
35(8) 1011­–1025
Longitudinal Changes © The Author(s) 2013
Reprints and permissions:
in Coping for Spouses sagepub.com/journalsPermissions.nav
DOI: 10.1177/0193945913484814
of Post–Myocardial wjn.sagepub.com

Infarction Patients

Heesook Son1, Sue A. Thomas2,

and Erika Friedmann2

Abstract
Spouses are the key in the recovery and coping of patients after a myocardial
infarction (MI). The purpose of this study was to examine changes in coping
for spouses of post-MI patients over time. The study determined the
contributions of a spouse’s demographic factors and of time since the MI
to the changes in coping. A secondary data analysis from the Patients’ and
Families’ Psychological Response to Home Automated External Defibrillator
Trial was conducted. On average, older spouses coped better than younger
spouses. Coping significantly decreased over time. The spouse’s coping
decreased for spouses whose baseline coping was higher. Coping decreased
more rapidly for spouses of patients who experienced an MI more recently.
Patients and spouses need support to improve coping after an MI.

Keywords
coping in spouses of post-MI patients, changes in coping, time since MI

Coping strategies have cognitive and emotional aspects and occur when a
stressful event arises (Santavirta, Kettunen, & Solovieva, 2001). After a

1Walden University, Minneapolis, MN, USA

2University of Maryland School of Nursing, Baltimore, USA
Corresponding Author:
Heesook Son, 100 Washington Ave S #900 Minneapolis, MN 55401, USA.
Email: heesook.son@waldenu.edu

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

1012 Western Journal of Nursing Research 35(8)

cardiac event, significant others experience uncertainty and anxiety about a

myocardial infarction (MI) and its consequences (Jackson, McKinstry, &
Gregory, 2011). Psychological distress is closely associated with inappropri-
ate coping use. Distressed spouses used significantly more negative coping
strategies such as withdrawal and avoidance of the problem and had lower
levels of family functioning than those spouses who were not distressed
(O’Farrell, Murray, & Hotz, 2000). Anxious and depressed partners of post-
MI patients experienced poor coping (Garnefski et al., 2009; Son, Friedmann,
& Thomas, 2012b; Son, Thomas, & Friedmann, 2012). Spouses of patients
with heart disease cope with stressors, including enduring the patient’s dis-
ability or death, child care and economic pressures, an unpredictable future,
the patient’s emotional responses to the illness, and their own emotional
responses (Hotz, Cazabon, O’Farrell, & Robbins, 1991). Spouses of post-MI
patients play a significant role in helping patients recover from the cardiac
event (McLean & Timmins, 2007). The spouse’s inappropriate coping may
influence negative health outcomes of the patient.

Factors Influencing the Coping Strategies in

Spouses of Patients With Heart Disease
Previous studies of the relationship between the age of the spouse and the
use of coping strategies produced inconsistent findings. In one study, older
spouses of post-MI patients used more coping strategies and coped more
effectively than younger ones (Yeh, Gift, & Soeken, 1994), but a recent
study showed older spouses tend to use more passive coping strategies
(Santavirta et al., 2001). A qualitative study reported older spouses used
spiritual conviction more frequently as a coping resource (Salminen-
Tuomaala, Åstedt-Kurki, Rekiaro, & Paavilainen, 2012). In contrast, there
were no age differences in coping scores for family members of critically
ill Chinese patients (Chui & Chan, 2007) or in specific use of coping strate-
gies for relatives of patients in the intensive care unit (Casarini, Gorayeb, &
Filho, 2009).
Gender did not influence the use of coping strategies in the early phase of
a patient’s recovery from an MI (Santavirta et al., 2001) or in family members
of critically ill Chinese patients (Chui & Chan, 2007). Male spouses of MI
patients, however, used more problem-focused coping strategies than female
spouses (Yeh et al., 1994). A qualitative study showed that coping experi-
ences of female spouses included melancholy, tiredness, hopelessness, and
fear of the patient’s death (Salminen-Tuomaala et al., 2012). No clear rela-
tionship of age or gender to changes in coping for spouses of post-MI patients
is apparent from these studies.

