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II I ‘ ‘ "‘ ' I .. «I J. ‘1‘ . ‘ ‘ ‘ x "1‘ \' I ' .‘IJ : i' . ‘ I ‘ ‘ . v ‘ I‘ { . . I' I ' " I I IV I 4’ It 3 ,:‘ ‘. In ' I ‘I‘ 1 :ill \ll II | ' 'I‘ 'I I | h I H 'I'I'I" ll ' I IIIIALIHLII I {h 55.: x I .‘NL‘EY Michigan State University This is to certify that the thesis entitled Husbands' and Wives Perceptions of Responsibility for Dimensions of the Postmyocardial Infarction Treatment Plan presented by Dana Lee Watt has been accepted towards fulfillment of the requirements for .ELSh__degree in m— y! l/‘d‘wj Major professor 0-1639 MSUI'. n. A'tfio—nn'm ‘ ‘ ’F‘ ' 3” ' J I-un’tun'n- Date June 20, 1985 MSU LIBRARIES ~ RETURNING MATERIALS: Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. HUSBANDS' AND NIVES' PERCEPTIONS OF RESPONSIBILITY FOR DIMENSIONS OF THE POSTMYOCARDIAL INFARCTION TREATMENT PLAN By Dana Lee Watt A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING College of Nursing 1985 ABSTRACT HUSBANDS' AND NIVES' PERCEPTIONS OF RESPONSIBILITY FOR DIMENSIONS OF THE POSTMYOCARDIAL INFARCTION TREATMENT PLAN By Dana L. Watt Husbands and wives may experience conflict during the implementation of treatment recommendations following a MI. In a self-report survey of 98 postmyocardial infarction males and their wives, subjects indicated how reSponsibility for activities related to the treatment regimen was allocated within the marital dyad. Husband and wife reSponses were tabulated and compared. Most husbands reported self-responsibility for all treatment dimensions except for food management which was shared with the wife. Most wives agreed that husbands were reSponsible for smoking cessation, alcohol limitation, medications and activity, but reported weight control, stress reduction and modification of sexual activity to be shared reSponsibilities, and food management to be their own reSponsibility. Iftests revealed significant mean differences between husband and wife responses for all treatment dimensions except for smoking cessation. There was increased agreement and sharing of responsibility when both husband and wife had received instructions concerning implementation of the treatment plan during the husband's hospitalization. ACKNOWLEDGEMENTS Many individuals contributed to the completion of this research. My thesis committee members contributed in Special ways. Brigid Warren, recognizing the differences in perceptions of postmyocardial infarction patients and their wives, designed and conducted the self—report survey from which the data utilized for this study was obtained. Mary Nugent-Polk provided guidance in the area of cardiac rehabilitation and Jacqueline Wright in the area of family theory. The thesis committee chairperson, Barbara Given, provided continual guidance in conceptual clarification and writing skills. Thanks to each of you. The encouragement and assistance provided by Bryan Coyle during statistical analysis of the data was valuable. His skill and patience in clarifying statistical concepts are gratefully acknowledged. A heartfelt thank you is extended to my family whose encouragement and assistance facilitated the completion of this work. Special thanks to my parents, Paul and Lucy Ludy, who taught me to value the search for knowledge. The affection and diversion provided by my children, Paula, Michael, and Jonathan helped me to maintain perSpective and lightened the load. Marina's committment and efficiency in caring for me and my family were invaluable. The willingness of my husband, Earl, to make a difficult but necessary sacrifice was essential to the completion of this research. His encouragement and demonstrations of total support are acknowledged with gratitude. ii TABLE OF CONTENTS LIST OF TABLES ........................ vi LIST OF FIGURES ........................ viii CHAPTER I: INTRODUCTION Background of the Problem ................. 1 Purpose of this Study ................... 5 Problem Statement ..................... 7 Research Questions .................... 7 Definitions of Concepts .................. 8 Extraneous Variables .................... 9 Study Assumptions ..................... 9 Study Limitations ..................... 10 Overview of the Chapters ................. 11 Chapter II: Conceptual Framework Overview .......................... 12 The Postmyocardial Infarction Treatment Plan ........ 13 Cardiac Risk Factors .................. 14 Treatment Plan Dimensions ............... 15 Treatment Plan Responsibility: A Transactional Model . . . . 13 The Process of Human Interactions ........... 19 Key Interaction Concepts ................ 19 Conceptual Model for ReSponsibility for Treatment Plan . . . 22 The Husband and Wife .................. 24 Husband's Perceptions of Health and Treatment Regimen. . 25 Wife's Perceptions of Husband's Health and Treatment . . 29 Task Allocation Interaction .............. 31 Perceptions of ReSponsibility for Treatment Plan . . . . 37 Extent of Agreement Concerning ReSponsibility ..... 40 Relationship of Time to ReSponsibility for Tasks . . . . 42 Summary of Model for Reseonsibility for Treatment Plan . 42 King's Nursing Theory of Goa Attainment .......... 44 Application of Theory of Goal Attainment .......... 45 Summary of Chapter II ................... 43 Chapter III: REVIEW OF THE LITERATURE Overview .......................... 50 Marital Couple Role Allocation Patterns .......... 50 Marital Couple Role Allocation Hypotheses .......... 54 iii Marital Couple Consensus Concerning Task Allocation . . Differences in Husband and Wife Perceptions ...... Nonagreement Arising from Measurement Error ...... Family Roles and Personal Health Practices ......... Responsibility for Treatment Plan Dimensions ........ Nursing Literature ..................... Summary of Chapter III ............ - ....... Chapter IV: Methodology and Procedures Background ......................... Sample ........................... Data Collection Procedures ................. Instruments ........................ Subscale Devel0pment .................. Reliability and Validity of Research Subscales ..... Operational Definitions of Variables ............ Husband and Wive Treatment Plan ReSponsibility ..... Husband and Wife Agreement Concerning ReSponsibility . . Time Following the MI ................. Possible Moderating Variables ............. Analysis of Data ...................... Protection of Human Subjects ................ Summary of Chapter IV ............ . ....... Chapter v: DATA ANALYSIS Introduction ........................ Sociodemographic Characteristics of Sample ......... Perceptions of Husband's Health Status ........... Treatment Plan Related Items ................ Reliability of ReSponsibility Instrument .......... Study Questions ...................... Question 1 ....................... 8uestion 2 ....................... uestion 3 ....................... Summary of Findings for Questions 1, 2, & 3 ...... Question 4 ....................... Question 5 ....................... Modifying Variables .................. Summary of Chapter V .................... Chapter VI: DISCUSSION, IMPLICATIONS AND CONCLUSIONS Overview .......................... Discussion of the Research Questions ............ Questions 1 and 2: Perceptions of Responsibility . . . . Question 3: Extent of Agreement Concerning Responsibility ..................... Questions 4 and 5: Importance of Time ......... Discussion of Other Findings ................ Instructions Concerning Treatment Plan ......... iv 98 98 103 107 111 112 113 114 116 119 121 121 122 127 129 129 129 131 134 135 135 Nursing Implications ................... 137 Implications for Nursing Practice ........... 137 Implications for Nursing Education .......... 143 Implications for Nursing Theory ............ 144 Recommendations for Future Research ............ 146 Summary and Conclusions .................. 149 BIBLIOGRAPHY .......................... 153 APPENDICES A. Physician Letter Of Invitation To Subjects ...... ix B. Letter Of Explanation And Consent Form ........ x C. Responsibility Questionnaire ............. xiii D. Items Composing 8 Subscales .............. xxiii E. Sociodemographic Questionnaire ............ xxiv F. M S U Approval of Study Protocol ........... xxxiii G Crosstabulations of Husbands' and Wives' ReSponses for 8 ReSponsibility Subscales .............. xxxiv 10. 11. 12. 13. 14. 15. 16. LIST OF TABLES Distribution of Age Ranges of Subjects ............ 99 Distribution of Years of Marriage Ranges ........... 99 Education Level Percent Frequencies for the 196 Subjects, and Adults Over 25 Years Old in Lansing/East Lansing and U. S. . . 101 Distribution of Combined Levels of Annual Income ....... 102 Distribution of Time Since the Husband's Last MI ....... 104 Distribution of Husbands‘ Ratings of Severity of Last Heart Attack ......................... 105 Couple Frequencies of Reporting HOSpital Instruction . . . . 109 Frequencies of Couple Reports of Individual or Joint Participation in a Hospital Teaching Program ......... 110 Pearson Correlation Matrix for the 8 Subscales With Crombach's Coefficient Alphas ................ 112 Distribution of Husbands' Mean Responses for the ReSponsibility Subscales ................... 113 Distribution of Wives' Mean ReSponses for the ReSponsibility Subscales ................... 115 Descriptive Statistics, T Tests and Pearson Correlations For Husband and Wife ReSponsibility Scores .......... 115 Classification of Subscale Crosstabulation Cells as Agreement (A), Near Agreement (NA), Competion (C), or Avoidance (AV) . . 117 Summary of Classification of Husband and Wife Paired ReSponses in Terms of Agreement, Near Agreement, Competition, or Avoidance ........................... 119 Significant Pearson Correlation Coefficients for Husbands' Subscales and Husbands Sociodemographic Items ........ 123 Significant Pearson Correlation Coefficients for Wives' Subscales and Husbands' Sociodemographic Items ....... 124 vi 17. 18. 19. G-l. G-Z. G-3. G-4. G-S. G-6. G-7. G-8. Significant Pearson Correlation Coefficients for Couple Different Scores and Husbands' Sociodemographic Items Ranked Subscale Means and Mean Differences ........ Frequencies of Reported ReSponsibility and Reported Instruction During H05pitalization ............ Mgritgl)Couple Responsiblity for Smoking Cessation Mean (N = 83) Mean (N = Mean 000000000000 O O O C O O O O O O O 0 Marital Couple ReSponsibility for Food Management 82 .......................... Marital Couple ReSponsibility for Medications (N = 87) Marital Couple ReSponsibility for Stress Reduction 90) .......................... Marital Couple ReSponsibility for Sexual Activity 30) .......................... Marital Couple Responsibility for Activity (N = 68) . . 126 130 136 xxxiv XXXV XXXV xxxvi xxxvii xxxvii xxxviii xxxviii LIST OF FIGURES Interaction model for cardiac rehabilitation with factors affecting perceptions of responsibility for treatment plan and potential disturbance from nonagreement .......... 23 Goal Attainment model for cardiac rehabilitation with factors affecting perceptions of reSponsibility for treatment plan and potential disturbance from nonagreement ......... 46 Goal attainment model for cardiac rehabilitation with * marking relationships verified through Pearson correlations . 138 viii CHAPTER I INTRODUCTION Background of the Problem Myocardial infarction (MI) is defined as “the damage and death of an area of heart muscle resulting from an interruption in the blood supply reaching that area" (National Heart, Lung, and Blood Institute, 1982, p. 37). The American Heart Association (1984) estimates that 1,500,000 Americans presently experience a myocardial infarction each year. Approximately 550,000 of the individuals who experience a MI will die. For half of the 550,000 individuals death occurs shortly following the MI, often before the individual reaches the hOSpital for treatment. Approximately 950,000 individuals do survive the MI and undergo treatment and rehabilitation. The goals of cardiac rehabilitation are defined by Segev and Schlesinger (1981) as: 1) to increase the patient's life expectancy by decreasing the chances for another MI and 2) to assist patients and their families to achieve psychosocial readjustment to their situation. As 90% of myocardial infarctions are attributed to changes in the heart resulting from coronary artery disease, the method for achievement of the first goal involves modification of select lifestyle factors so as to minimize cardiac risk factors. The method to achieve the second goal involves assisting patients to restore their mental, social, vocational, and economic potentials (Coe, 1978). 2 Successful rehabilitation involves a comprehensive approach which can probably be best accomplished by an interdisciplinary health care team. Nurses can contribute to the achievement of both rehabilitation goals by assisting clients to implement life-style changes and by assisting clients in the identification and resolution of psychosocial disturbances which result from the illness and illness treatment (Bennett, 1980). Recovery following a myocardial infarction is a very individual matter. The course of the illness and progress in rehabilitation is referred to as the illness trajectory (Corbin & Strauss, 1984). As this study is limited to husbands who have experienced a MI and their wives, the common illness trajectory for men with uncomplicated cases will be described. The common trajectory following a MI begins with a short period of hospitalization (often 6 to 10 days). When the husband's condition is stable, he is discharged from the hospital with a prescribed treatment plan which typically includes recommendations concerning diet, medications, smoking cessation, activity, sexual activity, and stress reduction (Maroc, 1980). For at least a couple weeks following discharge from the h05pital husbands experience physical weakness and activity is restricted. During this time, husbands are very dependent on their wives, who function as caregivers (Speedling, 1981). There is a gradual resumption of activities and former reSponsibilities. Many men are able to return to work and preinfarction activities within three months following the MI (Stern, Pascale, & Ackerman, 1977). The course of recovery may be interrupted at any time by a recurrence of a 3 M1, or by other illness. The fear of a recurrence which may result in death contributes to the stress which couples experience following the husband's MI (Hackett & Cassem, 1978). The modification of lifestyle required to implement the treatment plan occurs within the context of the family and Specifically within the context of the marital relationship. Typically, it is the wife who is reSponsible for providing needed physical care for the convalescing family member and for encouraging the implementation of the recommended modifications of lifestyle. Often, the wife has little or no preparation for the assumption of these tasks (Parsons & Fox, 1968). The consequences of failure to prOperly carry out the tasks are viewed as catastrOphic by the wife in that the patient may have a fatal recurrence of the MI. The implications of the MI for the couple and the reSponsibility for convalescence, with potential death a continuing threat, weigh heavily upon the husband and wife. Hackett and Cassem (1978) report that most convalescent patients at some time experience anxiety and depression. Wives interviewed following their husbands' infarctions also reported experiencing anxiety and depression. Some wives diSplayed severe emotional disturbances up to one year following the husband's MI (Skelton & Dominian, 1973) while others reported new physical symptoms and illnesses themselves following their husband's MI (Mayou, Foster, & Williamson, 1978). Thus, although the patient may return to work within two to three months following the MI, the marital couple's perceptions of the seriousness of the husband's health state may persist for at least a year. 4 In addition to reports of husband and wife anxiety and depression following the MI, there are reports of conflicts between the husband and wife during the recovery period. Conflict often centers around the husband's treatment plan. Each spouse may feel that he or she is best prepared to decide how much the husband should do and when. Wishnie, Hackett, and Cassem (1971) reported marked controversy over the Specific meaning of the physician's instructions. Kline and Warren (1983) noted that couples commonly appeared not to communicate with each other concerning their fears about death and the impact of the illness experience on their lives. Wives expressed frustration to health personnel concerning their perceptions of poor adherence by the husbands to their treatment plans and their inability to control their husbands' behavior. Wives often found it difficult to strike a balance between being helpful and allowing the patient to return to an appropriate level of activity (McLane, Kr0p, and Mehta, 1980). Husbands, in return, perceived their wives as overprotective and expressed frustration and hostility with their wives' behaviors. Husbands may become irritable and may ignore medical restrictions in an attempt to reassert their independence. The struggle for dominance may become a major issue. Husbands whose marital relationship has been characterized by wife dominance may use the illness to gain the dominant position. At the other extreme, some men may utilize the illness experience to avoid reSponsibilities and to be cared for long after the damaged heart muscle has healed (Davidson, 1979). In order to further investigate the impact of the husband's MI and treatment regimen on the marital couple, Kline and Warren (1983) 5 developed a tool to measure marital functioning following the husband's MI. In a study titled "The Devel0pment of Measures to Determine Marital Functioning and Treatment Activities Post-Myocardial Infarction”, 98 husbands who had experienced myocardial infarctions within the previous year, and their wives were surveyed. The purpose of the research was to collect descriptive data to determine if couple agreement in the areas of 1) the extent of adherence by the husband to the medical regimen and 2) the extent to which each Spouse was reSponsible for the medical regimen were predictors of marital functioning (mutuality). Kline and Warren (1983) found positive correlations between the wife's marital functioning score and 1) agreement with the husband about the husband's adherence and 2) agreement about responsibility for activity and stress reduction. Agreement about reSponsibility for diet and medication was negatively correlated with the wife's marital functioning score. The husband's marital functioning score was positively correlated with agreement about his adherence. In view of the findings by Kline and Warren (1983) and reports in professional literature concerning intramarital conflict in the postmyocardial infarction period which seems to revolve around implementation of the postmyocardial infarction therapeutic regimen, the focus of this study will be on husbands' and wives' perceptions of reSponsibility for the therapeutic regimen. Secondary data from the research of Kline & Warren (1983) will be utilized to describe a) the husbands' and wives' perceptions concerning who is reSponsible for Specific components of the treatment plan, b) the extent of agreement 6 between the husband's and the wife's perceptions of responsibility, and c) the effect of time since the M1 on perceived reSponsibility and agreement concerning responsibiity. Purpose of this Study The purpose of this Study is to analyze and present descriptive data concerning how reSponsibility for enacting the husband's postmyocardial infarction treatment plan is perceived within the marital couple. There are at least two reasons why information about the reSponsibility for postmyocardial infarction treatment is important. First, knowledge about who assumes reSponsibility for a treatment dimension will be useful to the nurse in planning patient education following the MI. The reSponsible Spouse for a treatment dimension should be prepared in terms of explicit instructions and /or educational sessions. Second, authors report the postmyocardial infarction recovery phase to be a time of high anxiety and marital conflict. If there are differences in perception between the husband and wife concerning which spouse is reSponsible for certain aSpects of treatment, this may contribute to marital conflict. Nursing intervention should be directed toward anticipatory counseling with couples concerning perceived differences regarding the treatment. Also, couples should be assisted in coming to an agreement about assignment of reSponsibility for each treatment dimension, with revisions of assignment as convalescence progresses. Problem Statement The problem statement is: What are the husband's and the wife's perceptions of the extent to which each Spouse is reSponsible for carrying out the husband's postmyocardial infarction treatment plan? Research Questions The major question to be addressed in this study is: How do the husband and wife perceive reSponsibility for the husband's postmyocardial infarction treatment plan? To facilitate addressing the major question the following sub- questions will be answered: 1. Who does the husband report as responsible for each of the treatment dimensions of smoking cessation, diet, medication, activity, sexual activity and stress reduction.? Who does the wife report as responsible for each of the treatment dimensions of smoking cessation, diet, medication, activity, sexual activity and stress reduction? What is the extent of agreement between the husband and the wife concerning responsibility for the husband's treatment plan? What is the relationship between time since the MI and who is reported as reSponsible for the treatment dimensions? What is the relationship between time since the MI and husband and wife agreement concerning responsibility for the treatment plan? Definitions of Concepts Husbands. Husbands will be defined as married males between the ages of 40 and 75 who were hospitalized and diagnosed by a physician as having experienced a myocardial infarction up to one year before completing the research instrument. Wives. Wives will be defined as women who are married to and living with men who participated in the study. Postmyocardial infarction treatment plan. Postmyocardial infarction treatment plan will refer to the therapeutic regimen which is prescribed by the health provider following the husband's myocardial infarction. For this study the following dimensions of the treatment plan will be considered: a) smoking cessation, b) diet, c) medication, d) activity, e) sexual activity and f) stress reduction. ResPOnsibility for the postmyocardial infarction treatment .3132. Responsibility for the postmyocardial infarction treatment plan refers to the subjects' perceptions concerning accountability for carrying out the duties connected to the treatment plan. Extent of agreement. Extent of agreement will refer to the similarity between husbands' and wives' reSponses on the instrument. Time since the MI. Time since the MI refers to the time in months which elapsed between the husband's MI and the subjects being surveyed for the study. Extraneous Variables There are several variables which may affect the marital couple's perceptions of who is reSponsible for the husband's postmyocardial infarction treatment plan. The importance of some of these variables will be determined through analysis of data from a sociodemographic questionnaire which was administered concurrently with the research instrument. Extraneous variables which will be considered for the marital couple include age, educational level, employment status, income, years of marriage and the activity capability of the husband. Study Assumptions The research is based on the following assumptions: 1. Husbands and wives will be able to understand the questionnaire. 2. Responsibility for treatment can be measured on a five point scale. 3. The instrument used does measure who is responsible for the treatment. 4. Postmyocardial infarction treatment plans, containing some or all of the treatment dimensions defined in the study will have been prescribed for the husbands. 5. Husbands and wives will be able to identify which of them is responsible for the dimensions of the postmyocardial treatment plan. 6. Subjects will truthfully record their perceptions concerning assignment of reSponsibility. 10 7. Husbands and wives will complete the questionnaire without conferring with one another. 8. Knowledge concerning who is reSponsible for the husband's treatment and couple agreement concerning responsibility will be useful for the nurse in planning nursing interventions for the marital couple following the husband's MI. Study Limitations 1. A convenience sample of patients from six mid-Michigan clinics and a cardiac rehabilitation center are used. The extent to which the results will be generalizable to other p0pulations will depend on their similarities to the study sample. 2. Differences between sites and between patients from different sites may act as confounding variables. 3. The study utilizes a volunteer p0pulation which may differ from the total p0pulation including those who did not agree to participate. 4. The questionnaire was mailed to the respondents and the extent to which spouses conferred about reSponses is unknown. 5. The study is of a descriptive nature concerning who couples report as reSponsible for the husband's treatment. Variables influencing who is responsible will not be identified. 6. Subjects were only surveyed once. Therefore changes in perceptions concerning reSponsibility which occurred over time within the same subjects cannot be identified. 11 7. The study does not control for the severity of the MI nor differentiate between men treated with Open heart surgery and men who received only medical treatment. Overview of the Chapters The description of the research study will be presented in six chapters. In Chapter I an introduction which describes the difficulties of the marital couple in implementing the postmyocardial infarction treatment plan is presented. The purpose of the research, statement of research questions, definitions, assumptions and limitations of the study are given. In Chapter II the conceptual framework for consideration of the husbands' and wives' responsibility for the dimensions of the treatment regimen based on King's (1981) theory for nursing and current postmyocardial infarction literature will be presented. A review of the current sociological literature concerning household task allocation and consensus within the marital couple and literature describing the husbands' and wives' reSponsibility for the postmyocardial infarction treatment plan will be presented in Chapter III. In Chapter IV the procedures for data collection, the develOpment of the instrument subscales and the statistical data analysis will be presented. A presentation of the findings obtained from the data analysis will be included in Chapter V. In Chapter VI the research findings will be discussed and nursing implications, recommendations for further study, and conclusions will be presented. Chapter II Conceptual Framework Overview In Chapter I the derivation of the study problem from difficulties experienced by the husband and wife following the husband's myocardial infarction was summarized. In Chapter II a conceptual framework for consideration of the husband's and wife's reSponsibility for the husband's postmyocardial infarction treatment plan will be presented. The purpose of the conceptual framework will be to develOp a model which can be used for theory building in the area of Spouse contribution to cardiac rehabilitation and to develon that model in a context which will be useful for nurses in planning and implementing nursing interventions for couples following the husband's MI. The study of the husbands' and wives' perceptions of reSponsibility for the postmyocardial infarction treatment plan can be viewed conceptually as one aSpect of the study of the roles which the husband and wife assume in regards to the husband's treatment. King (1981) describes three elements of the concept of role as: "1) role is a set of behaviors expected when occupying a position in a social system; 2) rules or procedures define rights and obligations in a position in an organization; and 3) role is a relationship with one 12 13 or more individuals interacting in Specific situations for a purpose" (p. 93). The focus of this study iS on how the husband and wife perceive obligations or reSponsibilities concerning the husband's treatment plan. The derivation of obligations results from husbands' and wives' expectations and interactions concerning the treatment plan. King (1981) has develOped a nursing Theory of Goal Attainment. This theory is based upon the process of human interaction. AS the determination by the husband and wife of the role each will play in regards to implementing the husband's regimen also results from interaction, King's theory appears to be both apprOpriate and useful as a framework for the discussion of the study problem. This chapter will be organized in two main sections. In the first section, the derivation and content of the postmyocardial infarction treatment plan will be presented. In the second section, King's Theory of Goal Attainment will be presented. A model which applies the Theory of Goal Attainment to the husband's and wife's perceptions of reSponsibility for the husband's postmyocardial infarction treatment plan will be presented and each component discussed. The nursing applications of the model and of this study will then be addressed. The Postmyocardial Infarction Treatment Plan When the husband iS discharged from the hOSpital, the two main emphases of the postmyocardial infarction treatment regimen are: 1) to decrease the patient's chances for another MI through reducing cardiac risk factors and 2) to promote healing of the damaged heart through 14 rest, initially, and then through gradual increases in activity. A considerable amount of research has been directed toward the identification and modification of cardiac risk factors. The benefits of cardiac risk reduction following a MI are currently being .investigated. Cardiac Risk Factors Donat (1977) lists three groups of primary risk factors for coronary artery disease. The first group consists of mainly unalterable factors such as increasing age, male sex, and a genetic predisposition for heart disease. The second group consists of illnesses and disorders such as arterial hypertension, hypercholesterolemia, hyperuricemia, and diabetes mellitus which provoke myocardial disease. The third group includes behavioral characteristics such as cigarette smoking, high stress, and lack of exercise. Obesity in itself is not a risk factor, but when occuring with other risk factors it is a multiplier of risk. Treatment plans often include recommendations for the avoidance or control of obesity. The primary risk factors are thought to contribute to the develOpment of coronary heart disease, and preliminary prevention often focuses on reducing the risk factors. Researchers are also investigating the effects of reducing the risk factors as a means of preventing subsequent myocardial infarctions once heart disease has occurred, and perhaps even reversing severe heart disease. Three areas where researchers report the most impact following a myocardial infarction are a) smoking cessation, b) control of hypertension and 15 c) control of hypercholesterolemia. Activity levels and effects of stress are also being researched to determine their relationship to recovery following a MI (Elmfeldt et al., 1978). The normal components of the postmyocardial infarction treatment plan include measures designed to reduce the risk factors for heart disease as well as measures designed to promote healing of the heart. These measures will be discussed in the following section. Treament Plan Dimemsions Dimensions of the treatment plan which will be considered in this study are: a) smoking cessation, b) diet, c) medications, d) activity, e) sexual relationships and f) stress reduction. Smoking The individual is usually encouraged to st0p smoking (Fuhs, 1976). As smoking cessation may decrease mortality following an MI by almost 50% (Elmfeld et al., 1978), physicians commonly urge complete smoking cessation. When this is not successful, a reduction in the quantity of tobacco smoked per day is encouraged or switching to a pipe is recommended (Dawber, 1980). Diet. Diet recommendations may include: a) low saturated fat and low total fat to reduce cholesterol, b) reduced salt intake when hypertension is present, c) a diabetic diet when diabetes is present, and d) a low calorie diet when the patient is overweight (C00per 8 Van Horn, 1980). Individuals are encouraged to be moderate in their consumption of alcoholic beverages. I Medications. Common categories of medications which may be prescribed following a myocardial infarction include agents which have 16 a direct action on the heart, agents which reduce heart disease risk factors, and agents which assist psychosocial adjustment. Medications with a direct action on the heart include nitrates, digoxin, and beta-adrenergic blocking agents. Medications which treat risk factor conditions for a MI include antihypertensive agents, antilipid agents, and antihyperglycemic medications. Medications intended to aid psychological adjustment include antidepressants (after 8 weeks post myocardial infarction), mild tranquilizers, and/or Sleeping pills (Froelicher, Curtis, & Shanley, 1980). Activity. Activity recommendations include the extent to which the patient can engage in normal activities of daily living, including self-care, work capability and ability to engage in social activities. The individual is commonly advised to gradually increase activity and activity recommendations are given for each phase of recovery. The trend is for an early return to usual daily activities. Some men return to work within six weeks following hOSpitalization (Stern, Pascale, & Ackermam, 1977). The physician may initiate range of motion exercise early during hOSpitalization to prevent circulatory stasis. Once the client's condition has stabilized, limited ambulation iS initiated to maintain muscular strength and flexibility of the body during convalescence. The client may continue the program following discharge with a progressive walking or stationary bicycle program, accompanied by range of motion and stretching activities. When the heart has healed, usually within six to twelve weeks, a progressive exercise program is begun to condition the cardiovascular and skeletal muscles. This 17 program may last up to a year, followed by a physical maintenance program that may be based on sports (Edgett and Porter, (1980). Treadmill testing may be used to determine appr0priate activity and exercise prescriptions throughout rehabilitation (Janz & Lampman, 1981). Some benefits of the exercise program are reported to be: decreases in angina permitting a greater range of safe,physical activities, improved physical conditioning resulting in increased self-confidence, prevention or relief of anxiety and depression, and ongoing contact with a rehabilitation team (Segev & Schlesinger, 1981). Sexual activity. Sexual activity can usually be safely resumed between 4 to 6 weeks following the MI, or whenever the client can perform exercises at 6 to 8 kcal/minute (the energy expense is equivalent to climbing two flights of stairs) without adverse changes such as angina, abnormal heart rate, or electrocardiogram changes. Doctors may recommend that the couple abstain during times of extreme temperatures, after a heavy meal or before other strenuous activity. Some physicians may recommend that the male use less active positions during sexual relations (Puksta, 1977). .