Journal of Advanced Nursing, 1999, 30(2), 479±488 Issues and innovations in nursing practice

Myocardial infarction, spouses' reactions

and their need of support
Sinikka Kettunen RN MSci
Postgraduate Student, Department of Public Health, University of Helsinki,
Helsinki

Svetlana Solovieva PhD

Researcher, Department of Orthopaedics and Traumatology,
Helsinki University Central Hospital, Helsinki

Ritva Laamanen PhD

Senior Lecturer, Department of Public Health, University of Helsinki, Helsinki

and Nina Santavirta PhD

Researcher, Fourth Department of Medicine, Helsinki University
Central Hospital and Orton Research Institute, Helsinki, Finland

Accepted for publication 22 October 1998

KETTUNEN S., SOLOVIEVA S., LAAMANEN R. & SANTAVIRTA N. (1999) Journal of

Advanced Nursing 30(2), 479±488
Myocardial infarction, spouses' reactions and their need of support
The purpose of this study was to investigate the impact of myocardial
infarction (MI) on survivor's spouses in terms of fears and symptoms during the
patient's recovery period. In addition the researchers sought to evaluate the
in¯uence of the support by the health care professionals on spouses' adjust-
ment. A total of 57 Finnish spouses participated in the study. Of the spouses 47
were female and 10 were male. Data were collected using a structured
questionnaire distributed to the spouses at a rehabilitation session at 2 weeks±
4 months after the MI. Topics covered included fears, emotional and physical
symptoms and the spouses' experience of the suf®ciency of the support that
they had received from health care professionals during the patient's recovery.
Data were analysed using quantitative methods including descriptive statistics
and multivariate methods. Fears and symptoms were classi®ed using factor
analyses. For fears two factors emerged which were named: disease-related fears
and personal fears. In respect of symptoms experienced by the spouse three
factors emerged: one which describes emotional distress, one which describes
dysfunction and one describing spouses' own vulnerability. The signi®cantly
most intensively experienced fears by the spouses were the disease-related fears
followed by the personal fears. The most frequently reported symptom was
dysfunction followed by emotional distress and vulnerability. In regression
analysis emotional distress was predicted by personal fears, support from the
health care professionals, the shock reaction, spouse's own health and time after

Correspondence: Nina Santavirta, Orton Research Institute,

Invalid Foundation, Tenholant. 10, FIN-00280 Helsinki, Finland.

Ó 1999 Blackwell Science Ltd 479

S. Kettunen et al.

MI. Dysfunction was predicted by spouse's own health and personal fears
whereas vulnerability was predicted by spouse's own health and support from
the health care professionals. Study ®ndings show that in the planning of the
care of patients with MI it is important to attend to the reactions and needs of
spouses. Their resources are required for optimal rehabilitation of the patient.