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

Son et al. 1013

Studies show that inappropriate coping strategies increase psychological

and physical distress in spouses of patients with heart disease. Anxious and
depressed spouses of post-MI patients experienced poor coping (Garnefski
et al., 2009; Son, Thomas, et al., 2012; Son, Friedmann, et al., 2012b). For
patients who underwent coronary artery bypass graft, those couples who used
positive coping strategies (redefining the illness, seeking spiritual support, and
adopting partnership) experienced better psychosocial outcomes compared
with those who did not (Whitsitt, 2012). Spouses of critically ill patients who
used more emotion-focused coping experienced more emotional and physical
distress (Nyamathi, Jacoby, Constancia, & Ruvevich, 1992). Distressed spouses
of cardiac patients used significantly more disengagement coping strategies
such as withdrawal and avoidance of the problem than those who were not
distressed (O’Farrell et al., 2000). The wives of post-MI patients who had very
low anxiety over the whole period of 10 years used less denial coping styles,
were more able to make plans for the future, and adjusted better to illness-related
problems than other wives (Arefjord, Hallaraker, Havik, & Maeland, 1998).
Spouses using denial coping experienced increased hopelessness and depression
over 12 months post MI (Salminen-Tuomaala et al., 2012). Therefore, psycho-
logical distress is associated with negative coping strategies.
The trajectory of heart disease requires patients and family members to
continuously adjust in the acute and recovery phases (Van Horn, Fleury, &
Moore, 2002). During early convalescence from a heart attack, patients and
their partners experienced coping with changes, including adjustments to
their lifestyles, a shift in roles, dealing with overprotection, and changes in
family activities and relationships (Wang, Thompson, Chair, & Twinn, 2008).
Coping strategies of spouses of post-MI patients seem to be stable over time.
A calm attitude toward MI at 4 months post MI was linked with a serene
attitude at 12 months whereas the attitude of denial was maintained up to 12
months (Salminen-Tuomaala et al., 2012).
Few studies have examined changes in coping over time for spouses of post-
MI patients. Changes in coping of post-MI patients are better documented than
those of spouses. For example, the patient’s coping did not change over time
after an MI (Kristofferzon, Löfmark, & Carlsson, 2005). Similarly, in a longi-
tudinal study of patients with traumatic brain injury, there was no significant
change in use of task and avoidance-oriented coping strategies between 2 and
8 years after the injury (Tomberg, Toomela, Ennok, & Tikk, 2007).

Purpose
Little is known about longitudinal changes in coping of spouses of post-MI
patients. The aim of the study was to examine changes in coping for spouses

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

1014 Western Journal of Nursing Research 35(8)

of post-MI patients over time. The research questions were to examine

whether (a) the total coping scores increase or decrease over 2 years in
spouses of post-MI patients; (b) older age, male gender, increased baseline
anxiety and depression, and lower baseline coping were related to decreased
coping in spouses of post-MI patients; and (c) a shorter period of the time
since MI decreased coping over 2 years in spouses of post-MI patients.

Method
Design
A secondary data analysis from the PRHAT (Patients’ and Families’
Psychological Response to Home Automated External Defibrillator Trial)
was conducted to test the research questions. As a substudy of the HAT
(Home Automated Defibrillator Trial) study (Bardy et al., 2008), the PRHAT
study was designed to compare the long-term effects of two interventions
(Cardiopulmonary resuscitation [CPR] training and CPR training plus auto-
mated external defibrillators [AED]) on psychosocial factors, including anxi-
ety, depression, coping, and social support, in post-MI patient couples. As an
international study, the PRHAT included 30 self-selected sites from four
countries: Australia (12 sites), Canada (5 sites), New Zealand (2 sites), and
the United States (11 sites). The parent study described the overall study
methodology (Thomas et al., 2011). The present study examined spouse cop-
ing measured at baseline, 1 year, and 2 years for the outcome variable. The
PRHAT data set included 460 couples. Each couple included a spouse or
companion who lived with the patient and agreed to be trained in CPR or
CPR and AED use. All participants signed a specific consent form for
PRHAT. All spouses and patients were instructed to complete the consent
form independent of each other. Nurse coordinators in the HAT study distrib-
uted the tools and were unaware of scores on the coping scales because all
tools were sent to the principal investigator and scored by research assistants.
Confidentiality in PRHAT was maintained by assessing a code number. No
patient or spouse identification was on any of the forms.
The parent study showed that home AEDs did not influence changes in
patients’ depression or anxiety or spouse depression as compared with the
CPR group (Thomas et al., 2011). The present study’s purpose targeted
spouses of post-MI patients, not focusing on the CPR and CPR/AED groups.
Therefore, the data were not divided into the two groups as in PRHAT, but all
analyses were adjusted for treatment group if necessary. The data set included
individuals who were spouses or domestic partners. Excluded from the data
set were siblings, children, and other relatives. The term spouses in this article
only includes spouses and partners of patients who were cognitively intact.