§EEE§§- Patients may be advised to modify their lives to reduce stress. Recommendations may include participation in stress reduction classes or cardiac support groups, modifying or changing the work environment, and modification of personal expectations (Slay, 1976; Selye, 1976). 18 In summary, the dimensions of the treatment plan are intended to reduce cardiac risk factors. The postmyocardial infarction treatment regimen commonly includes recommendations concerning smoking cessation, diet, medications, activity, sexual activity, and stress reduction. The physician prescribes an individualized plan which is modified according to the husband's health status and rehabilitation stage. The husband and wife are expected to implement the treatment plan at home. In order to implement the treatment plan, the husband and wife determine who will be reSponsible for the various dimensions of the plan. In terms of family sociology, the process of determining reSponsibility is referred to as division of labor or task allocation. In the next part of the chapter, King's (1981) Theory of Goal Attainment will be used as a framework for the discussion of the husband's and wife's perceptions of reSponsibility for the husband's postmyocardial infarction treatment plan. Treatment Plan ReSponsibility: A Transactional Model The physician prescribes a treatment regimen with recommendations concerning diet, medications, smoking cessation, stress reduction, activity and work guidelines, and recommendations concerning sexual relations. It is left to the couple to determine how and by whom the treatment recommendations will be implemented. The couple may or may not Specifically discuss who will be reSponsible for various components of the plan, but based on past experiences and current interactions they somehow come to an understanding of how the necessary work for implementation of the treatment regimen will be 19 accomplished. The process of interaction is an important concept in the allocation of task reSponsibility between the Spouses. The Process of Human Interactions King's (1981) nursing Theory of Goal Attainment is derived from systems theory and uses a model of the process of human interactions as a basic framework. The premise of the nursing Theory of Goal Attainment is that nurses and clients can interact in such a manner that goals are identified and decisions are made concerning means to achieve goals. These goal directed interactions are referred to as transactions. The theory of goal attainment is useful for nurses and will be discussed later in this chapter. The process of human interaction, which is the underlying framework for the Theory of Goal Attainment, will be used as the basis for a conceptual model for consideration of the husband's and wife's responsibility for the husband's postmyocardial infarction treatment plan. In the following section, basic concepts of the process of interaction will be defined and their relationship explained. Key Interaction Concepts Key concepts of the process of human interactions are individuals, perception, interaction, communication, and transaction. Individuals. Individuals are social beings who are rational, sentient, and who communicate thoughts, actions, customs and beliefs. Individuals usually are born and raised within a family social system. The family transmits beliefs, customs and values to 20 children through a process of socialization. Beliefs, attitudes, values and customs are learned throughout life as the individual comes into contact with social systems. AS each individual is unique in terms of biological inheritance and life experiences, so is each individual unique in terms of expectations, needs, and perceptions of life events. Individuals react to other persons, events, and objects in terms of their own perceptions, expectations and needs. Perception. Perception iS defined by King (1981) as "a process of organizing, interpreting and transforming information from sense data and memory. Perception gives meaning to one's experience, represents one's image of reality, and influences one's behavior" (p. 24). Interaction. King defines interaction as “the acts of two or more persons in mutual presence. Interactions are reciprocal. When one initiates an interaction with another, an action takes place, each person reacts to the other, and a reciprocal Spiral deveTOps in which the individuals either continue to interact or withdraw from the situation" (p. 84). Interactions involve both verbal and nonverbal communication and responses depend on each individual's perceptions of the communication. Communication. Communication is an interchange of thoughts and Opinions among individuals. Communication is a process which includes a message sent component and a message received component which may differ from each other. Communication may be direct or indirect and may be verbal or nonverbal. When two or more individuals are together, communication takes place on some level. 21 Transactions. Transactions are interactions that are goal directed. Transactions include interactions characterized by the sharing of values, beliefs, and expectations. The model of the process of human interaction begins with the meeting of two individuals. The individuals each occupy certain positions within social systems and each has knowledge, values, needs, expectations, and past experiences which affect the interaction. Individual A acts in a certain manner. Individual 8 perceives A's action, judges it and responds with a mental reaction. B's process of perception, judgement, and reaction cannot be observed. The behavior of B which results from the perception, judgement, and reaction can be observed and sends a message to A who then repeats the process. The sequence of behaviors which result, each arising from the meaning which iS perceived and attibuted to preceeding behaviors is interaction. When interactions are characterized by goal attainment they are transactions. King explains that communication and transaction can be directly observed. Communication is observed as the informational component of interactions. Transactions are the transfer of values between individuals. Transaction implies bargaining, negotiation, and social exchange. Through the exchanges which occur in transactions, goals can be attained. In the following section the process of human interaction will be applied to the marital couple as they interact to allocate reSponsibility for the dimensions of the therapeutic regimen. 22 Conceptual Model for Responsibility for Treatment Plan The allocation of reSponsibility for the husband's postmyocardial infarction treatment plan occurs through the process Of human interaction. A model, adapted from Kline & Warren's (1983) research model, demonstrating the application of King's (1981) process Of human interaction to the allocation of reSponsibility for the husband's postmyocardial infarction treatment plan is demonstrated in Figure 1. In Figure l the husband and wife are each represented as unique individuals. Due to differing past experiences, the husband and wife have unique values, attitudes, expectations and goals. The individual characteristics of the husband and wife affect their perceptions concerning the husband's health status and treatment regimen. Perceptions concerning the husband's health status and treatment regimen in turn affect the interaction of the husband and wife concerning the treatment plan. Through the process of interaction, the husband and wife determine who will be reSponsible for the various treatment plan tasks. Interaction involves perception, judgment, action and reaction. Communication iS a key component of interaction and involves both verbal and nonverbal behaviors. When communication is Open and clear, the husband and wife share their perceptions, define goals, and identify methods for goal attainment. Transactions are goal-directed interactions. At times the husband's and wife's perceptions of situations vary from each other and communication is blocked or unclear. Lack of agreement concerning the husband's rehabilitation and how to best 23 522.523.. 8.: 3523:: .2252. E: 5:. 2.8.2.: 8. 5:33.33... .o u=o_.a.ua.g on..u..~a naoauaw =«.3 ¢o_~..___nu=oa u._uaau sea .ouoa ¢o_.u~3..=_ .q.muaamm a: 2:5 _. .5... a... 22.3 E: 95. 3:3. _IIIIIIIII IIIIIIIIIIIIIIIIIIIIIIIIIIII 1. 5: 2.3:: 3:53.... 8. x5.22.2.5 szuhLmomwm *---—_-_-—- ua~a~m g._ao= n.u=aam== SE «55-...» m2o~hmmo¢wm / \ “wanxyo Epch—Jagmm mammflwgh u. m z o n h 0 ¢ a M .F 2 ~ o¢_om¢u 2.52.; 3* 5 3:8...“ m5_tmo¢ua \ 333.. 5 .2: -._m «3.....ap mane—hhmwo~mwm _ ._aoo u=o_.~.u.axo nae—a: mau=._auaue ans; a=.aaa _~_uo. mum: a_aoa n.o_.~.u.gxo a.=.~: nuns-.5-‘u. .ma. ma.a.a _~_uon E 3:: 3: ozcmmnz _ . l- I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I l. 24 accomplish the tasks connected to the rehabilitation effort may result. Nonagreement may lead to disturbances or blocks in transactions concerning cardiac rehabilitation. There iS a feedback component to the model in that each interaction becomes part of the experience of the husband and wife and therefore affects the perceptions which contribute to subsequent interactions. In the following sections, the various components of the model will be discussed as they relate to the husband's and wife's perceptions of responsibility for the treatment plan. The Husband and Wife In the conceptual model (Figure 1) the husband and wife are viewed as unique individuals. Corbin & Strauss (1984) suggest that the uniqueness can be expressed in terms of biography. Biography is defined by Corbin and Strauss (1984) as "a life course made up of progresssive and at times overlapping phases, during which is encountered a series of expected and unexpected circumstances and events (e.g., going away to school, getting married, buying a house, losing a job, the death of a family member) that require Special types of work to handle" (p. 10). In this study, the illness of the husband is viewed as an unexpected event which must be handled by the marital couple. The illness affects the future life course of the couple and the husband's and wife's biographies up to the point of illness also affect how the illness will be handled. 25 In research and theory develOpment, it is not possible to know the complete biography of each individual. Specific characteristics of the study sample are Observed or measured within a particular time frame. For this Study husbands and wives will be described in terms Of standard sociodemographic characteristics. The variables to be described and correlated will be the husband's and wife's perceptions of reSponsibility for the dimensions of the husband's postmyocardial infarction treatment plan and time since the husband's MI. According to the conceptual model, the marital couple's perceptions concerning treatment plan responsibility are affected by their perceptions Of the husband's health Status and the treatment plan. A discussion of the importance of the husband's and wife's perceptions of the husband's health status and the treatment plan will follow. Husband's Perceptions of Health and Treatment Regimen following the M1, the husband defines the meaning of the illness experience. This commonly involves some sort of projection as to what his chances are for recovery and how his life will change because Of his illness. Miller (1983) states that some of the work involved in COping with chronic illness includes: modifying routines and life-styles, maintaining a positive self-concept, dealing with role change, grieving with the losses associated with chronic illness, handling physical discomfort, maintaining a feeling of being in 2.6 control, maintaining hope deSpite an uncertain illness course, and dealing with the social stigma associated with the illness. A major factor in the experience of men following a MI is the necessity of assumption of the sick role for a period of time and the loss of independence which accompanies this state. Parsons (1951) presents four social expectations that accompany the sick role as: 1) the sick person is exempt from social reSponsibility, 2) the Sick person cannot be expected to take care Of Himself, 3) The sick person should want to get well, and 4) the Sick person Should seek medical advice and COOperate with medical experts. These expectations mean that the husband becomes dependent on others for his care, refrains from accustomed activities, and is expected to comply with the prescribed treatment plan. The close brush with death coupled with the possibility that another MI could happen at any time are a source of a great deal of anxiety for the husband. Adsett & Bruhn (1968) noted that a recurrent theme in a postmyocardial infarction therapy group was the loss of self-esteem and the conflict between the desire to be cared for versus the need to be manly and independent. Hackett and Cassem (1975, 1978) have Observed that depression is a universal accompaniment of recovery following a MI. The bases for the depression are thought to be a loss of self-esteem resulting from threat of invalidism and the loss of autonomy and independence. Upon discharge from the hOSpital, the patient is physically weak and must be cared for. There are fears concerning the future and the ability to return to work, family, and sexual roles. In addition, adherence to 27 the treatment regimen may mean the loss of cigarettes, favorite food, and excitement. Hackett and Cassem (1975, 1978) suggested that the more quickly the husband can begin exercises and regain his self-esteem, the better his recovery. The reaction of the patient to his MI will have an impact on his recovery. Garity (1980) found that the best six-month predictor of the patient's psychosocial adjustment, as measured by return to work, return to certain leisure activities and level Of morale following a MI, was the patient's perception of his health status. Those who felt their health was poor subsequently made poorer recoveries, irregardless of the physician's assessment of the patient's health. In a similar vein, Stern, Pascale, and Ackerman (1977) found that patients who were characterized as depressed while hOSpitalized were less successful in returning to work and sexual function, and had higher hOSpital readmission rates and mortality rates at one year following the MI, than those patients characterized as deniers. It is Significant that the depressed group had higher scores on the schedule of recent experiences scale, and demonstrated more marital adjustment difficulties. Based on his initial assessment of his health, the husband determines how he will reSpond. Some choose to remain in the sick role and, at the extreme, become "cardiac cripples". Gulledge (1975) suggested that the excessively helpless and dependent person may become overly concerned about body functioning. Such a person may comply meticulously to the treatment regimen except in the area of activity. 28 Inactivity may cause the person to actually become weaker and more dependent. Other men seem to deny the seriousness Of their illness, and quickly resume their former lifestyle and activities. These men may disregard their treatment regimens. Rahe, Tuffle, Suchor & Arthur (1973) observed that most men had seen themselves as masculine, strong, and invulnerable to illness before their MIS. "Their myocardial infarctions revealed to them that they were indeed vulnerable to illness, but after their hOSpitalization they tended to revert to their previous attitudes regarding their health. Unless they periodically reminded themselves of their coronary disease, they saw little reason to pursue dietary, exercise, and anti-smoking regimens or to change previous attitudes and behaviors" (p.87). The goal of cardiac rehabilitation is for the husband to decrease his chances for another MI and to achieve psychosocial readjustment. It is thought that this can be best achieved if the husband has a realistic assessment Of his at~riSk health status and.c00perates with the treatment plan (Dracup, Meleis, Baker, & Edlefsen, 1984). In summary, the MI experience may lead to a loss Of self-esteem for the husband. The issue of major concern for the husband may be regaining his self-esteem. The husband's definition of his illness appears to influence his health, psychosocial adjustment, and his behavior concerning the treatment regimen. Depending on his definition of his health status, the husband may need to strike a balance between maintaining quality Of life versus prolongation of life. 29 Wive's Perceptions of Husband's Health and Treatment Following the husband's MI, the wife also makes a projection of the husband's chances for recovery and how best to accomplish his recovery (Corbin & Strauss, 1984). The wife may perceive there is a good chance the husband may die and leave her a widow. She may perceive that her marital relationship with the husband was a causal factor for the husband's MI (Croog & Levine (1982). The wife's perceptions of her husband's risk, and methods of reducing those risks, will affect her behavior in regards to the treatment plan. Parsons & Fox (1968) stated that in the common nuclear family there are Only twO adults. Thus, when one member is ill, the other is obliged to assume the role as caregiver. The husband's illness often is unexpected and the wife must care for the husband in addition to maintaining family functioning and sometimes working outside the home. For the wife, the need to assume responsibility for the caregiver role is often a source of anxiety and fear. Bell (1979) points out that the wife needs knowledge and even medical skills to prOperly care for the husband. Yet, wives commonly report they received very little instruction from health personnel as to the exact manner in which treatment prescriptions should be carried out (Speedling, 1981; Hentinen, 1983). Wives eSpecially are fearful concerning the husband's physical activity and exactly how much he can safely do (Harding & Morefield, 1976; Garity, 1975; Lambert & Lambert, 1979; Skelton & Dominion, 1973; Gulledge, 1975). For the wife, the safest route is caution and limitation of activity. The wife's belief that the husband is 30 vulnerable to another MI may lead her tO be oversolicitous and overprotective (Croog 8 Levine, 1982). The wife's need to preserve the life of her husband and the husband's need to regain his self-esteem through returning to his former lifestyle may result in marital conflict concerning the treatment regimen. Some wives may assume a "watchdog“ role and carefully watch their husband's behavior for any variation from the prescribed regimen. Husbands may reSpond with irritation and anger (Speedling, 1981). Vachon et al. (1980) enlarge upon the wife's experience as decribed by women whose husbands had eventually died from a MI. The pressure placed upon women in getting their husbands to comply with doctor's orders cannot be overemphasized. Wives prepare special low sodium, low cholesterol diets which husbands refuse to eat; they hide cigarettes and liquor and nag about overwork. This type Of supervisions tends to lead to increased tension and the feeling of being caught in.a vicious cycle. If a husband does not change his life-style he might die, but, by forcing the issue, the wife might "kill" him. Usually, the women interviewed felt that the maintenance of this precarious balance was their sole reSponsibility. Immediately after the deaths of their husband, they were plagued by feelings of guilt about the quality Of care they gave.... (p. 298). In summary the wife, like the husband, defines the meaning of the husband's MI. The wife is initially assigned the role of caregiver to the convalescing husband. The wife may feel greatly reSponsible for both the husband's illness and recovery. The wife may assume ah overprotective manner in an attempt to keep the husband from overworking and in avoiding arguments or stress at home. Some wives 31 may assume a "watchdog" role in attempting to control the husband's habits. The wife's perceptions of the seriousness of the husband's illness may affect her perceptions Of the treatment plan. If the wife considers adherence to the treatment plan as the only means of prolonging the husband's life, she may do all in her power to assure adherence. If the husband appears not to assume much responsibility in regards to the treatment plan, the wife may perceive that the means to her goal are blocked and respond accordingly. The perceptions of the husband and wife concerning the husband's health status and treatment plan affect the interaction of the husband and wife concerning allocation of reSponsibility for the treatment plan. Task Allocation Interaction The differences in perceptions between the husband and wife which may occur concerning the meaning of the husband's illness, the husband's health status, and the meaning of the treatment regimen have been discussed. AS the issues surrounding the treatment tasks are emotionally charged and touch on the meaning of the husband's existence, it can be suspected that the assignment of reSponsibility for various dimensions of the treatment plan has far more meaning than Simple efficiency in getting things done. Task allocation theory prOposes that through interaction individuals with different perspectives, needs, expectations and goals allocate reSponsibility for treatment tasks. Blood (1969) suggests three processes which may be used by families in allocating 32 responsibility for tasks are a) allocation according to gender role norms, b) allocation according to Special needs or interests and c) allocation according to Special circumstances. As illness definitely creates Special circumstances, this area will be conSidered first. Allocation During Illness. There are normative expectations, in our culture, that adults are basically reSponsible for their own health and self-care (Orem, 1980). The Sick role and caregiver roles (Parsons 8 Fox, 1968) arise out of necessity following the husband's MI. The wife's involvement in the husband's treatment regimen is legitimized by the husband's physical inability to provide his own care. While the husband is convalescing at home, the wife usually functions as caregiver. During the initial phase of recovery, some men may assume a very passive role and allow or expect others to assume responsibility for their care (Hackett 8 Cassem, 1975, 1978; Speedling, 1982). Others will demonstrate their self-reSponsibility by taking an active part in making decisions concerning their care and in implementing the prescribed treatment plan. In the common illness trajectory, the husband's health gradually improves to the point where the husband leaves the sick role. The husband does not return to a "well" health status but remains "at-risk“ for further illnesses resulting from cardiovascular disease. This means that the tasks connected with the reduction of risk factors as prescribed in the therapeutic regimen need to be carried out on a regular and permanent basis (Dracup et al., 1984). On the basis of necessity alone, one could predict that as the husband's physical condition improves he would assume more 33 responsibility for most of his health care tasks and the wife's responsibility would lessen. This may happen to some extent, but Mayou, Foster and Williams (1978) reported that wives were actively involved one year following the husband's MI in consulting doctors concerning their husband's progress, giving medications, and actively encouraging their husbands to exercise, diet, and stOp smoking. The continued involvement of the wife in the husband's rehabitation may arise from normative values which lead to allocation Of health-related tasks to the female gender and/or from special needs and interests Of the husband and wife. Gender Role Norms. Gender or sex roles are normative cultural expectations which define Specific rights and duties for male and female roles (Reiss, 1980). Men and women are thought to be socialized from early childhood both within the family of origin and within other social systems such as schools or churches to assume appropriate adult gender roles. Gender role socialization results in ideology concerning who §h9u1d_be responsible for particular family tasks. Our culture is experiencing changes in ideology from traditional expectations that male and female roles should be distinct and separate toward the egalitarian Sharing of roles. However, at this point there are still generalized expectations that men should assume major reSponsibility for providing for the economic needs of the family while females Should assume major reSponsibility for housekeeping reSponsibilities (Feldman, 1982). 34 The association of household and child care tasks with the wife have also led to the association of tasks related tO maintaining the health of the family and caring for ill members with the wife (Nye, 1976; Litman, 1974; Pratt, 1976). These normative expectations may lead to husband and/or wife perceptions that the wife is reSponsible for various dimensions of the treatment task even when the husband is well enough that he could assume responsibility. Special Needs and Interests. Although normative expectations concerning gender roles appear to be Significant variables in task allocation, other factors arising from individual needs and drives also play a part (Blood, 1969). Sociologists believe that the amount of resources which the husband and wife bring to the marriage in terms of income, education, knowledge, skills, and time all contribute to the relative power Of each Spouse and affects the interaction process and results. (Ericksen, Yancy, 8 Ericksen, 1979; Hiller, 1984). King (1981) also recognizes the importance of power in interactions and defines power as: " the process whereby one or more persons influence other persons in a Situation. Power defines a situation in a way that peOple will accept what is being done while they may not agree with it" (p. 127). Reiss (1980) gives a commonly accepted definition of power as "the ability or potential of an individual to influence the behavior of other members Of a group" (p.234). Power is not absolute in that it varies with the specific individuals who are interacting and also the particular situation. Several bases for power are coercive power, reward power, expert power, legitimate power, referent power, and informational power. In 35 terms of illness task allocation, legitimate power may be the most important basis. It arises from the husband's reSponsiblity for caring for his health and the wife's obligation to assume the role Of caregiver during illness. The wife's continued involvement with the husband's treatment plan may legitimately arise from normative expectations for the female gender role. Expert power may arise from the recognition that one partner has special knowledge or Skills which may suit that partner to perform one or more treatment dimension. For example, this may result in the partner with a better understanding of foods being responsible for menu planning or meal preparation for the therapeutic diet. The differences in husband and wife perceptions of the husband's health and treatment regimen have been discussed. If the wife's anxiety causes her to assume more reSponsibility for implementing the treatment plan than the husband thinks is warranted, conflict may ensue. When the spouses disagree concerning reSponsibility coercive, reward, and referent power may come into play. Each may feel they are best qualified to interpret the physician's order (referent power) and conflict may ensue (Wishnie, Hackett, 8 Cassem, 1971). If the conflict escalates, one or both partners may use reward or coercive power in the attempt to get the other to see their way. Several authors refer to the power struggle for dominance which may occur during the postmyocardial infarction period (Lambert 8 Lambert, 1979; Speedling, 1982; Davidson, 1979; Segev 8 Schlesinger, 1981; Greenhill 8 Frater, 1980; Vachon et al., 1980). Although the power struggle may arise from differences in perceptions, some authors suggest that 36 power conflicts may have been present in some families before the MI, and the illness may serve as a focal point for the family to work out long term marital problems (Skelton 8 Dominion, 1973; Croog 8 Levine, 1981; and Mailick, 1979). Mauksch (1974) gives the following example of how responsibilty for diet, which is normatively the reSponsibility of the wife, can be used in the struggle for dominance. The physician who places a husband on a low calorie or a low sodium diet is affecting the family system. He may only view this diet as a modification of intra-organismic nutritional processes within that individual. If, in a traditional family, shopping, cooking, and serving is done by the wife, and if, thus, She becomes the Operational guardian of the physician's intent, the delicate balance of the intra-family network of dominance, power, initiative and claims has been altered. The physician has become a potential accomplice in shifting power to the wife or in facilitating the channeling of other labile intra-family issues into the negotiation between the wife as the implementor of the physician's prescription and the husband as the recipient of these meals. Food may have been successfully modified medically, but may range in its message to the recipient from conveying hosgility to subjugation, from loss of love to castration (p. 525 . The issue of Spouse struggle for dominance, often played out in regards to implementation of the treatment plan, is frequently mentioned by authors. However, the amount of attention usually ranges from one sentence to one paragraph, indicating a lack Of knowledge concerning the matter. Kline and Warren's (1983) study was an attempt to demonstrate a relationship between reSponsibility for the treatment regimen, adherence to the treatment regimen, and marital functioning. In summary, the bases for allocation of reSponsibility fer the treatment dimensions may arise from many sources. The allocation may 37 be made on the basis of necessity during the acute recovery phase. When the husband has entered the chronic phase, allocation may be based on the husband's self-care reSponsibility or on the wife's roles as homemaker and family health care manager. If the Spouses disagree, a power struggle may follow. The Spouses may finally come to an agreement, or there may be a chronic conflict concerning reSponsibility for the treatnent plan. In the following subsection, concepts Of importance to the description Of how the marital couple perceive reSponsibility for the dimensions Of the treatment plan will be presented. Perceptions Of ReSponsibility for Treatment Plan The importance of husband and wife perceptions concerning the MI and the treatment plan to the allocation of responsibility has been presented. The interaction process through which the husband and wife allocate reSponsibility has also been discussed as a context for the present study. The actual focus of this study is on the end result, or who the couple report as reSponsible for various dimensions of the treatment plan. Nye (1976) suggests that although roles may traditionally include certain tasks, the same task may be part of more than one role. Therefore, the couple may Share responsibility for a task or a task may be perceived as part of the role Of only one spouse. Shared tasks may be done by the couple together, or the Spouses may carry out the tasks separately, but interchangeably. Lee (1977) prOposeS that the trend toward industrialization and nuclear families 38 has resulted in a value system which emphasizes achievement and egalitarianism. These values tend to move couples away from traditional, separate sex roles for males and females and to move them toward flexibility in marital role expectations and behaviors. The central focus of the marital relationship is emotional intimacy, support, companionship, and communication. This may result in more sharing of family tasks. Turner (1970) agrees that task sharing may also be an expression of companionship. Turner (1970) suggests that collaborative interaction can be task-oriented or identity-oriented. Most interaction contains both components. Thus, a Shared task may be functional in completing a certain amount of work and also meet social needs of the couple. Blood (1972) reports that couples share a large number of tasks in early marriage, but the number Of shared tasks decreases with time. Blood (1972) reports that early marriage is a period of trial and error wherein partners learn which tasks they enjoy and can do best. Partners then tend to assume responsibility for such tasks and the trend is for specialization rather than Sharing. This may indicate that task Sharing is particularly useful when new tasks are being learned. The couple can problem solve together and also Share responsibility if the outcome is not satisfactory. The develOpment of tasks which are done separately is called role Specialization. The need for efficiency is thought to lead to the develOpment of role Specialization. Role Specialization tends to be associated with marriages where traditional sex roles are the norm 39 while task sharing is associated with more egalitarian marriages (Udry, 1971). It Should be noted at this point that acknowledging responsibility for a task is a separate concept from carrying out that reSponsibility. For example, corresponding with relatives may be perceived by everyone in the family as the wife's reSponsibility. However, the wife may fail to enact this responsibility, may enact it poorly, or may be an excellent correspondent. Similarly, the husband's perception that he is reSponsible for his health does not necessarily mean he will be faithful in adhering to his treatment plan. However, if one partner does not carry out a task and the task is considered essential, severe sanctions may be applied. The other partner may consequently assume responsibility for the essential task. In terms of this Study, responsibility for a treatment dimension may be perceived as shared or individual. The husband may be perceived as reSponsible for treatment tasks by virtue of his reSponsibility to care for his own health (DiMateo 8 DiNicola, 1982). The wife may be perceived as reSponsible for treatment tasks by virtue of fulfilling the caregiver role (Parsons 8 Fox, 1968), and normative expectations that wives _will function as family health care managers. In this study, the husbands' and wives' perceptions of responsibility and task sharing for dimensions of the husband's postmyocardial infarction treatment plan will be described. The extent to which the husband and wife agree on reSponsibility will also be noted. The significance of couple agreement will be discusssed in the following subsection. 