Keywords: crisis theory, fears, myocardial infarction, nursing research,

spouse's reaction, support from health care professionals, symptoms

priority. Informational needs include receiving speci®c

INTRODUCTION AND BACKGROUND
Despite major information campaigns and wide-spread
patient educational programmes, the number of patients
with myocardial infarction (MI) still remains high in
Finland. The mortality rate due to MI was 13 900 persons
in 1995. In a population of approximately 5 million the
number of patients with coronary heart disease entitled to
free or nearly free medicines under national health insur-
ance was 153 000 in 1993 compared to 166 137 (32á4% of
the population) in 1996 (Statistical Yearbook of the Social
Insurance Institution 1996 pp. 155±157).
A MI in a family member precipitates a psycho-social
crisis for the family, in particular for the spouse. While the
patient directly experiences the cardiac event, the spouse
lives through a parallel experience of his or her own that
may equal the patient's in intensity (Marsden & Dracup
1991). Gillis (1984) found that the spouses of patients
hospitalized for cardiac surgery reported signi®cantly
higher subjective stress than the patients. The spouses'
worries focus on loss of partner, the possibility of another
MI, possible death, recovering, ®nancial problems,
husband's future career prospects, patient's ability to re-
enter the marital relationship and resume previous social
activities, and the levels of residual disability (Skelton &
Dominian 1973, Bedsworth & Molen 1982, Thompson &
Cordle 1988, Miller & Wikoff 1989, Shan®eld 1990). The
period when the patient is discharged from the hospital is
particularly stressful for the spouse, especially for the
wife, who often feels vulnerable, unsupported and over-
protective towards her husband (Thompson & Cordle
1988). Earlier studies have found that the symptoms
experienced by the spouses were high levels of anxiety,
depression, tension, fatigue, sleeping and appetite distur-
bances and psychosomatic symptoms (Skelton &
Dominian 1973, Mayou et al. 1978a, b, Hentinen 1983,
Gillis 1984, Hilbert 1985, Thompson & Cordle 1988,
Shan®eld 1990, Coyne & Smith 1991, Hilbert 1993).
The perceived needs and concerns of family members
during the crisis of illness have been well explored
(Turton 1998, Hampe 1975, Molter 1979, Hentinen 1983,
Daley 1984, Leske 1986, Norris & Grove 1986, Hickey
1990, Moser et al. 1993). Informational needs have been
ranked in the majority of the studies as having the highest
facts about the patient and about patient progress and
prognosis, and receiving honest information in under-
standable terms (Moser et al. 1993). Other needs which
have been reported by family members were: need for reas-
surance and relief of anxiety, need for hope, need for
comfort and support from family members and need
for acceptance, comfort and support from health care
professionals. Although, the informational needs and
emotional support have been emphasized by the spouses
in numerous studies, the majority of their reported
support did not come from health care professionals,
rather from relatives and close friends (Hentinen 1983). In
a recent phenomenological study Theobald (1997) summa-
rizes the concerns of the spouses as crushing uncertainty,
overwhelming emotional turmoil, need for support, lack
of information which heightened anxiety, and acceptance
of life-style changes.
Since the spouse has a major role in the recovery of the
MI patient and family relations are important determi-
nants of the patient's rehabilitation process (Skelton &
Dominian 1973, Mayou et al. 1978a, Bramwell 1986,
Waltz 1986, Owen 1987, Beach et al. 1992) spouses' crisis
reaction to the acute cardiac event became an important
area of clinical concern (Marsden & Dracup 1991).
According to Cullberg (1993) recovering from a trau-
matic crisis is a dynamic process which passes through
four stages: the shock phase, the appraisal phase, the
elaboration phase and the reorientation phase. These
stages constitute the natural course of recovering. The
duration of the stages varies from individual to individual.
Complications in the process of healing occur when the
person cannot work through each stage and proceed to the
next phase in adequate time. The duration of the shock
phase is a few hours to a couple of days, followed by the
appraisal phase, which can be extended to several
months. For the ®nal restructuring phase and for long-
term management with a crisis the second stage is of great
importance. During this period the person gradually
becomes aware of the consequences of the event and
experiences deep feelings of fear, worry, grief, guilt and
anxiety. This is also the period when the person needs to
receive help and support from close relatives, friends and
from health care professionals.

