Thesis Nurs. 1995 N249f
c.2
Nash, Mary Alice

Family coping with
stressors produced by
1995.

Family Coping with Stressors Produced by
Coronary Bypass Graft Surgery

by
Mary Alice Nash

Submitted in Partial Fulfillment of the Requirements
for the Master of Science in Nursing Degree

Approved by:

Chairperson, Thesis Committee ~
Edinboro University of Pennsylvania

Committee Member

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Date

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Family Coping with Stressors Produced by

Coronary Bypass Graft Surgery

Mary Alice Nash

ABSTRACT

This study examined the coping patterns of the spouses and

adult children of Coronary Bypass Graft clients during the

six to twelve months following the surgical event, to
determine the patterns of adaptation used during this time

frame.

Data were collected in a phase II cardiac

rehabilitation program from a sample size of 16 spouses and

28 adult children of 16 clients who had their first coronary

bypass graft surgery.

Using the Family Crisis Oriented

Personal Evaluation Scale (F-COPES) by McCubbin, Larsen, and
Olson (1991) subjects were asked to identify from a list of

coping patterns those patterns they used to cope with the
stressors associated with the surgery.
The findings of the study revealed that the spouses and

adult children used a variety of coping patterns to deal

with the stressors.

Both groups utilized the Internal

Coping Patterns and External Coping Patterns as identified
on the F-COPES scale similarly or with near or egual

frequency when dealing with the stressors during the
recovery process.

Both groups identified the use of
ii

internal resources such as having confidence in their

problem-solving abilities and the ability to positively
redefine the situation.

External coping behaviors utilized

included relying on friends, seeking information from
doctors, relying on resources offered by community agencies,

and turning to their religious faith to assist them in
coping with the stressors of the surgery.

Implications for

nursing practice included the need to assess the coping

patterns utilized by spouses and children during the six to

twelve months following the coronary bypass graft surgery,

to better understand and support family coping.

iii

ACKNOWLEDGEMENTS
I wish to express my appreciation to Dr. Jean Weber

my committee chairperson, for her patience, guidance and

support during the thesis process.

I want to thank the

contributions of Dr. Alice Conway and Dr. Ron Renik my

committee members for their valued input.
To my friends and colleagues I am truly grateful for

your support and understanding throughout this process.
A special thanks to Margery Taylor whose contribution was

to this thesis was invaluable but most of all for her

friendship and reassurance during all stages of thesis

development.
I wish to express sincere appreciation to the
families who participated in the study for their
willingness to share and all the phone calls expressing
encouragement.
Lastly, I am forever grateful for my family, who

have consistently assured and consoled me during the

development of this thesis.

Especially to my mom, who

has given me unconditional love and encouragement

throughout my entire life, I dedicate this thesis to her.

iv

TABLE OF CONTENTS
Chapter

I

II

III

Page

1

INTRODUCTION
Background of the Problem.

1

Statement of the Problem

8

Definition of Terms

10

Assumptions

11

Limitations

12

REVIEW OF THE LITERATURE

Crisis Theory

16

Coping Theory

20

Family and Stress

27

Family and Coping

32

Conceptual Framework

36

METHODOLOGY

41

Setting

41

Sample

42

Instrumentation

IV

V

14

.45

Reliability and Validity

48

Data Collection Plan

49

Data Analysis Plan

51

PRESENTATION AND ANALYSIS OF DATA. .

.56

CONCLUSION

.103

Discussion

. 103
v

Conclusions

112

Recommendat ions

113

Implications for Nursing

114

REFERENCES

115

APPENDICES

122

Letter of Request for Double
ABCX Model

123

B

Letter of Permission

124

C

Letter of Request for F-COPES.

125

D

Letter of Permission

126

E

Family Crisis Oriented Personal
Scales

127

F

Cover Letter

129

G

Consent Form.

131

H

Follow-up Cover Letter

132

I

F-COPES Distribution and Mean Scores
for Spouses

133

F-COPES Distribution and Mean Scores
for Children

135

Percentage Distribution
for Spouses

137

Percentage Distribution
for Children

139

A

J
K
L

vi

LIST OF TABLES
Table

Page

1

Internal Coping Patterns

58

2

External Coping Patterns

59

3

Mean Scores on Internal and External Coping
Patterns for Families....................

61

4

5
6
7

8

9

10

11

12

13

Percentage Distribution of Internal and
External Coping Patterns of Families. .

. 62

Percentage Distribution of Internal Coping
Patterns Subcategories of Families. . . .

64

Percentage Distribution oF External
Coping Patterns Subcategories of Families.

.

.65

Percentage Distribution of Internal
Coping Patterns Reframing Subcategory
Items for Families..................

69

Percentage Distribution on Internal
Coping Patterns Family Passivity
Subcategory Items for Families. . .

71

Percentage Distribution on Internal
Coping Patterns Confidence in Family
Problem Solving Subcategory Items
for Families......................

72

Percentage Distribution of External
Coping Patterns Friends Subcategory
Items for Families................

. 75

Percentage Distribution of External
Coping Patterns Neighbors Subcategory
items for Families..................

. 76

Percentage Distribution of External
Coping Patterns Extended Family
Subcategory items for Families. . .

. 78

Percentage Distribution of External
Coping Patterns Church/Religious
Resources Subcategory items for Families.

vii

.

. 79

14

15
16

17

18
19

20

21

22
23

Percentage Distribution of External
Coping Patterns Community Resources
Subcategory items for Families. . .

81

F-COPES Mean Scores for the Spouse and
Children

83

Mean Scores on Internal and External Coping
Patterns of Spouses and Children

.84

Percentage Distribution of Internal
and External Coping Patterns of Spouses
and Children

86

Internal Coping Patterns Mean Scores
of Spouses and Children

87

Percentage Distribution of Internal Coping
Patterns Subcategories for Spouses and
Children

89

External Coping Patterns Mean Scores
of Spouses and Children

91

Percentage Distribution of External Coping
Patterns Subcategories for Spouses and
Children

93

Coping Strategies with High Percentage of
Agreement of Spouses and Children. . . .

97

Coping Strategies with High Percentage
of Disagreement for Spouses and Children. .

viii

. 100

Chapter I

INTRODUCTION

Background of the Problem

Every thirty-two seconds in the United States, one
person suffers from some form of cardiovascular disease,

making cardiovascular disease and its complications the

number one cause of death in the United States (American

Heart Association, 1994).

It has a mortality rate equal

to cancer, accidents and all other causes of death
combined.

According to the American Heart Association's

recent statistics, nearly 1,000,000 deaths per year have

resulted from cardiovascular disease, of which 53.6% were
a result of a myocardial infarction (American Heart

Association, 1994).

As a result, recent estimates reveal

2.3 billion dollars are spent yearly for physician and

nursing services, hospital and nursing home care, and
prescription medicines.

In addition lost productivity

and anxiety regarding the future extends the stress and

cost to the client (American Heart Association, 1994).

Due to the high profile heart-related illnesses
receive in the media, the American population is more

aware of cardiovascular disease and its effects.
1

Today's

2
society is advocating a healthier life style.

People are

taking charge of their lives and making changes that
reduce the risk factors, such as stress, associated with

cardiovascular disease.

Although mortality rates for cardiovascular disease are
high, the rates are beginning to decline.

Coronary

artery disease is diagnosed earlier and treatment

interventions are implemented earlier to deter the
development of complications.

Despite these efforts towards early recognition of

risk factors and early intervention with treatment, the
people of the United States continue to develop

complications from the effects of cardiovascular disease.

These complications may occur because of several reasons
such as the presence of a concurrent or chronic disease

or the client's non compliance with the medical treatment
plan, just to name a few.

Currently, treatment for

cardiovascular disease includes both medical and surgical
interventions .

One goal of medical intervention is to

improve blood flow through the coronary arteries, thus
increasing the oxygen supply to the myocardium.

Drug

therapy and modifying risk factors assist in this goal.

When an individual's clinical course no longer
responds effectively to medical management, surgical

intervention may be employed as an alternate treatment

3

modality (Canobbio, 1990).

Coronary artery bypass

grafting (CABG) is the surgical intervention most often

performed.

Surgery does not reverse the progression of

coronary artery disease nor cure it.

Rather the surgery

is employed to treat the effects of the disease.

Its

success depends upon the client modifying risk factors by
complying with a prescribed diet, medications, stress

reduction and exercise regimes after surgery (Marshall,
Peckner, and Llewellyn, 1986).

Reducing risk factors following CABG surgery ensures

the continued success of myocardial revascularization.
However, this may demand that the client change

established lifestyles.

Incorporating these changes

requires a great deal of support and positive
reinforcement.

The primary source of this needed support

comes from the family of the CABG client.

Family

involvement in the recovery process has been shown to

have a direct impact on an individual's recovery process
(Motler, 1979 ) .

The family is the basic unit in the human social
organization.

It is a complex social system providing

many physical, social, emotional and psychological

benefits to individuals within the family (Danielson,
Hamel-Bissell, and Winstead-Fry, 1993).

These

interrelated individual parts are greater than the sum of

4

the parts (Burgess, 1985).

The structure and process of

the family are defined by this unique interaction.
One of the functions of the family is to provide

physical care to its members in the form of clothing,
food, shelter, education, and caring for the ill

(Leventhal, Leventhal, and Van Ngyugen, 1985).