4O Extent of Agreement Concerning ReSponsibility Researchers have observed that the extent of agreement between husband and wife reSponses to self-report instruments varies with the nature of the concepts being measured. Couples tend to have high agreement on objective data such as socioeconomic variables. There is less agreement on task allocation measures and sometimes little agreement on measures regarding perceived power or decision-making. Researchers have not developed theory at this point to use in interpretation Of consensus study findings. Udry (1971) reports that there may be a general lessening of consensus with many years of marriage. Lack of consensus does not appear to affect marital satisfaction unless it is in an area which is related to marriage goals. Division of labor in the family is thought to be an area where consensus contributes to marital satisfaction. Davidson (1979) discusses the importance of couple agreement and states that following the myocardial infarction the patient defines his functional capacity. Once the husband decides his extent of illness or wellness (which definition may have little relationship to the physician's assessment of the patient's capacity) he tries to convince others to accept his assessment. If the family agrees with the husband's assessment and supports recovery, rehabilitation is facilitated. When the family's assessment of the husband's health state varies from the husband's assessment, conflict can ensue which may hinder rehabilitation efforts. 41 King (1981) states that transactions are interactions which move toward goal attainment. King proposes that congruency in role expectation and role enactment leads to transaction. Lack of agreement between the husband and wife concerning responsibility for treatment task dimension can create a barrier to transaction and goal attainment. Other authors concur that agreement concerning how care is to be given is conducive to successful implementation of the treatment plan (Corbin 8 Strauss, 1984; Dracup et al., 1982). Blood (1969) refers to two types Of behavior which may occur when couples disagree concerning responsibility for a task. In the competitive mode, both spouses claim reSponsibility for the task. This can result in the power struggle for ddhinance which has been described following the MI (Davidson, 1979). In the avoidance mode neither spouse wants to be reSponsible for a task. This may occur when the husband decides to disregard his treatment plan and the wife feels he Should be reSponsible (Tyzenhouse, 1973). Discrepancies in perceptions of responsibility for tasks between husband and wife can lead to marital strain and jeOpardize task accomplishment. In this study, the extent of agreement between the husband and wife concerning reSponsibility for treatment during the first year and in relationship to time Since the MI will be described. There is evidence in postmyocardial infarction literature that couples may experience both the competition and avoidance modes of nonagreement. 42 Relationship of Tine to ReSponsibility for Tasks Time appears to be an important variable in husband and wife responsibility for the therapeutic regimen. While task allocation based on gender roles may not change over time, task allocation based on Special circumstances such as the husband's stage of convalescence may be time dependent. Specifically, Speedling (1982) describes the wife's withdrawal from the caregiver role as the husband's activity level increases. This probably results in decreased wife responsibility for certain dimensions of the treatment plan, eSpecial~ ly for those those tasks which are less associated with gender roles. In addition, task allocation which is joint at first may become more segregated as couples learn the tasks well. Tasks based on Special needs may change as the husband's physical condition improves and it becomes less likely that his death is imminent. In terms of agreement concerning tasks, Skelton and Dominion (1973) reported nmre conflict at three months than at one year following the MI. It is possible that with time couples come to greater consensus concerning reSponsibility for tasks of the treatment regimen. In this study, time will be correlated with perceptions concerning task sharing and with the extent of agreement between husband's and wife's perceptions concerning reSponsibility for the treatment dimensions. Summary_of_MOdel for Responsibility for the Treatment Plan King's (1981) model of the process of human interactions has been utilized as a framework for the discussion of the husband's and wife's 43 perceptions of responsibility for the postmyocardial infarction treatment plan (Figure 1). The husband and wife are depicted as unique individuals who relate to each other as a marital couple. The husband and wife each have perceptions concerning the meaning of the M1, the husband's health status, and the importance of the postmyocardial infarction treatment plan. According to literature, the husband and wife may differ in their perceptions. ReSponsibility for the treatment plan dimensions is allocated through couple interaction. Allocation may be on the basis Of need or may be negotiated. One of the strongest basis for allocation may be legitimate power. The husband may be perceived as responsible for the treatment plan by virtue of a cultural expectation that peOple are reSponsible for taking care Of their health. The wife may be perceived as responsible for the treatment plan on the basis of the caregiver role and on the basis of normative expectations that women will be involved in neeting the health needs of the family. If the couple have Special needs, or if the legitimate power basis is not clear, the couple may utilize other basis such as expert power, reward power, coercive power, or referent power. The couple may negotiate in a collaborative manner or may utilize conflict to resolve differences. AS a result of interaction concerning the treatment plan, the husband and wife may perceive that reSponsibility for the treatment tasks is shared or that tasks are the reSponsibility of only one Spouse. If the Spouses disagree concerning who is reSponsible, the disagreement may take the form of competition or avoidance. Disagreement concerning task allocation is thought to be a barrier to 44 transaction and goal attainment. Agreement is thought to imply transaction in that means are identified for goal attainment. The interaction process is dynamic. There is a feedback lOOp and the process of determining reSponsibility for the husband's treatment plan will continue throughout the first year following the MI. The allocation of responsibility to a Spouse and agreement concerning reSponsibility may vary with time. In the final section of this chapter the Theory Of Goal Attainment will be presented and applied to the study problem. King's Nursing Theory of Goal-Attainment King's (1981) Theory of Goal Attainment is derived from the process of human interactions. In the theory, the nurse and client(s) are seen as the interacting individuals and the Objective of the nurse is to enter into transactions with the client. The nurse assesses the client's concerns and problems and identifies disturbances. Nurse and client mutually identify goals. Means to achieve goals are explored and agreed upon. Then nurse and client move toward goal attainment. The nurse can evaluate client-nurse interactions by identifying if transactions actually took place and if goals were attained. Following are some propositions which King (1981) derived from the nursing theory: 1. If perceptual accuracy is present in nurse-client interactions, transactions will occur. 2. If nurse and client make transactions, goals will be attained. 3. If goals are attained, satisfactions will occur. 45' 4. If goals are attained, effective nursing care will occur. 5. If transactions are made in nurse-client interactions, growth and develOpment will be enhanced. 6. If role expectations and role performance as perceived by nurse and client are congruent, transactions will occur. 7. If role conflict is experienced by nurse or client or both, stress in nurse-client interactions will occur. 8. If nurses with Special knowledge and Skills communicate apprOpriate information to clients, mutual goal setting and goal attainment will occur (p. 149). Application Of Theory of Goal Attainment The Theory of Goal Attainment can be useful as a framework for the nurse to use with clients during the postmyocardial infarction period. Some points at which the nurse might transact with the husband and wife following the husband's MI are demonstrated in Figure 2. Figure 2 is identical to Figure 1 except for the addition Of the nurse and nursing actions. The nurse, like the husband and wife iS viewed as a unique individual with a biography which includes past experiences and present social status. The nurse has personal values, expectations, and goals which result from the interaction of biography and life trajectory. The nurse's biography includes nursing education and experience. The professional preparation of the nurse interacting with other personal characteristics results in professional values, expectations and goals concerning the manner in which the marital 46 .unusé..oa=o= nae. .ueaaa:.m_u _a_.=..oa ecu =~.g .coaaaoa. ac. s.___a_m¢oaa.. .o uga_.g.ua.. as..u.»wa aao~uaw 3..) =o_.a~_._a.=.. u._uadu aoa .uuo- «cu-=_a~.a .aou .M1uumuwm a... 2:... a .2... .2. 3...... 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For the nurse, the goals of rehabilitation are to prolong the life of the husband through reducing cardiac risk factors and to facilitate psychosocial adjustment to life with a chronic illness. The husband and wife have individual goals which may or may not be compatible with the rehabilitation goals. Therefore, the nurse and marital couple mutually derive and agree upon Specific goals for the husband's rehabilitation. In this model, the nurse could enter into transactions at any point where disturbances block husband or wife goal attainment. Disturbances may arise from differing perceptions concerning the husband's health or the meaning of the treatment regimen to the husband and wife. Disturbances may arise if the couple uses a conflict mode rather than a collaborative mode in the process of determining who will be reSponsible for the various dimensions of the treatment regimen. In terms of reSponsibility for the treatment plan, the nurse would be alert to disturbances which could inhibit successful allocation of reSponsibility for the treatment plan. Disturbances may revolve around amibiguity arising from conflicting or vague normative expectations regarding how the husband and wife will enact their respective roles. One or both spouses may have little knowledge of the treatment dimensions and thus be inadequately prepared for 48 assumption of reSponsibility. At any point where a disturbance is detected, the nurse can transact with the husband and/or wife to move toward goal attainment. The nursing actions will center around removing or reducing the effects Of the disturbance. Means to achieve goals may include education concerning the purpose of the treatment plan and develOpment of Skills necessary for implementation. The means may also involve facilitating communication between the husband and wife. The husband and wife may be assisted to communicate concerning their perceptions of the husband's health status and the meaning of his illness in terms of immediate and long term goals. Perceptions of the role changes accompanying the illness may be explored, along with beliefs concerning who Should be reSponsible for the dimensions of the husband's treatment plan. Nursing evaluation of the transactions will be based on evidence of movement toward goals and goal attainment. The model in Figure 2 indicates areas of interest to the nurse when interacting with clients. The model can also be useful as a basis for research concerning how the husband and wife adapt to chronic illness. The focus Of this study, husband and wife perceptions of reSponsibility for the husband's treatment plan, is one component of the model. In future research, hypotheses could be develOped around the interactions between all the components Of the model. Summary Of Chapter II In Chapter II, a conceptual framework for the research problem was presented. First, the basis for the treatment plan was presented and 49 common dimensions of the plan were described. Then, a conceptual model based on King's (1981) process Of human intraction was presented. Major components of the model included the husband and wife, time following the MI, perceptions of the husband's health status and the treatment plan, perceptions concerning who is reSponsible for the dimensions of the treatment plan, interactions concerning the treatment plan, and transactions which affect movement toward attainment Of rehabilitation goals. When interaction is characterized by clear communication and collaboration, agreement concerning reSponsibility for the treatment will result and movement will be made toward rehabilitation goals. Nonagreement may cause a blockage in the transaction process. Finally, King's (1981) Theory of Goal Attainment was presented and applied to the research problem. In Chapter II, references were made to literature describing difficulties encountered by the husband and wife following the myocardial infarction. A review of the studies which relate to allocation of tasks between the husband and wife will be presented in Chapter III. Chapter III Review Of Literature Overview In Chapter II a conceptual framework was presented for the study of the husband's and wife's responsibility for the husband's post- myocardial infarction treatment regimen. There were no studies found, other than Kline and Warren's (1983), which Specifically measured allocation of responsibility for treatment plan activities during the postinfarction period. Therefore, allocation of responsibility for treatment plan dimensions was presented as probably utilizing normal methods through which the marital couple allocate family work, with modifications according to the Special circumstances of the husband's health status at a given time. In Chapter III a review of current literature concerning marital couple allocation of reSponsibility for household tasks, husband and wife agreement concerning responsibility for household tasks, and reSponsibility for treatment plan tasks will be presented. Marital Couple Role Allocation Patterns A common method Of studying family roles and task allocation is to request subjects to indicate which Spouse or other family member is reSponsible for a role or task. Nye (1976), conducted a questionnaire survey of 210 Washington State couples who were randomly selected from 50 51 lists of third grade students in the county. Only 46% of the parents selected completed the questionnaires. Nye compared the reSpondentS to the residents of Washington State and the United States in terms of education, income and occupations. The survey was designed to gather information concerning eight roles commonly associated with the positions of spouse and/or parent. The eight roles were: provider, housekeeper, child care, child socialization, sexual, recreational, therapeutic, and kinship. The instrument contained single items designed to measure: a) the normative dimensions Of the eight roles (who should do the role), b) the enactment of the role (who does the role), c) the existance of sanctions when the role was not performed, d) the extent of role competence, e) evidence of role strain (worry about competence), f) role conflict (arguments about role) and role power (who makes decisions when disagree). For the role enactment and role normative dimension questions there were five reSponse categories provided, ranging from husband always to wife always. No information was given concerning reliability or validity of the research instrument. Study findings were descriptive in nature with data presentation for each question consisting of husband and wife percent frequencies for each reSponse. Although differences in husband and wife responses were evident, there were no tests of Significance concerning husband and wife agreement. Couples tended to believe there should be Sharing of child care and socialization, recreational, and sexual roles. Couples indicated that husbands should predominantly be reSponsible for the provider 52 role and wives for the housekeeper and kinship roles, although some Sharing was expected. Enactment of the role resembled the normative expectations for the role except that men reported less participation in child care, socialization, and housekeeper roles than they reported believing that they Should. The least competence was reported in the housekeeper, kinship and recreation roles. Husbands and wives reported being most satisfied with their performance of the child care and sexual roles. An area of interest in terms of agreement concerning roles was Nye's findings concerning role stress. Half of the husbands and wives worried about their performance of the child socialization, therapeutic, and recreational roles. Half of the women also worried about their housekeeping performance and half Of the men about their performance in the provider role. Subjects reported the most arguments concerning the child socialization role. About one fourth Of the respondents reported some conflicts concerning the child care, housekeeper, kinship, and recreational roles. Albrect, Bahr and Chadwick (1979) from Brigham Young University attempted a replication of Nye's (1976) questions concerning normative role expectations and rOle enactment. In addition, the instrument contained questions concerning husband and wife power and extent of approval of three alternate family lifestyles. The sample was selected randomly from statewide telephone listings. There were 771 couples (about one third of those contacted) who both completed the questionnaires and who were included in the study. The study population is not described which limits generalizability. 53 Similar to Nye's (1976) study, husband and wife percent frequencies were given for reSponseS to each item. In comparison with Nye's results for the provider role, in the Utah pOpulation there was a Shift from "husband only" to "husband mainly" reSponses and a slight increase in the number who believed in equal sharing. The same Shift was evident in the housekeeper role. A major difference between the two studies was the marked Sharing Of the kinship role in the Utah pOpulation compared to wife reSponsibility in Nye's pOpulation. Wives also were given more responsibilily for child care in the Utah pOpulation. An addition to this study was the calculation of the effect of age on'role division. The effect of age was dependent upon the role and aspect being examined. There was a trend for younger couples to be more accepting of female participation in the provider role, but Older couples were more likely to actually share the provider role. Men tended to participate more in child care with age, but women shared more in decision-making about child care in the Older population. The Older reSpondents were less accepting than the young Of communal living. It is unclear whether the differences between Albrect, Bahr, and Chadwich's (1979) study and Nye's (1976) study were due to the effect of time on normative values or whether the two samples differed in terms of role norms and enactment. The Significance of the husbands' increased responsibility for child care with age iS questionable as it is unlikely that elderly couples would be primary caretakers for preschool children. 54 In summary, these two studies demonstrate a method for determining role allocation in the marital couple.~ Normative expectations concerning roles appeared to be related to actual patterns of role enactment. In addition there appeared to be definite normative expectations that men would be primarily reSponsible for the provider role and the wife for housekeeping and child care roles. There was recognition among couples of a "therapeutic role" in which each attempted to help the other solve problems. The husband's and wife's perceptions that the wife had some reSponsibility for the husband's postmyocardial infarction treatment plan may have arisen from expectations concerning the therapeutic role and/or recognition of the wife as having reSponsibility for health care functions in the family. Marital_Couple Role Allocation Hypotheses Some authors have attempted to go beyond Simple descriptive studies and to determine some predictor variables for marital couple task allocation. Perrucci, Potter, and Rhoads (1978) from Purdue University described three common hypotheses of task allocation within marital couples. The socialization hypothesis states there is a relationship between ideology concerning the marital relationship and participation in household tasks. Husbands with traditional ideologies are expected to participate less in household tasks than husbands with egalitarian ideologies. The time available hypothesis states that working wives have less time at home and by necessity their husbands participate in household activities to a greater extent than those husbands whose 55 wives are unemployed. The relative-resources hypothesis states that the relative statuses of the husband and wife determine the extent to which the husband participates at home. The expectation is that the more powerful the Spouse (higher status) the less likely that Spouse is to help with housework. Perrucci, Potter, and Rhoads (1978) utilized a prOportionate stratified-area probability sample obtained from a 28 block area in Lafayette, Indiana to test the three hypotheses Of task allocation. Sample Size consisted of 98 couples with an additional 30 couples who were selected but not interviewed because of inavailability. Husbands and wives were interviewed concurrently but separately. ReSpondents were asked to indicate how 12 family tasks were shared between the Spouses on a five-point scale. The reSpondents were also asked to indicate their agreement concerning 8 statements of ideology on a six- point scale. The ideology items failed to form a unidimensional scale of ideology and were maintained as separate items. Sociodemographic data included education, occupation, number of children living in the household, length of marriage, husband's age, and whether the husband expected the wife to be employed outside the home within the next ten years. Reliability and validity of measures were not discussed. Although data was collected from both Spouses, hypothesis testing was done only on husband's data which appears to be a limitation as there was a significant mean difference between husband's (6.4) and wife's (5.9) reports of the number of household activities in which husbands participated. The hypotheses were tested through simple correlation of predictor variables and the husband's task performance 56 score. Two ideology item correlations were Significant. None of the sociodemographic variable correlations were significant. For further testing of each hypothesis multiple regression analysis of items pertaining to each hypothesis was performed. For the ideology hypothesis, six Of the eight ideology items contributed to a significant coefficient of .47. The time-available multiple correlation coefficient was nonsignificant with number of children at home being the largest loading factor and negatively correlated with husband participation at home. The relative resources multiple correlation coeffficient was not Significant. The Study findings gave modest support to the ideology hypothesis that husbands who believe in egalitarian marriages help more at home than husband's who are traditional in ideology. The Study results failed to support the relative-resources and time available hypotheses The lack of support for the relative-resources hypothesis could be partially due to the low number of women in the study sample who were professionally employed. Atkinson and Huston (1984) from Pennsylvania State University also studied the effect of ideology on household task participation. Subjects were newly married couples (1 to 3 months) whose names were Obtained from public marriage license records from four Pennsylvania courthouses and who reSponded to a letter requesting participation. Of those contacted, 42% agreed to participate and were subsequently interviewed during a home visit. Measures taken during the home visit included: a) demographic data, b) a modified version of Spence and Helmreich's Attitudes 57 Toward Women Scale and Personal Attributes Questionnaire which were used to determine the reSpondent'S sex role orientation, and c) a questionnaire requesting how well subjects could perform 26 household “tasks. Following the initial home interview, nine phone interviews were made during which reSpondents were asked to report activities for the past 24 hour period. Respondents were requested to indicate which Of the 26 tasks they had performed during the preceeding 24 hour period and how many times. Correlations were made between measures of respondent's sex role orientation, skill at task performance and participation in household tasks. The degree of the wife's participation in the labor force was _found to be related to liberal (egalitarian) attitudes on the part of the husband and wife regarding the role of women. Division Of labor patterns at home followed traditional sex role patterns with greatest task sharing occuring in the area of nonfood purchases. Wives contributed twice as much to household activity as males. Multiple regressions were performed on variables to predict each Spouses prOportionate contribution to masculine and feminine sex-typed household tasks. The most important predictor of husband contribution to feminine sex-typed household tasks was the difference between husband and wife hours of outside employment. Two other Significant predictors were the husband's perceived skill at performing feminine sex-typed tasks (positive correlation) and the husband's perceived Skill at performing masculine sex-typed tasks (negative correlation). 58 Significant predictors of feminine participation in masculine sex-typed tasks were the wife's perceptions of Skill at masculine tasks, husband's sex role attitude's, husband's masculinity score, and number of Spouse's employment hours. The husband's femininity score and wife's perceptions of skill at feminine tasks were correlated negatively with feminine participation in masculine sex-typed tasks. The study results lend some support to Blood's (1969) Statement that task assignment may depend on the interests and drives of the Spouses. There is also support for the time available hypothesis in that husbands helped less at home if the wives were employed outside the home fewer hours than the husbands. The finding that women continue to assume major reSponsibility for household tasks and the correlation of husband's and wife's attitudes toward the role Of women and wife participation in the labor force lend support to the ideology hypothesis of task allocation. A strength of this study was its longitudinal nature, with repeated measures of the sample. However, the couple's knowledge that they were going tO report their activities for the day could have been a motivating factor in creating more consistency between beliefs and actions than some other studies have demonstrated. Ericksen, Yancey, and Ericksen (1979) attempted to test some variables related to relative resources theory. A probability sample of 1,212 couples was selected from urban Philadelphia. Dependent variables consisted Of husband and wife sharing of the provider role, husband and wife sharing of housework, and husband and wife sharing of child care. Independent variables consisted Of presence of a child 59 under age 12, proximity Of kinship network, the wife's education, the husband's income, and race. The statistical technique utilized was logistic regression. Four variables found to increase the extent Of provider role Sharing were low husband income, high wife education, no children under 12, or children under 12 with the presence of local kinship networks. Variables which predicted Sharing Of household work were race, wife's education, husband's income, and whether or not the provider role was Shared. The highest probability of shared housework was for the combination of black males with high incomes and wives with university educations and full time employment. Wife employment status appeared least important. The presence of children or local kin did not predict Sharing of household work. Variables which predicted the sharing of child care were the wife's education and the wife's part-time employment. There were trends for high income husbands to participate less and for black husbands to assist more with child care. The couples least likely to share child care were couples where the wife had only completed one to four years of elementary schooling and was working full time. The findings of this study lend some support to the relative- resources or power hypothesis. The higher the wife's status relative to the husband, the more likely She was to work outside the home and he was to help with household tasks. Although some predictor variables were identified during this study, the frequencies of the combinations of variables within the sample were not presented. 6O Perrucci, Potter, and Rhoads (1978), Atkinson and Huston (1984), and Ericksen, Yancey, and Ericksen (1979) all utilized similar methods to test hypotheses concerning theories of task allocation within the marital couple. Correlations and multiple regressions were utilized to test theoretical models Of family task allocation. Although all three studies found some support for the ideology or socialization hypothesis of task allocation, support varied for other hypotheses such as relative resources, time available, and Spouse skill at doing tasks. Differences in results may be due to differences between samples which were not randomly selected or to differences in design such as measurement criteria. Continued research is needed for the develOpment of sound theoretical models of marital couple task allocation. Marital Couple Consensus Concerning Task Allocation Larson (1974) reviewed the issues involved in consensus studies. One issue Of importance for family research is how to sample a marital couple or family. IS the response Of one Spouse, usually the wife, representative of the family or Should all family members be included in the study sample in order to give a broader perSpective of the family? Researchers have discovered considerable variance among members of the same family eSpecially when measuring power, values, or communication and have generated two possible explanations. One explanation is that the differences arose from measurement error because research instruments lacked concreteness. The second explanation is that members of the family actually did perceive the family differently. Larson (1974) conducted a study to discOver if family members perceived family roles differently. 61 Differences in Husband and Wife Perceptions (Larson (1974) sampled the entire pOpulation of seventh, ninth, and twelfth-grade students in public schools in a small community in Oregon and their parents. ReSponse rates for entire families was 50% and the final sample consisted of 465 families in which there were a mother, father, and one child. Subjects were requested to categorize their family power as father dominant, egalitarian or mother dominant. Family problem-solving was categorized as stalemate, mother dominant, father dominant, egalitarian, or no problems. Mothers and fathers were requested to indicate who did five categories Of household tasks: odd jobs, child care, chores, housework, and meals on a scale with points being father, father and/or sons, family, mother and/or daughters, and mother. Response frequencies concerning power and decision-making were presented for each family member. Between 65%to 80% of husbands and wives perceived both family power and decision-making as egalitarian in nature. For those perceiving power and decision-making as residing in one person, it was more common for the parent to perceive himself or herself as dominant. In terms of responsibility for household tasks, highest agreement was for sex-typed tasks such as housework. Much of the husband and wife disagreement for all task areas revolved around whether or not children were viewed as contributing. There was a trend for wives to perceive themselves as more reSponsible than their husbands perceived them in all areas. The difference in perception was marked in child care where one fifth of the wives perceived themselves as exclusively responsible while 62 husbands perceived the entire family as reSponsible. Only for the Odd jobs item did some wives perceive husbands as more reSponsible than husbands perceived themselves. Larson (1974) questioned whether disagreement arose in some situations from some Spouses replying in terms of normative expectations for the tasks while other Spouses responded in terms of observations concerning actual performance. This type of discrepancy between husband and wife responses is referred to as sex bias. In Larson's (1974) study the task categories were large and disagreement may have resulted from measurement error in that Spouses were thinking of different Situations when responding. Condran and Bode (1982) focused on differences between husband and wife perceptions of household task participation arising from sexual bias. One spouse of a random sample of 316 married couples from Middletown, Illinois was interviewed by telephone. Subjects were requested to indicate who was reSponsible for a) disciplining children, b) taking children to the doctor, c) preparing meals, d) paying the bills, and e) doing minor household repairs. All reSponses were categorized as "wife usually reSponsible" or "all other responses". Data was analyzed using log-linear regression techniques. The probability that subjects would rate the wife as primarily reSponsible for tasks was determined. Wives were perceived by both men and women as usually reSponsible for meal preparation and doctor visits. In the area of paying bills, the chances that the wife would be named as reSponsible were almost as great as the chance that anyone else or 63 shared responsibility would be named. Wives were not likely to be perceived as solely reSponsible for child discipline or home repairs. The interaction of the sex of the reSpondent and wife work status was added to the regression equation. In terms of sex of the respondent, women were more likely to reply that they were exclusively responsible for all tasks than were men to reply that wives were exclusively reSponsible. Men and women were least likely to agree that the wife was reSponsible for child discipline and doctor visits. Most agreement between the reSponseS of the sexes was in the area of bill payments. Work status of the wife was also a significant factor. Wives who didn't work were much more likely to be perceived by all subjects as solely responsible for all task areas except child discipline where working wives were Slightly more likely to be perceived as solely reSponsible. Bill payment again was the area of least difference. No interaction effects were noted for the variables Of husband and wife education, age, family income, religious involvement, perception of economic status and working history of repondent's mother. AS other researchers have noted, the data from this study suggest that husbands do not participate a great deal in home tasks. This study varied from others in that there was no pairing of husbands' and wives' scores, but rather emphasis was on differences in perception by sex Of the respondent. The nonpairing may explain why variables related to relative resources were not significant while time available was Significant. Condran and Bode (1982) concluded there was a difference between male and female perceptions of task 64 allocation. Men tended to perceive that they assisted more at home than women tended to perceive that their husbands participated. The extent to which the sex bias arouse from the influence of ideology on the reSponses of each sex is not known. AS part of a comprehensive ongoing study of household labor at the University of California, Berk and Shih (1980) addressed the area of husband and wife consensus concerning household task allocations. The data was generated from a national probablility sample of 350 husband and wives living in moderate to large urban areas Of the United States. Each subject was given a set of 45 cards on which were written different household tasks. The household tasks were derived from previous studies of household work (Berheide, Berk 8 Berk, 1977) and were intended to be representative of a wide range of commonly performed household tasks. Subjects were requested to sort the cards according to the frequencies of task performance. After removing all cards with tasks which were never performed, the subject was requested to write on the back of the card the family member who generally did the task. If more than one member did the task more than 50% of the time, each member was to be listed. For the purposes Of this study, only responses where husband and/or wife were named as performer were analyzed. Crosstabulations of husband and wife reSponses for each task were performed and a neasure of prOportion agreement was constructed. Cluster analysis Of data was performed on the basis of prOportion agreement concerning wive's contributions to household tasks and agreement concerning husband's contributions to household tasks. 