The experiences of female spouses of survivors of acute myocardial infarction: a pilot study of...

The experiences of female spousesof survivors of acute myocardial infarction:a pilot study of Lebanese-born womenin south-western Sydney, Australia

John Daly BA BHSc MEd(Hons) PhD RN FRCNA

Professor & Head, Division of Nursing, Director of Research,

Faculty of Health, University of Western Sydney Macarthur

Debra Jackson BHSc(Nsg) MN RN

Senior Lecturer in Nursing, Division of Nursing, Faculty of Health,

University of Western Sydney Macarthur

Patricia M. Davidson BA MEd RN CCRN

Clinical Associate Professor of Nursing, Division of Nursing, University of

Western Sydney Macarthur and Clinical Nurse Consultant (Cardiology),

St George Hospital, South-Eastern Sydney Area Health Service

Vicki Wade BN RN CCRN

Clinical Nurse Consultant (Cardiology), Bankstown-Lidcombe Health Service

and Conjoint Lecturer in Nursing, Division of Nursing, Faculty of Health,


Christine Chin DipN BHSc MEd RN

Research Assistant, Division of Nursing, Faculty of Health,


and Vicki Brimelow RN BA GradDipNsg(Ed)

Registered Nurse, Renal Unit, Liverpool Hospital,

South-Western Sydney Area Health Service, Sydney, Australia

Accepted for publication 8 December 1997

DALY J., JACKSON D., DAVIDSON P.M., WADE V., CHIN C. & BRIMELOW V. (1998)

Journal of Advanced Nursing 28(6), 1199±1206

The experiences of female spouses of survivors of acute myocardial infarction:

a pilot study of Lebanese-born women in south-western Sydney, Australia

Lebanese migrants form a signi®cant proportion of the population in south-

western Sydney (SWS), and in New South Wales, Australia. This pilot study

was undertaken in south-western Sydney, a rapidly expanding and socio-

economically disadvantaged region, to explore the experiences of English

speaking women of Lebanese origin whose spouses had recently experienced an

acute myocardial infarction (AMI). Semi-structured interviews were conducted

with seven Lebanese-born women at 2- and 4-week intervals, following the

discharge of their husbands from hospital. Qualitative analysis of narrative text

Correspondence: Professor John Daly, Division of Nursing/Faculty

of Health, University of Western Sydney Macarthur, PO Box 555,

Campbelltown, NSW 2560, Australia.

Journal of Advanced Nursing, 1998, 28(6), 1199±1206 Issues and innovations in nursing practice

Ó 1998 Blackwell Science Ltd 1199

revealed four distinct themes. These were: struggle to resolve distress; intensive

monitoring of the AMI survivor; searching for avenues of support; and re¯ecting

on the future. Study ®ndings are discussed in relation to the literature.

Implications for nursing practice and research are drawn from study ®ndings.

Keywords: acute myocardial infarction, spouses, women's health, culture,

multiculturalism, feminist research, nursing, Lebanese-born women

INTRODUCTION AND BACKGROUNDTO THE STUDY

Australia is a nation built on immigration. A large pro-

portion of the total population of Australia is made up of

immigrants or ®rst generation Australians. South-western

Sydney (SWS) has a population of »585 118 (Australian

Bureau of Statistics (ABS) 1997). A signi®cant portion

(48%) are migrants with English as a second language

(ABS 1997). The local government areas in SWS in which

the study was conducted have a high proportion of

families in which the language spoken at home is Leba-

nese (ABS 1997). The multicultural nature of Australian

society gives nursing and other health professionals an

imperative to ensure that health services are developed to

meet the needs of people from a variety of ethnic and

cultural backgrounds.

Culture is an important aspect of personhood, and may

be de®ned as `a system of shared beliefs, customs, values,

and behaviours that members of a society transmit from

generation to generation and use to cope with one another

and their world' (Keller & Stevens 1997 p. 15). Culture is

understood as a crucial variable in any individual's

experience of health and illness. The signi®cance of

culture and aspects of life shaped by culture are even

more central to recovery when one considers the so-called

`lifestyle factors', and their known role as contributors to

various types of illness and disablement. These include

known cardiovascular risk factors such as obesity, hyper-

tension, and sedentary lifestyle (Keller & Stevens 1997),

and this makes issues pertaining to culture a key area of

interest to nurses and other health professionals con-

cerned with the reduction of preventable cardiovascular

disease.