The

family also provides interactions through which

individuals develop an identity and self esteem, and
establish a system of values and beliefs.

These patterns

of beliefs and values evolve over a period of time as

family members interact with one another (Robinson, Roe,
and Boys, 1987 ) .

Unfortunately, in a dysfunctional or

split family situation so prevalent today, it becomes
more difficult for family members to fulfill these needs.
As individuals go through cycles of development in

their lives, so do families.

With these cycles, whether

it be divorce or marriage, new social, biological, and

psychological challenges emerge, which the family must
face as a whole.

Successful transition through these

cycles occurs when major tasks are confronted.

time of growth and change for the entire family.

This is a
Change

is inevitable for the family members as they continue to

co-exist and to grow as a whole.

Change affects each

member within the family system because of the

interdependent relationship.

When one member of the

5
system experiences change or disruption, all within the
system are affected.

Illness is just one example of

change or disruption within the family system.

It

creates stress for both the individual and the family.
Illness has a unique component of promoting change in the

family's established functional patterns.

During this time of illness the family's stability,
adaptability, resources, beliefs, and assumptions are
challenged (Williams, 1974).

The event may be seen as a

reminder of the individual's vulnerability to illness and

death.

Previously defined roles may be shifted among

members within the family system.

can be temporary or permanent.

This shift in roles

If a family member is not

able or willing to take on a change in role, the stress
brought on by the illness is only compounded, thus
predisposing the family to a crisis situation.

Relationships are strained and role conflicts begin to
emerge.

The family must manage the hardships of the

situation, maintain the family's integrity and morale,
and acquire and develop resources to meet new demands.

The family must create and implement a new structure
within the family system to accommodate everyone's needs.

A realistic balance between available resources and the

demanding changes must be achieved in order for the
family to continue to function.

Part of this balance

6

involves the effort made by the family to manage various

dimensions of family life, at the same time realizing
that a perfect solution is never possible.

Families

learn to compromise and accept the best possible outcome.

A central concept in understanding the family's
struggle to manage the situation created by the illness

is family adaptation.

It is used to describe the outcome

of family efforts to bring a new level of balance,

harmony, coherence, and functioning to a family-crisis

situation (Danielson, Hamel-Bissell, and Winstead-Fry
1993) .

McCubbin and Patterson (1983) identified three

elements of family adaptation:

(1) the individual, (2)

the family as a system, and (3) the community of which
members are a part.

all three components.

Adaptation is achieving a balance of

If a balance is not achieved, the

family will not adapt to the situation, and a crisis
state may ensue.

A positive balance or bonadaptation means a positive

change has been made by achieving a balance among all
three components (McCubbin and Patterson, 1983).

On the

opposite end of the spectrum, if a family does not

achieve a satisfactory level of functioning or

adaptation, maladaptation occurs and a crisis may ensue
(McCubbin and Patterson, 1983).

To prevent the

occurrence of a crisis new ways to adapt must be found.

7

Crisis is not always negative; it can be seen as a time

of change, of breaking traditions and developing new ways
of functioning and facilitating growth.

Coronary artery disease (CAD) is an example of an

illness which creates stress for individuals and their
families.

crisis.

This stress place the family at risk for a
Family support and care are needed as the

individual afflicted with coronary artery disease adjusts

to imposed restrictions and lifestyle changes.

These

necessary changes places stress on the family.

The

stress is compounded when the individual requires
coronary artery bypass grafting surgery to treat the

effects of the disease process.

The family is confronted

with many uncertainties and fears in relation to the
surgery and possible outcomes.

The family becomes

fearful that the individual may die or become permanently
disabled.

Culturally, the heart is seen as a symbol which
represents emotions, character, and psychological traits

far beyond its physical function (Carnes, 1971).

seen as the source of life.

It is

But, CABG surgery can be

viewed as a threat to a family member's life.

This

creates a great deal of stress and conflict for family

members of coronary bypass graft patients.

Stress

requires the family as well as the individual to respond

8

suddenly to changes in the environment, health status,
locus of control and living patterns by adaptation

(Rolland, 1990) .

Reorganization of the family structure

and its functions is a necessary goal for the family to

maintain stability.

To meet this goal, the family needs

to apply effective coping strategies and begin to

function as a unit again.

Statement of the Problem

Clearly, coronary artery bypass grafting surgery
has a psychological impact on the client and the family

which requires skilled and caring health care
professionals to intervene and assist in maintaining a

functional unit.

Unfortunately, most hospital staff's

energies are focused on meeting the needs of the client
with little regard in assisting the family.
A holistic approach is needed in order for health

care professionals to assist both the CABG clients and
their families to cope and understand the recovery phase

of the surgery.

To provide better care for CABG clients

and their families, health care professionals need to

gain a better understanding of how families struggle with
the fears, misconceptions, and uncertainties of the

surgery.

This understanding will assist health care

9

professionals in determining whether or not an illness or
health stressor will develop into a crisis for a family.
Those families can be recognized early and interventions

can be implemented to prevent the crisis.

Thus, the

family can be prepared to cope with the CABG individual

in a healthy and rational manner.

Purpose of the Research

The purpose of this research is to study the coping

patterns of families of CABG surgery clients during the

six months to one year after surgery.

CABG surgery may

precipitate individual and family crises.

The

effectiveness of coping with this crisis may affect the
outcome of surgery and general adaptation in both

immediate and later life.

Nurses need the training and

time to assist people with their health-related coping
patterns .

If useful individual and family coping

behaviors and problem-solving abilities can be identified

during the recovery phase of CABG surgery, the nurse can

then encourage the use of these skills to facilitate
client/family coping and eventually adaptation.

The

results of this study will provide direction for nurses
to assess, plan, implement, and evaluate interventions
which will assist family members to cope and manage role

10

changes necessary in the recovery phase of the surgery
experience.
The following research guestions were investigated

in this study:
1.

What coping patterns were used by families
during the six to twelve months following a
family member's CABG surgery?

2.

How did the adult children of CABG clients
cope with the stressors of the surgery as
compared to the spouses of CABG clients during
the six to twelve months following the
surgery?

Definition of Terms

The following terms were defined for this study:

Bonadaptation
the positive end of the continuum of
family adaptation which is characterized by a
balance of family functioning" (McCubbin and
Patterson, 1983, p.20).

Cardiovascular disease - disease of the heart and
blood vessels (Clayton, 1989).
Coronary Artery Bypass Graft (CABG) - a shunt
established surgically which permits blood to flow
from a major artery to a coronary artery at the
point past the obstruction (Clayton, 1989).

Coronary Artery Disease (CAD) - the disease of
coronary arteries which results in sufficient
narrowing of the coronary arteries. This narrowing
causes inadequate blood supply to the myocardium
(Clayton, 1989).
Coping behaviors - "the cognitive and behavioral
components wherein resources, perception, and
behavioral responses interact as families try
to achieve a balance in family functioning"
(McCubbin and Patterson, 1983, p.16).

11

Family - a basic societal unit in which members (two
or more people) have committed to nurture each
other emotionally and physically (Meisel,
1991).
Family Adaptation - a continuum of outcomes which
reflects the family's efforts to achieve balance,
harmony and coherence as well as a satisfactory
level of family functioning (McCubbin and
Patterson, 1983, p. 17).
Family crisis - "the family's inability to restore
stability and by the continuous pressure to make
changes in the family structure and patterns of
interaction" (McCubbin and Patterson, 1983, p.10)
Lifestyle - "a pattern of living involving mental,
physical, economic, recreational behaviors and
health behaviors" (Hayne, 1984, p. 190).

Maladaptation - negative end of the continuum of family
adaptation which is characterized by an imbalance
of family functioning (McCubbin, and Patterson,
1983, p. 20).
Myocardial Infarction (MI) - an ischemic process which
results in the development of necrosis of
myocardial tissue as a result of a sudden decrease
in coronary perfusion or an increase in myocardial
demand without adequate coronary perfusion
(Canobbio, 1990).

Passivity - "inactive" or passive behaviors a family
might employ (McCubbin, Olson, Larsen, 1991).
Stress - "a state which arises from an actual or
perceived demand-capability imbalance in the
family's functioning and which is characterized by
a multidimensional demand for adjustment or
adaptive behavior" (McCubbin, and Patterson,
1983, p. 9).
Stressor - "a life event or transition impacting upon the
family unit which potentially or actually produces
change in the family system" (McCubbin, and
Patterson, 1983, p. 8).

12
Assumptions

The following assumptions have been made in the

conceptualization of this research:
1.

A client's experience of and recuperation from
CABG surgery may be a stressor to the client's
family which may require the family to adapt in
new ways.

2.

Adaptation is a process which occurs over time.
Adapting to stressors is best managed when
interpersonal support is present.

3.

The family which adapts positively to the
stress of the client's CABG surgery may be a
support to the client experiencing coronary
bypass graft surgery.

4.

Primarily, nurses assist families to adapt
positively by providing support and information
to CABG clients and their family members during
the recovery phase of the surgery.

5.

Knowledge of adaptive family behaviors will
assist nurses to support and educate CABG
clients and their families, thereby facilitating
adaptation.

6.

Scores on F-COPES are valid and reliable
indicators of adaptation levels.

Limitations of the Study
The research study was subject to the following
limitations:

1.