65 Agreement generally was high. Mean prOportion agreement for wives contributions was .88, while mean prOportion agreement for husband's contributions was .74. Agreement concerning each Spouse's contribution varied according to the task cluster. For wive's participation, highest agreement was for tasks traditionally assigned to females such as laundry, making beds, diapering infants, keeping an eye on children, and an assortment of kitchen activities. Less agreement was present concerning tasks which were not typically sex-typed and for tasks which were typically male sex-typed such as taking out garbage, going to the gas station and shoveling snow. For husband's participation, there was most interSpouse agreement concerning the female sex-typed tasks Of cooking, cleaning, laundry, and mending. Two tasks clusters had mean agreements of .67 and .58 concerning husband participation. These clusters centered around male sex-typed activities and an assortment of child care activities. Thus, husbands and wives agreed more concerning both Spouse's contribution to typically female tasks than concerning both Spouse's contributions to typically male tasks. Regression analysis was done separately for reports of wives' contributions and reports of husbands' contributions. Large intercept coefficients were Obtained for wives' contributions which indicated that wives were likely to say they contributed to a task when their husbands didn't report a wife contribution. This indicated underestimation of wife participation by husbands. When husbands reported wife participtation, wives typically agreed. 66 Husband and wife reports concerning the husband's participation resulted in lower intercepts indicating less underestimation Of husbands' contributions. Only in the area of child care did wives demonstrate high underestimation of husbands' contributions. In other areas a wife report that the husband made a contribution to task performance was predictive that the husband would also report participation. The interaction Of years of marriage, education, employment status of wives, and husband's report Of frequency Of task performance with the husband's and wife's reports Of contribution was determined. There was no pattern to suggest that any Of the variables was significant over a range of tasks. The Study findings demonstrated variability of agreement with different tasks. Highest agreement was Obtained concerning the extent of the wife's contribution and for tasks which were sex stereotyped. Disagreement typically involved each Spouse attributing greater participation to themselves than the other Spouse attributed to them. Burk and Shih (1980) suggested that future research might also include a measure of husband and wife perceived consensus concerning task allocation in addition to calculated consensus. Larson (1974), Condran and Bode (1982), and Berk and Shih (1980) all found differences between husband and wife reSponses concerning the contributions which each Spouse made to household task performance. The most common difference was for the Spouses to overestimate their own contribution in comparison to the other Spouses' report. Spouses tended to agree more concerning tasks which were typically sex 67 stereotyped. Therefore, in studying husband and wife perceptions of reSponsibility for treatment plan dimensions, there may be more agreement concerning food preparation, which is commonly associated with females, than for dimensions where the Sex role norms are not SO clear. Although Berheide, Berk and Berk (1977) attempted to discover how wives felt about housework, none of the consensus articles reviewed included outcome variables such as satisfaction with the allocation of family tasks or the perceptions of the fairness Of the division of labor. Nye (1976) included some measures of role conflict, but did not correlate findings with differences in perception of husbands and wives concerning task allocations. Therefore, the effect of differing perceptions concerning task allocation on the marital couple is not known. In the following section, literature which addresses the issue of measurement error as a source of nonagreement will be discussed. Nonagreement Arising From Measurement Error Douglas and Wind (1978) focused on the incongruity of husband's and wife's reSponses concerning allocation of responsibility for various household tasks and decision-making. A convenience sample of 120 marital couples selected from 6 metrOpolitan areas in the United States was used. Husbands and wives were interviewed separately. Subjects indicated who generally was responsible for making eighteen family decisions and performing thirteen tasks. Congruence was determined by clustering decision and task items separately for husbands and wives and by correlation of husband and wife responses 68 for each item. Correlations were generally lower for decision areas (.15 to .65) than for task areas, a finding consistent with prior research findings. Correlations for the 13 task items ranged from a low Of .34 for shOpping for clothes for the husband to .86 for routine bill paying. Douglas and Wind (1978) reported there was higher congruence for areas where Specialization by sex occurred, such as cleaning house or cleaning the car. Attempts to differentiate couple reSponsibility for tasks by marital roles, attitudes, or household authority patterns were generally inconclusive. Incongruence was most evident between responses Of Spouses describing extent of joint participation as Opposed to reSponseS where one individual was viewed as reSponsible. Incongruence was more also evident where items were difficult to assess or occurred infrequently and thus were difficult to recall. The authors interpreted these findings as suggestive of the existance of measurement error. Douglas and Wind (1978) suggested that discrepancies between husbands' and wives' responses may have arisen from random error because questions were too general or ambiguous. Husbands and wives reSponding to questions concerning buying clothes may have remembered different instances when clothes were purchased and thus reSponded differently. Sometimes the reSpondent may have understood the question but may not have been certain as to the answer. Uncertainty was most likely to occur when subjects responded to complicated items such as those concerning responsibility for decision-making or for tasks items which were infrequently performed. 69 Quarm (1981) provided a literature review of past research on concensus and discussed methodology for identifying measurement error. Quarm (1981) stated that the commonly used method of reporting the number of husband and wife disagreements does not distinguish between bias arising from the sex of the reSpondent and other types of neasurement error such as between-Spouse differences in perception or random measurement error. Bias arising from the sex Of the respondent does not affect correlations because of the constant term. High between-Spouse correlations are possible even between items in which the bias due to the sex of reSpondent is large. Bias arising from the sex of the reSpondent could be detected by comparing between spouse mean differences. Low between Spouse correlations may arise from 1) random measurement error, or 2) error from some characteristic of the reSpondent such as perception or ideology. Quarm (1981) utilized data from the 1973 Detroit Area Study (Siebs, 1973) to demonstrate consensus concepts. In the study, husbands and wives reSponded to 8 task items and 35 marital power items. Between Spouse correlations were much higher for task items (.42-.77) than for power items (.01-.46). Quarm (1981) demonstrated the value of utilization of multiple item indices as a means of reducing random measurement error. Six indices were constructed for 23 of the 35 power items. Mean between- spouse correlations for single items ranged from a low of .12 for child discipline to a high Of .39 for wife's work. When between- Spouse correlations were calculated for the indices as a whole they decreased to .09 for child discipline and increased to .54 for wife's 70 work. When the indices were further corrected for attenuation because Of unreliability, the child discipline index between-spouse correlation became .16 and the wife's work index between-Spouse correlation became .76. These results indicated that random error was a probable source Of nonagreement concerning wife's work but was not a probable source of nonagreement concerning child discipline. In summary, major issues for the study of task assignment and consensus within the marital couple revolve around such issues of measurement as validity and reliability of research instruments and differences in perceptions versus some family "reality“. Although the general agreement between husband's and wife's reSponses is greater for items measuring task allocation than for items measuring decision-making or power, considerable variation exists. Reliability Of results can be increased through utilization of multiple item indices instead of single item measures. Examination of husband and wife mean reSponses can detect indications of bias arising from the sex of the reSpondent. The methological issues concerning measurement error and differences in perceptions of husbands and wives will be applied to the study Of husband's and wife's perceptions of reSponsibility for treatment plan dimensions in Chapters IV and V. Family Roles and Personal Health Practices Pratt (1976) included some task division measures as part of a study of the effect of family structure on health care practices. Pratt (1976) collected data from a representative cross-sectional sample Of 273 families in a New Jersey city by interviewing the 71 husband, wife, and one child between the ages of nine to thirteen, separately. The study attempted to determine the relationship between family structure and health and health behavior. The family structure concepts were a) extent and variety of interaction among family members, b) extent of family links to other social systems, c) extent of active c0ping efforts by family members, d) extent of freedom and responsiveness to individual members of the family, and e) flexibility-rigidity of family role relationships. The health and health behavior concepts were a) level of health and illness, b) quality of personal health practices, and c) extent and apprOpriateness Of the use of professional medical services. Women were found to have principle reSponsibility for health care tasks in about 60% of the families. Data analysis techniques utilized were correlation and Stepwise regression. The correlation coefficient for personal health practices and conjugal power was .15 (p_< .05) while the coefficient for personal health practices and conjugal division of tasks was .17 (BK .05). However, the division of tasks variables did not contribute significantly to the regression equation of variables contributing to family health practices. The biggest influence of other family structure variables on family health practices occurred in the areas of exercise, elimination, and dental hygiene. Nutrition practices were not demonstrated to be affected by family structure. The data supported to some extent Pratt's hypothesis that the energized family characterized by: individual freedom and family 72 reSponSiveness to the individual, active COping efforts, flexible and egalitarian structuring of relationships, regular and varied interaction among family members, and regular links with the broader community, was more effective in providing individual health care than the traditional family structure. In the following section, literature concerning the husband's and wife's responsibility for the postmyocardial infarction treatment plan will be discussed. ReSponsibility for Treatment Plan Dimensions There are few studies which address the husband's and wife's implementation of the husband's postmyocardial infarction treatment plan. Most of the literature is descriptive in nature and pertinent observations from literature describing the postmyocardial infarction period were presented in Chapter II. Croog and Levine (1977) conducted a major study of postmyocardial infarction patients. The initial pOpulation consisted of 345 Caucasion males between the ages of 30 and 60 who had recently experienced an initial myocardial infarction. Men were screened for other illnesses and only those without other major illnesses were included in the study. Men were interviewed while in the hOSpital, one month following discharge, and one year following discharge. Wives were interviewed separately during the one month and 1 year interview. An eight year follow-up interview was also conducted and results from the eight year interview are published separately (Croog 8 Levine, 1982). Croog and Levine (1977) collected extensive data concerning socioeconomic variables and the patient's health status (from 73 physician ratings) in addition to interviews concerning life adjustment following the MI. Areas discussed by Croog and Levine are: morbidity, mortality, and hOSpitalizationS, work and finances, use of services and supportive programs, compliance behavior, effects of illness on the family, psychological characteristics and emotional status. Although many areas were measured, the data presentation was basically descriptive in nature. At one year following the MI, 7% Of the men were doing more work around the h6use than before their MIs, 19% were doing about the same, and 73.5% were doing less (Croog 8 Levine, 1977). When asked at three months which family member had undergone the most changes, the majority Of the men had mentioned their wives. At one year, 44% of the men answered "no one" indicating that life was back to normal. The most frequently mentioned change in the life of the wife was increased reSponsibility for family maintenance and household activities. Specific changes mentioned at 1 month included: a more active role in disciplining children; increased participation in heavy housework, shOpping activities, and decision-making; changes in family diet; arranging rest or Sleeping times; protecting the husband and seeing to it that husbands obeyed the physician's instructions. At 1 year, fewer men reported a change in the wife's activities, but 31% reported wife anxiety. The illness may have set in motion role reformulations which were Still in effect one year later. Skelton and Dominian (1973) interviewed 65 wives of patients with a first myocardial infarction during the hOSpitalization and at three, six, and twelve months following the husbands' infarctions. At one 74 year wives were classified as to the degree of adjustment they had achieved. Satisfactory adjustment was made by 26 wives, all whose husbands also made good physical recoveries. Reasonable adjustment was made by 23 wives. These wives tended to experience anxiety concerning their husbands' health and to shield their husbands. Poor adjustment was made by 16 wives. Half of these wives had husbands who had done poorly physically or had died. An assessment of marital functioning was made. Of those whose husbands had made good recoveries, only 10 wives reported a change in the marriage. In these instances the wife appeared to have taken a more managing role, and tended to be overprotective. Speedling (1982) did a case study of eight Illinois couples. Observations and interviews were made in the home every one to two weeks during the first three to four months following the husband's MI. Some attempt was made to note similarities between some of the couples, but no data analysis was done. Speedling (1982) noted periods of conflict concerning who would be in charge of the husband's rehabilitation. The first couple weeks following discharge from the hospital was a time Of harmony and husbands were very dependent on their wives. Following this, there was an early period of internal streSS as husbands began to feel better and to increase activity. Wives challenged each activity increase by the husbands. Most Of the couples resolved this conflict with the wife still assuming major reSponsibility for the husband's care. Marital stress resulted when the wife assumed the role of "watchdog" of the husband's behavior. Husbands did not react favorably to their wives 75 comments concerning lapses in diet, smoking, and/or activity. By Six to eight weeks following the MI, the couples encountered another period Of conflict as the husbands attempted to normalize their lives. Husbands began to assume responsibility for deciding how much activity they could engage in and how they would care for their health. During this phase, wives who were able to withdraw from the caregiver role and to engage in other activities fared better than those wives who remained preoccupied with the husband's illness. Four of the eight couples were able to resolve their conflicts and to successfully enter the normalization stage during the study. Although the small sample Size and chances for observer bias which are inherent in the study design limit generalization of findings, Speedling's (1982) study provides a great deal of material which could be used for development of research problems. Skelton 8 Dominion (1973) and Speedling (1982) suggest that difficulties may arise when wives are overmanaging of the rehabilitation process. Hackett and Cassem (1975, 1978), psychiatrists at Massachussetts General Hospital, Boston have written several articles concerning psychological adjustment of the postinfarction patient during convalescence. Wishnie, Hackett and Cassem (1971) interviewed 24 former critical care unit patients between three to nine months following hospitalization. Observations were made concerning the patient's reports of physical and mental status, Sleep disturbances, changes in health habits, activities, return to work, family conflicts and doctor-patient relationships. There was no data analysis. Frequencies of certain phenomenon 76 were given. All but one patient expressed frustration at the forced reduction in activity during the first few months, while only two patients reported receiving instructions concerning exercise. Thirteen patients had returned to work when interviewed, although some were only working part time. Patients reported difficulties in changing habits. Of the fourteen who wanted to stOp smoking, only five actually stOpped. Two Of nine men were able to loose weight and one Of Six men was able to stOp drinking. Eighteen of the twenty four patients were married and lived with families. In all eighteen families Observers noted a steady conflict over implications of the illness. Eleven families experienced marked controversy over the Specific meaning of the physician's instructions. Arguments centered around the patient's activity, diet, and nervousness. Thirteen families demonstrated exaggerated anxiety concerning the patient's progress and attempted to Shield the patient from physical activity and unpleasant information. Conflicts occurred even when the premorbid home life had been quite stable. Mayou, Williamson, and Foster (1978), psychiatry researchers at Oxford, conducted semi-structured interviews of MI patients during hOSpitalization, and at two and twelve months following the infarction. Patient outcomes were described in terms of a) physical symptoms, b) physical activity, c) social activities, d) social interaction, and e) compliance with medical care. Wives were interviewed during similar time periods. Mayou, Foster and Williamson (1978) described the wives' involvement in the 77 husbands' recoveries. The wives reported their husbands to be very dependent during the first few weeks of convalescence and wives lacked clear advice concerning the apprOpriate amount of activity for their husbands. Some wives attempted to organize convalescence by throwing away ashtrays or planning exercise. At about two months, husbands and wives had similar views (3 < 0.05) about the potential effects of the illness on work, leisure, diet, and smoking. At one year, wives still continued to be involved in activities such as consulting with the physician, administering tablets, and actively encouraging their husbands to diet, stOp smoking, or engage in exercise. A third of the wives were reported to be openly protective of their husbands, while 13% were covertly protective. About one third of the husbands were noted to reluctantly accept their wives' concerns while 15% rejected the wives' protective behaviors. About 25% of the wives reported their marriages had improved since the MI while 20% reported that the marriage had deteriorated. Wives who were least distressed at one year reported satisfactory marriages, continued to work, enjoyed their jobs, and had maintained their leisure activities. This is consistent with Speedling's (1982) observation that wives adjusted better when they were able to withdraw from the caregiver role. Nursing Literature In a nursing study, Tyzenhouse (1973) investigated the relationship between the wife's knowledge about myocardial infarction and knowlege about the desired effects of the doctor's orders and the 78 husband's progress and the family's adjustment following the husband's MI. Twenty male patients who had experienced a MI within the past three to six months were selected for the study. The wife of each patient was interviewed to determine the family's reaction to the patient's illness and the husband's progress. Estimates were made of the patient's progress and family's adaptation. These estimates were correlated with the wife's knowledge concerning physiological effects of the MI and rationale behind the prescribed treatment. Criteria for the assessment of adaptation and wife's knowledge were not given. The wife's knowledge did not appear to lead to improved physical status for the husbands nor to more stable family relationships. Men were reported by their wives either to disregard their regimens or to assume such complete reSponsibility for following medical orders that the wives lacked detailed knowledge concerning the nature of their husband's medical regimens. NO information was given concerning the number of husbands who behaved in each manner. None of the wives reported influencing their husband's actions. Tyzenhouse (1973) suggests that teaching wives to be supportive may be more important than teaching them concerning the husband's regimen. The absence of wife participation reported in this study varies from the extensive wife participation reported by Mayou, Foster, and Williamson (1978). Differences may be due to the small sample Size in Tyzenhouse's (1973) study, unreliable measurements in both studies and/or actual differences between the Oxford and California samples. Hentinen (1983) addressed the need for instruction by the wives 79 of patients with myocardial infarctions. A questionnaire was sent to 73 wives eight weeks following their husbands' MIS. The questionnaire was completed and returned by 59 wives, 38% of whom were employed outside the home. Wives were requested to indicate whether they had received information concerning the following areas: exercise, use of nitroglycerine, smoking, sick leave, diet, procedure to use during a heart attack, and information concerning other drugs. Percentages of wives who reported receiving instructions ranged from a low of 32% who were instructed regarding other drugs to a high Of 49% who were instructed concerning exercise. In reSponse to an Open ended question, wives indicated a desire for more instructions about home care, diet, procedure to follow in the event of another heart attack, and suggestions concerning how to provide support to the husbands. The desire for more information may indicate that wives perceived themselves as having reSponsibility in the areas mentioned. There is need for further nursing research to determine the relationship between the wife's education concerning the treatment regimen, the Spouses' reSponsibility for treatment dimensions, the husband's compliance, and marital adjustment. Kline and Warren (1983) collected data in all of these areas, but data analysis is not completed. In terms of theory develOpment which could be useful during the postmyocardial infarction period, Meleis (University of California, 1975) develOped a conceptual model of role insufficiency and role supplementation. Meleis (1975) stated that role transitions occur during illness and during normal growth and develOpment. When 80 individuals are inadequately prepared to move into or out of roles, role insufficiency may occur. The model prOposed that nurses can assist clients through role transitions by deliberate role supplementation strategies. Role supplementation Strategies include role clarification, role modeling, role rehearsal, and utilization of reference groups. Dracup, Meleis, Baker, and Edlefsen (1984) have develOped a nursing intervention for cardiac patients and Spouses based on Meleis' (1975) model of role supplementation. Application of the nursing intervention and documentation Of outcomes can lead tO evaluation of the usefulness of the role insufficiency and role supplementation model. In a related area, Dracup 8 Meleis (1982) have develOped a conceptual framework based on interaction theory for utilization in compliance research and theory building. Four areas in which compliance research is needed were listed as: 1) the behaviors which are demanded by the performance of a new role, 2) the individual's self-concept, particularly as affected by the health status, 3) the counter-roles of Spouse, health professional and other Significant individuals, and 4) the periodic evaluations Of roles as enacted by self and counter-roles. Dracup 8 Meleis suggested that "compliance is enhanced when relevant other roles are congruent and /Or complementary with client roles. Compliance is enhanced if the compliance role is reinforced by significant others and other reference groups" (p.35). Although the relationship between husband and wife patterns of reSponsibility for the treatment plan and husband compliance is not 81 clear, there are indications that the manner in which the treatment plan tasks are divided does affect compliance (Speedling, 1982). Summary of Chapter III In addition to the few studies which address the husband's and wife's perceptions Of reSponsibility for the postmyocardial infarction treatment regimen, a review of current sociological literature describing research in the areas Of household task allocation and concensus was presented in Chapter III. Nye (1976) and Albrect, Bahr, and Chadwich (1979) described husbands' and wives' perceptions of responsibility for eight parental or Spouse roles. Men were clearly perceived as reSponsible for the provider role and the wife for the housekeeping and child care roles. There was Sharing Of the child socialization, kinship, therapeutic, recreational, and sexual roles. Perrucci, Potter, and Rhoads (1979), Atkinson and Huston (1984) and Ericksen, Yancey, and Ericksen (1979) tested hypotheses concerning allocation of family tasks. The socialization or ideology hypothesis of task allocation was supported by the research findings of each study. Less support was found for the relative-resources, time available, and degree of skill hypotheses. When comparing husbands' and wives' responses concerning division of labor in the home, Larson (1974), Conrad and Bode (1982), and Berk and Shih (1980) all observed a tendency for husbands and wives to overestimate their own contribution tO household labor in comparison to their Spouse's report. There was more agreement concerning sex-typed tasks. Douglas and Wind (1978) and Quarm (1981) focused on 82 measurement error as a source Of nonagreement between Spouses concerning task allocation. ‘ The themes of husband and wife conflict, wife overprotectiveness, and/or the couple's lack of preparation for carrying out treatment tasks were commonly addressed in postmyocardial infarction literature. Some authors reported that husbands and wives did not agree concerning who was reSponsible for treatment plan tasks (Wishnie et al., 1973) and that the amount Of disagreement was more pronounced during recovery transitions as the husband increased his activity and became more independent (Speedling, 1982). Mayou, Foster, and Williamson (1978) reported that half of the wives were actively involved in treatment activities while Tyzenhouse (1973) reported minimal wife involvement in the husbands's treatment regimen. Meleis (1975) develOped a role insufficiency and role supplementation conceptual framework which is compatible with King's (1981) Theory of Goal Attainment. Dracup et al. (1984) used the role insufficiency and role supplementation framework to develOp a nursing intervention for postmyocardial infarction patients and their Spouses. The focus of this study will be to describe the husband's and wife's perceptions of and agreement concerning reSponsibility for the husband's postmyocardial infarction treatment regimen. In Chapter IV the methods utilized in this study will be presented. CHAPTER 1V METHODOLOGY AND PROCEDURES Background Secondary data from a research project titled "The DevelOpment of Measures to Determine Marital Functioning and Treatment Activities Post—Myocardial Infarction" was utilized for this study. Kline and Warren, who were professors at the Michigan State University College of Nursing, develOped and conducted a self-report survey of 98 couples between 1980-1983. Subjects completed five questionnaires designed to measure: 1) therapeutic regimen content, 2) husband's adherence to the therapeutic regimen, 3) allocation Of reSponsibility for the therapeutic regimen, 4) marital functioning, and 5) sociodemographic variables. Significant findings from Kline and Warren's (1983) study are summarized in Chapter 1. For the present study, 5 research questions were develOped concerning husband and wife perceptions of reSponsibility for the treatment plan. Major variables of the study are: a) husbands' perceptions of who is reSponsible for dimensions of the treatment plan, b) wives' perceptions of who iS reSponsible for dimensions of the treatment plan, c) husband and wife agreement concerning who is reSponsible for dimensions of the treatment plan and d) time in months since the MI. 83 84 A discussion of the methods and procedures related to this Study follow. Procedures utilized by Kline and Warren to select the study sample, collect the data, and protect the human rights of the subjects will be identified. Descriptions of the methods used to develOp the research instruments and subscales will be presented, along with Operational definitions of the variables and methods utilized for Statistical analysis of the data. em Subjects for the study were a convenience sample of 98 couples drawn from seven sites. The sites were all located in mid-Michigan and consisted Of two community hOSpital cardiac clinics, 4 cardiology private practices, and a community college formal cardiac rehabilitation program. Subjects were selected for inclusion in the study according to the following criteria: a) Males hospitalized within one year of inclusion with a diagnosed MI; b) Males at least 35 years of age; c) Married and living with Spouse at time of inclusion; d) Agreed to participate and completed the questionnaires. Data Collection Procedures The researchers initially contacted physicians at several potential sites and explained the purpose of the study. Those physicians who were willing to participate identified a contact person, usually a nurse, who assumed responsibility for identifying potential subjects from those patients with a history of recent infarction. A 85 research assistant contacted each site at least every two weeks to inquire about prOSpective subjects. The researchers provided a letter for distribution by the site contact person to potential subjects. The letter was signed by the patient's physician, contained a description of the study, and requested patient and wife participation (see Appendix A ). A reply postcard was attached to each letter. Subjects indicated a willingness to participate by mailing the reply postcard to the researchers at the MSU College of Nursing. Upon receiving the postcard, the researchers contacted the potential subjects by telephone and explained the purpose of the study. Subjects were advised concerning the content Of the questionnaires and the amount of time needed to complete the questionnaires. Subjects were assured that reSponses to the questionnaires would be kept confidential and that neither participation nor refusal to participate would affect future health care. The researchers mailed or delivered a research packet to those couples who were enrolled in the study. The research packet contained: an explanatory cover letter which requested subjects not to confer with their Spouses while completing the questionnaires, a consent form with a letter defining subject rights and benefits (see Appendix B), 5 sets of questionnaires for the husband and 5 sets of questionnaires for the wife. Couples completed the questionnaires and consent forms and returned them to the investigators by mail. A telephone contact was made with each couple who failed to return the questionnaires 86 within 10 days and the couples were encouraged to complete and return the questionnaires and consent forms promptly. The researchers assigned each couple who returned the set of questionnaires an identification code number. Data from each questionnaire was coded and entered into a computer file. Data collection was completed in 1983. Instruments Data for this study was Obtained from subjects' responses to the responsibility questionnaire. As no existing instruments to measure marital couple perceptions of allocation of reSponsibility for treatment plan dimensions following the M1 were found, Kline and Warren (1983) developed a set of items assessing reSponsibility. The 28 items which composed the reSponsibility scale were develOped by the researchers following an extensive literature review of current components of medically prescribed therapeutic regimens following a myocardial infarction. Each item listed an activity related to carrying out an aSpect Of the treatment plan. For each treatment activity, subjects were requested to indicate which of five responses most nearly described the allocation Of reSponsibility. ReSponse scale points represented: completely my responsibility, mostly my responsibility, about even reSponsibility, mostly my wife's (husband's) reSponsibility, and completely my wife's (husband's) reSponsibility (see Appendix C). Husband and wife forms of the questionnaire were identical in terms of treatment activities but differed in that gender reference words were changed so as to be appropriate for the sex Of 87 the respondent. Subscale DevelOpment As discussed in Chapter III, researchers investigating division Of labor in the family have Often used single item measures Of division of labor and the validity of study results have been questioned by subsequent researchers because of the possibility of substantial measurement error (Quarm, 1981). One method of reducing measurement error is to construct multiple item scales. Similar responses by subjects to questions supposedly measuring the same concepts provides support for the reliability of the instrument. Although Kline and Warren's (1983) scale contained only a Single item for some treatment dimensions such as smoking, there were multiple items which pertained to the diet, medications, stress, and activity dimensions Of treatment. Multiple item subscales were develOped for these dimensions. To determine if husbands and wives reSponded Similarly to items, separate correlation matrices of the 28 items were computed for the husbands' and wives' responses. Each matrix was then submitted to an oblique multiple-group factor analysis. Both husband and wife matrices factored into distinct clusters of items for medications, stress, and food management. There were some differences between husband and wife factors for the sex and activity items. The correlation matrices were examined for each cluster to assess internal and external parallelism. Seven items with low intrascale or high interscale correlations were deleted. 