Perceptions of factors influencing the coping of wives of myocardial Adeline Musto Nyamathi, RN, PhD Assistant Professor School of Nursing University of California, Los Angeles Los Angeles, California 'URSES ARE concerned with optimiz- ing the health and general well- being of patients and their families, The ability to maintain wellness, however, depends on the nature of the stressful life event and the coping capacities of the per- son involved.’ While most nurses are cog- nizant of the impact a myocardial infarc+ tion (MI) has on patients,2 they may not be aware of (because of the lack of systematic documentation) the factors that influence the coping responses of the spouses of patients with cardiac disease. The great interest in understanding the coping responses of spouses can be explained by the intimate relationship between the ways spouses cope and their physiologic, psycho- logic, and social well-being.*® Within the last decade, studies dealing with spouses of patients with cardiac disease have focused primarily on the wives’ physiologic and psychologic reactions to their husbands’ MISS During the initial hospitalization period, wives of patients who have suffered an MI are confronted with a massive number of difficulties, such as the loss of a partner, child and household care problems, finan- cial strain, a change in role, a change in self-esteem, and an uncertain and unpre- dictable future.”“° The coping responses reported by spouses include activities that enable them to seek information, obtain assistance and support from various per- sons, and control as many aspects of their environment as possible“! The physi- cal and psychologic reactions most com- monly experienced are sleep and appetite disturbances, headaches, stomach and chest pains, poor concentration, anxiety and fear, and blaming themselves for their partners’ illness.°12 During the convalescent phase of the husbands’ illness, wives experience con- siderable distress over handling their hus- bands’ depression and moods following discharge, their own feelings of frustration and anger, the uncertainty related to their J Cardiovasc Nurs 1988;2(4}65~76 ‘© 1086 Aspen Publishers, Inc, 6566 THE JOURNAL OF CARDIOVASCULAR NURSING/ AUGUST 1988 sexual activity, and the conflict over the specific meaning of the physicians’ instruc- tions."94 Fears of a recurrent infarction lead wives to become oversolicitous and anxious. The coping responses during this phase focus on monitoring and controlling their partners’ diet, medication regimen, and activity level.°"! Psychosomatic com- plaints frequently include sleep, appetite, and bowel disturbances and heart palpita- tions.415-17 While recent studies have described the coping responses and subsequent physical and emotional outcomes of spouses of acutely ill or convalescing patients with cardiac disease, there is little understand- ing of the factors that influence these responses. To assess and support the spouses, nurses must become more cogni- zant of the multitude of factors that may affect the way spouses deal with their part- ners’ life-threatening illness, The purpose of this study was to provide a systematic description of the factors affecting the cop- ing of wives of patients who have suffered an MI during the initial hospitalization period and one year later. THEORETICAL FRAMEWORK The theoretical framework for this study is based on a modification of the Lazarus stress and coping paradigm wherein coping is defined as the cognitive or behavioral efforts or responses persons use to master, tolerate, or reduce their stress." The per- son's coping responses can be influenced by a variety of factors. These factors include (1) cognitive appraisal, (2) personal factors, (3) environmental factors, and (4) coping resources. Cognitive appraisal As an evaluation process, cognitive appraisal determines to what extent a par- It is when feelings of threat are experienced that a person calls into action his or her coping processes. ticular transaction between a person and the environment is stressful.’® Primary appraisal (what is at stake) and secondary appraisal (what coping options are avail- able) interact together to shape the quality of the emotional reaction."®-?° It is when feelings of threat are experienced that a person calls into action his or her coping processes. Lazarus"? contends that a relationship exists between the degree of threat experi- enced and the tendency for a person to use a more desperate or regressive type of cop- ing response. Injury to the heart signifies a life-threatening event for patients and their families, To the extent that persons judge themselves to have control in a threatening situation and maintain a positive self- esteem, they will more likely perceive the situation as less threatening. As a result, their feelings of reassurance and security are enhanced and they are able to demon- strate more adaptive coping skills. Personal factors ‘A person's sense of self-esteem and sociodemographic characteristics are per- sonal factors that can affect the coping response. Self-esteem has been defined as the personal judgment of worthiness that is expressed in the attitudes the person holds toward himself or herself; it is based on the persons’ ability to deal effectively with his or her environment.” Authors agree that persons with a high level of self-esteem are more likely to cope effectively than persons with low levels of self-esteem.1221.