480 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488
Issues and innovations in nursing practice
PURPOSE AND AIMS OF THE STUDY
The purpose of this study was to investigate the impact of
myocardial infarction (MI) on survivors' spouses in terms
of fears and symptoms during the patient's recovery
period. In addition the researchers sought to evaluate the
in¯uence of the support by the health care professionals
on spouses' adjustment. The more speci®c aims were to:
(a) determine what types of fears and symptoms the
spouses reported that they experienced during the early
recovery period; (b) investigate the predictors of fears and
symptoms reported by the spouses; and (c) determine the
role of the support of health care professionals in spouses'
adjustment to the crisis.
METHODOLOGY
Participants and ethics
Eighty spouses of patients who recovered after MI agreed
to participate in the study. The patients were treated for
acute myocardial infarction in two general hospitals in the
Helsinki City area of Finland, during 1997. After discharge
from the hospital the patients and their spouses were
referred to a cardiac rehabilitation nurse. Data were
collected by structured questionnaires which were distrib-
uted during April 1997 to October 1997 to 80 spouses
participating in such a rehabilitation session, 2 weeks±
4 months after their partner's MI. The inclusion criterion
was that the cardiac patient had suffered from his or her
®rst MI. Of the spouses, 61 (76%) returned the question-
naire, one was not included because it was ®lled in by the
patient's daughter and three others were returned without
being ®lled in. A total of 57 (71%) spouses participated in
the study. The Declaration of Helsinki (1989) was
followed throughout the study, which was approved by
the local ethics committee. All subjects participated on a
voluntary basis.
Description of the sample
Among 57 participants, 47 (82%) were women and 10
(18%) were men. The mean age of the spouses was
57 years (range 28±83). According to the classi®cation of
the spouses' occupation that they had at that time or had
before retirement, 33% (n ˆ 19) of the participants were
blue-collar workers whereas 29% (n ˆ 16) were white-
collar workers; 33% were manual workers (n ˆ 19). For
more than half of the patients (58%, n ˆ 33) the
infarction came suddenly without any previous heart
symptoms. Twelve patients (21%) had a severe infarction
with heart insuf®ciency, 13 patients (23%) had severe
infarction without heart insuf®ciency and 24 patients
(42%) had a small infarction. For eight patients (14%) the
grade of the severity of the infarction was unknown by the
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488
Myocardial infarction
spouse. According to the spouses 65% (n ˆ 37) of the
patients had recovered quite well and 25% (n ˆ 14) had
recovered very well, six (10%) patients had slight prob-
lems with recovering. The duration of the marriage was on
average 30 years and all spouses reported that the quality
of their relationship was close or very close. When asked
about life events during the last 12 months 14 (25%)
spouses had experienced some kind of negative life event,
e.g. unemployment, death or illness of close person or
falling ill themselves.
Design and measures
The questionnaire was developed by the authors with the
aim of examining the feelings and experiences of spouses
of MI survivors. The list of the statements regarding fears,
symptoms and support was constructed based on a careful
literature review and developed in correspondence with
instruments used in previous research concerning
spouses' reaction to MI (Hilbert 1985, Riegel & Dracup
1992, Moser et al. 1993). In particular, the instruments
described by Thompson & Cordle (1988) and Hentinen
et al. (1980) have served as models for the current ques-
tionnaire since they seemed to have assessed the spouses'
worries and symptoms in a comprehensive way. The
following set of questions were included in the question-
naire: demographic data, self-rated health of the spouse,
questions concerning the marriage (the duration of the
marriage and the quality of the relationship, number of
children), data concerning the infarction, spouse's life
events during last 12 months, spouse's shock reaction
(1 ˆ severely shocked, 4 ˆ not shocked at all).
Fears
The fears of the spouses of MI survivors were assessed
listing 13 different types of fears (recovering problems,
further MI, further investigations, problems in marriage,
sexual problems, changes with family life, patient's career
prospects, patient's leisure and social activities, loosing
own strength, overprotection, ®nancial problems and
anxiety of signi®cant others). The 4-point response scale
for each statement was anchored with not at all (1) and
very much (4). The fears listed by Thompson & Cordle
(1988) were thus completed in the current study by
recovering problems, problems in marriage, sexual
problems, changes in family life, loosing own strength,
overprotection and anxiety of signi®cant others.
Symptoms
The symptoms of the spouses were assessed listing 13
statements (fatigue, sleeping disturbance, depressive
mood, tearfulness, anxiety, unsafety, dependence, sexual
unwillingness, listlessness, eating disorders, tension, new
physical symptoms) on a four-grade scale with 1 ˆ not at
all, 4 ˆ a lot. Anxiety and unsafety were added to the
481
S. Kettunen et al.

Table 1 Factor solution regarding fears Table 2 Factor solution regarding symptoms

Items Loadings Items Loadings

Disease-related fears Emotional distress

Further MI 0á68 Depressive mood 0á85
Recovering problems 0á64 Anxiety 0á78
Anxiety of signi®cant others 0á44 Tearfulness 0á75
Overprotection 0á40 Listlessness 0á73
Eigenvalue 3á49 Unsafety 0á64
Chronbach's alpha 0á61 Tension 0á60
Sexual unwillingness 0á50
Personal fears
Eigenvalue 5á40
Problems with marriage 0á79
Chronbach's alpha 0á87
Sexual problems 0á68
Patient's career prospects 0á65 Dysfunction
Loosing own resources 0á45 Sleeping disturbance 0á88
Eigenvalue 1á29 Fatigue 0á75
Chronbach's alpha 0á83 Eigenvalue 1á30
Chronbach's alpha 0á71