88 The final result was eight subscales (see Appendix D) with identical content for husbands and wives. There was one subscale for each of the treatment dimensions except for the diet dimension for which there were three subscales. Although the concept diet was initially expected to be unidimensional, results from the factor analysis and correlation matrices demonstrated there were at least three concepts within the diet items. Those identified for this study were a) limitation Of alcohol consumption, b) weight control and c) food management. Four of the subscales contained multiple items, two subscales contained two items each and 2 subscales contained Single items. Reliability and Validity of Research Subscales The develOpment of multiple item scales was intended to reduce measurement error. The reliability of an instrument is the degree of consistency with which it measures an attribute. A reliable measure is also one which maximizes the true score component and minimizes the error component (Polit 8 Hunglar, 1978). The six husband and wife subscales containing two or more items were tested for internal consistency through calculations of Crombach's coefficient alphas for each subscale. Alphas for the male subscales ranged from .65 for the activity subscale to .85 for the medications subscale. Alphas for the female subscales ranged from .81 to .83 for all subscales. As all alphas for both husband and wife subscales demonstrated acceptable levels of reliability for social science research, the subscales were assumed to be applicable to both male and female respondents. Coefficient alphas were then calculated for the Six subscales using 89 pooled data from all the subjects. Validity refers to the degree to which an instrument measures the concept it is supposed to be measuring. A valid instrument must also be reliable. The validity of measures of perception, such as are utilized in this study, are difficult to assess (Polit 8 Hunglar, 1979). Content validity refers to the sampling adequacy Of the content areas being measured. Kline and Warren (1983) attempted to assure content validity by develOpment of items on the basis Of an extensive literature review of postmyocardial infarction treatments and by inclusion of a wide range of content related to various dimensions of the treatment plan. Construct validity refers to the adequacy with which the instrument measures the abstract concept under investigation. Construct validity is extremely difficult to assess, but is a crucial consideration in social science research. For this study, the 28 responsibility items were subjected to factor analysis. For most rotations, the factor clusters contained items which were related in terms Of content. This supports, but does not establish, the construct validity of the subscales. Operational Definitions of Variables The variables under consideration for this study were: husband and wife perceptions of who is reSponsible for the Six dimensions of the treatment plan, husband and wife agreement concerning who is 9O responsible for the six dimensions of the treatment plan and time following the husband's myocardial infarction. The Operational definitions of the variables follow. Husband and Wife Treatment Plan ReSponsibility Husband and wife perceptions of who is responsible for the postmyocardial infarction treatment plan were defined in terms Of subjects' reSponses to the 28 item questionnaire on reSponsibility (see Appendix C). Each item listed a postmyocardial infarction treatment task. Following each item was a Six point scale with points being: 1) completely my responsibility, 2) mostly my responsibility 3) about even responsibility, 4) mostly my Spouse's responsibility, 5) completely my Spouse's reSponsibility, and 6) not applicable to my (Spouse's) treatment plan. Subjects were requested to circle the reSponse which best applied to each item. Wives scores were later reflected SO that all scores were in terms of the husband's responsibility. Husband and wife reSponsibility for the treatment dimensions of smoking cessation, diet, medications, activity, stress reduction, and sexual activity were Operationally defined in terms of the subjects' mean reSponses to the items composing the eight subscales (see Appendix 0). There was one subscale to measure each of the treatment dimensions except for diet. Three subscales measured different aSpects of the diet dimension. A description of each of the subscales follows. Smoking. ReSponsibility for smoking was measured by item number 1 which was: "Modifying smoking habits". 91 Alcohol. A single item (number 26) which was: "Limiting alcohol intake to two drinks a day or less" composed the alcohol subscale. ngggg. The weight subscale consisted of two items (numbers 2 and 3) which were: "Reducing weight" and "Maintaining weight". Foods. Four food selection and preparation items (numbers 5 through 8) composed the foods subscale. A sample question is: “Preparing foods according to dietary restrictions.“ Medication. Four items (numbers 10 through 13) composed the medication subscale. Content focused on taking medication at the proper time, keeping a supply Of medications at home, and noting any medication side effects. A sample question is "Watching for negative effects of medicine". Activity. Five items (numbers 15 through 18 and 28) composed the activity subscale. Content focused on following activity restrictions, planning time for activity, and minimizing stair climbing. A sample question is “Organizing activity to keep stair climbing at a minimum". Stress_Reduction. Four items (numbers 19, 20, 22 and 23) composed the stress reduction subscale. Content focused on lessening reSponsibilities, recognizing stress, and taking steps to reduce stress. A sample question iS "Recognizing the right time to deal with a stressful Situation". Sexual Activity. Two items (numbers 24 and 25) composed the sexual activity subscale. Content was "Using medically recommended positions during intercourse" and "Postponing sexual intercourse when 92 I am tired, upset or after heavy meals." Husband and Wife Agreement Concerning ReSponsibility Extent of husband and wife agreement concerning responsibility was measured through computation of a difference score. Each wife's reSponses for subscales were subtracted from her husband's reSponses for the same subscales. The absolute difference between Spouses then represented the level of disagreement for each dimension. Time Following the MI lime following the husband's MI was measured by husbands' responses to the sociodemographic questionnaire item number 15 which read ”How long ago did you have your last heart attack?" ReSponses were analyzed in units Of months. Possible Moderating Variables In the conceptual model, (Figure 2) sociodemographic characteristics, perceptions of the husband's health status and perceptions of the husband's treatment plan affect the husband's and wife's perceptions of responsibility for the treatment plan dimensions. Therefore, three sets Of possible moderating variables were identified from the sociodemographic questionnaire (see Appendix E). These sets of variables were called: a) sociodemographic, b) husband's health status and c) treatment plan related. Operational definitions of these sets Of variables follows. 93 Sociodemographic. There were twelve sociodemographic items (numbers 1-12) which requested information concerning age, ethnic background, years of marriage, husband and wifeeducational status, hquand and wife employment status, combined annual income, number of children and number of children living at home. AS other studies have found high agreement between husband and wife reSponses to items measuring sociodemographic characteristics (Card, 1978), only the husband's reSponseS were utilized in the analyses. Health Status. There were five health status items (numbers 14, 16, 19, 22 and 32) which requested information concerning number of times hOSpitalized for a MI, severity of the MI, presence of other chronic illnesses and present activity levels. Treatment Plan Related. The three treatment plan related items (numbers 17, 21, and 32) requested information concerning reception of instruction regarding the treatment plan during hOSpitalization, current participation in a cardiac program, and the extent to which subjects believed that adherence to the treatment plan would allow them to return to their preinfarction activity levels. Analysis of Data Data analysis was utilized to answer the five study questions. Question 1: Who does the husband report as reSponsible for the treatment dimensions Of smoking cessation, diet, medication, stress reduction, sexual activity, and activity? Question 2: Who does the wife report as reSponsible for the treatment dimensions of smoking cessation, diet, medication, stress 94 reduction, sexual activity and activity? TO answer these two questions, descriptive statistics were computed using husbands' scores for the eight reSponsibility subscales and wives' scores for the eight reSponsibility subscales. Question 3: What is the extent of agreement between the husband and the wife concerning responsibility for the husband's treatment plan? To answer question 3, paired t_tests were used to calculate mean disagreement statistics from husband and wife scores for each subscale. Crosstabulations of paired husband and wife mean scores for each of the 8 subscales were computed to characterize the extent of agreement and disagreement between husband and wife reSponses. Question 4: What is the relationship between time since the MI and who is reported as responsible for the treatment dimensions? To answer question 4, Pearson product-moment correlation coefficients were calculated for time and the husbands' and wives' eight subscales SCOI‘ES. Question 5: What is the relationship between time since the MI and husband and wife agreement concerning reSponsibility for the treatment plan? TO answer question 5, Pearson product—moment correlation coefficients were calculated for time and the husband and wife difference scores for each subscale. Possible Modifying Variables: To test for relationships between the study variables and sociodemographic variables a correlation matrix was computed using the following variables: a) husbands' 8 reSponsibility subscale scores, b) wives' 8 reSponsibility 95 subscale scores, c) husband and wife difference scores for the 8 subscales, d) 12 sociodemographic items, e) 5 health status items and f) 3 treatment plan related items. Protection of Human Subjects Participant rights were protected during data collection by following protocol for protection of human subjects. Kline and Warren's (1983) research prOposal, from which this study's data was taken, was approved before data collection was begun by the University Committee on Research Involving Human Subjects (see Appendix F) and by research committees in the two community hOSpitals utilized as data collection Sites. To inform subjects of their rights, each subject received a letter explaining the purpose of the study. The letter stated that neither refusal to participate nor agreement to participate would influence future care. Subjects were also assured that their identities and reSponses would be kept confidential. Subjects were requested to Sign a consent form (see Appendix B) which contained further elaboration of participant rights. Upon receipt of the questionnaires, the researchers separated patient identifying data from the questionnaires and coded the questionnaires sequencially. Only coded data was utilized for this study. AS the identities of the subjects were unknown and as the data was used only for research for a master's thesis, there was no further risk to the research subjects. The present study met MSU criteria for exemption from review by the Human Rights Committee. 96 Summary of Chapter IV The data utilized for this study were part of a larger data bank Obtained from a questionnaire survey of a convenience sample Of 98 mid- Michigan marital couples whose males had experienced a MI within the previous year. ReSponseS to the 28 item reSponsibility scale were submitted to factor analysis with the purpose of constructing multiple item subscales for measuring several dimensions of the husbands' and wives' perceptions of responsibility for the postmyocardial infarction treatment plan. Eight subscales, two of which were Single items, were constructed to measure: smoking modification, alcohol limitation, weight control, food management, medications, stress reduction, sexual activity and activity. The Six subscales with two or more items were analyzed for reliability using Crombach's alpha. Descriptive statistics were computed for the husband's and wive's mean reSponses for the 8 subscales. Husband and wife nean reSponseS for the 8 subscales were compared through the use of.£ tests. Crosstabulations of paired husband and wife mean reSponseS for each subscale were performed in order to demonstrate the nature of the couple's agreement or disagreement. The relationship of time tO husband and wife perceptions Of reSponsibility and agreement concerning responsibility for the eight subscales was determined through use of Pearson's product-moment correlations. Pearson's product—moment correlation was also utilized to determine the relationships between a) husband and wife reSponseS to the 8 97 subscales, b) husband and wife agreement for the 8 subscales, and c) three sets of items from the sociodemographic questionnaire. Kline and Warren followed standard procedures to protect the rights of the research subjects. As coded data was used for this study, there were no further risks for the subjects. In Chapter V the study sample will be described in terms of sociodemographic characteristics. The results of the analysis of the subscale scores for reliability will be presented. The results of the analysis of data which was performed for each study question will be presented as well as other study findings in reSpect to sociodemographic characteristics, husband's health status, and treatment plan related items. Chapter V DATA ANALYSIS Introduction The analysis of data will be presented in Chapter V. The study subjects will be described in terms of sociodemographic characteristics and perceptions Of the husband's health status and treatment regimen. The results of the analyses Of the subscale scores for reliability and unidimensionality will-be presented. The husbands' and the wives' perceptions of reSponsibility for the eight subscales will be described. The extent to which the husband and wife agreed concerning reSponsibility for the treatment plan dimensions will be explored. The relationship between time following the MI and husband and wife perceptions of and agreement concerning the treatment plan will be presented. Significant correlations between subscales and sociodemographic modifying variables will be presented. Sociodemographic Characteristics of Sample The convenience sample consisted of 98 married couples who were living together. The husbands had all experienced a myocardial infarction within twelve months Of participation in the study. The data concerning sociodemographic characteristics was taken from the husbands' reSponseS to the socio-demographic questionnaire unless otherwise Specified. Husbands ranged in age from 40 to 74 years with a 98 99 mean Of 56.4 years. Wive's ages ranged from 28 to 72 years with a mean of 53.5 years. The distribution of husbands' and wive's ages is found in Table 1. There was no reSponse for one wife Table 1: Distribution of Age Ranges Of Subjects Age in Men Women Years No. % No. % 28-39 0 O 8 8 40-49 21 21 21 22 50-59 44 45 43 44 60-69 28 29 22 23 70-80 5 S 3 3 Total 98 TOO 97 100 The length Of time the couples had been married ranged from 1 to 43 years with a mean Of 29.8 years. The distribution of the number Of years of marriage is presented in Table 2. One couple did not report length of marriage. Table 2: Distribution of Years of Marriage Ranges Years Couples Couples No. % 1-10 9 9 11-20 11 11 21-30 17 18 31-40 51 52 41-50 9 10 Total 97' 100 100 Some conclusions concerning generalization of the study results can be derived from the sociodemographic descriptions of the study sample. Although the sample was a convenience sample, there were only 11 couples who met the inclusion criteria who declined to participate and another 2 couples who were eliminated because of incomplete data. As few couples declined to participate, the bias resulting from the use of a volunteer pOpulation is not likely to be Of significance. AS the sample included only married couples with husbands who had been hospitalized with a MI during the past year, caution Should be applied in generalizing study findings to single populations or to couples where the woman had experienced a MI. In considering sociodemographic data an issue of importance becomes the determination of the similarity of the subjects to the general pOpulation of postmyocardial infarction patients and their wives. There is no strong evidence at this time that MI patients differ from the general pOpulation in terms of income, education, family size or racial characteristics (National Heart, Lung, and Blood Institute, 1979). The subjects will be compared to the general adult pOpulation of the United States and the Lansing, Michigan area in terms of selected demographic characteristics. With the exception Of 1 male who was Indian, all Of the sample was white. The racial make-up of the United States consists of about 83% white, 12% black, .6% Indian, and 4.5% other (U. S. Bureau Of the Census, 1985). The Lansing/East Lansing area is more homogeneous than the United States pOpulation with 91.9% white, 5.3% black, .5% Indian, and 2.3% other (U. S. Bureau Of the Census, 1983). The uniformity of 101 racial characteristics in the study sample was not representative of the Lansing area nor of the United States pOpulation. The level of education of husbands and wives ranged from junior high school to beyond four years of college. The distribution of the husbands' and wives' levels of education is presented in Table 3 and comparison is made to the Lansing and United States pOpulations. Table 3: Education Level Frequencies for the 196 Subjects and Adults over 25 Years Old in Lansing/East Lansing* and the U.S.* Education Men Women Adults Levels Subjects Lansing Sphjects Lansing ’U.S Junior High School 7 2 11.6 4.1 9.9 18.2 Partial High School 10.3 12.5 8.2 13.6 15.3 High School 40.2 33.5 48.0 42.6 34.6 Some College 23.7 17.8 24.5 17.8 15.7 4 Years College 8. 2 10.2 8.2 8.3 16.2** Beyond 4 Years College 10. 3 14.4 7.1 7.8 Total 10070 'TOOTO 100.0 TOOTO’ 100.0 Note. * = 1980 Census Statistics. ** = 4for more years of’coTlege. The study sample had fewer subjects with less than a high school education and more with high school or beyond than is normal for the United States pOpulation (U.S. Bureau of the Census, 1985). The Lansing area has many institutions of higher learning and is a State Capitol. There are more Lansing adults with high school and some college levels of education (U.S. Bureau of the Census, 1983) than is the average for the United States. The study subjects were more similar to the Lansing area in terms of education level than to the United States as a whole. 102 Subjects were requested to indicate the range of their combined annual incomes. Husbands reported a range of combined couple income from below $9,999 to greater than $80,000. The most commonly reported range of income was $20,000 to $29,000 which is consistent with the median income for white pOpulations in the United States which was $26,493 in 1982 (U.S. Bureau Of the Census, 1985). The distribution of the subjects' levels of combined annual income is demonstrated in Table 4. Three couples failed to indicate their income levels. Table 4: Distribution_of Combined Levels Of Annual Income Income Levels Couples Couples Dollars NO. % 0- 9,999 8 8.4 10,000-19,000 12 12.6 20,000-29,000 28 29.5 30,000-39,000 17 17.9 40.000-50,000 19 19.4 50,000-59,000 2 2.1 60,000-69,000 2 2.1 70,000-79,000 3 3.2 80,000 or more 4 4.2 Total 98 100.0 Subjects were asked to indicate how many children they had and how many children were living at home. Number Of children ranged from none to 13 with a mean Of 3.7 children and a standard deviation of 2.36. Fifty eight (59.2%) couples indicated that no children were living at home at the time of the survey, 20 (20.4%) couples reported that one 103 child lived at home, 10 (10.2%) couples reported that 2 children lived at home and there were from 3 to 5 children reported to be living in the homes of the remaining 10 (10.2%) couples. The 2.76 mean size of the household at the time of the survey was just slightly above the national average of 2.67 for households with the householder being at least 35 years of age (U.S. Bureau of the Census, 1985). In summary, although the study sample was similar tO the pOpulation of the the United States in terms of income and family size, the sample appeared to differ in terms Of education and racial makeup. Therefore, caution should be utilized in generalizing findings to nonwhite pOpulations or to pOpulations with lower levels of education than were attained by the study subjects. Perceptions of Husband's Health Status In the conceptual model (Figure 2), husband and wife perceptions of the husband's health status influenced the interaction of the husband and wife concerning responsibility for the treatment plan. The sociodemographic questionnaire contained some items pertaining to perceptions of the husband's health status. Subjects were questioned concerning: the number of times hospitalized for a MI, the time Since the husband's MI, perceived severity of the MI, current activity level, presence of other chronic illnesses, and employment status. In reSponse to the question "Have you been hospitalized more than one time for a heart attack?" a total of 70 (71.4%) husbands reSponded no, and 28 (28.6%) husbands responded yes. The length of time since the last heart attack ranged from 1 to 12 months with a mean of 5.5 104 months. Two husbands did not respond to the question concerning time Since the MI. The distribution of months since the MI is demonstrated in Table 5. Table 5: Distribution of Time Since the Husband's Last MI Time in Husbands Husbands Months NO. % 1- 3 30 31.3 4- 6 31 32.4 7- 9 22 23.0 10-12 13 13.3 Total 96 ‘TUOTU' AS couples with previous experiences with chronic illness may differ from those couples without experience with chronic illnesses in terms of perceptions of reSponsibility and/or agreement concerning reSponsibility, subjects were asked "Do you have any chronic health problems?" A total of 47 (48%) husbands answered in the affirmative and 50 (51%) answered in the negative. One husband did not reSpond. Subjects were requested to indicate the severity of the husband's last heart attack. As differences between husband and wife reSponses to this question would have theoretical implications, a.£ test was performed on husband and wife reSponseS to this question. Husbands' and wive's reSponses for this question did not differ Significantly from each other. The distribution of husbands' reSponses are demonstrated in Table 6. Four subjects failed to respond. 105 Table 6: Distribution Of Husbands' Ratings Of Severity Of Last Heart AttaCK Severity Rating No. % Very Severe 30 31.9 Moderately Severe 35 37.2 Mild 22 23.5 No heart damage 7 7.4 lotal '94 10070 When requested to indicate their current levels of activity no husbands responded that they were completely disabled or confined to bed more than 50% of waking hours. Seventeen (17.4%) husbands indicated they were walking and capable of all self-care, but were unable to carry out any work activities. Fifty four (55.1%) husbands responded that they were restricted in physically strenuous activity, but were walking and able to carry out work of a light or quiet nature. Twenty seven (27.6%) husbands reponded that they were fully active and able to carry out all pre-heart attack activities without restriction. Ag; test of husband and wife mean responses. failed to Show a Significant difference for reSponses concerning activity level. Subjects were asked to indicate agreement or disagreement with the following statement: "My current physical activity level is no different than before my heart attack". A total of 25 (25.5%) husbands indicated agreement and 73 (74.5 %) husbands indicated disagreement with the statement. Again, a“: test did not demonstrate a significant mean difference between husband and wife reSponses 106 concerning current activity level. The husbands return to work following a MI is often used by researchers as an outcome measure. Husbands and wives were requested to indicate their employment status. A total of 50 (51%) husbands reported they were working, 47 (48%) reported they were not working, and 1 did not respond. The percentage not working is consistent with findings by Wishnie, Hackett, and Cassem (1971). Of those husbands who were not working, 22 (22.4%) husbands reported they were retired. Of those husbands who were working, 34 (34.7%) reported they were working full time and 17 (17.3) reported they were working part time. The percentage working full time was slightly higher than the 27.5% who reported being fully active. There was a Significant correlation between not working and a restricted activity level (i = .49, g = .001). The number of husbands who were both retired and physically unable to work is not known. A total Of 44 (44.9%) wives were reported to be working and 54 (55.1%) were reported to be not working. Of those wives who were not working, 10 (10.2%) were reported to be retired. 0f the wives who Were working, 26 (26.5%) were working full time and 16 (16.3%) were working part time. There were no reSponses given for 2 (2%) working wives concerning full time or part time employment status. Pearson product-moment correlations were computed between sociodemographic characteristics. The correlation between the husband's rating of severity of the MI and his activity level was .29 (g_= .002). The coefficient for presence of other chronic illnesses with increasing age was .17 ( E.< .05). The coefficient for presence 107 Of chronic diseases with disagreement that following the treatment plan would allow return to former activity levels was .23 (E.< .001). There was a tendency for the Older subjects not to have children living in the home (3 .33, p < .001) and for the husbands not to be employed (1 .30, g < .001). In summary, the majority of husbands reported that they had experienced only one MI, that their infarctions had been moderately severe or severe. Most of the husbands were active, with only 17.4% reporting that they were unable to engage in at least light work. However, 48% were not employed at the time of the survey. About one half of the husbands indicated that they had one or more other chronic illnesses. Treatment Plan Related Items In the conceptual model (Fig. 2) the husband's and wife's perceptions of the treatment plan are viewed as affecting the husband's and wife's interactions concering responsibility. Three items were considered to be related to perceptions of the treatment plan: a) current participation in an organized heart program, b) history of having received information concerning the treatment plan while in the hospital, and c) the subjects expectations concerning whether adherence to the treatment plan would result in return of the husband's activity capacity to former levels. Only 23 (23.5%) husbands reported that they were currently participating in an organized heart program. These subjects may 108 have been drawn from the formal cardiac rehabilitation site. A total of 70 (71.4%) husbands indicated that they had participated in a heart teaching program in the hOSpital while 26 (26.5%) denied participation. Two husbands did not reSpond to the question concerning education. The number of husbands who reported receiving instruction about Specific treatment dimensions such as smoking, diet, alcohol, medications, stress, exercise and work activity ranged from 52 (53%) for work to 70 (71.4%) for diet. There were some discrepancies between husband and wife responses concerning whether instructions had been given and to whom. In analyzing the responses to questions concerning instruction, a yes/no score was constructed to indicate whether instruction had been reported for specific treatment dimensions. Paired husband and wife scores were crosstabulated with four possible combinations of answers resulting: 1) the husband and wife both reported that some instruction had been received, 2) the husband reported instruction was received while the wife failed to report instruction, 3) the wife reported .instruction was received while the husband failed to report it, and 4) both the husband and wife failed to report that instruction was given. In all cases more wives than husbands reported that some instruction had been given. The most frequent area of reported instruction was diet, where 61.2% of the men and 64.3% of the women reported receiving instruction, followed by medication and exercise. Subjects were least likely to have received education concerning alcohol limitation or work. The findings from the crosstabulations of husbands' and wives' scores for reports of receiving treatment 109 instructions while the husband was hospitalized are demonstrated in Table 7. Table 7: Couplg_Frequencies of Reporting Hospital Instruction Treatment Husb Yes Husb Yes Husb No Husb No Subscale Wife Yes Wife NO Wife Yes Wife No No. % NO. % No. % No. % Smoking 50 51.0 10 10.2 14 14.3 24 14.5 Diet 64 65.3 6 6.1 12 12.2 16 16.3 Alcohol 38 38.8 13 13.3 21 21.4 26 26.5 Medications 60 61.2 5 5.2 16 16.3 17 17.3 Exercise 60 61.2 6 6.1 14 14.3 18 18.4 Stress 55 56.1 8 8.2 13 13.3 22 22.4 Work 42 42.9 10 10. 23 23.5 23 23.5 NOte.’HuSO =‘fiUSband. Yes = Report thati1nstruction was received. NOT? no report that instruction was received. ReSpondents were requested to indicate whether instruction had been given to husband alone, wife alone, or jointly. The wife only reSponse was chosen infrequently. Crosstabulations were made of paired husband and wife reSponses concerning who had received instruction. Four combinations of reSponses resulted: 1) the husband and wife agreed that the husband had received instruction alone, 2) the husband reported that instruction was received jointly while the wife reported that instruction was received by the husband, 3) the wife reported that instruction was received jointly while the husband reported that instruction was received alone and 4) the husband and wife agreed that instructions were received jointly. The results of the crosstabulations concerning joint or individual instruction are presented in Table 8. 110 Table 8: Frequencies of Couple Reports of Individual or Joint Participainn in a HOSpital Teaching Program H Indiv H Joint H Indiv H Joint Total W Indiv W Indiv W Joint W Joint Dimensions "‘N67 N67"%" NOT’—%_ NOT—'%" NOT—_%‘ Smoking 49 13 26.5 4 8.2 13 26.5 19 38.8 Diet 6O 6 10.0 1 1.7 6 10.0 47 78.3 . Alcohol 38 13 34.2 5 13.2 6 15.8 14 36.8 Medications 59 16 27.1 7 11.9 10 16.9 26 44.1 Exercise 60 19 31.7 5 8.3 10 16.7 26 44.3 Stress 55 19 34.5 5 9.1 10 18.2 21 38.2 Work 42 12 34.5 1 2.4 5 11.9 24 57.1 Note. H = husband. W = wife, Indiv = only hquandlinstructed. For all of the dimensions, more wives than husbands reported that instructions had been given jointly. The most common tOpic for joint instruction was diet, followed by medication and exercise. Husbands were most likely to have received individual instruction in the areas of alcohol limitation, stress reduction and work. Husbands were asked to indicate their level of agreement or disagreement with the following statement "My treatment plan will allow me to return to my pre-heart attack level of physical activity." A total of 63 (64.3%) husbands reported agreement with the statement, 33 (33.6%) husbands reported diSagreement and 2 husbands did not reSpond to the question. It is not known if the 33 disagreers were the more seriously ill, or included husbands whose activity levels had already returned to their preinfarction levels. In summary, less than one fourth of the husbands were involved in an organized heart program at the time they were surveyed. A total of 111 26 (26.6%) husbands denied participating in a cardiac teaching program while hOSpitalized. Of those who did participate about half Of the husbands had participated alone and the other half had participated with their wives except in the area of diet teaching where about 75% of the husbands reported participating with their wives. While only 25 (25.4%) husbands had reSponded that their activity levels were the same as before their MIs, 63 (64.3%) husbands agreed that their treatment plans would allow them to return to their former activity levels. Reliability of ReSponsibility Instrument Factor analysis and consideration of the interitem and interscale correlations were used to develOp the 8 subscales which are: smoking cessation (smoke), alcohol limitation (alcohol), weight control (weight), food management (food), medications (meds), activity, and sexual activity (sex). Each subscale of two or more items was tested for reliability using Cronbach's Coefficient Alpha. Pearsons product- moment correlations were computed to test for degree of subscale interrelatedness. In Table 9 the interscale correlation matrix is presented. The values on the diagonal are the coefficient alphas for subscales which are composed of two or more items. The subscales of two or more items all had alphas above .77. Alphas in this range are suitable for testing groups (Polit 8 Hunglar, 1979). The interscale correlations were below .50, except for the activity subscale, which correlated above .50 with the weight control, medication, stress reduction and sexual relations subscales. AS the 112 content appeared to be relatively distinct and the alphas were considerably higher than the interscale correlations, activity was maintained as a separate subscale. In the following section, results of the analyses which were performed on data from the subscales will be presented for each study question. Table 9: Pearson Correlation Matrix for the 8 Subscales With Crombach's Coefficient Alphas. Subscale smoke alcohol weight food meds activity stress sex smoke * - alcohol* .39 - weight** .30 .34 .89 food*** .11 .15 T46' .86 meds*** .32 .30 .48 T41 .84 activity*** .35 .45 .55 .49 T52' .82 stress*** .19 .33 .33 .39 .38 'T59 .88 sex** .22 .30 .32 .20 .22 .53 748 .77 Note. * = 1 item scale. ** = 2 item scale. *** = 3 or 4 item scale. Study Questions The problem statement for the study is "What are the husband's and the wife's perceptions of the extent to which each Spouse is reSponsible for carrying out the husband's postmyocardial infarction treatment plan?" The problem statement will be addressed through the presentation of the results Of the data analysis for the five research questions. 