# ‘The sociodemographic characteristics of sex, age, education, and income can alsoinfluence the coping response. Men have been found to employ more problem- focused coping responses than women, but only at work and in situations in which they are willing to seek and accept more infor- mation. The timing of the event has some bearing on why minor events can take on great significance, while normally distressing events seem insignificant. When an event occurs at an unexpected time in a person's life, the person and his or her spouse may be unable to prepare for a change in their roles, Such is the case with the unemployed wife of a man who has suffered an MI in the prime of life sud- denly having to become the breadwinner.24 Asa result, the stressor may become more threatening, leading to a less efficient cop- ing response and a greater risk of compro- mised health outcomes. With advancing age, people have been found to demon- strate coping responses that are more effec- tive and realistic,2>?° as well as more pas- sive and regressive.” Environmental factors The coping response of spouses of patients who have suffered an MI can be influenced by such conditions as climate, proximity to the treatment center, and visit- ing policies, To the extent that the physical environment is conducive to a person's plan of solution, his or her physical and psychologic adjustment becomes less difi- cult.1823 Coping resources ‘The resources available to a person clearly affect his or her coping re- sponse.”3529 Tp relation to physical and mental health, persons who are frail, sick, tired, or otherwise debilitated have less energy to expend on coping than healthy persons. Financial resources can facili- Coping of Wives of MI Patients 67 tate effective coping by increasing the options available in stressful encounters while providing easier and more effective access to legal, medical, and other profes- sional assistance.” Spiritual resources are known to influence coping by assisting the person in maintaining a positive belief about God and hope for a positive outcome. Finally, social support, which includes emotional and informational support and assistance,”**!-*4 has been identified as a protective factor in buffering the effects of stress 2598 Coping responses Coping responses refer to the constantly changing cognitive and behavioral efforts to manage specific external and internal demands appraised as exceeding the resources of the person.’® They serve to regulate distressing emotions (emotion- focused coping) and alter the problem causing the distress (problem-focused cop- ing)2” Folkman and Lazarus” maintain that both emotion-focused and problem- focused coping behaviors are necessary to achieve a balance of health and well- being. METHODS Sample A convenience sample of 40 women whose husbands had been hospitalized with an MI within the preceding year at one of two hospitals in the Midwest were asked to participate in the study. Twenty wives entered the study within the first six months of their husbands’ hospitalization, while 20 entered the study seven to 12 months after their husbands’ hospital admission. This cross-sectional design was used to obtain information on factors affecting the coping of wives during the68 THE JOURNAL OF CARDIOVASCULAR NURSING/ AUGUST 1988 acute episode and one-year convalescent period. Eighty-five percent of the women were American born, between the ages of 45 and 69 years (mean, 50 years}, and educated beyond the high-school level. Of the 82% of wives who were employed, 78% held middle- to lower-class jobs, as designated by the Hollingshead Two Factor Index.® No statistically significant differences were demonstrated in the sociodemographic variables of the women based on the time elapsed since their partners’ MI. Originally, 49 wives were asked to partic- ipate. Seven refused because of (1) lack of time from holding a full-time job; (2) a desire not to discuss the traumatic episode; or (3) claiming not to feel well. Two addi- tional wives were dropped from the study within the first week after both of their husbands died. Instrument ‘The primary data collection technique in this qualitative study was intensive inter- viewing using a flexible, semistructured interview guide. The guide, which assessed the wives’ perception of factors influencing their coping, was developed following a review of both the research and clinical literature on the coping of persons facing stressful situations. The content validity of the open-ended questions was assessed by a three-member expert panel consisting of two doctorally prepared nurses experi- enced in psychosocial research and one Master's prepared clinical nurse specialist skilled in the care of patients with cardiac disease and their families. The interview guide was pretested on a sample of five spouses of patients who had suffered an MI and was refined to eliminate poorly worded