The study was limited to families of clients who
had undergone CABG for the first time, had no
other serious chronic medical condition and had
the surgery performed in a hospital setting in
northwestern Pennsylvania.

13

2.

Family members consisted of adults, 18 years or
older, either living with the CABG client or
living apart from the CABG client.

3.

The study focused on families of CABG clients
during the six to twelve months following the
surgical experience.

4.

Reports of coping strategies used by families
were confined to those included on the F-COPES
Family Crisis tool which may not elicit other
strategies employed by families.

5.

The results of the study limited generalization
to other groups due to the size of the
convenience sample and the exclusion of
demographic data about the sample.

6.

Participants may be inclined to give less than
honest responses due to the timing of the study.

Chapter II

REVIEW OF THE LITERATURE
Each year thousands of adults undergo coronary

artery bypass graft surgeries to treat the effects of

coronary artery disease and to improve the guality of
life.

The decision to undergo the surgery is not easily

made.

Clients may feel that surgery is their only hope

to continue with productive lives, or they may not have a
choice regrading the surgery due to the severity of

coronary artery disease.

Whatever the circumstances

surrounding the surgical decision, the recovering client
and family may experience a considerably stressful and

emotional time.

Fears of mortality and disability may be

felt by the client and the family (Gaws-Ens, 1994).

The

family may be fearful of the outcome of the surgery and
what changes need to be made during the recovery process.

The focus of health care professionals has been to
meet the needs of the client.

Little time is spent on

preparing the family for the surgery or addressing their
concerns for the client's recovery.

Families experience

a great deal of anxiety due to this lack of preparedness

(Gaws-Ens, 1994).

An additional stressor for the family is the changes
occurring in today's health care system.

14

Clients are

15

being discharged from acute health care facilities

earlier, and family members are being asked to take on a
more active role in the clients' recovery process in the
home environment.

This new role for families is often

met with fearz uncertainty, and anxiety.

If the family

members are ill-equipped to handle this role change or if
they become overwhelmed with the tasks required of them,

they may be thrown into a crisis state (Dracup, 1993).
It is the family's interpretation of the challenges
encountered and the effectiveness of their coping

mechanisms, which will determine if a family will go into
a crisis state (Williams, 1974).

Effective coping strategies are necessary for a
family to stabilize itself and begin to function
cohesively again.

The family needs to function

bonadaptatively, in order to provide care and support for
the client recovering from CABG surgery.

The support

given by families to the CABG client is important to the
well-being and recovery of the client (Gagilone, 1984,

Artinian, 1989, Leske, 1986, Gillis, 1984).

As the

individual strives to regain the health previously
possessed before the surgical event, the family must
learn to adapt to the change in health status of that

individual member.

Nurses, through their frequent interactions with the

16

CABG client and families during the postoperative phase,
have the opportunity to assist families and clients in
coping with the stressors encountered by the surgery.

By

assessing the family's coping abilities, the nurse can

identify any weak areas which may predispose the family
to a crisis and plan strategies to enhance their coping
abilities.

Strengthening coping abilities of the family

will assist them in meeting the challenges of the

recovery and possibly preventing them from going into a

crisis state.

The experience may result in growth and

enrichment for the family.

This stdy exaimed the copin

patterns of family members of coronary bypass graft
clients.

This chapter reviews the literature for the

study by including crisis theory and coping theory and

studies relating to family stress and family coping.

Crisis Theory

One of the pioneers in crisis theory is Gerald
Caplan (Caplan, 1964).

He pioneered the field of

preventive psychiatry by developing a framework for
understanding crisis and its development.

This framework

focuses on prevention and the importance of social,

cultural, and material supplies to avoid crisis (Caplan,
1964).

17
Central to Caplan's theory is the prevention of a

crisis state.

Crisis can be prevented at each of three

levels of interactions:

primary, secondary and tertiary

prevention (Caplan, 1964).

In primary prevention,

harmful forces that operate in the community are
encountered, decreasing the capacity to withstand the

stress.

A crisis may occur if the abilities to withstand

the stressor are not adequate.

The focus is on the

prevention of a crisis through identification of risk

factors, health promotion and disease crisis prevention.

This is done by modifying risk factors, strengthening

coping skills, and improving problem-solving abilities.
Secondary prevention includes early problem

identification and initiation of prompt treatment once

the problem has been identified (Caplan, 1964).

The goal

is to provide short-term therapy and return individuals
to the community as soon as possible.

Health is

maintained through crisis resolution and the return to at

least a precrisis level of functioning (Caplan, 1964).
Tertiary prevention involves the reduction of
residual effects of maladaptation or crisis.

New coping

patterns are developed to provide an optimum level of

functioning.

Resources such as long-term counseling are

utilized to decrease the likelihood of further problems
or reoccurrences (Caplan, 1964).

18
Caplan views the individual as living in a state of

emotional equilibrium.

He believes that it is the goal

of the individual to always maintain that state of

equilibrium (Caplan, 1964).

The emotional reaction as

well as the available coping resources determine whether

a situation perceived as a threat will result in a

crisis.

This is one explanation why a crisis may result

in one individual and not in another.

Caplan observed that life is a succession of crisis
events occurring across the life span of an individual

and upsetting the equilibrium of the individual.

The

crisis event involves an actual or threatened loss.
Caplan further states that crisis is usually self­

limiting - lasting four to six weeks and consisting of
four phases (Caplan, 1964).

Phase one occurs when a

traumatic event or threat is encountered and anxiety

levels increase.

Phase two evolves when the usual

problem-solving abilities fail as the stressor continues

to produce tension.

In phase three, the anxiety levels

increase even further and the individual uses every
resource available, old or new, to reduce the anxiety and

to solve the problem.

At this phase, the individual is

most receptive to outside intervention to reduce the
emotional discomfort (Caplan, 1964).
The fourth phase is the state of crisis.

Tension

19

and anxiety are almost at an unbearable degree while
internal strengths and social support decline. The
unresolved problem continues to exist (Caplan, 1964).
During this time, individuals are in a transitional

period marked by cognitive and emotional upset.

They are

psychologically vulnerable and are willing to accept help

from others for solution to the crisis (Caplan, 1964).
By the end of the fourth phase, the crisis may be
resolved adaptively or maladaptively, depending on the

coping abilities of the individual.
Caplan's framework has limitations due to the

influence of the medical model.

Central to Caplan's

theory is the concept of homeostasis or equilibrium when
confronted with a stressor (Narayan and Joslin, 1980).

Caplan states that when individuals are confronted with
stressors, they strive to maintain a state of emotional
equilibrium.

The individuals' behavior is directed at

reducing tension by relaxing, meeting biological needs
and reestablishing a balance (socially, physiologically,
and psychologically) to maintain this equilibrium

(Caplan, 1964).

As Narayan and Joslin (1980) point out,

these concepts are more applicable in explaining physical
disease processes rather than the emotional processes

that occur when an individual is confronted with

stressors.

These concepts are rather limited by

20
definition when applied to human behavior because they do

not take into account human responses such as growth,

change, and creativity which emerge as a result of the
event.

Coping Theory

Another pioneer in crisis theory is Richard Lazarus.
His crisis theory on stress and coping adaptation is
based on a transactional model.

Transactional theorists

believe that stress is the interplay between the

environment and people (Lazarus and Folkman, 1984).
Lazarus' belief is that people do not live in a vacuum

isolated from the world, but rather they interact with

the environment surrounding them (Lazarus and Folkman,
1984) .

He believes that individuals are constantly

appraising their environment to understand the
significance of what is occurring in the environment.

He

also believes cognitive appraisal and self regulation
processes affect individuals reactions to stressful
transactions.

These processes shape the somatic outcome.

Humans cognitively appraise threatening situations to

evaluate the meaning of a harm-producing stimulus and

take inventory of their counter-harm resources (Lazarus
and Folkman, 1984).

21
Lazarus defines stress as the cognitive appraisal

that occurs when the relationship between the environment

and the individuals is thought to be taxing or exceeding
resources and endangering the individuals' well being
(Lazarus and Folkman, 1984).

In his opinion, stress is

not a stimulus, a response, or an intervening variable;

but a term that includes an individual's psychological,

sociological, and physiological functioning (Engel,1991).
Coping is viewed as a cognitive, dynamic process during

which the individual interacts with the environment.

The

individual's cognitive and behavioral efforts are
directed at reducing, mastering, minimizing, or

tolerating what has been appraised as stressful.

Coping

is viewed as the attempt to manage the demands of a
person-environment transaction.

Two classes of coping are identified, problem-

focused and emotion-focused (Lazarus and Folkman, 1984).

Problem-focused coping deals with the direct action taken
to eliminate or alter the threat through aggressive or

rational deliberate actions.

This type of coping is more

frequently used in situations thought to be changeable.

Emotion-focused coping deals with the regulation of
emotional tendencies such as distancing, seeking social
support, wishful thinking, escape avoidance, accepting

responsibility and positivism (Lazarus and Folkman,

22

1984).

Emotions are the product of the individual's

transaction with the environment.

The intensity of an

individual's emotional responses offers insight into how

the individual is managing the threat and offers a view
of what the individual evaluates as important (Folkman

and Lazarus, 1985).

Emotion-focused coping is used most

frequently in encounters thought to be unchangeable
(Lazarus and Folkman, 1984).