According to D'Cruz & Tham (1993), migrants from

different socio-cultural and linguistic backgrounds have

various perceptions of illness and health. Sex role social-

ization, and gender roles within marital and family

relationships are also strongly culturally constructed. In

most cultures, women are positioned as the carers of their

families, and it is often the responsibility of female

partners to ensure that recommended adjustments to

aspects of lifestyle, such as diet, are incorporated into

family life.

Recovery from AMI

Internationally the cardiac rehabilitation literature lacks

information on social, psychological and particularly

cultural implications of heart disease. Thompson et al.

(1995) note that socio-psychological aspects of myocardial

infarction have been subordinated to an emphasis on

pathophysiology and medical treatment in the profession-

al preparation and practices of health professionals. `Con-

sequently, psycho-social factors, such as the individual's

reactions and the availability of a range of support services

have been ignored, despite evidence to suggest that long-

term quality of life may depend as much on psychological

reactions and how they are managed as on medical care'

(Thompson et al. 1995 p.707). While extensive research

has focused on speci®c aspects of the recovery process

following AMI, for example variables including anxiety,

depression and rate of recovery, aspects of everyday

experiences associated with this process remain relatively

unexplored (Johnson1991, Thompson et al. 1995).

This is the case with AMI survivors and their spouses.

This illness experience requires further investigation, as

Morse & Johnson (1991 p. 2) note that perspectives derived

through study and analysis of individual's illness experi-

ences provide `a more comprehensive view, incorporating

individuals and their families as they make sense, and

cope with, and adapt to symptoms and disabilities'. Morse

& Johnson (1991) argue that theories of illness based on

patients' perspectives are needed to explain related expe-

riences, needs and guide care. Literature shows that the

initial recovery period following AMI is stressful and

unpredictable for the survivor and signi®cant others (Stern

& Pascale 1979, Hilgenberg & Crowley 1987, Coyne & Smith

1991, Marsden & Dracup 1991, Beach et al. 1992, Hilgen-

berg et al. 1992, Hilbert 1993, Moser et al. 1993, McGee

et al. 1994, Thompson et al. 1995). It is also acknowledged

that this transition period is one of storm and stress for the

survivor and the family system (Romanini & Daly 1994).

Several published studies have explored the process of

recovery from AMI from the perspective of female partners

of different cultural and ethnic origins. Among these are

studies which have focused on groups drawn from Tai-

wanese (Yeh et al. 1994), North American (Stern & Pascale

1979, Bedsworth & Molen 1982, Runions 1985, Bramwell

1986, Nyamathi 1987, Rif¯e 1988, Coyne & Smith 1991,

Marsden & Dracup 1991, Beach et al. 1992, Hilbert 1993,

J. Daly et al.

1200 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(6), 1199±1206

Moser et al. 1993), British (Skelton & Dominian 1973,

Mayou et al. 1978, Bramwell 1986, Thompson & Cordle

1988, McGee et al. 1994) and Finnish (Hentinen 1983)

communities. Additional work has also been conducted

focusing on survivors of AMI and their spouses from a

dyadic perspective (Thompson et al. 1995).

Common concerns arising from the above studies are:

psychological distress Ð due to potential loss of mate,

change in own life goals within family unit, change in

responsibility for care in the household, economic issues,

return to sexual activities, and fears of the recurrence of

myocardial infarction. In addition psychosomatic symp-

toms were reported to be present in the spouses (Skelton &

Dominian 1973, Stern & Pascale 1979, Rif¯e 1988,

Thompson & Cordle 1988, Marsden & Dracup 1991).