questions. Twelve questions were asked by the researcher along with probes when the need for clarification arose. Some sample questions are presented below: © Cognitive appraisal: When you first became aware your husband was ill, what did you think was wrong? * Personal factors: Did any factors such as your age, education, occupation, etc, help or hinder you in dealing with your husband's acute illness? * Environmental factors: When your husband first became ill, what factors in your environment, such as the weather, ability to visit, etc, helped or hindered you in dealing with his ill- ness? * Coping resources: Who or what were especially helpful to you in dealing with your husband's acute illness? An intercoder agreement of 92% was established by an independent coder on eight randomly selected, transcribed inter- views. Efforts to enhance the accuracy of data generated during the interviews were incorporated into all phases of the study.°? These efforts involved the researcher obtaining data by directly observing and interviewing spouses; the researcher par- ticipating in direct, face-to-face communi- cation with the subjects at all times; and the tape-recorded data being carefully and accurately transcribed. Procedure By reviewing their medical charts, the investigator identified subjects who met the following screening criteria. The subject had to be the wife of the patient, able to speak and understand the English lan- guage, and willing to be interviewed by the researcher, The patient had to be male, white, between the ages of 35 and 60 years, and diagnosed as having had a first-time MI. Potential subjects were telephonedand the study was explained to them. Women who agreed to be interviewed were informed of their rights and gave their written consent, including consent to have the interviews tape recorded. Their confi- dentiality was assured. Women whose husbands were hospital- ized within the previous six months were interviewed four to five times while those whose husbands were hospitalized within the previous seven to 12 months were inter- viewed three to four times. All wives were interviewed privately over a three-month period. A total of 160 home visits were made, predominantly to the homes of the subjects, during a 29-week period. During each scheduled visit, the investigator assisted the subject in focusing on specific time intervals of her husbands’ acute ill- ness and convalescence. In the first inter- view, subjects were asked to focus their discussion on the period of the acute illness (ie, the hospitalization). During the second visit, the subjects discussed their husbands’ early convalescence (ie, the first four weeks after hospitalization). The later convales- cent period (ie, week 5 to the present) was discussed at the third, fourth, and fifth visits. All interviews were conducted by the primary researcher and ranged from 40 to 90 minutes. Data analysis ‘A code book was developed, with the responses to each question being coded according to the categories developed from the modified stress and coping paradigm.’ These categories included (1) cognitive appraisal of the event, (2) personal factors present, (3) environmental factors present, and (4) coping resources available and used. Additional coded categories were constructed when the theoretical frame- work did not apply. Field notes were for- mulated from audiotaped and transcribed Coping of Wives of MI Patients 69 interviews. Segments of transcripts were placed into files that reflected the coded categories. Relationships among the coded categories were explored. Content analysis of the transcribed inter- views was performed based upon the coded categories developed. ‘The findings were reported by frequencies, means, and percentages, Because the timing of the car- diac event demonstrated no relation to the data in terms of the effects of selected factors on spousal coping, the discussion of the findings will omit this issue. Limitations ‘The study was limited by the use of a convenience sample of wives. In addition, the stress experienced by the wives may have affected their ability to respond to the questions and to reconstruct their feelings retrospectively over several months. RESULTS The findings confirmed that the factors that influenced spousal coping as concep- tualized were (1) cognitive appraisal, (2) personal factors, (3) environmental factors, and (4) coping resources. Additional factors reported to influence coping were the behaviors and characteristics of the ill part- ner and the ability of wives to fulfill their own needs. Cognitive appraisal The women's perception of the nature of their husbands’ illness varied according to their familiarity with cardiac disease. Of the 18 women (45% of total subjects) who did not consider the illness to be heart related, 13 (72%) did not encourage their husband to seek immediate medical care. These women did not believe their partner was experiencing an MI because he was young, healthy, or physically active;70 THE JOURNAL OF CARDIOVASCULAR NURSING/ AUGUST 1988 ‘The women’s perception of the nature of their husband’s iliness varied according to their familiarity with cardiac