Lazarus believes illness is an expression of
repeated or persistent forms of adaptive encounters with

the environment.

Although this definition does not

clearly state the relationship between stress and

illness, it does give insight into why individuals
continuously appraise their situations and regulate their
behavior.

Meaning is given to the illness as a result of
cognitive appraisal.

The illness may take on the

following meaning to the sufferer:

a challenge, an

enemy, a punishment, a weakness, a relief from burdens,
or an irreplaceable loss.

Individuals can cope with illness in many ways.

The

illness may be minimized or denied or it may be tackled

with vigilance (Norris, et al., 1987).

Yet, the full

meaning of the illness can not be fully absorbed by the
individuals because it is too traumatic.

Many details

23
are missed even after repeated explanations.

According

to Lazarus, this allows the individuals to regulate the
enormously painful emotions that may be evoked if the

individual is fully aware of the situation (Lazarus and

Folkman, 1984).

The individual is not deliberately

denying the situation;

rather the individual can not

permit himself to see all that is surrounding him.

Lazarus' theory of stress and coping has been used
as a framework guide for many studies.

His theory of

how individuals cognitively appraise threatening

situations to determine whether they are harmful or not
gives insight to understanding how individuals react to

stressful situations.

The view of coping as a dynamic

process gives a different perspective into the coping
strategies people choose to deal with the event.

This

view of coping identifies what concerns people have and
what their emotional response is over a period of time

(Lazarus and Folkman, 1984).

Folkman and Lazarus (1985) applied this theory in
their study of college students taking midterm exams.
They noted that the students prepared for the exam not

knowing what the exam was going to be like or what the
outcome was going to be.
anticipate the end result.

The students could only

During this time, the

students utilized a range of personality characteristics

24
(such as - values, commitment, goals, and beliefs about

oneself and the world) to prepare for the exam.

These

characteristics determined the magnitude and potential

cost or benefit of the exam to the individual (Folkman

and Lazarus, 1985).

This study demonstrates the dynamic

process of coping with various emotions, the range of
coping strategies, and the use of social support which

did not remain stagnant (Folkman and Lazarus, 1985).

Raleigh, Lepczyk, and Rowley (1990) used Lazarus'
theory to explore the knowledge and anxiety of

significant others of cardiac surgical candidates

preparing for surgery.

In the preoperative phase,

families were more anxious and expressed feelings of

helplessness more than the candidates themselves did.

It

was reasoned that this difference was due to the
families' sense of lack of control over the event.

According to Lazarus, this feeling of helplessness or
lack of control may be appraised as a harm-producing
stimulus because of the anticipated negative outcomes of

the surgery.

Clients, on the other hand, had some

control over the situation because they chose to have the

surgery or not.

It was also noted that during the

preoperative phase, support from all sources was given to
clients with little to none given to the family.

This

influx of support made it possible for the client to call

25
upon a variety of coping resources such as the use of
denial or avoidance as a means of coping to minimize the
threat of the impending surgery (Raleigh, Lepczyk, and
Rowley, 1990) .
King (1985) used Lazarus' theory in her study of

measuring coping strategies, concerns, and environmental
responses in clients undergoing CABG surgery.

She

developed a questionnaire based on Lazarus' concepts

which grouped coping strategies into categories:
information seeking, direct action, turning to others,
avoidance, imaging and positive thinking.

King came to

similar conclusions as Lazarus - coping is a dynamic

process.

She observed that coping strategies changed

from the preoperative period to the postoperative period.
In the preoperative phase, information seeking was used

more as a method of coping with the uncertainties of the
surgery;

while in the postoperative phase, information

seeking was utilized by the clients to compare their
recovery progress with others.

King (1985) noted that direct-action coping
strategies were the lowest during the preoperative phase
and highest in the postoperative phase.

She theorized

that the reasoning behind this difference was that the

preoperative clients did not perceive that any specific

actions were available to address the threats and dangers

26
of having surgery.

In the postoperative phase, the

clients could take specific actions which would aid in

their recovery. The findings suggested that direct

actions were dependent on the situation and the
appropriateness of participation.
King also concluded that if the outcome of the event
was clear then the level of concern would decrease.

On

the other hand, if the outcome was ambiguous,
ramification of the experience was uncertain and the
level of concern would remain high.

She felt that

further research was needed to gain an understanding
about the relationship between coping strategies,

concerns, emotional states, and outcomes that can be used

for client in the clinical practice.

O'Keefe and Gillis (1988) also used Lazarus'
framework of coping to present a case study of a client
and family as they faced a life-threatening cardiac

event.

The framework evaluated the success of

interventions with the family.

Family coping and stress

were dependent on how the situation was interpreted by

individual members, what degree of threat to well-being

was involved and whether needed resources were available.
Many family members saw the cardiac event as a threat and
appraised the situation as a potential loss.

The more

intense people's commitments were, the greater the

27
potential for appraisals of threat.

This appraisal of threat was evident in Hopkins'
(1994) study of families of trauma victims.

The families

were faced with much stress and used a variety of coping
mechanisms at various phases of the trauma victims'
hospitalization.

Coping mechanisms were identified and

grouped according to Lazarus' coping categories of
emotional-focused and problem-focused strategies.

During

the early phase of hospitalization and during the
clients' acute medical phase, emotional-focused coping

was identified.

Families used denial, displacement of

anger, self-pity as well as blame, or blame on others as
means of coping.

In the later stages of hospitalization,

problem-focused coping responses were employed by the

families such as researching the clients' diagnoses and

prognoses to gain a better understanding of the clients'
health status (Hopkins, 1994).

Family and Stress

As previously stated, all members of the family

are interdependent.

Each member is an integral part of a

whole, having a place and role within the family
structure.

When one member becomes ill, all are affected

and the stress of caring for the ill member is felt by

28

everyone.
During the phases of CABG surgery and the recovery

process, the family members and the client are faced with
much stress.

Fear is experienced by the family due to

the lack of control over the events and the uncertainty
of the outcome.

Stressors pile up, placing greater

demands on the family's coping abilities.

Dracup, Meleis, Baker, and Edelfsen (1984) noted
that increased anxiety contributed to the emotional and
behavioral changes among married couples when a member

experienced coronary bypass graft surgery or myocardial

infarction.

Anxiety, depression, and low self-esteem

were consistently documented during the crisis event.

These emotions persisted for up to one year following the
event.

Millar (1989) studied families of critically ill

patients in an intensive care unit.

The intensive care

unit is a strange, unfamiliar environment in which the
family may have experienced fear of the unknown, anger,
mistrust, helplessness or hopelessness.

Many of these

emotions were due to the lack of understanding of the

relatives' diagnosis and hospital routines.

Millar

explained that clients entering an ICU are in a

biological crisis whereas the family is in a
psychological crisis.

The relationship the clients had

29

with them was not static or isolated because of the
admission to the ICU, but continued to be dynamic and

ongoing.

She found that families have a direct effect on

clients7 emotional states.

By getting them involved in

family-focused care programs, the anxieties were reduced

and the stability of family structure was maintained
(Millar, 1989).

Hodovanic, Readon, Reese, and Hedges (1984)

identified several stressors that affected families of
medical intensive care unit clients.

Several of the

stressors identified were role changes, isolation from
other family members, financial concerns, fear of loss of

a loved one, and possible emotional turmoil when family

members were hospitalized.

Supplying the family with

information regarding clients' conditions, procedures to

be performed and discharge instructions, decreased
family's anxieties, thus enabling them to effectively
cope with the situation (Hodovanic, Readon, Reese, &

Hedges, 1984) .

Artinian's (1989) study of family members'
perceptions of the cardiac surgery event concluded that

the family was threatened by the surgical experience.
The family feared the loss of a member which drastically
threatened to alter the makeup of an intact family
system.

To maintain family integrity, communication was

30
an essential component.

Family members needed

encouragement to express emotions and fears.

The study

concluded that nurses needed to be more sensitive to the
family's needs and concerns and answer all questions even

if they were repeated over and over again.

In addition,

Artinian found that the cardiac surgery event was more
stressful for the spouse than for adult children due to

the added responsibilities placed on the spouse during
the event.

The children did not experience the direct

effects of the surgery, since most did not reside in the
home of the client (Artinian, 1989).

Artinian also

pointed out that being in group sessions with other CAB
families facilitated client and family coping (Artinian,
1989) .

Dhooper's (1983) study of families of myocardial

infarction clients revealed the vulnerability of families
during high stressful episodes.

The emotional health of

families was the most vulnerable characteristic

throughout the crisis period and the six months following

the event.

Dhooper (1983) reported that spouses had an

increase in anxiety which he believed caused behavioral
changes within the family, disruption of family routines
and deferred participation in social activities.

Gillis (1984) found that clients hospitalized for

coronary bypass graft surgery reported experiencing less

31

stress than their spouses.

Their spouses identified the

lack of control over hospital events, the inability to

ventilate fears, and the fear of caring for the client
after discharge without feeling competent to do so as

major stressors.

Supplying clients and spouses with

information about the recovery process reduced many of
the fears.
Brown, Glazer, and Higgins (1983) studied the

support given to open heart clients and their families
during the recovery period of open heart surgery.

They

studied the clients and families of a support group.

The

support group focused on the exchange of information
regarding the recovery from the surgery and the

psychosocial aspect which would have otherwise gone
unaddressed.