Numerous authors (Bedsworth & Molen 1982, Marsden

& Dracup 1991, McKay 1991, Beach et al. 1992) have

acknowledged that the spouses' response to their partner's

AMI may have profound effects on the emotional adapta-

tion of the patient and signi®cant others to the patients's

illness, recovery and rehabilitation. Mayou et al. (1978),

and Thompson & Cordle (1988) report relationship break-

ups as a result of the inability to cope with the patients'

illness, whilst other studies reported couples' relation-

ships becoming stronger as a result of the AMI illness

experience (Wishnie et al. 1971, Skelton & Dominian

1973, Hilgenberg et al. 1992). It is manifest that the nature

of coping is multifaceted and complex and dependent

upon both situational and dispositional factors in which

cultural beliefs and practices are entwined.

Although the aforementioned studies may have includ-

ed participants of various cultures within their study

samples, this was generally not stated. The reviewed

literature re¯ects an assumption of homogeneity rather

than acknowledgement of diversity. An exception was a

North American study by Rif¯e (1988), which explored

relationships between perceived supportive behaviours of

others, and coping ability in the female partners of men

experiencing initial AMI. Of the 31 women who partici-

pated in Rif¯e's (1988) study, 94% were described as

`white', 3% were described as `black' and 3% as `Mexican-

American'. The ethnic origin of those participants de-

scribed as `white' was not speci®ed. Apart from the study

by Yeh et al. (1994), none of the aforementioned studies

explore spousal coping within a distinct cultural group.

The study

The aims of this pilot study were to:

· explore the impact of AMI survivors' illness on Leba-

nese-born female spouses in south-western Sydney;

· describe the process of adjustment for the research

participants during the ®rst 2±4 weeks following the

AMI survivors' discharge from hospital; and

· identify the potential needs of the research participants

in the ®rst 2±4 weeks following the AMI survivors'

discharge from hospital.

METHODOLOGY

Research participants

The study used a convenience sample of seven Leba-

nese-born women, who were the partners of men hospi-

talized following a diagnosis of AMI. An additional

inclusion criterion required that potential participants be

English-speaking. Potential participants were selected by

the research team in consultation with the AMI survi-

vors' physician and specialist nursing staff in coronary

care areas of acute hospitals. Initial contact was made

with the women prior to the discharge of their husbands

from hospital, and at this point of contact, women

meeting the inclusion criteria were recruited into the

study. At this point, following procedures of informed

consent (National Health & Medical Research Council

1992), demographic data were collected, and arrange-

ments were made to conduct the serial interviews at the

homes of the participants. All of the women were

married to Lebanese-born men. Participants were all

engaged full-time in domestic duties and were econom-

ically dependent on their male partners. Ages of partic-

ipants ranged from 38 to 64 years; all women were also

mothers, with number of children ranging from 2 to 9.

All participants were of Islamic (n � 3) or Christian

faith (n � 4).

Design and method

In order to capture aspects of everyday experience, the

study utilized a qualitative, exploratory-descriptive de-

sign. Data were collected using a semi-structured inter-

view schedule, which was comprised of open-ended

questions devised to collect information regarding the

participants' experiences and needs. Questions covered

progress since the AMI survivors' discharge, general ¯ow

of living day-to-day, concerns and needs. All contacts

with participants, including the initial induction into the

study, and the subsequent interviews, were conducted by

experienced female registered nurses, with expertise in

cardiac rehabilitation. This meant that, in addition to

providing information for researchers, the interview en-

counters also had inherent bene®t to research participants,

by giving them access to expert nursing care and advice at

their homes on two occasions post-discharge. Interviews

were audio taped and conducted at 2 and 4 weeks post-

patient discharge. Each interview ranged from 60 to

90 minutes, generating in excess of 14 hours of audio

taped information. Audiotapes were transcribed verbatim

for qualitative analysis.

Issues and innovations in nursing practice Acute myocardial infarction

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(6), 1199±1206 1201

Data analysis

Thematic analysis of the narrative text was informed by

the work of Anderson & Jack (1991), which was selected as

appropriate for this study, because the participants were

women belonging to a distinct cultural group, and this

method permits the cultural dimension of personhood to

become visible. This method involves a three-step pro-

cess, which aims to facilitate understanding of people's

stories. The ®rst step, `listening to the narrator's moral

language' (Anderson & Jack 1991 p. 24), allows researchers

to explore self-concepts and accepted cultural standards.