disease. because his symptoms were minor, such as indigestion; or because his parents had lived to an old age without any evidence of heart disease. As a result of their error, the women reported an overwhelming sense of disbelief, shock, and subsequent guilt as their initial emotional responses. Fourteen women (35% of total subjects) were immediately concerned that their husbands’ symptoms were heart related and, as a result, responded by calling for assistance or driving their husband to the hospital. These women were aware of the general signs and symptoms of an MI or were aware of a family history of cardiac disease. While they did become anxious over the diagnosis of MI, these women were less likely to use denial as a coping response, In addition, they did not experi- ence guilt over failing to recognize the signs and symptoms of cardiac disease. Personal factors Self-esteem ‘The women were questioned regarding their perceived level of self-esteem. Self- esteem was defined as the general sense of worthiness a person has about himself or herself.2” Thirty-one women (78%) ac- knowledged having a high level of self- esteem, The majority of these women were employed or socially active and reported a great need to fulfill their own needs and spend time away from home. Nine women (22%) claimed their level of self-esteem to be fair. The majority of these women classi- fied themselves as being emotionally dependent on their husbands. During the early convalescent period, these women were particularly overprotective in their efforts to control their husband's diet and activity levels and tended to experience increased worry and frustration. Age ‘A small percentage of the women reported that their age had an influence on their coping responses. Of the 23 spouses (58% of total subjects) aged 50 years or more, four (17%) reported that being older helped them deal with their husbands’ illness dur- ing the acute illness and convalescent peri- od. The women stated this was due to the fact that their partner was retired and their children older and more supportive. How- ever, of the 17 women (42% of total sub- jects) who were less than 45 years of age, two women (12%) reported that being young contributed to the difficulty they experienced in coping, particularly during the convalescent period. The relatively young age of their children and partner and the unexpected nature of the illness also contributed to this difficulty. All remaining women claimed that their age had no influence on how they dealt with their partner's illness. Education ‘The educational level of the wives was not found to be an important factor in promoting coping. Rather, the ability of 35 ‘women (88%) to actively seek information related to cardiac disease and subsequent care—regardless of their educational lev- el—was what was important. Occupation Occupation was also reported to enhance coping. The desire to return to work was a coping response that enabled 33 of the women (83%) to maintain independence, feel productive, and as a result reduce the impact of their husband's illness on theirlife. The majority of women who were unemployed reported experiencing greater periods of being nervous and tense, greater difficulty in leaving their partner at home for a short time, and a greater tendency toward overprotectiveness than did the employed or outgoing women. Environmental factors Proximity to partners Thirty-six wives (90%) expressed com- fort and security in being physically close to the hospital. Of the 33 employed wives, 30 (91%) chose not to work the first few days of the convalescent period so that they could closely monitor their husbands’ activity and dietary patterns. Similarly, of the seven unemployed women, five (71%) experienced difficulty leaving their hus- band even for short periods of time. Weather ‘The weather was yet another influential environmental factor. Ten women (25%) whose husband experienced the MI during the winter months were distressed when unable to visit him, During the later conva- lescence, the bad weather negatively affected the husbands’ attitudes and increased the couples’ frustration. In addi- tion, wives who needed a respite were at times unable to get away. Women whose husband experienced the MI during the spring and summer months were grateful for the opportunity to perform activities together as desired. Coping resources Family and friends ‘Thirty-nine women (98%) remarked that family and friends positively influenced their ability to cope during their husbands’ initial hospitalization by assisting with Coping of Wives of MI Patients 71 child care, transportation, physical chores, and financial matters. During the early convalescence, although their need for physical assistance greatly diminished, 29 ‘women (73%) continued to comment on the beneficial effects of emotional support from family and friends. Health care professionals Thirty-eight women (95%) discovered that nurses, physicians, and other hospital staff were supportive, informative, and helpful to them during the time that their husband was hospitalized. Fourteen women (35%) continued to benefit from such services during their husband's early