Vulnerability
symptoms measured in the current study, as compared to New physical symptoms 0á78
those measured in Hentinen et al. (1980), whereas palpi- Dependence of others 0á72
tations was deleted from those mentioned in Thompson & Eigenvalue 1á10
Cordle (1988). Chronbach's alpha 0á61

Support from the health care professionals

The support was assessed using nine statements on a tion. Based on the factor solutions six sum-variables were
three-grade scale with 1 ˆ very insuf®cient, 2 ˆ adequate, created: personal fears, disease-related fears, emotional
3 ˆ very suf®cient. The statements were: understanding of distress, dysfunction, vulnerability and perceived suf®-
spouse's distress, talking about spouse's fears, comforting, ciency of support from health care professionals. The
encouraging, giving hope, showing interest in the close factor score for each sum-variable was calculated as a
relatives, willingness to discuss with close relatives, mean of the scores for the original items.
emphasizing positive things and supporting in practical
matters.
Statistical analysis
Factor analysis The BioMedical Data Processing (BMDP) Statistical Soft-
In order to test the validity of the instrument and to ware, V 7á1 (1994) was used to analyse the data. Cases with
exclude fears and symptoms not speci®c for this sample, missing data were excluded from further analysis. In order
factor analyses were conducted. A factor analysis was to reduce the amount of variables and to detect the
conducted within each of the following groups of vari-
ables: (a) fears, (b) symptoms and (c) support. Two factors
Table 3 Factor solution regarding perceived suf®ciency of
emerged regarding fears and they were named: disease-
support from health-care professionals
related fears and personal fears with eigenvalues equal
3á49 and 1á29, respectively. These two factors explained Items Loadings
73% of the variance (53% and 20%, respectively) of the 13
variables measuring the fears. In Table 1 the factor solu- Talking about the fears of spouse 0á89
tion of fears is presented. Regarding the symptoms Understanding the distress of spouse 0á88
experienced by the spouse three factors emerged: one Encouraging 0á88
which describes emotional distress (eigenvalue 5á40), Giving hope 0á88
one which describes dysfunction (eigenvalue 1á30) and Showing interest in close relatives 0á88
one describing own vulnerability (eigenvalue 1á10). These Willingness to talk with close relatives 0á88
Emphasizing positive things 0á88
three factors explained 61% of the variance of the 13
Comforting 0á87
variables assessing the symptoms. In Table 2 the factor
Supporting in practical matters 0á86
solution is presented. Regarding the support the spouses Eigenvalue 7á14
got from the health care professionals only one factor was Chronbach's alpha 0á97
found (eigenvalue 7á14). Table 3 presents the factor solu-

482 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488
Issues and innovations in nursing practice Myocardial infarction

Table 4 Fears experienced by spouses. Results are expressed as numbers and percentages

Severity

Fears Not at all A little Moderately Very much Total

Recovering problems 3(5%) 26(46%) 17(29%) 10(18%) 56(98%)

A further MI 6(10%) 26(46%) 14(24%) 10(18%) 56(98%)
Further investigations 24(42%) 29(51%) 3(5%) 1(2%) 57(100%)
Problems with marriage 35(61%) 17(29%) 5(10%) 0 57(100%)
Sexual problems 33(58%) 18(32%) 4(7%) 2(3%) 57(100%)
Changes with family life 39(68%) 13(23%) 4(7%) 1(2%) 57(100%)
Patient's career prospects 35(61%) 10(18%) 7(12%) 2(3%) 54(94%)
Patient's leisure activities 8(14%) 36(63%) 10(18%) 3(5%) 57(100%)
Patient's social activities 48(84%) 5(9%) 4(7%) 0 57(100%)
Loosing own strength 18(31%) 25(44%) 13(23%) 1(2%) 57(100%)
Overprotection 17(30%) 28(49%) 10(18%) 2(3%) 57(100%)
Financial 34(60%) 14(24%) 9(16%) 0 57(100%)
Anxiety of signi®cant others 19(33%) 23(40%) 14(24%) 1(2%) 57(100%)