The support group provided the families and

clients an opportunity to ventilate their feelings,

unique to the recovery of open heart surgery.

The

benefits of the support group revealed that stress and
anxiety were reduced during the recovery process.

Hickey and Lewandowski (1988), in their study of
families of critically ill clients, concluded that the

family plays a supportive role in the clients' recovery
and should be included in the decision making process.

When families took a more active role in the clients'

care, anxieties were reduced for both the clients and the

32

families.
Family and Coping

Family coping is a complex process.

It takes

coordinated problem-solving behaviors of the whole system

to maintain the integrity of the system when a stressor
or hardship is encountered.

The behaviors are directed

at establishing a balance between the demands of the
stressor and the available coping resources of the

family.

Alonzo (1986) studied the impact of family care

during an acute cardiac event.

The family had a positive

impact on care of a client faced with a life-threatening

illness.

It was often a family member who made the

initial contact with the physician.

Alonzo (1986) also

noted that the family played an active role in the
client's care during an acute cardiac event.

Family

members provided physical care and emotional support to

the client during the rehabilitation phase of recovery.
Robinson, Roe, and Boys (1987) in their study of
families, described stages of crisis that families

progressed through when faced with a serious illness.

When faced with a serious illness or crisis, the family's

level of functioning dropped, relationships were
strained, conflicts among members increased and role

33

^allocations were disrupted.

In the first stage, the

family often paralleled that which clients were
experiencing.

Both the family and the clients were

dependent on others, especially the medical team.

They

were compliant and unquestioning in their acceptance of

treatments.

Denial and anger were often used in this

first stage much in the same manner they are used in the

stages of grieving over the death of a loved one

(Robinson, Roe, and Boys, 1987).

In the second stage,

the family members began to regain control over their
lives and adapted to the illness by making improvements
in family behaviors and relationships.

The family's

problem-solving abilities increased and a new level of
functioning was achieved.

In this stage, the family

gradually adjusted to the illness.

Flexibility and

adaptability were needed for the family to withstand the

tension or strain evoked by the illness.

The third and

final stage involved further assessment of understanding

the illness and to some degree the purpose of life.

This

stage was not always attained (Robinson, Roe, and Boys,

1987).
Cray (1989) studied families of critically ill

clients and developed an assessment framework to identify
and implement interventions to assist families dealing

with a critical event.

Cray noted that families went

34

through a grieving process as they dealt with the crisis

event.

Resolution occurred when the family had gone

through the process and gained acceptance of the illness

and its effects.

Cray concluded that nurses could

facilitate the process by demonstrating a conscientious
concern for the family's loved ones.
Bradley and Williams (1990) compared the concerns of

open heart clients and their spouses during the
preoperative phase.

They found that the open heart

clients and their spouses had multiple concerns ranging

from the fear of complications, the effectiveness of the
surgery, and death as a possible outcome of the event.

Coping effectively with the event depended on nursing

interventions directed at assisting the clients and their
families in identifying and resolving their concerns.

Stanley and Frantz (1988) assessed the social
adjustment of spouses of patients who had undergone

coronary bypass graft surgery.

Many spouses expressed

dissatisfaction with the decrease in social activity,
role changes, sexual functioning, vigilance, and economic
adequacy after the surgery.

Role reversal was found to

be a common thread throughout many of the studies during
the rehabilitation phase of recovery.

Role ambiguity led

to confusion and frustration within the family unit.
Stanley and Frantz concluded that educating the family

35

regarding the adjustments needed during the recovery
process would prepare the family to cope more effectively

with the situation.
Dhooper (1983) studied families of clients who had
suffered their first myocardial infarct.

A variety of

coping strategies were employed by family members to

understand and control the stress during the event.

The

families welcomed outside help to assist them in dealing

with this crisis, yet only a small fraction of the
families knew or had utilized social agencies available

to them.

Nearly half of the families felt that they

emerged stronger and better because of the crisis.

A

fifth of the families felt that they were worse off in

their overall functioning.

Dhooper theorized that had

the families known about the availability of social

services to assist them during their crisis, they would

have been able to better cope and function during the
crisis event (Dhooper, 1983).
The literature identified a family's stability,
adaptability, resources, and beliefs are challenged when

confronted with a illness.

A balance must be established

between the stress of the illness and the family's coping

abilities in order for the family to avoid a crisis
situation and continue functioning.

The literature

supported interventions aimed at supporting the family

36

through informal or formal means to assist them in coping
with stressors of the illness.

Conceptual Framework

The Double ABCX Model of Family Assessment and

Adaptation focuses on family coping efforts to manage a

stressful event or situation over time (McCubbin and
Patterson, 1983).

The model takes into account the

family's adjustment to a stressor through the interaction
with pre-crisis and post- crisis variables.

Four major

concepts are the foundation of the framework:

demands or

stressors (aA), the adaptive resources(bB), appraisal or
perception of the stressors (cC), and coping

strategies(xX) (McCubbin and Patterson, 1983).
The aA factor refers to the family's demands or

pile-up of stressors.

Not only is the stressful event

included in this factor but also the associated

hardships, other concurrent events, and prior family
strains.

The demands produce internal tension on the

family that require family resources (bB), the family's

perception or definition of the situation (cC) and the
family's coping abilities.

The bB factor represents the family's adaptive

resources that are needed to assist family functioning at

37

the time of stress.

These resources are called upon to

prevent the stressor from creating a crisis or disruption
within the family functioning. Family resources include
economic stability, cohesiveness, flexibility, spiritual
beliefs, open communication, routines, and organization
(McCubbin and Patterson, 1983).

The third factor of the model (cC) represents the

family's perception or definition of the event.

This

appraisal of the stressor by the family gives a

definition of the seriousness involved, the hardships

encountered, the family resources available to meet the
demands, and actions needed to maintain equilibrium

within the family unit.

A crisis may occur due to

ineffective coping mechanisms of family members and lack
of social support for the family.

state of disequilibrium.

This causes an overall

Equilibrium is maintained if

family coping and appraisals meet the demands of the

stressor and promote family adaptation.
Coping is the fourth major concept in this model.
bridges the bB and cC factors.

It

Coping is the interaction

between the stressor and the families' capabilities to
meet the demands of the stressor.

interaction is adaptation (xX).

The result of this

Adaptation is a process

in which families must come to realize the necessity of
changing in order to restore their functional stability.

38

The changes include restructuring patterns of
functioning, rules, and boundaries (McCubbin and
Patterson, 1983).

Through family effort, the changes are

incorporated to improve family functioning and
effectively deal with the crisis situation.
bonadaptation is facilitated.

Thus

This balance or

equilibrium enables the family to continue to function as
a whole when confronted with stressors.

On the other

hand, families may not adapt effectively to the changes
causing maladaptation or disequilibrium within the family

(McCubbin and Patterson, 1983).

As a result, the family

will return to a crisis situation and new ways to adapt
must be found.
The model is used as a guide to assess critical
elements of family functioning, the knowledge of which

can be useful in planning family interventions during

illness.

A holistic and systematic approach is provided

in diagnosing and evaluating family functioning as family

members cope and adapt to the stressors caused by the
illness experience (McCubbin and Patterson, 1983).
Gillis, Neuhaus, and Hauck (1990) used the Double
ABCX model as a framework to study the families of

coronary bypass graft clients.

The model was used to

specifically identify the influences which augment the

family's coping abilities and adaptation after cardiac

39

surgery.
Leavitt (1990) used the Double ABCX model to study
family recovery after vascular surgery.

Specific areas

of study included the family's perception of the

stressful event and the coping strategies used to deal

with the event.

Application of this framework to the

crisis of CABG surgery can encourage health professionals

to look at the family's natural healing abilities.

By

recognizing the family's natural abilities to handle

stress, interventions can be identified and health
professionals can assist the family in overcoming the

barriers which block the healing process.
The Double ABCX model also served as the theoretical

framework for the Nolan, Cuppies, Brown, Pierce, Lepley,
and Ohler (1992) study of the perceived stress and coping
strategies of families of clients waiting for organ

transplants.

They noted that family homeostasis was

maintained by the family by increasing the number of
coping strategies.

Supporting the families' existing

coping strategies and exploring new ones helped maintain

family integrity.
The theories on stress and coping can be used as a

foundation to understand how individuals and families

deal with stressful situations.

By understanding how

stress affects individuals or families, health care

40
professionals can develop strategies to assist them in
coping with the stressful event.

CHAPTER III

METHODOLOGY

This descriptive comparative research study

investigated the patterns of adaptation that family

members experience when a member undergoes coronary
bypass grafting surgery.

The coping behaviors of the

CABG clients' spouses and the adult children are the

dependent variable in the study. The coronary artery
bypass graft surgery is the independent variable.
McCubbin's and Patterson's (1983) Double ABCX Model of
Family Assessment and Adaptation provided the conceptual

framework for the study.

This chapter describes the

study including the participants, setting,
instrumentation, reliability and validity of instruments,
procedures for data collection, and data analysis.

Setting

The sample chosen for this study included families
of clients six to twelve months post coronary bypass

graft surgery.

These clients were participants in a six

week course at a cardiac rehabilitation center in a large

city in Northwest Pennsylvania.

41

The services offered by

the cardiac rehabilitation center included cardiac
diagnostics and a structured exercise program for

diagnosed cardiac clients.
The program had been in existence for seven years

and drew membership from the community.