convalescence. While the majority of women spoke of the healthcare professionals in general, several wives reported that nurses in par- ticular enhanced their coping during their partners’ initial hospitalization. Sixteen women (40%) maintained that the nurses were very helpful in answering questions and explaining various procedures to be performed. Seven women (18%) said the nurses were compassionate and reassuring, while 11 women (28%) said they were pleasant. Twenty-six women (65%) were comforted by the excellent care delivered by the nurses. As a result of their positive perceptions of nursing intervention, the wives expressed feelings of security and confidence, an ability to sleep better, and a motivation to attend to other matters of concern. Three women, however, vocal- ized negative feelings based on their per- ception that the nurses were withholding information unnecessarily during their husband’s hospitalization and as a result experienced anger and frustration. Physical and mental health ‘Twenty-six women (85%) who claimed to be in excellent health reported an72 Tae JOURNAL OF CARDIOVASCULAR NURSING/ AUGUST 1988 enhanced ability to deal with stress, Eleven women (28%] considered themselves to be in good health despite suffering from chronic problems such as diabetes, chronic leg and back pains, hypertension, divertic- ulitis, or depression. The majority of these women reported exacerbations of their own illness during their partners’ acute illness and convalescence and manifested. coping behaviors that were overprotective and controlling in nature. One woman (2%) claimed that her physical health was fair because of a severe eye condition that left her legally blind, As a result of her inability to leave her house, she reported bouts of depression during the early and later con- valescence of her uncooperative husband. Another two women (5%) with a history of psychotic disorders reported that their psy- chiatrist had increased their medication to control depression during their partners’ convalescence. Financial resources A stable financial status is a resource seven wives (18%) claimed was beneficial. Inadequate finances led to insecure feel- ings for two wives (5%) throughout the acute and convalescent periods of illness. The remaining women (77%) reported that their financial status did not have any influence on their coping. Spiritual resources Religion and a belief in God were con- sidered to be coping resources by 21 women (58%) primarily during the initial hospitalization. Two women (5%] were dis+ tressed that they had never used religion as a resource. Behaviors and characteristics of ill partner During their husbands’ initial hospital- ization, the women’s perception of their husbands’ positive attitude and cooperation with the medical regimen (n ~ 5), his young age, and his previously healthy status (n= 10) were favorable factors that en- hanced their coping abilities. Nineteen women (48%) were encouraged by the fact that their husband looked good during the early and later convalescent period. In addition, the ability of the couple to com- municate (n= 5) and plan activities together (n = 1) was deemed to be benefi- cial. Conversely, the husbands’ perceived uncooperativeness during his hospitaliza- tion led ten women (25%) to experience despair and anxiety. During the early and later convalescent period, the husbands’ lack of motivation and an irritable and argumentative nature led 23 wives (58%) to experience frustration and anger. Ability of wives to fulfill own needs ‘Thirty women (75%) revealed that their ability to fulfill their personal needs and comforts enhanced their ability to deal with their husband's illness. Ten women (25%) expressed the need to visit their husband during his hospitalization. Other factors that were helpful to women during the initial hospitalization were the ability to keep busy, seek emotional support from family and friends, maintain positive thoughts, diminish their guilt, and perform comforting measures such as sewing, drinking wine, or relaxing. During the con- valescent period, the women disclosed concerns and fears regarding their sudden loss of independence and freedom, their Thirty women (75%) revealed that their ability to fulfill their personal needs and comforts enhanced their ability to deal with their husband’s illness.marital discord resulting from spending long periods of time with their husband, their having to leave their husband unat- tended, and their resumption of sexual activity. The women reported that they were able to minimize the effects of the illness by leaving the house for periods of time, asking for information from nurses and physicians regarding the diet and activity levels of their partner, and dispel- ling their misconceptions. DISCUSSION AND IMPLICATIONS FOR NURSING ‘The findings of this study support the modified Lazarus stress and coping para- digm in that a number of factors exist that influence coping responses. Illuminating the factors that are specific to the coping of spouses of patients who have suffered an MI serves to improve the understanding of coping and assist nurses in planning inter ventions directed toward