113 Question 1 Question 1 is: "Who does the husband report as reSponsible for each Of the treatment dimensions of smoking cessation, diet, medications,_activity1_sexual activity and stress reduction? To answer Question 1 husbands' reSponseS to each item within a subscale were averaged and rounded to whole numbers. ReSponses were scored from 1 to 5 with the following meanings: l = completely the husband's responsibility, 2 = mostly the husband's reSponsibility, 3 = shared, 4 = mostly the wife's reSponsibility and 5 = completely the wife's reSponsibility. Frequencies of the five reSponse levels for the eight reSponsibility subscales are presented in Table 10. Table 10: Distributions of Husbands Mean ReSponses for the ReSponsibility Subscales Treatment Husb. M. Husb Shared M. Wife Wife Total Subscales No. % No. %* No. % NO. % No. % No. % Smoking 53 86 4 7 4 7 O O 1 2 61 100 Alcohol 55 8O 10 14 4 6 O O 1 2 69 100 Weight 22 27 35 42 26 31 O O O O 83 100 Food 3 4 9 11 25 30 41 50 4 5 82 100 Meds 47 54 23 26 16 19 1 1 O O 87 100 Activity 22 36 33 54 6 10 O O O 0 61 100 Stress 16 18 38 42 36 4O 0 O O O 90 100 Sex 6 20 7 23 17 57 O O O 0 30 100 Note. Husb = completely hquand's reSponsibility, M Husb = mostly the husband's reSponsibility, Shared = about even responsibility, M Wife = mostly wife's responsibility and Wife = completely wife's reSponsibility Some husbands and/or wives failed to reSpond to each item, and some husbands and/or wives chose the "not applicable to my treatment 114 plan" reSponse. There was both pairwise and within scale listwise deletion for missing or "not applicable" scores. Therefore, the number of reSpondents varied between subscales and percentages'are based on the number of couples responding to all items composing a subscale. The number of couples whose scores were included ranged from a low of 30 for the sexual activity subscale to 90 for the stress subscale. With the exception of the food management dimension, there are only three instances where the husband responded that the wife was mainly or completely reSponsibile for a treatment dimension. The husbands reported assuming the most responsibility for smoking and alcohol. Husbands reported little wife involvement in the activity and medication dimensions. Husbands tended to perceive their wives as mostly responsible for food management. There was some sharing of reSponsibility for stress and weight, although the modal response for each was "mostly husband". Sexual activity was most often reported to be a Shared responsibility. Question 2 Question 2 is: "Who does the wife report as responsible for each Of the Six treatment dimensions Of smoking cessation, diet, medication, activity, stress reduction, and sexual activity? The wives reSponseS were averaged within subscales and rounded to the nearest whole number. The same subscales were used for both husbands and wives, and the inclusion of a score in the subscale analyses was dependent on both husband and wife reSponding to each item within the subcale. The stress reduction subscale data contained sscores from the largest number of couples (90). The weight control, 115 food management and medication subscales data contained scores from 82 to 87 couples, while the smoking, alcohol, and activity subscales data contained scores from 61 to 69 couples. The sexual activity subscale data contained scores from only 30 couples, due to large number of subjects who selected the “not applicable reSponse". Frequencies of the five reSponse levels for the eight reSponsibility subscales are presented in Table 11. Table 11: Distribution_of_Wives_Mean ReSponses for the Responsibility Subscales. Treatment Husb. M. Husb Shared M. Wife Wife Total Subscales No. % NO. % NO. % NO. % No. % No. % Smokin 45 73 11 18 3 5 1 2 1 2 61 100 Alcoho 35 51 26 38 7 10 O O 1 1 69 100 Weight 7 8 17 21 51 61 8 10 O O 83 100 Food 0 O l 1 18 22 49 6O 14 17 82 100 Meds 17 20 42 48 20 23 7 8 1 1 87 100 Activity 7 12 33 54 20 33 1 1 O O 61 100 Stress 1 1 11 12 58 64 19 21 1 1 90 100 Sex 1 3 1 3 24 80 4 14 O O 30 100 NOte. Husb = completely husband's reSponsibility. M Husb = mostly the husband's reSponsibility. Shared = about even reSponsibility. M Wife = mostly wife's reSponsibility. Wife = completely wife's responsibility. Most wives rated their husbands as responsible for smoking and alcohol. Wives rated the husbands as mostly reSponsible for medications and activity. Weight control, stress reduction and sex were rated as shared reSponsibilitieS. Food management was rated as mostly or completely the wives' reSponsibility by the majority of wives. 116 Question 3 Question 3 is: What is the extent of agreement between the husband and the wife concerning reSponsibility for the husband's treatment plan? Husband and wife responses for each subscale were compared through computation of a) paired 3 tests and b) Pearsons product-moment correlations. The results of these tests are demonstrated in Table 12. Table 12: Descriptive Statistics, T-Tests and Pearsons Correlations For Husband’and’WifeTReSponsibiTity Scores. Treatment Husbands Wives Dimensions NO. M SD SE M ’SD‘ SE MD .E 5 Smoking 61 1.19 .80 .103 1.39 .54 .069 .20 1.89 .31a Alcohol 69 1.26 .56 .067 1.63 .79 .957 .37 3.72c .25a Weight 83 1.95 .73 .081 2.65 .75 .081 .67 6.39c .10 Food 82 3.30 .84 .093 3.84 .62 .069 .54 5.76c .34b Meds 87 1.57 .69 .074 2.14 .82 .088 .57 6.99c .51c Activity 61 1.71 .53 .068 2.28 .58 .075 .57 5.51c -.03 Stress 90 2.11 .62 .066 3.01 .61 .064 .90 11.07c .22a Sex 30 2.20 .77 .141 2.96 .56 .102 .76 4.68c .12 0 Note. a = p < .05. b = p < .01. = p < .001. The results in Table 12 demonstrate significant correlation coefficients between husband and wife reSponseS for the smoking, alcohol, food management, medications and stress subscales. The mean differences between husbands' and wives' scores ranged from .20 for the smoking subscale to .90 for the stress subscale. The differences attained statistical significance at the .001 level of probability for all subscales except smoking. 117 In order to further characterize the nonagreement between Spouses, each husband's mean subscale response was crosstablated with his wife's mean subscale reSponse. The crosstabulation results are presented in Appendix G. The diagonals of the crosstabulation tables represent levels Of agreement or nonagreement. The classifications of agreement which can be derived from the crosstabulation tables are demonstrated in Table 13. Table 13: Classification of Subscale_Crosstabulation Cells in Terms of Agreement (A), Near Agreement (NA), Competiton (C) and AvOidance (AVT Wives Husbands Husb M Husb Shared M Wife Wife Husb A NA AV Av Av M Husb NA A NA AV AV Shared C NA A NA AV M Wife c c NA ' A NA Wife . c c c NA A NOte- Hqu = hquand's responsibility, M husb = mostly husband's reSponsibility, Shared = even responsibility, M Wife = Mostly wife's reSponsibility, and Wife = wife's reSponsibility The main diagonals of the crosstabulation tables (See Appendix G) represent agreement between the husband and wife in that both selected the same reSponseS or had identical means for the subscale. The cells above and to the right of the main diagonal represent those situations 118 where the husband rated the wife as more reSponsible than the wife rated herself. ReSponses in these cells indicate an avoidance mode of interaction concerning responsibility. The cells below and to the left of the main diagonal represent those Situations where the wife rated herself as more responsible than her husband rated her. These cells represent a competition mode of interaction concerning reSponsibility. The diagonals on either side of the center diagonal represent those Situations in which the husband's and wife's responses to an item or subscale were only one reSponse level apart. These diagonals are considered to be near agreement as husbands and wives could perceive responsibility Similarly and still differ in their choice Of reSponse levels by one point. Examination of the crosstabulations tables (see Appendix G) demonstrates that the modal reSponseS fall within the agreement diagonal for five of the subscales. The modal response for the smoking and alcohol subscales was "husband completely", while "husband mostly" was the modal response for activity. The modal reSponse for the sexual activity subscale was "about even responsibility" and "wife mostly“ was the modal reSponse for the food management subscale. The modal reSponses for three subscales were characterized by differences in husband and wife perceptions of reSponsibility. The modal reSponse for medication was for the husband to select "husband completely reSponsible" while the wife selected "about even reSponsibility". The modal reSponses for the weight control and stress crosstabulations were for the husband to select "husband mostly reSponsible" while the wife reported "about even reSponsibility". 119 Almost as common for the stress subscale was agreement that reSponsibility was about even. The competition mode, where each Spouse rated himself or herself as more reSponsible than the partner rated him or her occured 74 times while the avoidance mode where each Spouse rated the other spouse as more reSponsible occurred only 7 times. The near agreement scores were also characterized by from 2 to 8 times more scores on the competition side Of the diagonal than on the avoidance Side. A summary of the classification of the crosstabulations in terms of agreement, competition, and avoidance is presented in Table 14. Table 14: Summary of Classification Of Husband and Wife Paired ReSponses in Terms of Agreement, Near Agreement, Competition and AVoidance. Subscales Agree Near Agree Compete Avoid Total NO. % No. % NO. % TNO. % No. % Smoking 46 (75) 10 (17) 3 (5) 2 (3) 61 (100) Alcohol 38 (55) 26 (38) 1 (1) 1 (1) 66 (100) Weight 28 (34) 37 (42) 16 (20) 2 (2) 83 (100) Food Prep 40 (49) 33 (41) 9 (10) O (O) 82 (100) Medication 35 (40) 43 (50) 9 (10) O (O) 87 (100) Stress 31 (35) 39 (43) 20 (24) 0 (O) 90 (100) Sex 16 (53) 7 (23) 7 (23) 0 (0) 30 (100) Activity 29 (47) 22 (36) 9 (15) 1 (2) 61 (100) Mean%—T497—T357 TTTZTT—TTT_TTODT Summary of Findings for Questions_1,2_8_3 Most of the husbands perceived themselves as mainly or completely responsible for all the subscales except for food management, which 120 was perceived as Shared with the wife (Table 12). Wives perceived that their husbands were primarily responsible for smoking cessation, alcohol limitation, medications, and activity. Weight control, stress reduction, and modification of sexual activity were perceived as Shared reSponsibilitieS, while food preparation was perceived as mostly the wife's reSponsibility. In terms of agreement, the Pearsons correlations between husband and wife scores for weight control, activity, and sexual activity did not attain statistical significance. The mean differences between husbands' and wives' scores were statistically significant at the .001 level of probability for all subscales except for smoking. Examination of the crosstabulations of husbands' and wive's reSponseS revealed that for the five subscales of smoking, alcohol, food management, sexual activity, and activity the most common classification was husband and wife agreement, followed by near agreement wherein the husband's and wife's scores varied by one scale point. For the three subscales of weight control, medication, and stress the most common classification of husband and wife reSponseS was near agreement, followed by agreement. The least agreement was evidenced in the stress, sexual activity, and weight control crosstabulation scores which had the largest percentages of husband and wife reSponses differing by two or more scale points. The smoking, alcohol, food management, and medication subscales demonstrated the greatest agreement in that 90% of the reSponding couples' scores were characterized by agreement or near agreement. 121 Question_4 Question 4 is: "What is_the_relationship between time since the MI and who is reported as responsible for the treatment dimensions?“ Pearsons product-moment correlation was used to determine the relationship between time in months and the husbands' and wives' reSponses for the eight treatment plan reSponsibility subscales. Only one or the Sixteen correlations was significant. The correlation between time in months since the MI and the husbands' reSponses to the stress subscale was -.18 with p = .04. This would indicate that the husbands rated themselves as increasingly more responsible for stress reduction as time in months since the MI increased. Question 5 Question 5 is: What is the relationship between time Since the MI and husband and wife agreement concerning responsibility for the treatment plan?" To answer this question, difference scores for each subscale were correlated with time since the MI using Pearsons product-moment correlation. None of the resulting coefficients attained statistical Significance but there was a trend for Spouse differences in responses for the activity and stress reduction subscales to increase with time (B < .1). In summary, time since the MI was not a significant variable in this study. The only significant correlation with time was the Shift in the stress subscale from sharing reSponses to reSponses indicating the husband's reSponsibility. 122 Modifying Variables Product-moment correlations were performed between some possible modifying variables identified in the conceptual model and the husband and wife responsibility subscale scores and difference scores. The modifying variables were intended to measure a) sociodemographic characteristics, b) perceptions of the husbands' health status and c) perceptions of the treatment plan. Husbands' Subscales. The Significant correlation coefficients for the husband's reSponseS for the 8 reSponsibility subscales are presented in Table 15. In terms of sociodemographic characteristics, increasing husbands age and years Of marriage were correlated with the husband reporting more self-reSponsibility for alcohol and food management. Increasing husband and wife education levels and wife unemployment were correlated with more Sharing of reSponsibility for sex. In terms of perception of health and the treatment plan, husbands who had less severe heart attacks assumed more reSponsibility for food management and medications and less for alchohol limitation. Increased levels of activity were correlated with increased husbands' reSponsibility for stress reduction. There appeared to be a trend for the husband to report more sharing of reSponsibility for weight, food management, medications and activity if the spouses had both participated in a hOSpital instruction program. Wives Subscales. Significant correlation coefficients for the wife are demonstrated in Table 16. In terms of sociodemographic characteristics for the wives, increased levels of husband and wife 123 Table 15: Significant Pearson Correlation Coefficients for Husbands Subscales and Husbands SOciodemographic Items* Demo Questionnaire** Subscales No. COntent Smoke Alcohol Weight Fooa Meds Stress Sex Activity Socio Demo 1 Rush Age -.186a 5 Yr Mar .182a 6 Husb Ed .206a .301a 7 Wife Ed .407c 8A Full/part -.373a 9 Wife Unemp .277b H Health Status 14 TSt HOSp .189a .297a 16 Severity .189a -.198a 16(W) Severity -.l94a 19(W) W Act level -.276b 22 Chronic Ill -.205a 32 Act normal -.221a .314b .223a Perc lreat Plan 31(WT AchRtnTNOr .251 17A Educ Med Y/N .211a 17A Husb/Couple .272a .278a 17A(W) Husb/Couple .295b .332b .381c 17B Educ Diet Y/N .216a 17B Husb/Couple .230a .248a 17B(W) Husb/Couple .244a 17C Husb/Couple .361b .362b 17C(W) Husb/ Couple .268a .428c 17D Educ Alcohol .272b 17D Husb/ Couple .265a .312a 17B(W) Husb/Couple .279a .420c .328b .336a 17E Educ Exerc Y/N .200a .230a 17E Husb/ Couple _ .237a .355b 17E(W) Husb/Couple .220a .450c .467c .213a .339b 17F Husb/ Couple .2593 .349b 17F(W) Husb/ Couple .208a 17G Educ Work Y/N .259a 17G Husb/ Couple .306a .320a 17G(W) Husb/ Couple .478c .264a Note: a = p < .05, 6’= p < .01, and c = p < .001 *The use of wives' responses to a question is noted by (W) following the question number. **See Appendix E for a sample demographic questionnaire. 124 Table 16: Significant Pearsons Correlation Coefficients for Wives Subscales and Husbands SOEiOdemographic Items* Demo Quest.** Subscales No. Content Smoke Alcohol Weight Fooa Meds Stress Sex Activity Socio Demo 6 Hush Ed -.291b 7 Wife Ed 8 . Husb Unemp .237a 8A Full/part .518c .281a 9 Wife Unemp .209a .230a 9A Full / Part -.350a 10 Income -.297b 11 NO. Children .183a .175a 12 Children Home .190a Health Status 14 Ist Hosp .298A 16 Severity -.219a -.293b -.172a 16(W) Severity -.273a -.252b -.194a 19 Act level .195a 19(W) Act level -.248b -.172a 32 Act Norm .2416 32(W) Act Norm .360c .172a Perc Treat Plan 21 Caraiac Frog -.331a 31 Act Rtn Norm -.192a -.223a 17A Educ Med Y/N -.175a 17A Hus/ Couple .240A .SOOb .299a 17A(W) Hus/Couple .314b .234a .261b .214a .227a 17B Educ Diet Y/N 17B Husb/Couple .372a .368b 17C Husb/C.Smoke .272a 17D Husb/C. Alco. .257a 17E Husb/C. Exer. .355b 17E(W) Husb/C. Exer. .323 .212a .216a .230a .249a .260a 17F Educ Stress Y/N -.199a 17F Husb/Couple .273a .411b 17F(W Husb/Couple .208a 17G Educ Work Y/N .230a 17G Husb/Couple .329b 17G(W) Husb/Couple .258a .428c .275a .322b Note: a = p < .05,76 = p < .01, 8 c = p < .001 *Use of wives' reSponses to an item is indicated by (W) following the question number. **See Appendix E for a sample sociodemographic questionnaire. 125 education and increasing income were correlated with increased husbands' reSponsibility for smoking. Number of children at home and husband unemployment correlated positively with more sharing of reponsibility for smoking cessation. Husband and wife unemployment or part time employment was correlated with a shift toward sharing or wife's responsibility for weight, food preparation, medications, stress, and activity. In terms of perceptions of health or the treatment plan, when the husband's heart attack was perceived as less severe, there was a trend for the wife to perceive him as more responsible for weight, smoking, food management and medications. There was increased wives' responsibility for sexual activity when the husband had experienced only one MI. When the husband's activity was restricted, there was more Sharing of food preparation and more reSponsibility by the husband for stress. If the wife had been included when instructions were given in the hOSpital, She perceived herself as more responsible for all of the subscales except smoking. Significant correlations for wives reSponsibility and sociodemographic items are presented in Table 16. Subscale_Difference_§cores. Some variables which were significantly correlated with the husband and wife difference scores are demonstrated in Table 17. In terms of sociodemographic characteristics, when the husband was unemployed, worked only part- time, or when the wife worked only part-time there were increasing husband and wife differences concerning reSponsibility for alcohol, weight, food and stress. In terms of health status, husbands with less severe heart attacks or less restricted activity levels disagreed less 1126 Table 17: Significant Pearson Correlation Coefficients for Couple Difference Scores and Husbands SOciOdemographic Items.* Demo Quest.** Subscales No. Content Smoke Alcohol Weight Fd PFep Meds Stress Sex Activity Socio Demo 1 Bus Age .222a 4 Wife Age .216a 6 I-(usb Ed -.285b -.219a 7 Wife Ed - 184a 8 Husb Unempl .210a 198a -.193a 8A Full/part .281a .326c .329b 9A Full/Part -.326a 10 Income -.248a 11 NO. Children .188a .192a 12 Children Home .353c .216a Health Status 16 SEverity -.207a 16(W) Severity -.256a -.224a 19 Act level .263a -.323c -.2885b 32 Act Norm .221a 32(W) Act Norm -.202a Perc Treat Plan 17A Eauc flea Y7N -.227a -.201a 17A Hus/ Couple .262a 17A(W) Hus/Couple .303b -.311b 17B Educ Diet Y/N -.280b 17B Husb/Couple -.280a 17B(W) Husb/Couple -.493c 17C Educ Smoke Y/N -.183a -.222a 17C Husb/Couple -.249 -.346a 17D Educ Alcoh Y/N -.332c 17B(W) Husb/Couple -.311b 17E Educ Exerc Y/N -.246a 17E(W) Husb/Couple .414c -.416c 17F Educ Stress Y/N -.218a -.Z30a 17G Educ Work Y/N -.286b 17G(W) Husb/Couple -.355b Note:a=p<.05,b=p<.01,ac=pz.001 *Use of wives' responses to an item is noted by (W) following the question number. **See Appendix E for a sample questionnaire. 127 with their wives concerning weight, food management and medications. Instruction during hOSpitalization appeared to decrease couple differences concerning food management, medications, and activity while increasing disagreement concerning responsibility for alcohol. Summary of Chapter V The study sample of 98 couples was described in terms of socioeconomic characteristics, perceptions of the husband's health status and perceptions of treatment plan instructions. The reliability of the 8 reSponsibility subscales was described. In terms of the study questions, data analysis demonstrated that the majority of husbands reported themselves to be mainly or completely reSponsible for smoking cessation, weight control, medications, stress reduction, and activity. The majority of husbands reported their wives to be mainly or completely reSponsible for food management. The majority of husbands reported that reSponsibility for modification of sexual relations was a Shared reSponsibility. The wive's reSponses were similar to the husbands except that weight control and stress reduction were reported to be shared reSponsibilities. In general, wives reported more "Sharing" responses and fewer "husband only" responses for all scales than husbands reported. .1 tests were utilized to determine levels of Significance for husband and wife mean differences for each subscale. There were significant mean differences between husband and wife responses for all subscales except the smoking subscale. Crosstabulation of husband 128 and wife mean reSponses for each subscale was performed. Over 90% of the reSponding couples agreed or differed by one point about who was reSponsible for the smoking cessation, alcohol limitation, food management and medications subscales. Fewer than 80% of the couples agreed or nearly agreed concerning stress reduction, sexual activity, and weight control. There was agreement or near agreement for 83% of the couples concerning activity. Pearsons correlations of time Since the MI with the husband's and wive's reSponsibility subscale scores, revealed only one significant correlation. Husband's tended to rate themselves as more reSponsible for stress reduction with time. Time was not significantly correlated with differences between husband and wife reSponseS. As predicted by the conceptual model (Figure 2), there were numerous significant correlations between the modifying variables of socioeconomic characteristics, perceptions of the husband's health status, the treatment plan related items and the husbands' and wives' subscale responses and difference scores. In Chapter VI the the results of the data analyses will be discussed. Implications of the study findings for nursing practice, education, and research will be given. Recommendations for further study of the husband's and wife's reSponsibility for the treatment dimensions will be presented. CHAPTER VI DISCUSSION AND IMPLICATIONS Overview In Chapter VI the results of the analysis will be discussed and implications for nursing practice, education, and research will be addressed. In the first section the significant findings related to the five research questions will be summarized and discussed. Then the findings concerning the relationships between variables represented in the conceptual framework will be discussed. The research instrument will be evaluated in terms Of reliability and validity. Implications for nursing, based on King's (1981) Theory of Goal Attainment will be presented. Recommendations for future research will be identified. Finally, a summary of the study with conclusions will complete the chapter. Discussion of the Research Questions Questions 1 and 2: Perceptions of ReSponsibility In Chapter V frequencies of husband and wife responses for each subscale were demonstrated in Tables 10 and 11. Wives consistently reported more Sharing of responsibility for the treatment dimensions than the husbands reported. To summarize and compare husband and wife responses, the husband and wife subscale means and mean differences from Table 12 were ranked from low to high. The rankings are presented 129 130 in Table 18. The subscale mean rankings indicate increasing wives' responsibility as the rank numbers become larger. The mean difference rankings indicate increasing differences between husbands' and wives' responses for a subscale as the rank number becomes larger. Table 18: Ranked Subscale Means and Mean Differences. Subscales Husbands* Wives* Difference Smoking 1 1 1 Alcohol 2 2 2 Medications 3 3 4 Activity 4 4 5 Weight 5 5 6 Stress 6 7 8 Sex 7 6 7 Food 8 8 3 * 1 = least wives' reSponsiBility. ** I = smallest mean difference. The rankings in Table 18 demonstrate that husbands and wives perceived the subscales similarly in terms of the extent to which the wife was reSponsible for a dimension. The reversal of the wives' rankings for stress and sex in comparison to the husbands' is probably not significant as husbands means for the two scales differed by .09 points and wives means differed by only .05 points. The husband and wife mean rankings appear to be logical. Husbands and wives perceived the husband as having primary reSponsibility for abstaining from the "vices" of smoking and drinking, while the dimension of greatest wife reSponsibility was food management. Wives were perceived as less reSponsible for the self-care dimensions of 131 medications, activity, and weight control and as more responsible for the dimensions involving interpersonal relations such as stress reduction and modification of sexual activity. Question 3: Extent of Agreement Concerning_ReSponsibility The husband and wife mean subscale differences indicate the extent of husband and wife agreement concerning reSponsibility for the treatment dimensions. The E-test results in Table 12 Show significant mean differences for all subscales except for smoking. The mean difference rankings in Table 18 are interesting in that they are Similar to the wive's mean subscale rankings for responsibility with the exception that the food management subscale difference is ranked number three. This seems to indicate that husbands and wives demonstrated more agreement concerning dimensions which were perceived as the reSponsibility Of one Spouse or the other, and disagreed most concerning the interpersonal dimensions where there was increased Sharing of reSponsibility. This is consistent with findings by Douglas 8 Wind (1978) that couples agreed more concerning reSponsibility for individually performed tasks and sex-typed activities and less concerning reSponsibility for Shared tasks or for tasks which were nonspecialized by sex. The greatest mean differences were for the activity, weight control, stress reduction and sexual activity subscales. In relation to differences concerning activity, authors describing the postmyocardial infarction period commonly referred to the wives' overprotectiveness (Croog 8 Levine, 1978; Wishnie, Hackett 8 Cassem, 132 1971; Mayou, Foster 8 Williamson, 1978) and attempts to limit the husbands' behavior. Other authors referred to the wives' feelings of guilt over having contributed to the husbands' MI through marital conflict and to their consequent determination to avoid future stress (Adsett 8 Bruhn, 1968; Vachon et al., 1980). Husbands and especially wives are reported to have experienced fears that resumption of sexual activity could overtax the husband and lead to recurrence Of a MI and possible death (Puksta, 1977; McLane, Kr0p, 8 Mehta, 1980). Therefore, the finding Of significant differences between husbands' and wives' perceptions Of responsibility for activity and the interpersonal dimensions of modification Of sexual activity and stress reduction is consistent with other authors' observations of the postmyocardial infarction period. The finding in Table 12 Of Significant differences between husband and wife responses for all subscales except smoking, and that the husbands subscale means are always lower than the wives means supports the existence of sex bias among the study subjects. Each Spouse overrated his or her own responsibility in comparison to the Spouses' rating of reSponsibility. The findings of spouses overrating their own reSponsibility is consistent with findings by Larson (1974), Conrad and Bode (1982), and Berk and Shih (1980) who all found evidence of sexual bias. In contrast to household task studies where the wife had primary reSponsibility, in this Study husbands were primarily reSponsible. Husbands' responses reflected high self-care responsibility while wives reSponses reflected normative expectations that women function as caregivers and family health care managers. 133 The Pearson correlations for husband and wife scores for the 8 responsibility subscales ranged from a low of -.03 for activity to a high of .51 for medication. Douglas 8 Wind (1978) found correlations from'.15 to .65 for decision-making items and from .34 to .86 for task items, while Quarm (1981) reported correlations from -.O3 to .46 for marital power items and from .40 to .77 for household task items. The correlations for the reSponsibility subscales are lower than the household task correlations reported by Douglas 8 Wind (1978) and Quarm (1981). Two possible explanations are 1) that reSponsibility for tasks is a more abstract concept than "who does" a task resulting in correlations in the range reported for marital power and decision-making and 2) husband and wife roles concerning household task performance are more crystalized than roles concerning chronic illness task performance, resulting in the higher correlations for household task items. In contrast to the low Pearson correlations, the agreement classifications in Table 14 demonstrate that 85% of the husbands and wives responses were characterized by either complete agreement (49%) or near agreement (39%). Only 15% Of the paired reSponses were two or more points apart. AS the extent to which disagreement represents actual differences in perception or represents measure error is not known, it is difficult to draw conclusions from these findings. An assumption is that agreement facilitates the implemetation of treatment recommendations. An area for further study would be the relationship between extent of agreement and outcome variables. 134 In summary, husbands and wives tended to agree more concerning responsibility for those dimensions for which reSponsibility was clearly assigned to one Spouse or the other, such as smoking and food management. With the exception of the food management dimension, husbands' and wives' mean differences increased as the wives' responsibility for the dimension increased. This may indicate that couples found it easier to rate reSponsibility when one or the other clearly had reSponsibility for an area, but found it more difficult to assess the degree of sharing when reSponsibility was shared. There is evidence of sex bias in that the tendency was for overestimation of the responder's reSponsibility. The husbands appeared to respond from the perSpective Of their self-care reSponsibility while the wives appeared to reSpond from the perspective of their normative roles as caregivers and family health care managers. Percent agreement was found to be more descriptive of the extent Of husband and wife agreement than Pearson correlations. Questions 4 8 5: Importance of Time Time following the MI did not prove tO be significantly correlated with reSponsibility for most of the the treatment plan subscales. The finding regarding the husband's perceptions of increasing self-responsibility for stress reduction with increasing time since the MI is logical. In the early convalescent period the husband iS confined to home and may have responded to the stress items in terms of home stress for which both husband and wife were reSponsible. With time, the wife continues to assume some 135 responsibility for reducing stress at home, but the husband begins to consider additional sources of stress, such as job stress, for which he would be primarily responsible. It was expected that couple differences in perception concerning reSponsibility for the treatment regimen would decrease with increasing time since the MI. This was not the case, and the trend was for increased differences in responses with increasing time. Some possible explanations for the seeming insignificance of the time variable would include: a) perceptions of responsibility and agreement concerning reSponsibility do not change over the first year in a predictable manner, and b) as Speedling (1982) described the first two months following the MI as the time Of greatest role change the relationship may be curvilinear and thus not detected by Pearson correlations. Discussion of Other Findings Instructions Concerning Treatment_Plan A basic assumption concerning the importance of this study was that knowledge concerning who was usually considered responsible for various dimensions of the treatment plan would be useful to the nurse in planning for patient and Spouse education following the MI. Although ideally both husband and Spouse would be included in all instructions concerning the treatment plan, this is not always possible. However, each spouse should be instructed in at least those areas where they are perceived to have responsibility. In Tables 7 and 8 are presented frequencies Of reports of hospital instruction and frequencies of joint and individual instruction 136 concerning treatment dimensions. In Table 19, a comparison is made between numbers of subjects reporting reSponsibility for a treatment dimension and numbers of subjects who reported receiving instruction concerning that dimension while hOSpitalized. Table 19: Frequencies of Reported_ReSponsibility and Reported Instruction During Hospitalization. Husbands WiVeS ReSponsible Instructed ReSponsible Instructed Dimensions NO. No. I No. NO. % SmokihT 61 6O 98 16 32* 200 Alcoho 69 51 74 34 20 59 Diet 78 70 9O 82 52 63 Medications 87 65 75 70 36 51 Exercise 61 66 108 54 36 67 Stress 9O 63 7O 89 31 35 Work 61 52 85 54 29 54 Note. Percent = number instructed / number reSpOnSible. Reports of reSponsibility were defined as any answer for husbands except "wife completely" or "not applicable" and any reSponse for wives except "husband completely" or “not applicable". As there were some reSpondents for each subscale who reSponded "not applicable", the number who indicated some responsibility varied between subscales. In some cases, reSpondentS reported receiving instruction for dimensions for which they did not perceive themselves responsible. Therefore, for two subscales the percentages are greater than 100. The frequencies in Table 19 demonstrate that subscales with the lowest percentage of responsible husbands who were instructed were: stress reduction, alcohol limitation, and medications. Except for the smoking dimension, 33 to 65 percent of wives reported lack of 137 instruction concerning the treatment dimensions. Dimensions for which the lowest percentage of wives reported instruction were stress reduction, medications, work, and alcohol limitation. Wishnie, Hackett 8 Cassem (1971) described conflict between the husband and wife concerning the treatment plan instructions. Exact therapeutic prescriptions and instructions concerning how the prescriptions should be carried out may decrease marital couple conflict over the treatment plan. The findings in Table 17 demonstrate that reports Of having received education are correlated with decreasing husband and wife response differences for the food management, medication, and activity subscales and increasing differences concerning responsibility for the alcohol subscale. Joint instruction also was correlated with husband or wife reports Of increased wives participation in the areas of alcohol, weight reduction, food management, medication, stress, sexual activity and activity (Tables 15 8 16). As joint instruction was correlated with changes in seven subscales, the question becomes whether wife participation in instruction was a factor of the hOSpitalS' time and personnel for instruction, or whether wife participation was a factor of greater interest on the part Of the wife, who made an effort to be present during educational activities. Experimental research would be needed to determine whether Spouse instruction is a causative variable in increasing couple collaboration concerning the treatment plan or whether the relationship between joint instruction and sharing of responsibility is dependent on one or more other variables such as the value placed on companionship or egalitarian marriage ideology. ‘138 .2. at... .. .5... .2. 