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

Son et al. 1015

Measures
The instruments used for measurements have previously been reported (Son,
Friedmann, et al., 2012b). The ALFI-MMSE (Adult Lifestyles and Function
Interview Mini Mental State Examination) was used for the exclusion criteria.
For the present study, cognitive impairment was defined as a score of 17 points
or less and spouses with those scores were excluded. The FCOPES (Family
Crisis Oriented Personal Evaluation Scales) was used to measure spouse cop-
ing. The FCOPES is composed of 30 items that explain a choice of coping
behaviors that individuals use in a stressful situation (M. A. McCubbin &
McCubbin, 1987). The total score ranges from 30 to 150, and a lower total
FCOPES score shows less coping strategies are used, which contributes to
poorer adaptation. The FCOPES consists of five subscales including Acquiring
Social Support, Reframing, Seeking Spiritual Support, Mobilizing Family to
Acquire and Accept Help, and Passive Appraisal. For the present study, the
total coping scores were significantly related to each time point: p < .001, r =
.714, between baseline and 1 year; p < .001, r = .647, between baseline and 2
years; and p < .001, r = .753, between 1 and 2 years. To assess baseline anxiety,
the state portion of the STAI (State/Trait Anxiety Inventory) was used. The
STAI is based on two facets of the theoretical conception of anxiety, which are
the state scale and the trait scale. The state scale was developed to measure the
transient state of arousal subjectively experienced as anxiety whereas the trait
scale was designed to assess the more enduring characteristic presence of the
emotion (Spielberger & Gorsuch, 1983; Spielberger, Gorsuch, & Lushene,
1970; Tluczek, Henriques, & Brown, 2009). For this study, the state anxiety
scores were significantly related to each time point: p < .001, r = .524, between
baseline and 1 year; p < .001, r = .470, between baseline and 2 years; and p <
.001, r = .569, between 1 and 2 years. The BDI-II (Beck Depression Inventory–
II) was used to measure depression symptoms. The BDI assesses depression
symptoms over the past 2 weeks (Beck, Steer, & Brown, 1996). For this study,
the BDI scores were significantly related to each time point: p < .001, r = .563,
between baseline and 1 year; p < .001, r = .521, between baseline and 2 years;
and p < .001, r = .704, between 1 and 2 years.

Analysis
Descriptive statistics were completed. For longitudinal analysis, Linear
Mixed Models (LMMs) were used to test the aims using PASW SPSS 19.0
for Windows (SPSS Inc., Chicago, Illinois, United States). Unconditional
means models were tested for the dependent variable (total coping score) to
provide a baseline model for comparison. Next, unconditional growth models
were used to determine whether there was a significant change over time for

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

1016 Western Journal of Nursing Research 35(8)

the dependent variable. A third model included treatment, time, and the inter-
action between time and treatment group (0 = CPR only; 1 = CPR and AED
use). For each of these models, Akaike’s Information Criterion (AIC) and
Bayesian Information Criterion (BIC) were examined to evaluate model
improvement. Smaller values indicate better fitting models. Fixed and ran-
dom effects were explored for a best model. Fixed models were examined
first. Next, random effects were explored to see if the model improved pre-
diction. Deviance tests (χ2) were conducted to compare nested models.
Prior to LMMs, normality tests were conducted for continuous variables.
The dependent variable, spouse total coping score, was normally distributed.
Spouse’s age and baseline coping scores were also normally distributed.
Spouses’ baseline anxiety and depression scores were transformed to improve
normality: natural log for baseline anxiety and square root for baseline
depression. Time since MI was dichotomized as two levels based on a median
split: experienced MI recently (less than 1.5 years) versus experienced MI
long ago (more than 1.5 years).
The best models from the first research question were used as the basic
models for the second and third research questions. Treatment was included
in all models because of its centrality to the design.

Results
Participant Characteristics
A total of 442 spouses were included in analyses, of which 18 participants
were excluded: siblings (n = 2), children (n = 10), associates (n = 4), or other
family relative (n = 1) of the patient, or participant with score below 17 on
ALFI-MMSE (n = 1). Table 1 describes the demographics of the spouses
(N = 442) in the PRHAT data set. The mean age was 57.65 (range = 27-82
years) and 86.2% were female spouses. Most patients (97.6%) had a mild
degree of heart failure: NYHA (New York Heart Association) Class I (78.1%),
Class II (19.5%), Class III (2.3%), and Class IV (0.2%). The patient’s experi-
ence of his or her MI was not recent and the median time since MI was 1.5
years (range = 0-28.33 years).
Data were obtained from patients and spouses at sites in four countries:
United States, Canada, New Zealand, and Australia. The commonality of
variability in spouse coping within the four countries was examined with
unconditional intraclass correlation criterion (ICC). Total coping among
countries was 0.053 and was ignorable (Kreft, 1996), indicating that total
coping scores were not nested within countries. Missing data analysis was
conducted prior to the analysis of LMMs. Pattern mixture models were used

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

Son et al. 1017

Table 1.  Baseline Characteristics of Spouses of Post-MI Patients in the PRHAT

Data (N = 442).