Membership was

voluntary but a physician referral was required.
Participants in the program received a six week

structured exercise program.

Progression was monitored

by staff who are available to reinforce or clarify

information relating to the clients' recovery.

The

center also offered diet and risk factor modification

classes.

The families were encouraged to attend sessions

with the clients.

These sessions were usually offered in

early afternoon.
At the time of the study, the center did not have a

formal support group for clients or families.

Support

was given informally to clients or families by staff.

Once the program was completed, the clients were
encouraged to participate in a long term exercise program
and to continue to make necessary healthy lifestyle

changes.

The program was subsidized by Medicare and

private insurance.

Sample

The convenience sample of this study consisted of

42

43

spouses and children of clients who underwent coronary

bypass graft surgery during the calendar months March
1993-October 1993.

The coronary bypass graft clients

were six to twelve months post surgical event,

The six

to twelve months' time interval was chosen because
literature has shown that by that time frame, families
have begun to settle into a comfortable routine and have

assimilated changes necessary to continue family
functioning and coping (Baker 1990, Dhooper,1983, Gillis,
1984).

During this time frame, families are often

overlooked by health care professionals since the

coronary bypass graft client is no longer in the acute
health care setting.

This time frame was short enough to

allow the participant to recall with a fair amount of
accuracy the stressors associated with the coronary
bypass graft surgical event.

The initial pool of participants consisted of fifty

families comprised of spouses and adult children of

coronary bypass graft clients who were enrolled in a

cardiac rehabilitation center program.

The families had

to meet three criteria in order to participate in the
study.

One criterion used for the selection of

participants was that the CABG surgery was the initial

cardiovascular surgery.

The second criterion was that

family members were eighteen years of age or older,

44

either residing with the CABG client or not.

The third

criterion used for the selection of participants was
imposed by this researcher to assure some consistency in

family selection:

all families participating in the

study were selected from a list of post CABG clients who
voluntarily participated in the rehabilitation program

offered by a cardiac rehabilitation center.
A list of possible clients and their families was

obtained from the Director of the Cardiac Rehabilitation
Center for the sample.

Letters of permission for the

study are on file at Edinboro University of Pennsylvania
Department of Nursing.

From this list, families who met

the criteria for the study were selected.

There was an

initial pool of 50 clients who were contacted and asked

to participate in the study.

Thirteen clients and

families were later excluded from participation because
of the following reasons:

widowed, never married,

divorced, never having children, or rehospitalized.

The

remaining thirty-seven families met all of the criterion

to participate in the study.
to the request.

Sixteen families responded

A sample of 44 respondents, 16 spouses

and 28 adult children, of CABG clients voluntarily
consented to participate in the study.

45

Instrumentation

A questionnaire was utilized to collect data for

this descriptive survey.

McCubbin's, Olson's, and

Larsen's Family Crisis Oriented Personal Evaluation

Scales (F-COPES) was chosen to determine the coping

behaviors utilized by families when confronted by a
problematic or difficult situation such as coronary

bypass graft surgery (McCubbin, Larsen, & Olson, 1991).
Permission to use the scale was granted by the authors
(see Appendices A,B,C, and D).

The scale is based on the

coping dimension of the Double ABCX Model of Family
Assessment and Adaptation (McCubbin and Patterson, 1983).

The F-COPES integrates the resources and perceptions or
meanings identified by the family into coping strategies
(McCubbin, Olson, and Larsen, 1991).
of the following components:

The model consists

pileup of stressors, family

resources , meaning/perception of the event, and the

coping and adaptation.

The instrument consists of 30 items relating to
coping behaviors.

A five point Likert type scale

(5=strongly agree, 4=moderately agree, 3=neither disagree
or neither agree, 2=moderately, and l=strongly disagree)

was used to elicit participants' self-reported levels of
agreement with each statement on the questionnaire.

A

46

sum score was obtained by totaling each participant' s
responses for all items.

Responses of "strongly

disagree" and "moderately disagree" were defined as
coping behaviors that did not describe the participants'

responses when confronted with a problem or stressful

event.

Strongly disagree" or

"moderately disagree"

responses indicated the extent to which the participants
disagreed.

Responses by the participants to "strongly

agree" and "moderately agree" were defined as coping

behaviors that did describe their response when
confronted with a problem or stressful event.

Responses

by the participants of "strongly agree" and "moderately
agree"

further described to which degree they agreed.

Responses by participants to " neither agree" or "neither
disagree" described a neutral response to the items on

the questionnaire.
Possible total F-COPES scores ranged from 30-150.

The instrument focused on two levels of interactions as
outlined in McCubbin's and Patterson's (1983) Double ABCX

Model of Family Assessment and Adaptation.

The two

levels of interactions were: " (1) individual to family
system (internal coping patterns) - relating to the
internal management of conflicts between family members
and (2) family to environment (external coping patterns)

- relating to the external management of problems or

47
difficult situations which originated outside the family

boundaries" ((McCubbin, Olson, & Larsen, 1991 p. 203).
Each level consisted of scales to measure the family's
coping patterns.

Internal Coping Patterns consisted of three
subscales:

confidence in problem solving, reframing, and

passivity.

Confidence in problem solving included four

items dealing with the family' s appraisal of the problem

and the sense of mastery in dealing with unexpected
events (McCubbin, Olson, & Larsen, 1991).

Reframing

family problems also consisted of four items reflecting

the family's views on stressful experiences or the change
in family's view of the situation - negatively,

positively or neutral.

Family Passivity focused on

"inactive or passive behaviors"

utilized by the family

such as avoidance behaviors based on the lack of

confidence in the family's ability to change the outcome
(McCubbin, Olson, & Larsen, 1991, p. 204).

passivity contained four items.

Family

Scores for Internal

Coping Patterns ranged from 12-60.
External Coping Patterns consisted of five scales

which measured the family's external coping behaviors;
church/religious resources, extended family, friends,

neighbors, community resources (McCubbin, Olson, &
Larsen, 1991) .

Church /religious resources consisted of

48
four items evaluating the family's involvement with

religious activities and ideology in dealing with

difficulties.

The extended family component contained

four items which reflect on the family obtaining support
by communicating with and being involved in activities

with relatives.

Friends consisted of four items focusing

on the support obtained through friends.

Neighbors

contained three items focusing on the help and support

received from individuals within the community.
Community resources contained three items that focused on

the use of neighborhood agencies and programs, such as

professional counseling and physician advice (McCubbin,
Olson, & Larsen, 1991).

Scores for External Coping

Patterns range from 18-90.

See Appendix E for a copy of

the tool.

Reliability and Validity

The F-COPES Scale developed by McCubbin, Olson, and
Larsen, has a Cronbach alpha reliability of 0.87.

Reliability coefficients have been determined in all five
subscales and are from 0.64 to 0.87 (McCubbin & et al.

1991) .

Content validity was established by the authors

through studies utilizing students at the University of

Minnesota.

A pilot instrument consisting of 49 items was

49

developed based on research in the literature on family
coping.

After the initial testing the instrument was

reduced to 30 items with eight strong factors emerging.

This 30 item tool was retested four to five weeks later
on the same research population.

Based on the results of

this study the final F-COPES was developed.

The final F-

COPES was then tested for reliability on a large sample

consisting of 2740 participants.

The results obtained in

this final study were close to the results obtained in

the initial studies (McCubbin & et al. 1991).

Data Collection Plan

On March 15, 1993, the guestionnaire with an
introductory cover letter and a self-addressed return

envelope was sent to all the spouses and adult children
who met the criteria for participation in the study (see

Appendix F).

The subjects were informed that completing

the questionnaire was voluntary, that findings would be
reported in the aggregate, and that the results would be

confidential.

The questionnaire was mailed to all

participants with instructions to complete the

questionnaire and to mail the completed form in the
postage-paid envelope provided within seven days.
Spouses were asked to complete a yellow questionnaire,

50

and the adult children were asked to complete a green
questionnaire, in order to facilitate sorting of the

responses.

An attempt was made to reach all families by

telephone prior to the mailing of the questionnaire to

verify addresses and to promote cooperation with the

survey.

Confidentiality was assured to each participant,

and consent for participation in the study was obtained
from the participant through signing of the consent form

(see Appendix G).

Subjects were assured that their

participation in the study was voluntary.

Refusal to

complete the questionnaire had no impact on their family
member's opportunity to participate in the program or on

their membership in the cardiac rehabilitation program.
One week after the initial mailing, a letter (see

Appendix H) was sent to thank the families who had

responded, to stress the importance of cooperation and to
offer a replacement questionnaire if necessary to those

who had not responded.

Generally, the suggestions for

data collection and cover letters were patterned
according to Dillman's (1978) recommendations to ensure a

high response rate.
Anonymity of subjects was maintained by use of code

numbers, with identification of subjects known only to
the investigator.

All lists containing individual names

and scores were destroyed.

All findings were reported in

51
the aggregate.
Data collection ended April 25, 1993.

A return of

44 respondents - 16 spouses and 28 children, was
realized.

The sixteen spouses' questionnaires and

twenty-eight children's questionnaires provided data for
analysis.

Data Analysis Plan

The descriptive data were analyzed to identify the

respective coping patterns which spouses and children of

CABG clients agreed or disagreed they used, to deal with
the stressors of the surgery.