The second step involves focusing on the `meta-state-

ments', and can signal disparity between what is cultur-

ally expected, and what is actually being manifested. The

®nal step of looking to the `logic of the narrative' allows

researchers to consider the narrative within a context

which recognizes the `assumptions and beliefs that inform

the logic and guide the woman's interpretation of her

experience' (Anderson & Jack 1991 p. 22).

FINDINGS

Analysis of narrative text revealed four major themes;

struggle to resolve distress; intensive monitoring of the

AMI survivor; searching for avenues of support; and

re¯ecting on the future. These four themes were evident in

the narrative text arising from the ®rst encounter (at

2 weeks post-discharge), and remained essentially un-

changed at the second encounter (at 4 weeks post-dis-

charge). The themes are discussed below, and include

excerpts from the narrative text of the participant women,

where appropriate.

Struggle to resolve distress

All of the study participants experienced a range of

distressing emotions in response to the AMI survivor's

illness. This was accompanied by a struggle to resolve the

negative thoughts and feelings, and regain a sense of

control in their lives. The initial occurrence of the illness

precipitated a state of struggle and ¯ux which continued

throughout the illness trajectory. The cumulative effects of

this struggle on the wives were apparent by 2 weeks post-

discharge, with several participants describing somatic

complaints, such as sleep disturbances and gastro-intes-

tinal upsets. That extreme distress experienced by the

women manifested itself physically, is evident in the

narrative text below.

It's like you're in a cage and you want to get out¼ you've got

nowhere to go, you know. It's dif®cult. He [husband] can't

understand that, he expects us [wife and family] just to take it

easy and forget it. But you can't Ð not when your stomach's

squeezing up.

This extreme distress involved a myriad of negative

emotions including anguish, fear, exhaustion, depression,

isolation, and, for some, feelings of guilt and self-blame. In

some cases, the participant women felt the burden of

blame from others.

¼ the day that it [the AMI] happened, he [male relative] said to

me, it's your fault, it's your fault, you brought it on him. You talk

too much¼ they blame me, they blame me. They said to me, you

shout too much at the kids and you're making him sick.

The anguish of this participant is tangible, and the fact

that she feels blamed for the condition of her husband, has

added considerably to her distress. Her self-blame, and the

ostracism that she felt from those around her, is a

recurring theme in her narrative text.

For several participants the continued burden of negative

emotions became overwhelming, and ultimately, poten-

tially hazardous to their own health. The women described

their attempts to manage their stress, and also the burden

that they felt to repress the outward evidence of the

pressure that they were under. Frequently, when it became

unbearable, they attempted to release their stress secretly,

in ways that would not be witnessed by others. In this way,

they sought to minimize the stress on their families.

I wanted to scream and scream and this time in the shower. I just

sat there, just sat on the ¯oor. I thought, hey, wake up woman,

what's wrong with you? Go ahead, get out, you're going to run out

of water soon. The hot water's going to run out. I felt like I just

wanted to blow up. I cried and cried and cried just for no reason. I

thought what are you crying for? Your husband's at home, he's

well¼ what are you crying for?

By the second interview, which took place 4 weeks after

their husbands' discharge from hospital, most of the

women were still experiencing life as acutely stressful.

At this point, several participants had became so con-

cerned about the effects of unrelieved stress on their own

health, that they themselves had consulted a medical

practitioner.

He [family doctor] gave me tablets and he told me, you know, you

can use this now for this time and you can stop at any time. I had

a blood test to see¼ `cause I feel, like I feel dizzy, I feel as if

someone pushed me, I fainted. Like I feel I want to faint¼ I know

it's too much stress.

As with the participant above, several of the women

were prescribed medication to assist them in coping with

the demands of caring for their husbands. For these

women, being a part of a distinct ethno-cultural commu-

nity, meant that tangible help and moral support was often

available. However, for some participants, the expecta-

tions of the community were an added source of stress.

Last Sunday we had about 16±18 people come in through the

day¼ he comes from a big village and they're all here in

J. Daly et al.


Australia. They all come and visit. It's nice in a way, that he

doesn't feel lonely¼ it was tiring for me though.

The struggle in which these women were engaged

combined their normal roles and responsibilities, with

the new responsibilities which came into play as a result of

the survivor's illness. These new responsibilities effective-

ly problematized previously uncomplicated aspects of the

lives, with negative health consequences for the women.