Possible Range M (SD) Range

Age 57.65 (10.28) 27-82
Time (year) since most recent 3.76 (5.08) 0-28.33
MI
Total coping scores 30-150 98.61 (15.69) 52-148
  Acquired social support 9-45 29.79 (7.40) 9-45
 Reframing 8-40 31.97 (4.56) 17-40
  Seeking spiritual support 4-20 11.73 (5.14) 4-20
  Mobilizing family to acquire 4-20 13.62 (3.69) 4-20
and accept help
  Passive appraisal 4-20 8.48 (3.09) 4-19
Anxiety 20-80 31.65 (9.80) 20-64
Depression 0-63 6.93 (6.18) 0-40

Note: MI = myocardial infarction; PRHAT = Patients’ and Families’ Psychological Response to

Home Automated External Defibrillator Trial.

to determine whether the missingness was random. The pattern mixture

approach provides assessment regarding whether a model requires the miss-
ingness mechanism to be ignorable (Hedeker & Gibbons, 1997). Pattern mix-
ture models indicated that data were missing at random or completely at
random (Son, Friedmann, & Thomas, 2012a).

Changes in Coping for Spouses of Post-MI Patients

Spouse coping changed significantly over time. The unconditional growth
model for total coping, χ2(df = 1) = 11.03, p < .01, was significantly better at
predicting spouse coping than the unconditional means models. In the uncon-
ditional growth models, time made a significant contribution to spouse total
coping score (parameter estimate = −1.311, t = −3.342, p = .001). Total cop-
ing scores decreased significantly over time. The addition of type of interven-
tion and the interaction of intervention with time did not improve model fit.

Factors Contributing to Changes in Coping for Spouses of Post-

MI Patients
Spouse’s age and gender were related to the total coping score. The best
model included the spouse’s age and gender, and it significantly improved the
model fit as compared with the unconditional growth model for total coping,

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

1018 Western Journal of Nursing Research 35(8)

χ2(df = 5) = 37.69, p < .01. The spouse’s age was associated with the total
coping score (parameter estimate = 0.313, t = 3.193, p = .001). For every year
of the spouse’s age, the average coping score increased by 0.313, which indi-
cated that older spouses coped better than younger spouses. The spouse’s
gender did not predict total coping scores (parameter estimate = −2.721, t =
−0.902, p = .367). The spouse’s age (parameter estimate = 0.028, t = 0.728, p
= .467) and gender (parameter estimate = −0.274, t = −0.233, p = .816) did
not interact significantly with time, which indicated that the changes in the
total coping score did not depend on age or gender.
The spouse’s baseline anxiety was related to total coping. The best model
included the spouse’s baseline anxiety, and it significantly improved the
model fit as compared with the unconditional growth model for total coping,
χ2(df = 3) = 93.28, p < .01. The spouse’s baseline anxiety was significantly
related to total coping (parameter estimate = −8.136, t = −2.252, p = .025).
On average, coping was significantly worse for those who had higher base-
line anxiety scores. However, the spouse’s baseline anxiety did not interact
significantly with time (parameter estimate = 0.692, t = 0.490, p = .624),
which indicated that the changes in total coping score did not depend on
spouse’s baseline anxiety.
The spouse’s baseline depression was associated with total coping. The
best model included the spouse’s baseline depression, and it significantly
improved the model fit as compared with the unconditional growth models for
total coping, χ2(df = 3) = 79.918, p < .01. The spouse’s baseline depression
was significantly related to coping (parameter estimate = −2.966, t = −3.548,
p < .001). For every 1 point of increased depression, the average coping score
decreased by 2.966, indicating that, on average, coping was significantly
worse for those who had higher baseline depression scores. However, the
spouse’s baseline depression did not interact significantly with time (parame-
ter estimate = 0.410, t = 1.260 p = .208), which indicated that changes in total
coping score did not depend on spouse’s baseline depression.
The best model included the spouse’s baseline coping, and it significantly
improved the model fit as compared with the unconditional growth models
for total coping, χ2(df = 3) = 1441.689, p < .01. The spouse’s baseline coping
was significantly related to coping (parameter estimate = 1.135, t = 24.728,
p < .001), which indicated that on average, coping was significantly better for
those who had higher baseline coping scores. As 1 point of the baseline cop-
ing score increases, the overall total coping score increased by 1.135 (see
Table 2). There was a significant interaction between time and baseline cop-
ing scores. Coping decreased over time for spouses who had higher baseline
coping scores, whereas coping was stable over time for those who had lower
baseline coping scores (parameter estimate = −0.164, t = −7.228, p < .001),