3...... E. 9.... 25...... 3.. .53....» 3.232... 3.. .......mee...¢ $52.88“... a:o..a_...ou coo.~.m goao.ga 9......, 2.2.8.3... 9...... . 5... 825:3... 3...... e. .33 .583... :8 .1241. .1. maaaum 5.3.. 3.232... =a_m aaq5.ao.h mZo_hmmomwm / \ . .38.. 5.2:...33 2...»... 23: m z o . e o a .. m e z . 8.9.8 . » ago..ua .\\\\ ////; o._..ae . . . S... . 23...... 8. 2...... 5:... . b. .2382... s... .53.... 0 $3588.. mEEmomm... m_aoa m=o_.a~..gx. mas... u.ue._..ax. .maa ma..~u _a_uom a _z 35.. 2.: 9:3 «_aoo m=o_.a.u.ax. u.:.~: nou=._.oauu «man on...» _~_uom a‘IulI'IIIU _z 3...... 3.: mmzaz a_aoa m=o_~a~u.sx. a.=..: mou=._..axo .man .32. .28. a L: 3.:m 2.: 92069....— ._ r. 1111111111111111111111111111111111111 n— 139 Nursing Implications Implications for NursingfiPractice Three areas, presented in Chapter I, for how the study of husband and wife reSponsibility for the postmyocardial infarction treatment plan would enable the nurse to better interact with postmyocardial infarction couples centered around increasing the nurse's ability to : a) assure that the reSponsible individual receives explicit instructions concerning the treatment dimensions, b) give anticipatory counseling concerning dimensions of the treatment plan for those dimensions where couples experience the most differences in perceptions concerning who is reSponsible and c) assist couples to come to agreement concerning allocation of reSponsibility throughout the convalescent period. The role of the nurse in these three areas will be discussed in more detail. In the conceptual model (Figure 2) the nurse occupies a central, stabilizing position in interaction with the husband and wife concerning the treatment plan and in transacting with husbands and wives to facilitate the attainment of Cardiac rehabilitation goals. King (1981) suggests that role conflict can decrease transactions while congruency in role expectations and performance increases transactions. Corbin and Strauss (1984) applied these role concepts to the marital couple during chronic illness. Corbin & Strauss (1984) reported that the manner in which illness tasks are divided is not important as long as couples collaborate (transact) and mutually agree on how and by whom tasks will be done. 140 A primary function of the nurse becomes the facilitation of husband and wife transaction concerning the implementation of necessary lifestyle alterations following the myocardial infarction. King (1981) states that nurse-client transactions include the mutual identification of goals, exploration of means to achieve goals and mutual movement toward goal attainment. Dracup et al. (1984) have develOped a nursing intervention for postmyocardial infarction clients which is intended to promote nurse and marital couple transaction and movement toward cardiac rehabilitation goals. Dracup et al's. (1984) nursing intervention is derived from Meleis' (1975) role insufficiency and role supplementation conceptual framework. Dracup et al. (1984) state “A nursing intervention of role supplementation can assist couples to develOp role clarification and role rehearsal skills and to sharpen their styles of c0ping. It provides them with a framework for the continuous analysis of new experiences and encourages them to communicate their concerns and fears to each other" (p. 119). The intervention assists husbands and wives to assume complementary roles in regards to treatment plan implementation. The nursing intervention consists of ten weekly group sessions for clients and Spouses. The group facilitators include the cardiovascular nurse coordinator of the cardiac rehabilitation program, who is reSponsible for extensive assessment of the couple at the initiation of the rehabilitation program and who has ongoing contact with the couple, and a nurse Specialist in group dynamics and crisis theory. During the first session the facilitators review coronary risk factors 141 and the reasons for the therapeutic recommendations. Role changes since the MI are identified and discussed. For the second session, the focus is on psychological reactions to the MI and common fears are identified. There are two sessions each devoted to problem-solving and stress management skills. Other sessions focus on family relationships, facilitation of communication, and dealing with behavior changes and attitudes which result from the husbands “at-risk" health status. An entire session is devoted to instruction about and discussion of issues related to sexual activity. Specific nursing strategies are utilized during sessions to provide role supplemention. Role clarification is facilitated through the use of audiovisual materials, presentation of instructional materials, and discussion. Role modeling occurs through the inclusion of couples who are at different stages of rehabilitation and through inviting couples who have sucessfully attained rehabilitation goals to share experiences with the group. Opportunity for role rehearsal is provided through the anticipation of problems , which may arise during future phases of rehabilitation and the exploration of positive ways of problem-solving and caping. Finally, the use of group instruction is therapeutic in that a reference group is provided for the couple which can serve as a source of support throughout the postmyocardial infarction rehabilitation period. Dracup et al. (1984) report that the benefits of the nursing intervention include: the imparting of information, the instillation of hape, a redefinition of wellness in terms of reduction of risk factors, the provision of a support group where problems can be shared, and the 142 Opportunity for the participants to offer support, suggestions, reassurance and insights to other group members. The Opportunity to perform altruistic acts helps to release couples from the characteristic self-absorption that characterizes crisis and releases healing forces. Dracup et al's. (1984) intervention is holistic, couple-centered, and based on interaction theory. Although the family clinical nurse specialist in primary care (FCNS) may not always have the resources to implement Dracup et al's nursing intervention in its entirety, the FCNS should utilize as many of the role supplementation strategies as possible. At a minimum, teaching following the MI could incorporate the content of the ten group sessions as outlined. The discussion questions provided by Dracup et al. (1984) would be useful as- assessment tools for perceptions of roles, psychosocial adjustment and difficulties encountered in attempting to implement the treatment plan. The findings of this study concerning the extent to which husbands and wives reported receiving instruction concerning the treatment dimensions while hOSpitalized should alert the FCNS to the probability that even though instruction concerning treatment dimensions would be considered a standard of care for the hOSpitalization period, up to one fourth of the husbands who were surveyed failed to report receiving instruction concerning one or more treatment dimensions while hospitalized. Up to two thirds of the wives failed to report receiving instructions concerning the reduction of stress even though this is a major area of concern for wives. Therefore, the FCNS cannot . 143 assume that clients received, or perhaps, during the extreme stress, remembered receiving instructions concerning the treatment plan. The FCNS should incorporate role clarification strategies into the nursing . management plan. Some management strategies, derived from Corbin & Strauss (1984), Dracup et al. (1984) and King (1981) follow. 1. The FCNS can assess the husband's and the wife's knowledge concerning the normal recovery from a M1, the purposes of the treatment regimen and correct implementation of the postmyocardial infarction treatment plan. Knowing that presentation of material does not assure mastery, individual assessment and planning for education would be apprOpriate. 2. The nurse could begin early in the postmyocardial period to assist the couple to identify role changes which they are experiencing and to anticipate further role modifications as the husband's health status changes during convalescence. 3. The FCNS could assist the socialization of couples to their roles by clarifying apprOpriate behavior. For example, the reSponsibility of the wife as caregiver should not take away the responsibility of the husband to make the ultimate decisions concerning his body. The weakness which the husband experiences upon leaving the hOSpital is temporary and usually does not result in prolonged dependence on others. Socialization to apprOpriate roles should increase husband and wife agreement concerning responsibility for the treatment dimensions. 144 4. The couple should be educated concerning the stress which can result from the wife assuming a "watch-dog" role wherein the wife assumes responsibility and accountability for an area which in reality is the husband's reSponsibility. The couple should be assisted to place ultimate reSponsibility for adherence with the husband, where it belongs. The wife should be assisted to assume a complementary and supportive role in regards to implementation of the treatment plan, instead of an authoritarian or coercive role. 5. The FCNS can assist the husband and wife to identify goals for the husband's rehabilitation and for their life trajectories. Through transactions, the FCNS can assist in identifying means to achieve goals and couples can be assisted to move toward goal attainment. 6. Perhaps the most important function the FCNS can play is to assist the husband and wife to communicate their anxieties, perceptions of necessary lifestyle modifications to reduce cardiac risks, and proposed methods for implementation of the lifestyle modifications with each other. 7. Speedling (1982) suggests that couples often perceive that they are abandoned by the health care providers once the acute crisis of the MI is resolved. The FCNS can be aware of the need to coordinate the transfer from the cardiologist back to the primary care provider so that there is continuity of health care services throughout the rehabilitation period. 8. Finally, the FCNS can evaluate the quality of nursing services on the basis of the transactional process. ApprOpriate nursing intervention should result in movement toward the attainment 145 of mutually derived rehabilitation goals. Implications for Nursing Education The CNS will need to have a firm foundation in both role and interaction concepts in order to have the skills to implement a nursing intervention such as Dracup et al.'s postmyocardial infarction intervention. King (1981) states that the nursing Theory of Goal Attainment defines the role of the nurse in terms of the facilitation of nurse-client transactions and movement toward the attainment of mutually derived goals. King's (1981) theory is derived from interaction role theory and utilizes systems concepts which are applicable to a wide range of situations. The inclusion of King's theory in nursing school curriculums would combine well with the adoption of a goal-directed approach to family-centered assessment, intervention, and evaluation. King (1981) suggests that students learn to keep goal-oriented nursing records. The nurse uses a health promotion framework for goal- oriented nursing records which is more apprOpriate for nursing practice than the commonly used problem-oriented records. Experience with goal-directed nursing practice on the student level should lead to the develOpment of nurses with solid backgrounds in both nursing and family theory. Nursing school curriculum planners should give careful consideration to means of providing FCNS students with quality clinical experiences in family-centered care. Assessment of the role changes related to acute and chronic illness and of the differences in 146 Spouses' perceptions of roles, needs, and goals is complex. Faculty should assist students in the develOpment of assessment, intervention, and evaluation skills for families. Meleis (1975) identifies Specific strategies which can be utilized by nurses to provide role supplementation. Curriculum for the FCNS and for lower levels of nursing education should provide students with role supplementation knowledge and the necessary skills to facilitate role clarification, role modeling, role rehearsal, and establishment of a reference group. In summary, implementation of King's (1981) Theory of Goal Attainment as a basis for curriculum planning could result in nurses who are better trained to intervene on the level of the marital couple. This would lead to more comprehensive care of clients following a major illness such as a myocardial infarction. Implications for Nursing Theory The purpose of the study was to describe the husbands' and wives' perceptions of the allocation of reSponsibility for the postmyocardial infarction treatment plan. The study findings concerning responsibility for treatment dimensions can be added to present knowledge concerning the roles which are assumed by the marital couple in dealing with acute and chronic illness. Findings of interest were that husbands demonstrated marked self-reSponsibility for the treatment dimensions and that both husband and wife rated the subscales Similarly in terms of the extent of wives' participation. The incorporation of these findings into illness role theory would benefit nursing practice. 147 One of the study questions focused on husband and wife consensus. Although sociologists have Studied marital dyad consensus in a number of areas, little research has been done in the area of consensus concerning treatment plan implementation. As the conflict surrounding - the implementation of the treatment regimen has been frequently described, the FCNS could play an important role in the develoment of theory concerning the Significance of couple consensus and the prediction of outcomes based on different modes of conflict resolution. Issues addressed in this study which are common to the study of consensus such as the significance of sex bias and the development of research tools with a minimum of measurement error should be explored in more depth. The finding that joint husband and wife instruction concerning the‘ treatment regimen was related to increased consensus in the areas of medication, food management, and activity and to increased wife's responsibility for most of the treatment dimensions could be used in the develOpment of theory which is unique to nursing. The FCNS should be striving to develOp sound theoretical constructs concerning the importance of the participation of significant others in the attainment of rehabilitation goals for chronic illnesses. As multiple factors affect marital couple interaction, research which is systematic and well planned is needed. Such research could provide a basis for the development of nursing expertise in assisting marital couples through the difficulties which accompany acute and chronic illnesses. 148 The develOpment and testing of conceptual models are an important part of theory develOpment. The conceptual model for this study was based on King's (1981) Theory of Goal Attainment, marital couple task allocation, consensus, and postmocardial infarction literature. The relationships of variables in the conceptual model are depicted in Figure 3. Through the use of Pearson correlations, the proposed relationships between modifying variables and the responsibility subscales were supported. As the relationships between variables which were selected for this study were supported, the next step would be to incorporate the outcome variables depicted in the conceptual model into a study which could test the entire model. Recommendations for Future Research Concerning ReSponsibility The ideal method for validation of the model would be to design a longitudinal study using an experimental design to test the model in its entirety. An initial step in designing such a study would be to perfect research instruments to measure husband and wife roles following a MI. The instrument could perhaps incorporate some of the role concepts develOped by Nye (1976) for marital couple role analysis. Some sample areas of exploration might include: Who should be reSponsible for the treatment dimensions? Who is reSponsible? How frequently do you perform the treatment plan tasks? How frequently does your Spouse perform the tasks? How often do you disagree with your Spouse concerning treatment dimensions? How satisfied are you 149 with the way treatment tasks are carried out? what do you do when your Spouse does not carry out the treatment tasks which are assigned to him or her? Dracup et al.'s (1984) family-focused intervention is designed to assist postmyocardial infarction patients and their wives to facilitate cardiac rehabilitation through role clarification and supplementation. A longitudial study could be designed utilizing Dracup et al.'s (1984) intervention for the experimental group and selecting a control group from clients receiving typical cardiac health care. By assessing changes in roles over a period of time, the benefits of interventions based on role theory could be determined. Results from the experimental study would contribute to nursing theory construction and would also have practical implications. The significance of the relationships identified in this study between joint instruction about the treatment dimensions and increased wife's involvement in some of the treatment dimensions could be clarified through a comprehensive experimental study. More research is also needed to identify Spouse behaviors which facilitate rehabilitation. As examples, Mermelstein, Lechtenstein, and McIntyre (1983) studied the kinds of behaviors exibited by significant others in regards to the subjects attempts to quit smoking, Hoebel (1976) studied the effects of brief interactional therapy for wives on regimen compliance in the husbands, and Corbin and Strauss (1984) studied characteristics of couple behavior which facilitated adaptation to chronic illness. Additional research is needed to clarify the effects of the Spouse's participation in 150 treatment dimensions on the implementation of the treatment plan recommendations and on the husband's and wife's psychosocial adjustment to the MI. Summary and Conclusions A descriptive self report survey of 98 husbands who had experienced a MI within the previous 12 months and their wives was conducted to determine the husbands' and wives' perceptions of reSponsibility for dimensions of the postmyocardial infarction treatment plan. Husbands' and wives' reSponses to eight subscales representing smoking cessation, alcohol limitation, weight control, food management, activity, stress reduction, and sexual activity were described. The extent of agreement between husbands' and wives' responses was determined and reported. The relationship between time since the MI and the husbands' and wives' perceptions of and agreement concerning responsibility for the eight subscales was determined. Modifying variables which were identified in the conceptual framework were correlated with the subscale and difference scores. The following conclusions are derived from the study findings: 1. Husbands perceived themselves as primarily reSponsible for all of the subscales except for food management, which was viewed as a shared reSponsibility with the wife. 2. Nives perceived their husands as primarily reSponsible for smoking cessation, alcohol limitation, medications and activity. Weight control, stress reduction and modification of sexual activity 151 were perceived as Shared responsibilities, and food management was perceived as mostly the wife's reSponsibility. 3. The differences between the husbands' and wives' reSponses were consistent between scales and are best explained in terms of sex bias. 4. Time following the MI was not an important predictor of the extent to which the husband and wife were perceived to be responsible for the treatment plan subscales. 5. The extent to which the wife was involved in the treatment plan was related to the husband's health status and to the wife's employment. 6. Joint participation in education concerning the treatment plan was correlated with increased Sharing of responsibility for all subscales except smoking. The relationships depicted in the conceptual model (Figure 3) between individual biography, perceptions of the husband's health status, perceptions of the treatment plan and husbands' and wives' perceptions of reSponsibility for carrying out the postmyocardial infarction treatment plan were supported by significant Pearson correlations. Implications for nursing practice were develOped using King's (1981) Theory for Goal Attainment and Dracup et al.'s (1984) role supplementation intervention for postmyocardial infarction patients and their wives. Recommendations for further research in the area of postmyocardial infarction rehabilitation were presented. The present study contributes to knowledge of postmyocardial infarction roles through description of husbands' and wives' perceptions of 152 reSponsibility for dimensions of the therapeutic regimen and through description of the extent to which husbands and wives agree concerning reSponsibility for the treatment dimensions. References Adsett, C. A., & Bruhn J. (1968). Short term psychotherapy for post myocardial infarction patients and their wives. The Canadian Medical Association Journal, §g(12), 577-584. Albrecht, S. L., Bahr, H. M., & Chadwick, B. A. (1979). Changing family and sex roles: An assessment of age differences. Journal of Marriage and the Family, 41, 41-50. American Heart Association (1984). Heart Facts. Dallas, Texas: American Heart Association Office of Communications. Atkinson, J, & Huston, T. L. (1984). Sex role orientation and division of labor early in marriage. Journal of Personality and Social Psychology. 46_(2),330-345. Bell, R. R. (1979). Sickness: A sociological view. In J. R. Folta & E.S. Deck (Eds.), A sociological framework for patient care (pp. 248-261). New YOrk: JOhn Wiley & Sons. Bennet, J. L. (1980). The role of the nurse. In P. S. Fardy, J. L. Bennett, N. L. Reitz, & M. A. Williams (Eds.), Cardiac rehabilitation: Implications for the nurse and other Health professionals (pp. 6-13). St. Louis: The C. V. Mosby Company. Berheide, C. w., Berk, S. F., & Berk, R. A. (1976) Household work in the suburbs: The job and its participants. Pacific Sociological leview,.19(4), 491-517. Berk, S. F. & Shih, A. (1980). Contributions to household labor: Comparing wives' and husbands' reports. In S. F. Berk (Eds.), Nomen_and_Household Labor (pp. 191-227). Beverly Hills: Sage Publications. Blood, R. O. (1969). Marriage. New York: The Free Press. Blood, R. O. (1972). The Family. New York: Collier-Macmillan Press. Card, J. J. (1978). The correSpondence of data gathered from husband and wife: Implications for family planning studies. Social Biology, _2_§ (3), 196-2040 Coe, R. M. (1978). Sociology of Medicine. New York: McGraw-Hill. Condran, J. C., & Bode, J. G. (1982). Rashomon, working wives, and family division of labor: Middletown, 1980. Journal of Marriage and the Family, 44, 421-426. 153 154 C00per, R. & Van Horn, L. (1980). Nutrition and the coronary patient. In P. Fardy, J. Bennett, N. Reitz, & M. Williams (Eds.), Cardiac rehabilitation: Implications for the nurse and other health profesSionals‘Tpp. 174-186).‘St.‘Louis: C._V.‘MOSby Company. Corbin, J. M., & Strauss, A. L. (1984). Collaboration: Couples working together to manage chronic illness. Image: The Journal of Nuring Scholarship, 46(4), 108-114. Croog, S. & Levine, S. (1977). The heart patient recovers. New York: Human Sciences Press. Croog, S. & Levine, S. (1982). Life after a heart attack: Social and psychological factors eight years later. NeW’York: Human Sciences Press. Davidson, D. M. (1979). The family and cardiac rehabilitation. Ihg Journal of Family Practice, §(2), 253-261. Dawber, T. (1980). The Framingham Study: The epidemiology of atherosclerotic disease. Cambridge, Mass: Harvard UniVersity Press. OiMatteo, M. & DiNicola, D. (1982). Achieving patient compliance: The psychology of the medical practitionerTS’roTeiTNEw YOrk: Pergamon Press. Donat, K. (1978). Secondary prevention and associated drug therapy. Advances in Cardiology, 24, 84-93. Douglas, S. P., & Wind, Y. (1978). Examining family role and authority patterns: Two methodological issues. Journal of Marriage and the Family, 40, 35-47. Dracup, K., & Meleis, A. (1982). Compliance: An interactionist approach. NursingResearch$§4_(l), 31-36. Dracup, K., Meleis, A., Baker, K. & Edlefsen, P. (1984). Family- focused cardiac rehabilitation: A role supplementation program for cardiac patients and spouses. Nursing Clinics of North America, 99(1), 113-124. Edgett, J. & Porter, G. (1980). Clinical rationale for cardiac rehabilitation. In P. Fardy, J. Bennett, N. Reitz & M. Williams (Eds.), Cardiac rehabilitation: Implications for the nurse and other health professi0naTs (pp. ZI-Zgl. St.‘LoUis: Ci’V.*MOSby Company. Elmfeldt, D., Wilhelmsen, L., Vedin, A., Wilhelmsson, C., Hjalmarson, A., & Bergstrand, R. (1978). General aspects of secondary prevention after myocardial infarction. Advances in Cardiology, 24, 94-103. 155 Erickson, J. A., Yancey, W. L., & Erickson, E.P. (1979). The division of family roles. Journal_of_Marriage and the Family, 44, 301-313. Feldman, L. B. (1982). Sex roles and family dynamics. In F. Walsh (Ed.) Normal family processes. (pp. 354-379). New York: The Guilford Press. . Froelicher, V. F., Curtis, 6., & Shanley, I. (1980). Cardiovascular medications: Their role in cardiac rehabilitation. In P. S. Fardy, J. L. Bennett, N. L. Reitz, & M. A. Williams (Eds.), Cardiac rehabilitation:_Implications for the nurse and other health professionaTSCpp. 90-109). St. Louis: CT V. Mosby Company. Fuhs, M. E. (1976). Smoking and the heart patient. Nursing Clinics of North America, 44(2), 361-369. Garity, T. F. (1975). Morbidity, mortality and rehabilitation. In W. D. Gentry & R. B. Williams (Eds.), Psychological aspects of myocardial infarction and coronary care (pp. 124-133). St. Louis: The C. V. Mbsby Company. Greenhill, M. 8 Frater, R. (1980). Changes in family inter- relationships following cardiac surgery. In J. Reiffel, R. OeBellis, L. Mark, A. Kutscher & B. Schoenberg (Eds.), Psychosocial aSpects of cardiovascular disease. New York: Columbia UniVersity Press. Gulledge, A. D. (1975). The psychological aftermath of a myocardial infarction. In W. D. Gentry & R. B. Williams (Eds.). Psychological aSpects of myocardial infarction and coronary care (pp. 107-123). St. Louis: The C. V. MOSby Company. Hackett, T.P. & Cassem, N. H. (1975). Psychological management of the myocardial infarction patient. Journal of Human Stress, 4, 25-38. Hackett, T. P. & Cassem, N. H. (1978). Psychological factors related to exerCise. In N. K. Wenger (Ed.). Exercise and the Heart (pp. 223-231). Philadelphia: F. A. Davis Cbmpany. Harding, L. & Morefield, M. (1976). Group intervention for wives of myocardial infarction patients. Nursing Clinics of North America, fl(2) 9 339-347. Hentinen, M. (1983). Need for instruction and support of the wives of patients with myocardial infarction. Journal of Advanced Nursing ‘8, 519-524. Hiller, D. V. (1984). Power dependence and division of family work. Sex Roles, 49, 1003-1019. 156 Hoebel, F. C. (19/6). Brief family-interactional therapy in the management of cardiac-related high-risk behaviors. The Journal of Family Practice, 3(6), 613-61 . Janz, M. & Lampman, R. M. (1981). The treadmill stress test: coaching your cardiac patient along the path to recovery. Nursing, 11(12), 37-41. "’ King, M. I. (1981). A theory for nursing: Systems, concepts, process. New York: John Wiley 8 Sons. Kline; N. & Warren, B. (1983). The relationship between husband and wife perceptions of the prescribed health regimen and level of function in the marital couple post-myocardial infarction. Family Practice Research Journal, 2(4), 271-280. ""_—'" Lambert, V. A., & Lambert, C. E. (1979). The impact of physical illness_and_related mental health concepts. EnglewooHTCTiffs, N. J}: PrentiCe-Hall. Larson, L. E. (1974). System and subsystem perception of family roles. Journal of Marriage and the Family, 36, 123-138. Lee, G. R. (1977). Family Structure and Interaction: A Comparative Analysis. New York: J. B. Lippincott Company. Litman, T. (1976). The family as a basic unit in health and medical care: a social behavioral overview. Social Science and medicine, .§. 495-519. MacVicar, M. & Archbold, P. (1976). A framework for family assessment in chronic illness. Nursing Forum, 15(2), 180-194. Mailick, M. (1979). The impact of severe illness on the individual and family: An overview. Social Work in Health Care, 5(2), 117-128. Maroc, J. A. (1980). Coronary artery disease risk factors. In P. S. Fard , J. L. Bennett, N. L. Reitz & M. A. Williams (EdS.) Cardiac reha ilitation: Implications for the nurse and other health“""' professionals (PP. 14-20). St. Louis: C. V. MoSBy Company. Mauksch, H. 0. (1974). A social science base for conceptualizing family health. Social Science and Medicine, 8, 521-528. Mayou, R., Foster, A., & Williamson, B. (1978). The psychological and social effects of myocardial infarction on wives. British Medical Journal, 1, 699-701. Mayou, R., Williamson, B., & Foster, A. (1978). Outcome two months after myocardial infarction. Journal of Psychosomatic Research 22, 439-445. 157 Mc Lane, M., Kr0p, H.& Mehta, J. (1980). Psychosocial adjustment and counseling after myocardial infarction. Annals of Internal Medicine, 92, 514-519. Meleis, A. (1975). Role insufficiency and role supplementation: A conceptual framework. Nursing Research, 24(4), 264-271. Mermelstein, Lechtenstein, & McIntyre. (1983). Partner support and relapse in smoking-cessation programs. Journal of Consulting and Clinical_Psychology, Vol. 51, No. 3, 465-466. Miller, J. F. (983). COping with chronic illness. in J. F. Miller (Ed.) C0ping with Chronic Illness: Overcoming Powerlessness. Philadephia:‘F. A. Davis. National Heart, Lung, & Blood Institute. (1982). Handbook of heart terms. Hillside, New Jersey: Enslow Publishers. National Heart, Lung, & Blood Institute. (1979). WorkingAgroup on heart disease epidemiology. Washington D. C.: U. S. Department of Health;TEducati0n, & welfare. Nye, F. I. (1976). Role structure and analysis of the family. Beverly Hills: Sage PUbllcatlonS. Orem, D. E. (1980). Nursing: Concepts of Practice. New York: McGraw Hill Book company. Parsons, T. (1951). The social system. Glencoe, Ill.: Free Press. Parsons, T. & Fox, R. (1968). Illness, therapy, and the modern urban american family. In N. Bell and E. Vogel (Eds.), A modern introduction to the family (pp. 377-390). New York: The Free Press. Perrucci, C. C., Potter, H. R., & Rhoads, D. L. (1978). Determinants of the male family-role performance. Psychology of Women Quarterly, 3(1), 53-67. Polit, D., & Hunglar, B. (1978). Nursing research: Principles and Methods. London: J. B. Lippincott Company. Pollock, M. L., Ward, A. & Foster, C. (1980). Prescription of exercise in a cardiac rehabilitation program. In P. S. Fardy, J. L. Bennett, N. L. Reitz, & M. A. Williams (Eds.). Cardiac Rehabilitation, (pp. 73-89). St. Louis: C. V. Mosby Company. Pratt, L. (1976). Family Structure and effective health behavior:_The energized family. Boston: Houghton Miiilin Company. Puksta, N. S. (1977). All about sex...after a coronary. American Journal of Nursing, 22, 602-605. 158 Quarm, D. (1981). Random measurement error as a source of discrepancies between the reports of wives and husbands concerning marital ower and task allocation. Journal of Marriage and the Family, 42, 521- 35. Rahe, R. H., Tuffli, C. F., Suchor, R. J. and Arthur, R. J. (1973). Group therapy in the outpatient management of post-myocardial infarction patients. Psychiatry_in_Medicine, 4(1), 77-87. Reiss, I. L. (1980). Family Systems in America. New York: Holt, Rinehart and Winston. Segev, U. & Schlesinger, Z. (1981). Rehabilitation of patients after acute myocardial infarction: An interdisciplinary, family-oriented program. Heart and Lung, 40(5), 841-847. Selye, H. (1976). The Stress of Life. New York: McGraw-Hill Book Co. Siebs, J. (1973). Sampling memorandum. Detroit area study memorandum. Ann Arbor: University of Michigan, Department of Sociol69y. Skelton, M. and Oominian, J. (1973). Psychosocial stress in wives of patients with myocardial infarction. British Medical Journal, 2, 101-103. Slay, C. L. (1976). Myocardial infarction and stress. Nursing Clinics of North America, 14(2), 329-338. Speedling, E. (1982). Heart_attack:_The_family_response at home and in the hOSpital. New York: Tavistock Press. Stern, M. J., Pascale, L. & Ackerman, A. (1977). Life adjustment postmyocardial infarction. Archives of Internal Medicine, 137, 1680- 685. Turner, R.H. (1970). Family interaction. New York: John Wiley & Sons. Tyzenhouse, P. (1973). Myocardial infarction. American Journal of Nursing, 22(6), 1012-1013. Udry, J. R. (1971). The_social context of marriage. New York: J. B. Lippincott Company. U. S. Bureau of the Census. (1983). 