Intensive monitoring of the AMI survivor

Scrutinization of all aspects of their partners' lives became

an area of focus for the participants in this study. All the

participants reported undertaking close surveillance and

supervision of their partners. Much of these monitoring

activities centred around diet, with the women concerned

that, left unsupervized, their partners would revert to

previous poor eating habits.

I'm worried sometimes his food, to do something behind my back,

to eat something behind my back. I push him to eat this food, the

one I cook for you, don't touch the others¼ If he goes to the shop

for a few hours, I'm worried about him. I tell him, please, you

know, try to touch nothing. Sometimes, I don't know if he listens

to me or not¼

The fact that some of the men chose to ignore dietary

restrictions when in the company of others was distressing

to the wives, who felt unable to challenge their husband's

behaviour. This became a source of tension for many of the

participants.

In front of people he doesn't¼ he doesn't respect me. In front of

people, his attitude is, who are you to tell me what to do? He will

eat whatever. But, when we're alone he's like a pussy cat. He does

anything and everything that I ask him to do. Like if I make a

sandwich for him with no salt and no pepper, he just eats it, he

doesn't worry. But if somebody's around, you know, he'd make a

comment about it and make a fuss out of it and I dislike that.

Supervision of aspects of their husbands' lives, such as

his diet, became part of the women's daily routine. This

marked a substantial change in their relationships be-

cause, prior to the AMI, the husbands had been free to

choose to eat whatever they wished. For many of these

women, taking responsibility for, and attempting to con-

trol aspects of their husbands' behaviour represented a

clash with cultural mores, which demand certain behav-

iours of wives, particularly when in the presence of

others. This need of the women to monitor all aspects of

their husbands' behaviour, complicated previously enjoy-

able and stress-free activities, such as social evenings out

with friends and relatives.

We had a barbeque last Saturday and I was watching him, he was

good. I didn't even look at him at all, just like kept on looking out

of the side of my eye to see what he was up to.

In an interview which took place 4 weeks after her

husband was discharged from hospital, Mrs M disclosed

that she had not left her husband at all during his post-

discharge period.

I still can't leave him by himself and go [next door for a cup of

coffee]. Even when he's sleeping, I always come, I open the door, I

check to see he's alright ¼ to see if he's breathing¼ I close the

door slowly. I can't leave him in the house by himself. I'm not the

type to leave my husband home and go next door. Like if he's

home, that's it, I can't go nowhere because he's home.

As this theme shows, the preoccupation with supervi-

zing and monitoring the activities of their husbands

became the over-riding concern for these women. This

resulted in subordination of their own needs, as they

privileged those of the AMI survivor.

Searching for avenues of support

All participants made active attempts to seek avenues of

support. These searching activities centred around social

supports and professional supports, and generally in-

volved family, friends, and physicians. One of the women

described pro-active follow-up by the hospital, which

involved telephone contact with a member of the nursing

staff, and she found this to be helpful. Many of the

participants felt that they were fortunate in having access

to health professionals from the same language back-

ground.

¼ to make me more comfortable, I speak to the Arabic doctor, the

family doctor¼ so he explain everything and he tell me not to,

you know, he say don't you worry. It makes me feel better¼

In addition to these avenues, participants actively

sought to develop the knowledge and skills that they

perceived would enhance their ability to deal with this

crisis event, and help their husbands to regain their

health. Information was therefore an important consider-

ation for the women. Again, the main sources of informa-

tion were health professionals, most often general

practitioners, but some of the women were also able to

access culturally relevant information from the ethnic

media. However, in relation to some issues, the informa-

tion needs of the participants were not adequately met.

Stress for example, was a very real and on-going issue for

the women in this study, and all participants made

attempts to manage their stress. However, none of the

women had been able to develop strategies to assist them

in managing their stress. The fact that it was on-going and

unrelenting, meant that it remained a challenge to them,

and indeed, persisted beyond the duration of this study.