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

Son et al. 1019

Table 2.  Linear Mixed Models Predicting Changes in Spouses’ Coping Over 2
Years According to Spouse Baseline Coping Scores and Time Since MI.
95% confidence
interval

Lower Upper
Parameter Estimate SE df t p bound bound

Predictors: Baseline coping, time, and interaction

 Intercept −12.165 4.586 761.0 −2.653 .008 −21.168 −3.162
  Baseline coping 1.135 0.046 761.0 24.728 .000 1.045 1.226
 Time 14.705 2.263 620.7 6.498 .000 10.261 19.149
  Baseline coping −0.164 0.023 621.1 −7.228 .000 −0.208 −0.119
× Time
Predictors: Time since MI, time, and interaction
 Intercept 98.406 1.467 848.5 67.070 .000 95.526 101.285
  Recent MI 4.004 2.125 852.1 1.884 .060 −0.168 8.176
 Time −0.762 0.542 507.4 −1.407 .160 −1.827 0.302
  Recent MI × −1.825 0.809 516.7 −2.257 .024 −3.413 −.236
Time

Note: MI = myocardial infarction. Recent MI < 1.5 years since MI.

140
Higher baseline coping
120
Spouse coping

100
80
Lower baseline coping
60
40
20
0
Baseline 1 year 2 years

Figure 1.  Changes in spouse coping according to spouse baseline coping scores.
Note: Higher baseline spouse coping was graphed at 1 standard deviation above the mean and
lower baseline coping was 1 standard deviation below the mean of the baseline coping score. The
estimated score difference of coping scores between baseline and 2 years was 8.079 for spouses
who had higher baseline coping and 2.213 for those who had lower baseline coping score.

which indicated that changes in total coping score depended on spouse’s

baseline coping (see Figure 1). Higher baseline coping was graphed at 1

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

1020 Western Journal of Nursing Research 35(8)

103
102
Experienced MI recently
Spouse coping
101
100
99
98
Experienced MI long ago
97
96
95
94
Baseline 1 year 2 years

Figure 2.  Changes in spouses’ coping according to time since MI.

Note: MI = myocardial infarction. Experienced MI recently is time since an MI is less than 1.5
years and long ago is greater than 1.5 years. The estimated score difference of coping scores
between baseline and 2 years was 5.174 for spouses of patients who experienced MI more
recently and 3.349 for those who experienced MI long ago.

standard deviation above the mean, and lower baseline coping was 1 standard
deviation below the mean of the baseline coping score.
The time since the most recent MI was a significant predictor of the
spouse’s total coping. The best model included time since the most recent MI,
and it significantly improved the model fit compared with the unconditional
growth model, χ2(df = 3) = 399.475, p < .01. The significant interaction
between time and time since MI revealed that total coping deteriorated more
rapidly over time (parameter estimate = −1.825, t = −2.257, p = .024) for
spouses of patients who experienced an MI more recently (see Table 2 and
Figure 2) than for those who experienced MIs longer ago.

Discussion
The experience of an MI is a source of stress for patients and their family
members, and the cardiac event may be viewed as a family crisis (Van Horn
et al., 2002). An MI influences family relationships and can disrupt family
functioning and dynamics (Hildingh, Fridlund, & Lidell, 2007). This study
examined the longitudinal changes in coping of spouses of post-MI patients.
We found that the total coping score significantly decreased over time for
spouses of post-MI patients. On average, older spouses cope better than