structure of the variables concerning fears, symptoms and
support, factor analyses were conducted. Three different
factor procedures were done. The principal factor analysis
method was used for extracting the factors. The number of
factors was chosen based on Kaiser's criterion. Varimax
rotation was applied and loadings higher than 0á40 were
considered as signi®cant (Dillon & Goldstein 1984). The
Shapiro-Wilcoxon test was used for testing of normality.
The descriptive data were mean ‹ sd for normally distrib-
uted variables, median and range for skewed variables,
and frequency and percentages for ordinal variables. Due
to the skewed data non-parametric methods were used for
further analysis. For comparison between two groups the
Mann±Witney test was applied, and between several
groups the Kruskal±Wallis test was used. The relationship
between variables was measured by Spearman's rank
correlation coef®cient. Multiple linear regression analyses
with a stepwise procedure were used to determine the
predictors of fears and symptoms. Statistical signi®cance
was accepted if P < 0á05 (Munro & Page 1993).
RESULTS
Description of the fears and symptoms
experienced by spouses
The spouses reported that they experienced to some extent
(a little, moderately, very much) in chronological order the
following fears: recovering problems (93%, n ˆ 53), a
further MI (88%, n ˆ 50), fears of patient's leisure activ-
ities (86%, n ˆ 49), fears of overprotection (70%,
n ˆ 40) and anxiety of signi®cant others (69%, n ˆ 38)
(Table 4). The spouses experienced less fear regarding the
patient's social activity (16%, n ˆ 9), changes in family
life (32%, n ˆ 18), patient's career prospects (33%,
n ˆ 19), problems in the marriage (39%, n ˆ 22) and
®nancial problems (40%, n ˆ 23). The most frequently
reported symptoms experienced by spouses with the
different degree of severity were: fatigue (88%, n ˆ 50),
sleeping disturbance (80%, n ˆ 46), anxiety (79%,
n ˆ 45), tension (79%, n ˆ 45), depressive mood (76%,
n ˆ 43) and listlessness (70%, n ˆ 40) (Table 5).
Perceived suf®ciency of support from health care
professionals
Four spouses (7%) did not have any contact with health
care professionals when the MI patient was hospitalized.
Of the spouses, 17 (30%) had experienced that the
health care professionals were neglecting the spouses
and showing no interest in them. The spouses needs
regarding support from health care professionals were
unmet in a varying degree (Table 6). Some of the
spouses reported that they considered the following
types of support as totally insuf®cient: willingness of
the health care professionals to discuss problems with
them (19, 33%), talking about the fears of spouse,
showing interest in close relatives, and supporting in
practical matters (17, 30%). Understanding the distress
of the spouse was reported as very suf®cient by 21
(37%) spouses. Furthermore, 16 (28%) spouses reported
that they had got very suf®cient support regarding both
encouraging and giving hope.
Relationship between fears, symptoms,
perceived suf®ciency of support from health
care professionals and other variables
The signi®cantly most intensively experienced fears by
the spouses were the disease-related fears, followed by the

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488 483
S. Kettunen et al.

Table 5 Symptoms experienced by spouses. Results are expressed as numbers and percentages

Severity

Symptoms Not at all A little Moderately Very much Total

Fatigue 7(12%) 31(55%) 15(26%) 3(5%) 57(100%)

Sleeping disturbance 10(18%) 32(56%) 8(14%) 6(10%) 56(98%)
Depressive mood 13(22%) 36(64%) 6(10%) 1(2%) 56(98%)
Tearfulness 25(44%) 21(37%) 9(16%) 2(3%) 57(100%)
Anxiety 11(19%) 30(53%) 14(24%) 1(2%) 56(98%)
Unsafety 18(32%) 28(49%) 9(16%) 2(3%) 57(100%)
Dependence 29(51%) 25(44%) 3(5%) 0 57(100%)
Sexual unwillingness 25(44%) 27(47%) 1(2%) 2(3%) 55(96%)
Listlessness 17(30%) 27(47%) 10(18%) 3(5%) 57(100%)
Loss of appetite 40(71%) 15(26%) 2(3%) 0 57(100%)
Increase of appetite 47(82%) 9(16%) 1(2%) 0 57(100%)
Tension 11(19%) 30(53%) 14(24%) 1(2%) 56(98%)
New physical symptoms 34(60%) 19(33%) 3(5%) 1(2%) 57(100%)