Thirty-seven families were

asked to participate in the study.

responded to the request.

Sixteen families

A sample of 44 respondents, 16

spouses and 28 adult children, of CABG clients

voluntarily consented to participate in the study.
A statistician was consulted for data analysis.

Based on the statistician's recommendations, the data

were analyzed according to mean scores of the total F-

COPES score of each participant, the mean scores of the
categories, subcategories, and each statement identified

on the F-COPES of each participant, and the frequency

distribution of responses, and percentages of
disagreement, neither agreement nor disagreement, and

52
agreement responses.

Data sheets were used for

tabulation of the data as the questionnaires were
returned.

To obtain a score, numbers one to five were assigned

as a score signifying relative levels of agreement or
disagreement for each item on the questionnaire.

The

numbers were then added to acquire a single total coping
score based on all thirty items.

High scores reflected

the use of multiple coping behaviors.

Low scores

reflected fewer coping behaviors being utilized.

The

scores for the F-COPES items reflected the use of self­
reported coping strategies by the individual, not the

effectiveness of the coping strategy.

A mean score (for

the aggregate) was calculated from the total scores of
all questionnaires.

An item analysis was performed on

the questionnaires to indicate distribution of the

participants' responses to the items on the

questionnaire .

A mean score was then calculated on each

item on the scale.
The responses were organized into internal and
external coping patterns categories as identified by

McCubbin, Olson, and Larsen.

The percentage of

distribution of the participants' responses to strongly

disagree, moderately disagree, neither disagree nor
disagree, moderately agree, or strongly agree were

53
calculated to provide information on which coping
patterns the participants agreed or disagreed they

utilized when dealing with stressors.

In order to

organize the data, the responses of strongly disagree and
moderately disagree responses were added to determine the

participants' disagreement responses.

The responses to

strongly agree and moderately agree were added to provide
information on the participants agreement response.

The

responses of the participants to neither disagree nor

agree were added to provide information on the
participants neutral response. The data were further
analyzed according to the percentage distribution of
disagreed (strongly and moderately), neither disagreed

nor agreed (neutral), and agreed (strongly and

moderately) responses on the guestionnaire for internal
and external coping patterns of families.

To determine

which specific coping patterns were utilized by the
families, responses were analyzed according to the
internal coping patterns and external coping patterns

subcategories.

The mean scores and the percentage of

disagreement, neither disagreement nor agreement, and

agreement were calculated for each of the subcategories.

The percentage of disagreement, neither disagreement nor
agreement, and agreement were calculated for each of the
items contained in each of the subcategories.

54

The questionnaires were separated into the two
groups (spouses and adult children) to determine the

frequencies with which the various coping patterns were

utilized by each group.

The responses of the spouses and

the children to the F-COPES questionnaires were tabulated
as described above and scored.

These score were averaged

to gain the mean scores of each group.

The data were

further analyzed according to the percentage distribution
of disagreed (strongly and moderately), neither disagreed

nor agreed (neutral), and agreed (strongly and
moderately) responses on the guestionnaire for internal
and external coping patterns of the spouses and children.

To determine which specific coping patterns were utilized

by each group, the spouses' and children's responses were
analyzed according to the internal coping patterns and

external coping patterns subcategories.

The mean scores

and the percentage of disagreement, neither agreement nor

agreement, and agreement were calculated for each of the
subcategories. The percentage of disagreement, neither
disagreement nor agreement, and agreement were calculated

for each of the items contained in each of the
subcategories.

The returned questionnaires were deemed

acceptable for the study if the form was completed.

Chapter IV presents the findings from the data
collected and analyzed about family coping behaviors.

55

Data relevant to the self-reported coping behaviors of

the spouses of CABG clients and the adult children of
CABG clients are analyzed as score data.

The coping

behaviors are identified according to frequency of self­
report of use, as well as according to McCubbin's and

Patterson's (1991) Internal and External coping patterns
categories and subcategories.

Chapter IV

Presentation and Analysis of Data

The purpose of this research was to study coping
behaviors of spouses and children of coronary bypass

graft clients.

The initial pool of research subjects

consisted of families of 50 clients who were six to
twelve months post coronary bypass graft surgery.

The

clients had surgery within the calendar months of March

through October, 1993.

These clients had participated in

a cardiac rehabilitation program following discharge from
the hospital.

Of the families of 50 clients initially

contacted, 16 spouses and 28 adult children agreed to
participate in the study and returned their

guestionnaires.

All guestionnaires used in the study

were completed;

that is all of the questions were

answered.
The Double ABCX model of Family Adjustment and

Adaptation by McCubbin and Patterson (1983) provided an
organizing framework for the study.

The Family Crisis

Oriented Personal Evaluation Scale (F-COPES Scale) by

McCubbin, Olson, and Larsen (1991) was utilized to elicit
self-reports of family coping behaviors.

The returned

questionnaires were separated into two groups, those of

56

57

spouses and adult children.

Each guestionnaire was

scored by adding the response numbers (1-5) to the
individual items.
analyzed.

The tabulated responses were then

The higher the total score, the more coping

behaviors were identified by the spouses and adult

children of CABG clients as used to assist them in coping
with the stressors produced by the surgical event.

The

responses to the guestionnaires were then analyzed
according to the freguency distributions and percentages

of responses.

This chapter addresses the results of the

study that were guided by the research guestions outlined
in Chapter 1.

The first guestion was posed,

"What coping patterns

were used by families during the six to twelve months
following a family member's CABG surgery?"
As previously discussed, the Family Crisis Oriented

Personal Evaluation Scale (F-COPES Scale) by McCubbin,
Olson, and Larsen (1991) focused on two levels of
interaction:

Internal and External Coping Patterns.

Internal Coping Patterns gave definition to the way
individual family members handle difficulties by using

internal resources and support from the immediate family.
Internal Coping Patterns scores ranged from a possible

12-60.

Internal Coping Patterns category contained three

subcategories;

"Reframing", "Family Passivity", and

58
Confidence in Problem Solving".

Table 1 summarizes the

subcategories of Internal Coping Patterns and the

corresponding questionaire items.

Table 1
Internal Coping Patterns

Subcategory

Item Numbers*

Confidence in Family Problem Solving

3,7,11,22

Reframing Family Problems

13,15,19,24

Family Passivity

12,17,26,28

* Refer to Appendix E

"Refraining" related to the family's ability to

positively redefine the situation.

"Family Passivity"

focused on the family's 'inactive' or passive approach in

dealing with stressful or difficult situations.
"Confidence in Problem Solving" reflected the family's

appraisal and sense of mastery in dealing with unexpected

events (McCubbin, Olson, Larsen, 1991).
External Coping Patterns evaluated how the family

managed the problem outside the immediate family matrix
by acquiring outside resources or support (McCubbin,

59

Olson, and Larsen 1991).

External Coping Patterns

contained five subcategories:

"Church/Religious

Resources", "Extended Family", "Friends", "Neighbors",
and "community Resources."

External resources consisted

of looking for support and assistance from friends,

neighbors or family members outside the immediate family
unit such as grandparents, aunts, or uncles, church or

religious resources, and community resources.

Also

included in this category was professional counseling and
seeking advice from the family doctor.

Possible scores

for External Coping Patterns ranged from 18-90.

Table 2

summarizes the subcategories of External Coping Patterns

and the corresponding questionaire items.

Table 2

External Coping Patterns

Subcategory

Item Numbers*

Friends

2,4,16,18

Neighbors

8,10,29

Extended family

1,5,20,25

Church resources

14,23,27,30

Community resources

6,9,21

*Refer to Appendix E

60

"Friends" focused on the involvement with friends to
obtain support.

The "Neighbors" subcategory centered

around receiving favors and support from individuals

within the community.

"Extended Families" focused on the

support and encouragement obtained from relatives.
"Church Resources" reflected the families' involvement

with church activities and their religious beliefs.
"Community Resources" emphasized support obtained from

community agencies, professional counseling and

physicians.
To determine which category of coping patterns the
families of the CABG clients utilized, the mean scores

for each category were determined.

Table 3 summarizes

the mean scores for the internal coping patterns and
external coping patterns for families.

The mean scores for internal and external coping

patterns for families indicated that both categories were

utilized by the family when dealing with the stressors of
coronary bypass graft surgery.

Based on the mean scores,

it cannot be determined which category of coping patterns

were more effective in dealing with the stressors

associated with the CABG surgery.

Nor can it be

determined which coping patterns were utilized more. The

results did indicate that both internal coping patterns
and external coping patterns were utilized by the

61

families in this study.

Table 3

Mean Scores on Internal and External Coping Patterns for
Families

Category

Maximum
Possible
Scores

Mean
Scores

Internal Coping

60.00

40.18

External Coping

90.00

59.73

n=44

To further determine which coping patterns were
utilized by the families of CABG clients, the data were
analyzed according to percentage distribution of
disagreed (strongly and moderately), neither disagreed

nor agreed (neutral), and agreed (strongly and

moderately) responses on the guestionnaire for internal
and external coping patterns by the families.

Responses

of strongly disagree and moderately disagree to the items
on the questionnaire were combined under the heading of
disagree for easier data analysis.

The responses of

neither disagree nor agree remained under the heading of
neither disagree nor agree or a neutral position.