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

Son et al. 1021

younger spouses. The average coping scores were lower for spouses who had
higher anxiety or depression scores. Baseline coping scores contributed to the
changes in coping, which indicated that coping decreased over time for
spouses who had higher baseline coping scores. Coping decreased more rap-
idly over time for spouses of patients who experienced MI more recently.
The mean of the spouses’ total coping scores was relatively high (M =
98.61) as compared with the norm (M = 93.3; H. I. McCubbin & Thompson,
1991). This finding may be related to the good prognosis after the MI and that
most patients (97%) had a mild degree of heart failure. Most patients had
experienced the cardiac event a long time ago (median time since an MI = 1.5
years), which also may have contributed to the high coping scores. The
spouse’s age did not contribute to the change in coping, but younger spouses
had lower coping scores on average. The finding that older spouses cope better
is consistent with the Yeh et al. (1994) study, but contradictory to the results of
Chui and Chan (2007), Santavirta et al. (2001), and Casarini et al. (2009). This
finding may be due to the difference in mean age (M = 44.9 in Chui & Chan’s,
2007, study), the use of different instruments to measure coping (Folkman and
Lazarus’s Ways of Coping Questionnaire was used in Santavirta et al., 2001),
or the difference in study populations (patients intensive care unit in the study
of Casarini et al., 2009). In addition, spouse gender was not associated with
either overall coping or changes in coping. This finding is consistent with
some cross-sectional studies of Chui and Chan and Santavirta et al. Another
descriptive study found that male spouses coped better (Yeh et al., 1994), but
the result is not comparable with the present study because of the small sample
size (n of male spouses = 10) in Yeh’s study.
Higher spouse baseline anxiety and higher spouse baseline depression
predicted lower overall coping scores. The findings of the relationship
between lower coping scores and psychological distress were consistent with
other studies that found that inappropriate coping was related to increased
psychological distress in spouses of cardiac patients (Garnefski et al., 2009;
Son, Thomas, et al., 2012; Son, Friedmann, et al., 2012b). In the present
study, the spouse’s psychological distress (anxious or depressed) did not con-
tribute to changes in coping, which was contradictory to a qualitative study
that spouses using denial coping experienced an increase in hopelessness and
depression over 12 months post MI (Salminen-Tuomaala et al., 2012). It may
be related to the time elapsed since the MI or different sample size (28 vs. 442
spouses in the present study).
Coping significantly decreased over 2 years for spouses who had higher
baseline coping scores (change in estimated coping score = 8.079), whereas
coping stayed relatively the same for those who had lower baseline coping

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

1022 Western Journal of Nursing Research 35(8)

scores (change in estimated coping score = 2.213). The difference of changes

in coping between the two groups may be explained by the Lazarus and
Folkman’s (1984) model. According to the model, a stressful event requires
coping to regulate distress. Spouses might adapt to the stressor over time. As
a result, they might need to use less coping strategies.
There are several limitations in the present study. First, all participants
were trained in CPR or in their use of defibrillator. The changes in coping
may not be the same in post-MI patient couples who are untrained in resusci-
tation. In addition, most of the patients did not have symptoms of heart failure
(NYHA Class I or II). The time since the most recent MI was 1.5 years. These
three factors limit generalizability. In addition, the questionnaires measuring
coping and psychological distress were based on self-report, which are sim-
ple and practical to measure at busy clinical settings but may overestimate or
underestimate the findings. This study examined the changes in total coping
scores. For any future study, the changes in different aspects or types of cop-
ing must be examined.
As a longitudinal study, this study shows the trajectories of changes in
coping and the factors influencing the changes in coping for spouses of post-
MI patients. This study included 442 patient couples in multiple sites in four
countries and which included male and female spouses. Most of the partici-
pants experienced MI a relatively long time ago. Even in this population,
coping decreased more rapidly for spouses of patients who experienced MI
more recently. This finding indicates that the continuous assessment of cop-
ing should be immediately followed early after the MI. Attention should be
paid to the spouses who experienced MI more recently.
Our study shows that spouses of post-MI patients have difficulty coping
long after the cardiac event. Few studies have examined how to improve
spouse coping. Most nursing interventions center on patient concerns and not
on helping the spouse cope. Nurses can enhance spouses’ coping by refram-
ing patient concerns as couple issues whenever feasible (Martire, Schulz,
Keefe, Rudy, & Starz, 2008). Interventions targeting on couple issues with
spouses and patients with osteoarthritis and pain increases spousal support
and decreased symptoms of depression in the patients (Martire, Schulz,
Helgeson, Small, & Saghafi, 2010). Meeting the needs of the patient and the
spouse may improve communication and coping. Interviews of MI patient
couples showed that the spouses focused on evaluating the MI as more posi-
tive in the absence of a poorer outcome whereas the patients focused on
regaining control of their lives (Panagopoulou, Triantafyllou, Mitziori, &
Benos, 2009). This supports our study findings of spouses’ difficulties in cop-
ing after an MI.