personal fears (Md ˆ 2á0, range 1±3á7 vs. Md ˆ 1á4, range
1±3á2, P < 0á00005).
In the regression analysis negative life events and recov-
ering were signi®cant predictors of disease-related fears
(R2 ˆ 0á32, F ˆ 11á8, P < 0á001, Table 7). Additionally a
mild negative correlation was found between age and
disease-related fears (r ˆ )0á27, P ˆ 0á045), for women
this relationship was stronger (r ˆ )0á31, P ˆ 0á03).
Regarding personal fears there were gender and age
differences found: younger females experienced more
fears than older ones (r ˆ )0á41, P ˆ 0á004). In the
regression analysis age, negative life event and perceived
suf®ciency of support from health care professionals were
signi®cant predictors of personal fears (R2 ˆ 0á35,
F ˆ 8á8, P < 0á001, Table 7).
The severity of the infarction did not in¯uence the
spouse's shock reaction or the strength of the spouse's
fears. A statistically signi®cant relationship was found
between the shock reaction and the disease-related fears
(r ˆ ±0á27, P ˆ 0á04), the more shocked the spouses
were, the stronger fears they experienced.
There was a signi®cant positive correlation between
disease-related and personal fears (r ˆ 0á33, P ˆ 0á01).
There were signi®cant differences in reporting of symp-
toms experienced by spouses (P < 0á01). The most
frequently reported symptom was dysfunction (Md 2á0,
range 1±4) followed by emotional distress (Md 1á9, range
1±3á3) and vulnerability (Md 1á5, range 1±3).
Emotional distress, dysfunction and vulnerability were
positively correlated (r ˆ 0á54, P < 0á00005; r ˆ 0á47,
P ˆ 0á0002; r ˆ 0á44, P ˆ 0á0006, respectively).
In regression analysis emotional distress was predicted
by personal fears, perceived suf®ciency of support from
health care professionals, shock reaction, spouse's own
health and time after infarction (R2 ˆ 0á58, F ˆ 11á1,
P < 0á001, Table 8); dysfunction was predicted by spou-

Table 6 Perceived suf®ciency of support from health care professionals. Results are expressed as numbers and percentages

Grade of suf®ciency

Totally Very
Type of support insuf®cient Adequate suf®cient Total

Understanding the distress of spouse 10(17%) 22(39%) 21(37%) 53(93%)

Talking about the fears of spouse 17(30%) 17(30%) 14(24%) 48(84%)
Comforting 14(25%) 23(40%) 15(26%) 52(91%)
Encouraging 15(26%) 22(39%) 16(28%) 53(93%)
Giving hope 13(23%) 23(40%) 16(28%) 52(91%)
Showing interest in close relatives 17(30%) 21(37%) 14(24%) 52(91%)
Willingness to talk with close relatives 19(33%) 21(37%) 13(23%) 53(93%)
Emphasizing positive things 11(19%) 29(51%) 13(23%) 53(93%)
Supporting in practical matters 17(30%) 24(42%) 12(21%) 53(93%)

484 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488
Issues and innovations in nursing practice Myocardial infarction

Table 7 Results of multiple linear regression analysis on fears

Variables Total R2 Change in R2 F Beta

Dependent: Disease-related fears 0á32 11á8

Predictors
Negative life event 0á20 0á48**
Recovering 0á11 )0á38*

Dependent: Personal fears 0á35 8á8

Predictors
Age 0á20 )0á36*
Support1 0á09 )0á32*
Negative life event 0á05 0á28*

*P < 0á05, **P < 0.01, ***P < 0.001;

1
Perceived suf®ciency of support from health care professionals.

se's own health and personal fears (R2 ˆ 0á30, F ˆ 9á3,
P < 0á001, Table 8) and vulnerability was predicted by
spouse's own health and perceived suf®ciency of support
from the health care professionals (R2 ˆ 0á28, F ˆ 8á3,
P < 0á001, Table 8).
DISCUSSION
Several interesting results were found in this study, which
was mainly focused on the relationships between spouse's
fears, perceived suf®ciency of support from health care
professionals and spouse's management with MI of their
partner. Apparently Cullberg (1993) was right when he
described the appraisal phase of a crisis as a period of
emotional turmoil. All spouses in this study reported a
wide range of emotions to live through and to cope with
after their partner's MI. The most frequently recognized
fears were on the item level: recovering problems, a
further MI, fears of patient's leisure activities and fears of
overprotection. This result is broadly in agreement with
those of previous studies (Skelton & Dominian 1973,
Bedsworth & Molen 1982, Thompson & Cordle 1988,
Miller & Wikoff 1989, Shan®eld 1990). However, most of
the Finnish spouses did not fear ®nancial problems or
problems concerning the patient's career prospects as was
the case in several corresponding American studies
(Shan®eld 1990, Coyne & Smith 1991). This might partly
be due to the solid state welfare system with national
sickness allowance guaranteed for every citizen. Also, the
fact that some of the patients were retired before the MI
had an in¯uence on this result. An important result to
note was that the severity of the infarction did not