1980 Census of the Population, Vol. 1: Characteristics of the pOpulation, Chapter C? General social and economic characteristics, Part 24: Michigan. Washington D. C.: U. S. Department of Commerce. U. S. Bureau of the Census. (1984). Statistical abstracts of the U. S. (105th ed.). Washington D. C: U. S. Department of Commerce. 159 Vachon, M. L., Freedman, K., Rogers, J., Lyall, W. A., Formo, A. & Freeman, S. J. (1980). Living with cardiovascular disease: A widow's perspective. In J. Reiffel, R. DeBellis, L. Mark, A. Kutscher, P. Patterson, & B. Schoenberg (Eds.), Psychological aspects of cardiovascular disease: The life—threatened patient, the family, and the staff (pp. 295-302). New York: Columbia University Press. Wishnie, H. A., Hackett, T. P., 8 Cassem, N. H. (1971). Psychological hazzards of convalescence following myocardial infarction. Journal of the American Medical Association, 215(8), 1292-1296. APPENDIX A PHYSICIAN LETTER OF INVITATION TO SUBJECTS October 23. 1980 Dear : I am writing to you about a research study being conducted by Nancy Kline and Brigid Warren. Assistant Professors in the Michigan State University College of Nursing. They are gathering information about how the experience of a heart attack has affected the lives of married couples like yourself. Through this study. they hope to gain information that will help nurses more effectively assist couples who have recently undergone a heart attack experience. Agreeing to participate in this study would be of no cost to you other than approximately forty-five minutes of your time. Both of you would individually complete a five-part questionnaire which asks about yourself, your spouse. and the post-heart attack treatment plan. You would be free to withdraw from the study at any time and your identity would be kept strictly confidential. Please consider their request for your participation. Complete the enclosed postcard and return it to the College of Nursing at your earliest convenience. Thank you. Sincerely, APPENDIX B LETTER OF EXPLANATION AND CONSENT FORM MICHIGAN STATE UNIVERSITY COLLEGEOFNATUIALSCIENCE°SCHOOLOFNUISING EASTLANSING'W'UN Hello: Thank you very much for agreeing to participate in our research study. Your assistance will help guide nurses and other health professionals in the care of people who have had a heart attack. Following this letter, you should find five (5) questionnaires asking different questions about yourself, your spouse and the post-heart attack treatment plan. They will take about 45 minutes to complete. Please answer each question as honestly as possible. There are no right or wrong answers. PLEASE DO NOT CONSULT YOUR SPOUSE UHILE YOU ARE FILLING OUT THE FORMS. Thank you again! If you have any questions or comments, feel free to contact any of the investigators. Sincerely, Nancy W. Kline, R.H., M.N. Agfi:fiéHL‘L"L““’ ZQV/Atodlna/ Brigid A. Warren, R.N., M.S.N. NWK/BAN/jmm MICHIGAN STATE UNIVERSITY COLLEGE OF NURSING CONSENT FORM Investigators: Brigid A. Warren, R.N., B.S., M.S.N. Assistant Professor of Nursing, Michigan State University A107 Life Sciences Building Telephone: 353-8686 Nancy Kline, R.N., 3.8., M.N. Assistant Professor of Nursing, Michigan State University A129 Life Sciences Building Telephone: 353-6499 Investigators Statement The experience of a heart attack may affect peoples' lives in many ways. The purpose of this study is to gather more information about the experience of a heart attack and how it affects the lives of married couples like yourself. We hope that the information gained from this study will provide a better understanding of how nurses can assist couples who have recently undergone a heart attack experience. Participation in this research study will require approximately forty-five minutes of your time. You will be asked to complete a questionnaire about the health information you have received, your present health practices and your view of your relationship as a couple since your heart attack. In addition, you will be asked information about yourself and your spouse. Your participation in this study will in no way interfere with the care you are now receiving. There will be minimal risk or expense to you. You are free to ask questions now and throughout the study. You may withdraw from the study at any time without jeopardizing your future care. Your identity will be kept confidential and 22 information that could identify you will be used in any reports of the study. Responses you make on your question- naire will not be revealed to your physician or spouse with any identifying information, unless you so request. The results of the study will be made available to you upon request. xi Subject's Statement I, the undersigned, agree to participate in this study about people who experience heart attacks. I understand that this study may not benefit me personally but could help future patients with heart attacks. I have been given the opportunity to ask questions and I understand that I may ask questions at any time during the study. I understand that this study will not affect the care I am now receiving. I also understand that my anonymity will be maintained and that my responses will be kept confidential. I understand my participation in this study is voluntary and that I may withdraw at any time. Signature of Subject Date Witness Date APPENDIX C RESPONSIBILITY QUESTIONNAIRE Pt. No. 9 H. 1-2-3-4 Site 5-6 Date QUESTIONNAIRE # 3 7-8-9 Card No. 05 IO-ll Rehab. Code l2 Since your heart attack you may have been told to follow a treatment plan by doctors, nurses and other health professionals. The treatment plan you were told to follow may include some of the activities listed below. We are interested in learning more about who (you, your wife, or both) assumes responsibility for different parts of your treatment plan. For this questionnaire, please indicate the extent to whigggyou or your wife are responsible for ifferent parts of the treatment plan. Do this by circling the most appropriate response after each statement. You will be using the following scale: 1) completely my responsibility 2) mostly my responsibility 3) about even responsibility 4) mostly my wife's responsibility 5) completely my wife's responsibility 6) not applicable to my treatment plan Remember, there are no right or wrong answers. 1. Modifying smoking habits. 13 l 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi— responsi- wife's my wife's to my treatment sibility bility bility responsi- responsi- plan bility ' bility 2. Reducing weight. 14 1 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi— responsi- wife's my wife's to my treatment sibility bility bility responsi- responsi- plan bility bility 3. Maintaining weight. 15 I 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- wife's my wife's to my treatment sibility bility bility responsi- responsi- plan bility bility © 1980 Nancy W. Kline Brigid A. Warren For each statement below, circle the appropriate response to indicate the extent to which you or your wife are resgonsible for the activigy. 4. 10. Avoiding certain fgfds. 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan friend's home). 0 not applicable to my treatment plan 0 not applicable to my treatment plan 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's ny'wife's sibility bility bility responsi- responsi- bility bility Following a special diet while at home. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Encouraging specific foods which are good for my diet. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Preparing foods according to dietary restrictions. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility. bility responsi- responsi- bility bility Reading food labels to decide which foods are allowed on my diet. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Selecting foods when we are away from home (i.e., restaurant or 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Taking the right amount of medicine(s). l 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility xiv l6 17 18 19 20 22 For each statement below, circle the appropriate response to indicate the extent to which you or yog;,wife are resygggible for the activigy. ll. 12. 13. 14. 16. 17. Remembering to take medicine(s) at the prescribed time(s). 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- . responsi- bility bility Keeping an adequate supply of medicine available. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility watching for negative effects of medicine(s). l 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- 'wife's my wife's sibility bility bility responsi- responsi- bility bility Reporting side effects of medicine(s) t5 the doctor. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Organizing a schedule to include a planned time for exercise. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Watching for symptoms which indicate poor toleration of an activity. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Following activity restrictions. 1 2 3 ' 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility XV 23 24 25 26 27 28 29 For each statement below, circle the appropriate response to indicate the extent to which you or your wife gge responsible for the activigy. 18. 19. 20. 21. 22. 23. 24. Planning time for recreational activities. 1 2 3 4 5 completely mostly my about even mostly my completely my respon— responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Tryinglto lessen regponsibilities to reduce stress. 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Recognizing the right time to deal with a stressful situation. 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Talking over problems with my wife to help reduce stress. 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Recognizing when situations are stressful. l 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Taking steps to reduce stress and tension. 1 2 3 4 5 completely mostly my about even mostly my completely my respon- responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- bility bility Using medically recommended positions during intercourse. 1 - 2 3 4 5 completely mostly my about even mostly my completely my responr responsi- responsi- wife's my wife's sibility bility bility responsi- responsi- . bility bility xvi 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 0 not applicable to my treatment plan 30 31 32 33 34 35 36 For each statement below, circle the appropriate response to indicate the extent to which you or your wife are resgonsible for the activity. 25. 26. 27. 28. Postponing sexual intercourse when I am tired, upset or after heavy meals. 37 1 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- wife's my wife's to my treatment sibility bility bility responsi- responsi- plan bility bility Limiting alcohol intake to two drinks a day or less. 38 1 2 3 4 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- wife's my wife's to my treatment sibility bility bility responsi- responsi- plan bility bility Modifying daily work activities to reduce stress. 39 l 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- wife's my wife's to my treatment sibility bility bility responsi- responsi- plan bility bility Organising activities to keep stair climbing at a minimum. 40 1 2 3 4 5 0 completely ‘ mostly my about even mostly my completely not applicable my respon- responsi- responsi- wife's my wife's to my treatment sibility bility bility responsi- responsi- plan bility bility xvii For each statement below, circle the appropriate response to indicate the extent to which you or ypur husband are responsible for that part of your husbands treatment plan. 7. 10. Ayoiding certain foods. 1 2 completely mostly my my respon- responsi- sibility bility Following a special diet while at home. 1 2 3 completely mostly my my respon- responsi- sibility bility 3 4 about even mostly my responsi- husbands bility responsi- bility 4 about even mostly my responsi- husbands bility responsi- bility 5 completely my husbands responsi- bility 5 completely my husbands responsi- bility Encouraging specific foods which 3are good for :y husband's 5diet. l 2 completely mostly my my respon- responsi- sibility bility about even mostly my ' responsi- husbands bility responsi- bility Preparing foods accogding to diet;ry restrictipns. completely mostly my my responr responsi- sibility bility about even mostly my responsi- husbands bility responsi- bility completely my husbands responsi- bility 5 completely my husbands responsi- bility 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan Reading food labels 2to decide whigh foods are :llowed on my5 husbands dieot. completely mostly my my respon- responsi- sibility bility Selecting foods whenéwe are 1 completely mostly my my respon- responsi- sibility bility Taking the right amognt of medici§e(s). 1 completely mostly my my respon- responsi- sibility bility about even mostly my responsi- husbands bility responsi- bility completely my husbands responsi- bility not applicable to my husbands treatment plan away gram home (i.:., restauranst or friends'ohome). about even mostly my responsi- husbands bility responsi- bility 4 about even mostly my responsi- husbands bility responsi- bility xix completely my husbands responsi- bility 5 completely my husbands responsi- bility not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 16 17 18 19 20 21 22 For each statement below, circle the appropriate response to indicate the extent to which you or your husband are resppnsible for that part of your husbands treatment plan. . 11. Remembering to take medicine(s) at the prescribed time(s). l 2 3 4 s 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi— husbands my husbands to my husbands sibility bility bility responsi— responsi- treatment plan bility bility 12. Keeping an adequate supply of medicine available. 1 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility l3. Watching for negative effects of medicine(s). 1 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- rasponsi- husbands my husbands to my husbands sibility bility bility responsi- responsi— treatment plan bility bility 14. Reporting side effects of medicine(s) to the doctor. 1 2 3 4 S 0 completely mstly my about even mostly my completely not applicable my respon- responsi— responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility ‘bility ‘ 15. Organising a schedule to include a planned time for exercise. 1 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan . bility bility 16. watching for symptoms which indicate poor toleration of an activity. 1 2 3 4 5 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 17. Following activity restrictions. 1 2 4 S 0 completely mostly my about even. 'mostly my completely not applicable my respon- responsi- responsi— husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility . XX 23 24 25 26 27 28 29 For each statesmnt below, circle the appropriate response to indicate sh: extent to which you or your husband are resppppible for that pprt of ypur husbands treatment plan. 18. Plannipg time for regreational ac§ivities. S 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responai- treatment plan bility bility 19. T n to lessen.res nsibilities to reduce stress. 171 81 go 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 20. Recognizing the righ; time to dug. with a stres:ful situatign. 0 completely mostly my about even mostly my completely not applicable my respon- responai- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 21. Talking over problee; with my husgand to help rgduce stress; 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi— responsi- treatment plan bility bility 22. Recognizing when sitgations are egressful. 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 23. Taking steps to reduce stress and tension. 1 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 24. Using radically recap-ended posit3ions during inEercourse. 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 3O 31 32 33 34 35 36 For each statement below, circle the appropriate response to indicate 25. 26. 27. 28. to whichgyou or your husband are resppnsible for the activity. Postponing sexual intercourse when my husband is tired, upset or heavy meals. 1 2 completely mostly my my respon- responsi- sibility bility Limiting alcohol intake to two drinks a day or less. 1 2 completely mostly my my respon- responsi- sibility bility 3 about even mostly4 my responsi- husbands bility responsi- bility 3 4 about even mostly my responsi- husbands bility responsi- bility Kodifyling daily work2 activities tao reduce stress. 4 completely .mostly my my respon— responsi- sibility bility Organifing activitin: to completely mostly my my respon- responsi- sibility bility PLEASE GO ON TO THE NEXT SET OF QUESTIONS about even mostly my responsi- husbands bility responsi- bility 5 completely my husbands responsi- bility compliidly my husbands responsi- bility 5 completely my husbands responsi- bility keep sta3ir climbing at‘a minimum. 5 about even mostly my responsi- husbands bility responsi- bility xxii completely my husbands responsi- bility the extent after 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 37 38 39 4O For each statement below, circle the appropriate response to indicate to whichgyou or your husband are resppnsible for the activity. 25. 26. 27. 28. Postponing sexual intercourse when my husband is tired, upset or heavy meals. 1 2 3 4 completely mostly my about even mostly my my respon- responsi- responsi- husbands sibility bility bility responsi- bility Limiting alcohol intake to two drinks a day or less. 1 2 3 4 completely mostly my about even mostly my my respon- responsi- responsi- husbands sibility bility bility responsi- bility Hodifyling daily work2 activities tao reduce stres:. completely .mostly my about even mostly my my respon- responsi- responsi- husbands sibility bility bility responsi- bility 5 completely my husbands responsi- bility complfiiely my husbands responsi- bility 5 completely my husbands responsi- bility Organilzing activitiezs to keep sta3ir climbing at4a minilmim. 5 completely mostly my about even mostly my my respon- responsi- responsi- husbands sibility bility bility responsi- bility PLEASE GO ON TO THE NEXT SET OF QUESTIONS xxii completely my husbands responsi- bility the extent after 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 0 not applicable to my husbands treatment plan 37 38 39 40 Pt. No. 8 1-47 Site S-é QUESTIONNAIRE # 3 Date 7 9 Card No. 06 lO-ll Rehab . Code _; Ll Since your husbands heart attack, he may have been told to follow a treatment plan by doctors, nurses and other health professionals. The treatment plan may include some of the activities listed below. we are interested in learning more about who (you, your husband. or both) assumes responsibility for different parts of your husbands treatment plan. For this questionnaire, please indicate WW; your husband are responsible for different arts of the treatment lan. Do this By cIrcIIng the most appropriate response aEter each statement. You will be using the following scale: 1) completely my responsibility 2) mostly my responsibility 3) about even responsibility 4) mostly my husbands responsibility 5) completely my husbands responsibility 6) not applicable to my husbands treatment plan Remember, there are no right or wrong answers. 1. Modifying smoking habits 13 1 2 3 4 5 0 completely mostly my about even mostly my completely not applicable my responr responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 2. Reducing weight. 14 l 2 3 4 S 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility 3. Maintaining weight. 15 1 2 3 4 S 0 completely mostly my about even mostly my completely not applicable my respon- responsi- responsi- husbands my husbands to my husbands sibility bility bility responsi- responsi- treatment plan bility bility C) 1980 Nancy W. Kline Brigid A. warren xviii APPENDIX D ITEMS CUMPOSING 8 SUBSCALES ITEMS COHPOSING 8 RESPONSIBILITY SUBSCALES 1. 7. Smgk'gg Modifying smoking habits. Algghol Limiting alcohol intake to two drinks a day or less. . wei ht n r l Reducing weight Maintaining Height Fpog Mgngggmgnt Following a special diet while at home Encouraging specific food which are good {or my (husbands) diet Preparing food according to dietary restrictions. Reading food labels to decide which foods are allowed on my (husbands) diet. Nggiggtipn Taking the right amount of medicine(s). Remembering to take medicine(s) at the prescribed time(s) Keeping an adequate supply oi medicine available watching for negative efiects of medicine(s) Agtivitz Organizing a schedule to include a planned time for exercise. Hatching for symptoms which indicate poor toleration of an activity Following activity restrictions. Planning a time for recreational actitivities. Organizing activities to keep stair climbing at a minimum W Trying to lessen responsibilities to reduce stress. Recognizing the right time to deal with a stressful situation. Recognizing when situations are stressful. Taking steps to reduce stress and tension. figxgg] ggtivigz Using medically recommended positions during intercourse. Postponing sexual intercourse when I (my husband) is tired, upset, or after heavy meals. xxiii APPENDIX E SUCIODEMOGRAPHIC QUESTIONNAIRE Pt. No. 9 1‘2-3-4 Site T-é QUESTIONNAIRE #5 Date 7-8-9 Card No.11 10-11 Rehab. Code 12 SOCIO-DEHOGRAPHIC The following questions describe general things about yourself and your wife. Please answer all the questions to the best of your ability. There are no right or wrong answers. All information will be confidential! 1. AS‘: 13'14 2. Ethnic background: (Please check (X) appropriate category) 15 White Black 1 I Oriental Mexican-American ""‘17"" ""'5""' Indian Other ""1F"" 3. Marital status: (Please check (X) appropriate category) 16 Married Separated Widowed """3"" ""17“"’ Single Divorced * 4. If married, age of your wife: 17‘13 5. How long have you been married to your current wife? 19'ZC 6. Your educational level: (Please check (X) highest grade completed) 21 fewer than seven years of school (grades 1-6) 1 Junior high school (grades 7-9) partial high school (grades lO—ll) 3 high school (completed 12th grade) 4 partial college education (3 years or less) 5 ' college education (4 years) 6 beyond 4 years of college 7 © 1980 Nancy W. Kline Brigid A. Warren xxiv The following questions describe general things about yourself and your wife. Please answer all the questions to the best of your ability. There are no right or wrong answers. All information will be confidential! 7. Wife's level of education: (Please check (X) highest grade completed) 22 fewer than seven years of school (grades 1-6) 1 Junior high school (grades 7-9) 2 partial high school (grades lO-ll) 3 high school (completed 12th grade) r partial college education (3 years or less) 5 college education (4 years) 6 beyond 4 years of college 7, 8. are you presently working outside the home? Yes No 23 ' I 2 a) If yes, are you working: full time part time 24 b) what is your current occupation (check(X) one)? 25 clerical 0 professional j executive in large-to-madium-sized business 2 skilled worker 3 semiskilled or unskilled worker 4 owner of business establishment S retired 6, currently unemployed. but looking for work 7 ether (please specify): 8 . c) How would you rate the stress associated with your job (check (X) one) 26 high stress moderate stress low stress 30 OCT... I‘XV The following questions describe general things about yourself and your wife. Please answer all the questions to the best of your ability. There are no right or wrong answers. All information will be confidential! 9. Is your wife currently working outside the home? Yes No 27 a) If yes, is your wife working: full time pirt time 28 b) What is your wife's current occupatiin (check (X) one)? 2 29 clerical 0 professional 1 executive in lsrge-to-madium-sised business : skilled worker 4 semiskilled or unskilled worker 5 owner of business establishment retired 6 7 currently unemployed. but looking for work 8 other (please specify): c) flow would you rate the stress associated with your wife's job (check (X) one)? 30 high stress : moderate stress low stress 3 no stress 4 10. What is your combined annual income? 31 __ O - 9.999 _g_ 50,000—59.999 0 l0.000-l9,999 ______ 60,000-69.999 1 . 20,000-29,999 __:__ 70.000-79,999 2 30,000-39,999 __;:__ greater than 80,000 3 40.000-69.999 8 4 11. How many children do you have? 32-33 xxvi The following questions describe general things about yourself and your wife. Please answer all the questions to the best of your ability. There are no right or wrong answers. All information will be confidential! 12. How many children do you have living at home? 34-35 13. Living arrangement: (please check(X) the description which best fits your 36 current living arrangement) married. living with wife alone : married. living with wife and children 3 married. living with wife. children and other relatives 7 unmarried, living alone (include widower, single. divorced) 5 unmarried, living with relative(s) or non-related person 6 other (please specify): 14. Have you been hospitalized more than one time for a heart attack? 37 Yes No 38-39 15. How long ago did you have your lag; heart attack? “0'41 3 years # months ___!___. 16. How severe was your last heart attack? 42 1 Very severe; I have a lot of heart damage 2 Moderately severe: I have some heart damage, but not a lot 3 Mild; I have only a little heart damage 4 I have no heart damage xxvii The following questions describe general things about yourself and your wife. Please answer all the questions to the best of your ability. There are no right or wrong answers. All information will be confidential! 17. When you were in the hospital for your last heart attack. did you participate in a heart teaching program? (1) Yes (2) No If yes, please check (X) what topics were covered and if the information was presented to you alone. to your wife alone, or to both of you together. myself my wife my wife and medication: alone alone and myself I myself 2 my wife 3 my wife and diet: alone alone and IVself I. myself 2 my wife 3 my wife and smoking: alone alone and myself I myself 2 my wife 3 my wife and alcohol: alone alone and myself 1 myself 2 my wife 3 my wife and exercise: alone alone and myself I myself 2 my wife 3 my wife and stress: alone alone and myself 1 myself 2 my wife 3 my wife and work activity: alone alone and myself 1 2 3 18. Did your instruction include weys to deal with problems that could develop at home? Yes No 1 2 19. These statements deal with your current activity level. Please check the one statement that best describes your current activity level. Completely disabled. Cannot carry on any self-care; totally confined l to bed or chair. Capable of only limited self-care; confined to bed or chair more 2 than 502 of waking haurs. Walking about and capable of all self-care; but unable to carry out 3 any work activities; up and about more than 502 of waking hours. Restricted in physically strenuous activity, but walking and able to 4 carry out work of a light or quiet nature, i.e., light housework, office work. Fully active; able to carry out all pre-heart attack activities 5 without restriction. 43 44 45 46 47 48 49 50 52 The following questions describe general things about yourself and your wife. Please answer all the questions to the best of your ability. There are no right or wrong answers. All information will be confidential! 20. 21. 22. Do you eat a special diet? Yes No "'_I"" ""I_""' a) If yes. please check(X) all the responses that apply: I 2 43 other (please specify): 4 In some communities there are special organized programs for people who have had Are you presently participating in any organized heart program? heart attacks. "'1T—' 3) If yes, does the program include (Please check (X) all that apply): low salt low calorie low cholesterol Yes No ""f"' physical exercise relaxation techniques methods of stress reduction diet instruction general information about a heart attack participation of wives other (please specify): Do you have any chronic health problems? Yes No '___T__'_' a) If yes. please check (X) all that apply: arthritis cancer high blood pressure lung disease (asthsma, bronchitis, emphysema) sugar diabetes other (please specify): xxix S3 S4 55 57 58 S9 60 61 62 63 64 65 66 67 68 69 The following questions describe general things about yourself andfiyour wife- Please answer all the questions to the best of your ability. or wrong answers. All information will be confidential! 23. Before your heart attack, did you drink alcoholic beverages? Yes a) If yes, please specify: occasional l weekends only 2 several times a week 3 one or two drinks a day 4 two to five drinks a day 5 more than five drinks a day 24. Beforf’your heart attack, did you smoke cigarettes? Yes No a) If yes, please specify: 1 less than 1/2 pack a day 1 1/2 - 1 pack a day 2 l - l-l/2 packs a day 3 1-1/2 - 2 packs a day 4 more than 2 packs a day 5 CARD 12 (Keypunch: Dup. 1-9. 1 2 Dup. 12) 10 ll XXD< There are no right No 70 71 72 73 25. Below is a list of things which happen in many families. Which of these have you experienced in your family during the past year? Please check (X) all that apply. I menopause 13 1 Presnancy ' 14 1 an addition in the household l5 f retirement ( _:_your retirement __3__ your wife's retirement) 16 1 moving 17 I marital problems 19 1 divorce or separation from your wife 19 f major sickness or injury in your family 29 1 death of a close friend or family member 21 I children left home 22 1 got laid off or fired from work 23 I concern over aged parents or inlaws 24 change in work hours or responsibility 25 1 PLEASE TURN TO THE NEXT PAGE xxxi For questions 26 through 32. circle the response which best describes how you feel about that statement. 26. I am able to make contact with my doctor easily when I need medical 26 attention. 1 2 3 4 S 6 strongly moderately . agree disagree moderately strongly agree agree disagree disagree 27. I have cultural traditions which are a support to me. 27 1 2 3 4 5 6 strongly moderately agree disagree moderately strongly agree agree , disagree disagree 28. My religion is a source of comfort and support during difficult times. 28 1 2 3 4 5 6 strongly moderately agree disagree moderately strongly agree agree disagree disagree 29. Socializing with friends is an important part of my life. 29 l 2 3 4 5 6 strongly moderately agree disagree moderately strongly agree agree disagree disagree 30. Since my heart attack, it has been necessary for me to limit socializing with 30 friends. 1 2 3 4 5 6 strongly moderately agree disagree moderately strongly agree agree disagree disagree 31. My treatment plan will allow me to return to my pre-heart attack level of 31 physical activity. 1 2 3 4 S 6 strongly moderately agree disagree moderately strongly agree agree disagree disagree 32. My current physical activity level is no different than before my heart 32 attack. 1 2 - 3 4 5 6 strongly moderately agree disagree moderately strongly agree agree disagree disagree PLEASE TURN TO THE NEXI PAGE xxxii APPENDIX E M S U APPROVAL OF STUDY PROTOCOL MICHIGAN STATE UNIVERSITY L'NIVERSH Y COMMITTEE ON "BRANCH INVMVING EAST LANQNG ' MICHIGAN ‘ 4““ IIUMAV St'fljl-CFS (UCIIIIS) m annwminion autumn isriuinn- July l3, l98l Professor Nancy W. Kline College of Nursing Dear Professor Kline: Subject: Proposal Entitled, "The Relationship Between Husband and Wife Perceptions of the Prescribed Health Regimen and Level of Function in the Marital Couple Post- Hyocardial infarction" The above referenced project was recently submitted for review to the UCRIHS. We are pleased to advise that the rights and welfare of the human subjects appear to be adequately protected and the Cummittse. therefore. approved this project at its meeting on Ju'Y 6 Projects involving the use of human subjects must be reviewed at least annually. if you plan to continue this project beyond one year. please make provisions for obtaining apprOpriate UCRIHS approval prior to the anniversary date noted above. Thank you for bringing this project to our attention. If we can be of any future help. please do not hesitate to let us know. Sincerely. H nry E. Bredeck Chairmen. UCRIHS HEB/jms cc: Professor Brigid A. Warren xxxiii APPENDIX G CROSSTABULATION 0F HUSBANDS' AND NIVES' RESPONSES FOR 8 RtSPONSIBILITY SUBSCALES Appendix G The following tables contain cross-tabulations of paired husband and wife reSponses for the 8 reSponsibility subscales. For each of the tables, the following abbreviations used in table headings have the following meaning: Husb = completely husband's reSponsibility M Husb = mostly husband's reSponsibility Shared = about even reSponsibility M Wife = mostly wife's reSponsibility Wife = completely wife's reSponsibility Table G-l Marital Couple ReSponsibility for Smoking Cessation (N = 61) Wives Husbands Hu§B___—M_Husb Shared Husb No. 42 l 2 % (68) (2) (3) M Husb No. 8 3 - % (13) (5) - Shared No. 2 - 1 % (3) - (2) M Wife No. - - 1 % - - (2) Wife No. 1 - - % (2) - - xxxiv Table 6-4 Mean Marital Couple ReSponsibility for Food Management (N = 82) Wives Husbands Husb M HusB Shared M Wife Wife Husb No. - - — - - % - - .. - - M Husb No. - - 1 - - z - - <1) - - Shared No. 1 4 10 3 - % (1) (5) (12) (4) - M Wife No. - 4 13 29 3 % - (5) (16) (36) (4) Wife No. 2 1 1 9 1 % (2) (l) (l) (11) (1) xxxvi Table G-Z Marital Couple ReSponsibility for Alcohol Limitation (N = 69) Wives Husbands Husb M Husb Shared Husb No 31 3 1 % (45) (5) (1) M Husb No 20 5 1 % (29) (7) (1) Shared No. 3 2 2 % (5) (3) (3) M Wife No. - - - 1 .. - - Wife No. 1 - - % (1) Table G-3 Mean_Marital Couple ReSponsibility for Weight Control (N = 83) Wives Husbands Husb M Husb Shared Husb '—__' No. 3 2 2 % (4) (2) (2) M Husb No. 7 6 4 % (8) (7) (5) Shared No. 9 23 19 % (11) (28) (23) M Wife No. 3 4 1 % (4) (5) (1) XXXV Table G-S Mean Marital Couple ReSponsibility for Medications (N = 87) Wives Husbands Husb M Hu§5“‘Sfi§red M Wife Husb No 14 3 — - z (16) (3) - - M Husb No 25 13 4 - % (29) (15) (5) - Shared No 5 6 8 1 % (6) (7) (9) (1) M Wife No 2 1 4 % (2) (1) (5) - Wife No 1 - - - % (1) - - - Table G-6 Mean Marital Couple ReSponsibility for Stress Reduction (N = 90) Wives Husbands Husb M Husb Shared Husb No. 1 - - % (1) - - M Husb No. 2 7 2 % (2) (8) (2) Shared No. 10 25 23 % (11) (28) (26) M Wives No. 3 6 10 z (3) (7) (11) Wives No. - - 1 % - - (1) xxxvii Table G-7 Mean Marital Couple ReSponsibility for Sexual Activity (N = 30) Wives Husbands Husb M Husb Shared Husb No. - 1 - % — (3) - M Husb “‘“’No. - 1 - x - (3) - Shared No. 5 4 15 % (17) (13) (50) M Wife '_ Mo. 1 1 2 % (3) (3) (7) Table G-8 Mean Marital CoupleBesponsibility for Activity (N = 68) Wives Husbands Husb M Husb Shared Husb No. 4 2 1 % (6) (3) (2) M Husb No. 9 22 , 2 % (15) (36) (3) Shared No. 8 9 3 % (13) (15) (5) M Wife No. 1 - - % (2) - - xxxviii ER "(I'lllfilllfl(llrfllfllflmlflllfllfl1|)“