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

Son et al. 1023

Nurses assess the physical and psychological needs of the patient after an
MI. It is crucial to assess spouses coping after the event. The nurses could
identify spouses who are coping poorly. Interventions including support
groups and educational programs for spouses may be helpful to improve cop-
ing by modeling more positive coping strategies. Future research is needed to
establish the specific coping strategies that are most beneficial when used by
spouses. This would provide direction for future interventions.

Authors’ Note
The contents of this study were researcher-initiated proposals. The authors are solely
responsible for the study design, data collection, analysis, interpretation, manuscript
preparation, and decision to publish. The researchers have complete access to all data.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: The PRHAT and HAT studies were
partially supported by Grants R01 NR008550 from the National Institute of Nursing
Research, National Institutes of Health, Bethesda, MD, United States, and Grant
UO1-HL67972 from the National Heart, Lung, and Blood Institute, National Institutes
of Health, Bethesda, MD, United States.

References
Arefjord, K., Hallaraker, E. L. I., Havik, O. E., & Maeland, J. G. (1998). Life after a
myocardial infarction—The wives’ point of view. Psychological Reports, 83 (Pt. 2),
1203-1216. doi:10.2466/pr0.1998.83.3f.1203
Bardy, G. H., Lee, K. L., Mark, D. B., Poole, J. E., Toff, W. D., Tonkin, A. M., &
Schron, E. B. (2008). Home use of automated external defibrillators for sudden
cardiac arrest. New England Journal of Medicine, 358, 1793-1804. doi:10.1056/
NEJMoa0801651
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). BDI-II, Beck Depression Inventory:
Manual. Boston, MA: Harcourt Brace.
Casarini, K. A., Gorayeb, R., & Filho, A. B. (2009). Coping by relatives of critical
care patients. Heart & Lung, 38, 217-227.
Chui, W. Y. Y., & Chan, S. W. C. (2007). Stress and coping of Hong Kong Chinese
family members during a critical illness. Journal of Clinical Nursing, 16, 372-381.
doi:10.1111/j.1365-2702.2005.01461.x

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

1024 Western Journal of Nursing Research 35(8)

Garnefski, N., Kraaij, V., Schroevers, M. J., Aarnink, J., van der Heijden, D. J., van
Es, S. M., & Somsen, G. A. (2009). Cognitive coping and goal adjustment after
first-time myocardial infarction: Relationships with symptoms of depression.
Behavioral Medicine, 35, 79-86. doi:10.1080/08964280903232068
Hedeker, D., & Gibbons, R. D. (1997). Application of random-effects pattern-mixture
models for missing data in longitudinal studies. Psychological Methods, 2, 64-78.
doi:10.1037/1082-989x.2.1.64
Hildingh, C., Fridlund, B., & Lidell, E. (2007). Women’s experiences of recovery
after myocardial infarction: A meta-synthesis. Heart & Lung, 36, 410-417.
Hotz, S. B., Cazabon, A. M., O’Farrell, P., & Robbins, B. (1991). Adjustment to heart
disease: Helping families cope. Canadian Family Physician, 37, 641-647.
Jackson, A. M., McKinstry, B., & Gregory, S. (2011). The influence of significant
others upon participation in cardiac rehabilitation and coronary heart disease self-
help groups. International Journal of Therapy and Rehabilitation, 18, 450-461.
Kreft, I. G. G. (1996). Are multilevel techniques necessary? An overview, includ-
ing simulation studies. Unpublished manuscript, California State University, Los
Angeles.
Kristofferzon, M.-L., Löfmark, R., & Carlsson, M. (2005). Coping, social support
and quality of life over time after myocardial infarction. Journal of Advanced
Nursing, 52, 113-124. doi:10.1111/j.1365-2648.2005.03571.x
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY:
Springer.
Martire, L., Schulz, R., Helgeson, V., Small, B., & Saghafi, E. (2010). Review and
meta-analysis of couple-oriented interventions for chronic illness. Annals of
Behavioral Medicine, 40, 325-342. doi:10.1007/s12160-010-9216-2
Martire, L., Schulz, R., Keefe, F. J., Rudy, T. E., & Starz, T. W. (2008). Couple-
oriented education and support intervention for osteoarthritis: Effects on spouses’
support and responses to patient pain. Families, Systems, & Health, 26, 185-195.
doi:10.1037/1091-7527.26.2.185
McCubbin, H. I., & Thompson, A. I. (1991). Family assessment inventories for
research and practice. Madison: University of Wisconsin–Madison.
McCubbin, M. A., & McCubbin, H. I. (1987). Family assessment inventories for
research and practice. Madison: University of Wisconsin–Madison.
McLean, S., & Timmins, F. (2007). An exploration of the information needs of spouse/
partner following acute myocardial infarction using focus group methodology.
Nursing in Critical Care, 12, 141-150. doi:10.1111/j.1478-5153.2007.00215.x
Nyamathi, A., Jacoby, A., Constancia, P., & Ruvevich, S. (1992). Coping and adjust-
ment of spouses of critically ill patients with cardiac disease. Heart & Lung, 21,
160-166.
O’Farrell, P., Murray, J., & Hotz, S. B. (2000). Psychologic distress among spouses
of patients undergoing cardiac rehabilitation. Heart & Lung, 29, 97-104.
doi:10.1016/s0147-9563(00)90004-9
Panagopoulou, E., Triantafyllou, A., Mitziori, G., & Benos, A. (2009). Dyadic benefit
finding after myocardial infarction: A qualitative investigation. Heart & Lung,
38, 292-297.