¼ sometimes it gets to me¼ maybe I'm doing the wrong thing,

maybe I shouldn't be stressed. What am I supposed to do, where

am I going to go? Go bash my head on the wall? Who am I going to



talk to? Who is going to help me not to worry so much? I need to

talk to someone, otherwise I'll blow up.

Although there were stress management courses avail-

able to the patients (the AMI survivor) themselves, they

were not available to the wives. Some of the women

commented that they would have appreciated profession-

al support in this area.

I wished I went to this stress management course. I think that if I

had gone to it I would have been¼ I would have controlled

myself more. I think that any woman that goes through stress

should be able to go to the stress management course.

As previously stated, the feeling that their husbands

required close and sustained supervision, affected the

social activities of the women. They felt unable to leave

their husbands alone, even for short periods, and this

severely curtailed their day-to-day activities, and cut off

many potential sources of support.

All the women who participated in this study expressed

similar sentiments, and indicated that they would not be

comfortable with the idea of leaving their husbands to

pursue their own interests and activities. While they

themselves had de®nite needs, in terms of support and

access to information, all of the women gave primacy to

the needs of their husbands during this time. For these

women, being accessible and available to meet the needs

of their husbands was their highest priority, and despite

their own needs for support and information, this re-

mained the focus of their energies.

Re¯ecting on the future

At one month post-discharge, the women were still

mainly concerned about helping their husbands achieve

a full recovery from the AMI. Fear of recurrence was an

additional area of concern for all the women. Indeed, for

some, achieving recovery, and avoiding a repeat event

were of such overriding concern, that there were no other

thoughts of the future. Generally though, the women

were hoping for long-term lifestyle changes so as to

ensure that their husbands continued to lead a healthier,

lower-stress lifestyle. There was understanding that the

recurrence of certain previous lifestyle practices could be

injurious to the health of their partners. The cumulative

effects of occupational stress were recognized by the

participants as bad for the health and wellbeing of their

husbands, and the women held hopes that, in the future,

the effects of occupational stress could be reduced. These

hopes for the future included some women hoping that

their husbands would agree to selling up family busi-

nesses.

I think he [husband] want to sold it [the family business] after.

Because what for? Like, they work hard for nothing, so if he sold it

and like, we do something more easier. Like if he worked ®ve

days a week it's more easier for him, like [prior to the AMI he

worked] seven days a week and he work, work, work long hours

and just for payments.

For other women, there was a feeling that their hus-

bands could not return to their previous occupations, and

thus the wives hoped for a change of employment, to what

could be perceived as lower stress occupations.

You see, his work is very stressful, brainwise and bodywise¼ It's

physically and mentally hard and he cannot do that. He said he

went in a couple of times, he couldn't handle it, looking at the

factory, it just looks so stressful. He can't really do that job.

When considering the future, the women looked to a

time when their husbands would be restored to full

health, their own stress and anxiety would be reduced,

and life could return to as it was in the days before the

AMI. Some of the women, however, also viewed the AMI

as having positive aspects as it had triggered lifestyle

changes for them and their husbands which were per-

ceived as bene®cial to both partners and experienced as

enriching to the marital relationship.

¼ we went for a 20 minute walk, it was really beautiful. I felt like

I was in heaven, because I had always wanted him to walk with

me in the park. I have this thing about parks, nature¼ I even tell

him. I want to grow old holding hands with you and walking on

the beach, watching the sunset or sunrise. I mean, I married him

because I love him. I didn't marry him for his money or anything

else. Maybe for his looks, he was really handsome, he still is to me

anyway. I love him, and I don't have any interest in being with

other people. There's nothing wrong with that is there?

For the participant who recounted the narrative above,

the lifestyle changes which were precipitated by the AMI

had resulted in her husband making time for things that

previously were not included in their lives together. Like

the husbands of the other women in the study, he had

worked very long hours for many years to establish

himself and his family in Australia, and this had only

been achieved at the expense of leisure activities, such as

taking walks with his wife.

In anticipating a full recovery, many of the women

looked toward an associated special event. Several for

example, were looking to the time when their husbands'

health improved to a point that the couple could take

holidays away from home. This desire to take a holiday,

and get away from what was perceived as a stressful

lifestyle, was a wish that was frequently expressed by the

participant women. This was because many of the women

felt that, as migrants, their husbands had worked so hard

to become established in Australia, that they had spent

little time relaxing and enjoying life, and this was viewed

by the participants as a contributing factor to the devel-

opment of heart disease.