enhancing the coping of such spouses. Cognitive appraisal is a crucial fector that influences coping in that the person must evaluate the significance of the event and the coping options available. Lazarus and Folkman” maintain that for an out- come to be effective, a person's appraisal of the environment must approximate the flow of events. When a person fails to recognize harm or threat in situations in which they exist, his or her coping responses will be affected. Moreover, other researchers” maintain that when a per- son experiences excessive threat, his or her problem-focused forms of coping may be affected according to the impact of the threat on the person's cognitive functioning and the person's capacity for information processing. For spouses of patients who have suffered an MI, the ability to ade- quately process information about the prognosis, procedures and treatments to be Coping of Wives of MI Patients _ 73 performed, and posthospitalization guide- ines can be critically impaired by the high level of threat experienced at the time of the diagnosis, The findings revealed that women who perceived their husband's illness to be heart related actively encouraged their husband to seek immediate medical atten- tion and consequently experienced less disbelief when the diagnosis of an MI was verified. Women who did not suspect an MI as the cause of the illness reported that they were devastated by the seriousness of the event, that they experienced greater confusion and denial, and that they were less able to consider a plan of action in the initial hospitalization period than women who suspected an MI. These findings are consistent with those of Powers and Jalo- wiec”® and Roberts et al,“ who reported that persons who are adjusting to a stressful illness are more likely to use problem- focused coping and less likely to use avoid- ance strategies. By assessing their percep- tion of the nature of the event, nurses can identify spouses who are at risk for ineffec- tive coping. Individualized nursing strate- gies can focus on encouraging verbalization of feelings, clarifying misconceptions, re~ ducing potential guilt feelings, assessing and facilitating support from family and friends, and working with the physicians to provide concise, consistent, and up-to-date information. ‘The finding that almost all of the women benefited from expert nursing care and informational and emotional support of nurses and other health care professionals is not surprising. Several studies have reported that spouses are very eager to receive specific information about their partner in understandable terminolo- gy2-4114 Activities that health care pro- fessionals can perform that are helpful to wives include providing expert nursing and medical care, answering questions,74 THE JOURNAL OF CARDIOVASCULAR NURSING/ AUGUST 1988 clarifying misconceptions, explaining pro- cedures, and holding classes on cardiac disease and the care of the discharged patient. The relatively few women who were dissatisfied with nursing care ex- pressed frustration over the lack of infor- mation that they perceived they needed to relieve their distress. ‘The majority of the women considered the assistance and emotional support of family and friends to be crucial. The impor- tance of social support has been well docu- mented in feelings of social isolation, strengthening the internal repertoire of coping resources, and ultimately facilitat- ing the adjustment to a life-threatening illness.2241-43 Moos" contends that for health care pro- fessionals to be helpful, they must be famil- iar with typical coping responses and the factors that facilitate or hinder them. A quarter of the women emphasized the importance of visiting their partner during his initial hospitalization. Most recalled the tremendous need to receive information and to feel supported during this period. To enhance the coping responses of spouses of patients who have suffered an MI, nursing strategies can be effectively directed toward ascertaining the existence of physi- cal conditions that might prevent the spouses from meeting their needs success- fully and assessing the available support systems and other resources. For example, when visiting hours are restricted, nurses can help by adjusting the policies in an effort to enhance spousal coping. During the convalescent period, over half of the wives reported being concerned about their husbands’ lack of motivation REFERENCES Stressful life events and coping meth- ods in mental illness and wellness behavior. Arch Gen Psychiatry 197;17:277-284. and ability to do for himself; his uncoopera- tive, irritable, and argumentative nature; and his lack of cooperation in following the physician's orders, While almost a third of the wives reported having a need to get away or keep busy, others reported experi- encing difficulty in leaving their home for short periods of time. To facilitate the cop- ing of these women, nurses need to advise them of concerns that are commonly expe- rienced during the convalescent period and to warn them of the dangers of over- protectiveness, which commonly occurs. 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