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015

Son et al. 1025

Salminen-Tuomaala, M., Åstedt-Kurki, P., Rekiaro, M., & Paavilainen, E. (2012).

Spouses’ coping alongside myocardial infarction patients. European Journal of
Cardiovascular Nursing. doi:10.1177/1474515111435603
Santavirta, N., Kettunen, S., & Solovieva, S. (2001). Coping in spouses of patients
with acute myocardial infarction in the early phase of recovery. Journal of
Cardiovascular Nursing, 16, 34-46.
Son, H., Friedmann, E., & Thomas, S. A. (2012a). Application of pattern mixture
models to address missing data in longitudinal data analysis using SPSS. Nursing
Research, 61, 195-203.
Son, H., Friedmann, E., & Thomas, S. A. (2012b). Changes in depressive symptoms
in spouses of post myocardial infarction patients. Asian Nursing Research, 6,
158-165.
Son, H., Thomas, S. A., & Friedmann, E. (2012). The association between psycholog-
ical distress and coping patterns in post-MI patients and their partners. Journal of
Clinical Nursing, 21, 2392-2394. doi:10.1111/j.1365-2702.2012.04165.x
Spielberger, C. D., & Gorsuch, R. L. (1983). Manual for the State-Trait Anxiety
Inventory (Form Y) (“Self-Evaluation Questionnaire”). Palo Alto, CA:
Consulting Psychologists Press.
Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). STAI manual for the
State-Trait Anxiety Inventory (“Self-Evaluation Questionnaire”). Palo Alto, CA:
Consulting Psychologists Press.
Thomas, S. A., Friedmann, E., Lee, H.-J., Son, H., & Morton, P. G., & the HAT
Investigators. (2011). Changes in anxiety and depression over 2 years in medi-
cally stable patients after myocardial infarction and their spouses in the Home
Automatic External Defibrillator Trial (HAT): A longitudinal observational
study. Heart, 97, 371-381. doi:10.1136/hrt.2009.184119
Tluczek, A., Henriques, J. B., & Brown, R. L. (2009). Support for the reliability and
validity of a six-item state anxiety scale derived from the State-Trait Anxiety
Inventory. Journal of Nursing Measurement, 17, 19-28.
Tomberg, T., Toomela, A., Ennok, M., & Tikk, A. (2007). Changes in coping
strategies, social support, optimism and health-related quality of life follow-
ing traumatic brain injury: A longitudinal study. Brain Injury, 21, 479-488.
doi:10.1080/02699050701311737
Van Horn, E., Fleury, J., & Moore, S. (2002). Family interventions during the trajec-
tory of recovery from cardiac event: An integrative literature review. Heart &
Lung, 31, 186-198.
Wang, W., Thompson, D. R., Chair, S. Y., & Twinn, S. F. (2008). Chinese cou-
ples’ experiences during convalescence from a first heart attack: A focus
group study. Journal of Advanced Nursing, 61, 307-315. doi:10.1111/j.1365-
2648.2007.04529.x
Whitsitt, D. R. (2012). Coping strategies and adaptation to coronary artery bypass
surgery as experienced by three couples. Heart & Lung, 41, 350-359.
Yeh, M., Gift, A., & Soeken, K. (1994). Coping in spouses of patients with acute
myocardial infarction in Taiwan. Heart & Lung, 23, 106-111.

Downloaded from wjn.sagepub.com at UNIV OF WISCONSIN OSHKOSH on June 8, 2015