J. Daly et al.


DISCUSSION

Similarly to other studies which focus on spouses of AMI

survivors, the Lebanese-born women in this study expe-

rienced the post-discharge period as a time of crisis and

change. Features of this include considerable distress

comprised of a range of negative emotions, over-solici-

tousness toward the AMI survivor, psychosomatic symp-

toms, fear of recurrence of AMI or loss of the male spouse,

searching for support, and anticipating the future. These

®ndings parallel those uncovered in previous studies

(Thompson & Cordle 1988, Marsden & Dracup 1991,

Moser et al. 1993, Thompson et al. 1995).

For the participants in this study, the issues are com-

plicated because of matters pertaining to culture, which

impact upon gender and family roles. The primary con-

cern for all of the women in this study was the provision

of care and companionship to their husbands. It may also

be signi®cant that all the participants in this study were

home-bound, and economically dependent on the AMI

survivor's income. Thus the concern for the survivor's

ability to return to productive working life was of vital

importance for these women. Between them, the seven

participants had mothering responsibilities for 32 chil-

dren, and had very limited options in terms of ability to

earn a living. Of further interest here, is the young age of

presentation for the males who sustained AMI (age range

42±67 years, mean � 48, median � 49), and their on-

going familial responsibilities, and the need for their

economic productivity.

The reluctance of these women to leave their partners

unattended suggests that to be effective in terms of

meeting the cultural needs of the women, caring strategies

should perhaps take the form of outreach, rather than

expecting the women to leave their homes and attend

services. The one woman who did experience pro-active

follow-up in the form of telephone contact expressed her

appreciation for this intervention.

Despite the small sample size which limits the extent to

which one can generalize from the study ®ndings, the

study has uncovered insights which have implications for

nursing practice and on-going research. All of the partic-

ipants experienced a deterioration in their health status

and perceived quality of life. The ®ndings suggest that

additional support in the community following the AMI

survivor's discharge may have a role in maximizing health

gains and minimizing health threats for the women. An

additional limitation of the study was the inclusion

criterion that participants have ¯uency in spoken English.

The research team is in the process of conducting a more

comprehensive study to establish the extent to which

these ®ndings are shared by other members of this cultural

group. The study in progress includes Lebanese-born

women who are non-English speaking. By extending

knowledge of the illness experience associated with AMI

for survivors and spouses within the Lebanese culture, it

may be possible to devise and test a number of culturally

appropriate nursing interventions in the initial discharge

period to enhance quality of life and health status.

The research approach used in the study meant that

each participant received two home visits from a nurse

who they met while their husbands were in the hospital.

This in itself, proved bene®cial to the women, who were

pleased to have the opportunity to discuss their feelings

with a health professional. A number of audio-taped

interviews exceeded 60 minutes, indicating the spouses'

need to ventilate concerns in order to relieve distress.

Similar to the participants in the study by Thompson et al.

(1995), the women in this current study demonstrated

emotional fragility during the interviews with several

becoming tearful while re¯ecting on their experiences. It

is acknowledged that appropriate support can ease the

stressful nature of the recovery period post-AMI for

survivors and their families (Wiggins 1989). Provision of

appropriate support requires needs assessment together

with information regarding family dynamics, and existing

support structures. It is also imperative that social and

cultural aspects be considered when formulating the

individual's plan for rehabilitation post-discharge.

CONCLUSION

Nursing has an imperative to build knowledge and

understanding across a range of illness experiences. This

requirement is central to provision of appropriate and

holistic nursing care. The need to explore all aspects of the

illness associated with AMI is clearly acknowledged in

the literature. Culture is a critical variable which in¯u-

ences quality of life in health and illness. This study is an

example of how a culturally relevant qualitative explora-

tion of living day-to-day through the illness experience

can generate new and useful insights into the deeply

human aspects of confronting and managing its associated

challenges. It is crucial that nurses explore the illness

experience for different cultural groups so as to enable

nursing to be responsive to the unique experiences and

needs of recipients of care.

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