Table 8 Results of multiple linear regression analysis on symptoms

Variables Total R2 Change in R2 F Beta

Dependent: Emotional distress 0á58 11á1***

Predictors
Personal fears 0á29 0á48***
Support1 0á12 )0á42**
Shocked reaction 0.05 )0á36*
Spouse's own health 0á06 )0á39*
Time after infarction 0á05 0á33*

Dependent: Dysfunction 0á30 9á3***

Predictors
Spouse's own health 0á20 )0á49***
Personal fears 0á10 0á36*

Dependent: Vulnerability 0á28 8á3***

Predictors
Spouse's own health 0á19 )0á40**
Support1 0á09 )0á34*

*P < 0á05, **P < 0.01, ***P < 0.001;

1
Perceived suf®ciency of support from health care professionals.

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488 485
S. Kettunen et al.
determine the spouse's shock reaction or in¯uence the
strength of the fears. A shock reaction does not follow a
rational pattern with evaluation of the severity of the event
and a corresponding reaction. Rather it is individual and
based on several factors such as personality, previous
experiences, knowledge and education. For health care
professionals who spontaneously focus their attention on
the more severe patients and their spouses it is good to bear
in mind that all spouses need attention, also the spouses of
those patients who have a milder infarction. Fatigue and
sleeping disturbances, which are typical stress reactions for
the appraisal phase, were the most commonly reported
symptoms in this study, followed by anxiety, tension and
listlessness. This result corresponds with previous ®ndings
(Skelton & Dominian 1973, Mayou et al. 1978a, Hentinen
1983, Gillis 1984, Hilbert 1985, 1993, Thompson & Cordle
1988, Shan®eld 1990). Generally, the spouses in this study
did identify a wide range of fears and symptoms, but the
intensity of the reaction was not very strong, either for fears
or for symptoms, which can be seen from the median values
reported for the fear and symptom factors.
Based on the results of factor analysis the fears experi-
enced by the spouses were classi®ed into two groups:
disease-related and personal fears, with disease-related
fears dominating. These two groups of fears were related,
the more disease-related fears the spouses experienced the
more personal fears they had or vice versa. The symptoms
were classi®ed into three groups: emotional distress,
dysfunction and vulnerability. The same pattern of
relations identi®ed for fears, was also found regarding
symptoms. The fears combined into the disease-related
factor were most frequently reported and the severity of
these fears were related to age, the older the spouses the
more severe were their worries regarding the patient's
recovery. Regarding age, gender and fears we found that
the younger female spouses had more personal fears than
disease-related fears. This result can be considered to be
natural, with older age concerns regarding health become
more prominent.
In regression analysis regarding fears and symptoms our
attempt was to identify the factors in¯uencing on spouse's
fears and symptoms. A negative life event experienced
during the last year is a factor to keep in mind when
dealing with spouses of MI survivors, since this appeared
as a signi®cant predictor of both types of fears. The
previously experienced crisis seems to have consumed the
mental strength of the spouse and there is a risk that a new
crisis, the MI, can be overloading for the spouse.
Regarding predictors of symptoms the spouse's
own health was a signi®cant predictor of all types of
symptoms. Furthermore, the combination of the reduction
of the spouse's own health and dissatisfaction with the
support from the health care professionals can exacerbate
the spouse's dif®culties in managing the patient's MI. This
results are important since the spouse is the key person in
486 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488
the process of facilitating necessary life-style changes for
the patient (Beach et al. 1992) and therefore the resources
of the spouse are of utmost signi®cance.
In 1973 Skelton and Dominian concluded that spouses'
emotional distress can be alleviated by help and support
from health care professionals. Generally, on the item level
the spouses were not very satis®ed with the suf®ciency of
the support from the health care professionals. It seems as
if the personnel understood the distress of the spouses, but
they did not show very much willingness to talk with close
relatives or talk to the spouses. Furthermore, only 12
spouses reported that they got support regarding practical
matters. Still, for all types of listed support there is a group
of spouses who felt that the support was very suf®cient.
Perhaps this group of spouses are themselves active in
establishing communications with the personnel and
therefore also get more support from them. The commu-
nication process is always reciprocal and interpersonal but
for the health care professionals it is not always easy to
decide who should take the initiative, the patient or the
personnel. Many nurses, for example, fear to be obtrusive
and experience uncertainty about the appropriateness of
giving advice to spouses (Mayou et al. 1976, Thompson &
Cordle 1988). Intuition, experience and discretion are
needed in order to be able to approach a person in a crisis.
The results of the current study showed that the more
suf®cient support the spouses thought they got the less
severe fears, emotional distress and vulnerability they
reported. Thus, in this study, as well as in several others,
the buffering role of support was con®rmed (Greenley et al.
1982, Ahmadi 1985, Thompson 1989, Marsden & Dracup
1991). In the future clinicians and researchers need to
de®ne the needs of both MI patients and their spouses in
order to be able to plan interventions designed to meet the
needs of both of them. Then the support can be ef®cient,
focused and tailored for spouses as well as for patients. A
promising step in this direction is the recent article by
Turton (1998) investigating the importance of information
evaluated by MI patients, spouses and nurses. The results
indicated that some congruency existed between the three
groups in terms of what they perceived as the most and
least important categories of information. However, the
patient/spouse groups rated `symptom management' and
`life-style' factors as the most important categories of
information whereas nurses rated `explanatory informa-
tion' regarding the disease and medication higher.
Implications for nursing
According to Marsden & Dracup (1991), nursing is unique
within health care professions in its orientation to the
family as the unit of care. The nurses are often the only
observers of the interchange between patients and their
families. They have access to `the window of opportunity'
Issues and innovations in nursing practice
that occurs during a sudden catastrophic illness. From
this point of view the nurse can help family members to
deal effectively with their own anxiety and thus facilitate
the cardiac patient's recovery. During the last decade,
however, the cutting of resources within the specialized
health care sector, which has been the tendency in many
western countries, limits the possibilities for the nurses to
care for the cardiac patient and his/her psycho-social
environment as a whole. The intention to care for the
patient as an integrated whole and to include the family
members in the recovery process might be dif®cult to fully
realize in times of decreased resources and downsizing of
personnel. Therefore it is important for researchers and
clinicians to de®ne the needs of MI patients, of the
spouses and of the nurses in order to provide health care
administrators with relevant data and information which
should be applied when decisions regarding distribution
of resources are taken.
Limitations
Some limitations in the current study need to be
addressed. One shortcoming regarding the evaluation of
the support, in this study, was that the different categories
of health care professionals were not separately evaluated.
Thus, we do not know who the spouses alluded to when
they evaluated the support they got, the nurses or the
physicians. Neither do we know if the spouses' experience
of insuf®cient support/suf®cient support originates from
the time spent in hospital or after discharge of the patient.
The gender distribution among the spouses makes it
dif®cult to generalize the results regarding male spouses,
even though the gender perspective was included in our
study. This is an urgent topic for future investigations,
while the number of female MI patients is increasing.
CONCLUSIONS
The spouse plays a major role in the patient's recovery and
readjustment after a MI. Spouses of MI survivors live
through an emotionally strenuous time experiencing
several types of fears and suffering from different types
of stress symptoms during the appraisal phase of their
crisis. The fears, symptoms or shock reaction are not
related to the severity of the infarction. Factors in¯uencing
fears and symptoms are the spouses' own health, negative
life event during the last year and support from health care
professionals. The support was found to alleviate the fears
and symptoms. Nurses should be provided with clear
guidelines in order to be able to include the spouse in the
care. Clear guidelines make it possible for nurses to plan
activities in advance and to regulate the nursing process
not only in accordance with the patients' but also in
accordance with the spouses' needs.
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 30(2), 479±488
Myocardial infarction
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