Responses of strongly agree and moderately agree to the

62

items on the questionnaire were combined under the
heading of agree for easier data analysis,

Table 4

summarizes the percentage distribution of the responses
of disagree, neither disagree nor agree, and agree by the

families for the internal and external coping patterns.

Table 4

Percentage Distribution of Internal and External Coping

Patterns of Families

Disagree

Category

NA/ND*

Agree

n=44

Internal Coping

30%

18%

52%

External Coping

26%

21%

53%

*NA/ND= neither agree nor disagree

The percentage scores of families were close for

both the internal and external categories.

This

indicated that the families of CABG clients reported that

they utilized coping patterns in these categories at
similar rates to cope with the stressors associated with

the surgery.

This result was not surprising since the

families are interconnected by similar boundaries and

63

beliefs.
The data were further analyzed according to the
subcategories of Internal Coping Patterns and External

Coping Patterns to determine which coping patterns were
utilized. The data for each of these subcategories were

analyzed according to the percentage distribution of
disagreed (strongly and moderately), neither disagreed

nor agreed (neutral), and agreed (strongly and
moderately) responses on the questionnaire for Internal
Coping Patterns subcategories.

Table 5 summarizes the

percentage distribution of families for Internal Coping

Patterns subcategories.
Analysis of the data revealed that the subcategories

of reframing (72%) and confidence in problem solving
(73%) had the highest percentage of agreement and the

lowest percentage of disagreement (10%).

This indicated

that the families of CABG clients agreed that the coping

patterns in these subcategories assisted them in dealing
with the stressors associated with coronary bypass graft
surgery.

The results indicated that the families viewed

change positively and were able to feel a sense of

mastery or control over the stressors and events

associated with the coronary bypass graft surgery.

64

Table 5

Percentage Distribution of Internal Coping Patterns
Subcategories of Families

Subcategories

DA*

NA/ND*

A*

Reframing
(13,15,19,24)+

10%

18%

72%

Family Passivity
(12,17,26,28)+

71%

19%

10%

Confidence in Problem Solving
(3,22,27,11)+

10%

17%

73%

n=44

+Refers to statements in Appendix E
*DA= disagree, NA/ND= neither agree nor disagree, A=agree

The Internal Coping Patterns subcategory of "Family
passivity" had the lowest percentage of agreement (10%)
and the highest percentage of disagreement (71%).

This

indicated that the coping patterns in this subcategory
were not utilized by the families.

The families

indicated by these results that they did not take a

passive a pproach to problem solving or with coping with
the stressors associated with the coronary bypass graft
surgery.
The subcategories of external coping patterns were

65
analyzed.

External coping patterns consisted of five

subcategories:

"Friends", "Neighbors", "Extended

Families", "Church Resources", and "Community Resources".
These subcategories were analyzed according to the

percentage distribution of disagree (strongly and
moderately), neither agreed nor disagreed (neutral), and
agree (strongly and moderately) responses to the

questionnaire.

Table 6 summarizes the percentage

distribution of the External Coping Patterns

subcategories for families.
Table 6

Percentage Distribution of External Coping Patterns

Subcategories of Families

DA*

NA/ND*

A*

Friends
(2,4,16,18)+

16%

25%

59%

Neighbors
(8,10,29)+

48%

23%

29%

Extended family
(1,5,20,25)+

34%

20%

46%

Church resources
(14,23,27,30)+

16%

16%

68%

Community resources
(6,9,21)+

23%

18%

59%

Subcategories

n=44

+Refers to statements in.Appendix E
agree nor disagree, A=agree
*DA= disagree, NA/ND- neither
i

66
"Church Resources" had the highest percentage of

agreement (68%) and the lowest percentage of disagreement

(16%) of all the External Coping Patterns subcategories.
This percentage score reflected the importance religious
beliefs and involvement in church activities had in
assisting families cope with the stressors associated

with the surgery.
External Coping Patterns subcategory "Friends" was
analyzed. Sixty percent of the families agreed that

friends were a source of support and encouragement in
helping them cope with the stressors associated with the

CABG surgery.

Friends offered ideas or gave suggestions

that reduced the burden of the stressors encountered with

the surgical event.
In the subcategory of "Community Resources", fifty-

nine percent of the families surveyed agreed that

external resources found in the community helped them
cope with the stressors encountered by the CABG surgery.
Community resources involved the utilization of community

agencies and programs as well as professional services
such as counseling.

One community agency identified was

a Phase II Cardiac Rehabilitation Center.

This program

provided information to the families regarding lifestyle
changes, cardiac risk factor modifications, diet, and

exercise.

The informal make up of the rehabilitation

program also offered the families an avenue to gain

support and to offer encouragement to other families who

faced the same or similar circumstances.
The External Coping Pattern subcategory of "extended
family*

focused on the support obtained by communicating

and interacting with relatives.

Forty-six percent of the

families surveyed agreed that they utilized their
relatives for support in helping them cope with the
stressors associated with the surgery.

This result (less

than half of the families surveyed) indicated that not

all families looked to their relatives for support.

Distant geographical locations of relatives, no existing

relatives, or not having an existing relationship may
have been contributing factors for why the families did

not utilize this particular coping pattern.

The External Coping Patterns subcategory of
"Neighbors" had the lowest percentage of agreement (29%)

and the highest percentage of disagreement (48%).

This

subcategory included the support and favors received from
neighbors within the community.

The results indicated

that to a degree, the families in this study did utilize
their neighbors for favors.

A reason families in this

study may not have utilized their neighbors with greater

frequency might have been that many do not know, or have

minimal interactions with, their neighbors.

Therefore,

68

the families may not have been comfortable in asking
neighbors for favors or discussing concerns with them.

The Internal Coping Patterns and External Coping
Patterns subcategories were then analyzed according to

specific items contained in each of them.

Internal

Coping Patterns contained three subcategories and each of
these subcategories contained four items.

The responses

to each item were analyzed according to the percentage of
distribution of disagree, neither disagree nor agree, and

agree.

Tables 7,8, and 9 summarizes the percentage

distribution of internal coping patterns subcategories

items.

The first subcategory to be analyzed was "Reframing"
family problems.

This subcategory contained four items

which dealt with families' ability to redefine the

situation or their view of making the outlook more
positive .

Table 7 summarizes the percentage of

distribution of disagree, neither disagree nor agree, and
agree for the items contained in the Internal Coping

Patterns subcategory of "Reframing".
The coping pattern with the highest percentage of
agreement (95%) and the lowest percentage of disagreement

(0%) was "Accepting that difficulties occur

unexpectedly".
belief that

This statement reflected the families'

difficulties were often unexpected and

69

unpredictable.

The statement

"Accepting stressful
events as a fact of life"
had a 71% agreement and a 7%
disagreement by families. This result indicated that the
families in this study accepted stress as a part of
living.

By accepting stress as a part of life, the

families were able to give a reason why stress exists in
life which enabled them to move forward.

Table 7
Percentage Distribution of Internal Coping Patterns

Reframing Subcategory, Items for Families

Specific Subcategory items

DA*

NA/ND*

A*

n=44

11%

27%

61%

Accepting stressful events
as a fact of life.

7%

16%

71%

3.

Accepting that difficulties
occur unexpectedly.

0%

5%

95%

4.

Defining the family problem
in a more positive way so that
we do not become too discouraged.

20%

25%

55%

1.

Showing that we are strong.

2.

*DA= disagree, NA/ND= neither agree nor disagree, A=agree

The statement

Showing that we are strong" had a

61% agreement by families.

This result reflected the

70

families belief in themselves and their
abilities to face
any difficulties encountered as a
family. The item
Defining the family problem in a
more positive way" had
a 55% agreement by families.

families

This reflected the

agreement that positively redefining the

problem enabled them to make the problem more acceptable.
The Internal Coping Patterns subcategory "Family
Passivity" was analyzed.

The items contained in this

subcategory reflected the families view on the passive

approach to dealing with stressful events.
subcategory contained four items.

This

Table 8 summarizes

the results.
Overall, the percentage of agreement for the items

in this subcategory were low, and the percentage of

disagreement were high.

These results indicated the

families did not passively deal with the stressors of the
CABG surgery.

They took an active approach in problem

solving and stress reduction.

The statement "Believing

if we wait long enough, the problem will go away"

had

the highest percentage of disagreement (89%) and the
lowest percentage of agreement (2%).

This indicated that

the families did not passively wait for the stressors of
the surgery to

dissolve rather they took an active

approach to problem solving and coping with the stressors
associated with the CABG surgery.

The statements

71

"Watching television" and
"Knowing luck plays a big part
in how well we are able to solve family problems"
had
70% and 68% disagreement, respectively and a low

percentage of agreement (9%).

These results reinforced

the families active approach to coping with the stressors
of the CABG surgery.

The families in this study did not

leave anything to chance by passively coping.

Instead,

they actively dealt with the stressors associated with
CABG surgery.

Table 8
Percentage Distribution of Internal Coping Patterns
Family Passivity Subcateqory, Items for Families
Specific Subcategory items
n=44

DA*

NA/ND*

A*

1.

Watching television.

70%

20%

9%

2.

Knowing luck plays a big part in
how well we are able to solve
family problems.

68%

23%

9%

Feeling that no matter what we
do to prepare, we will have
difficulty handling problems.

55%

25%

20%

Believing if we wait long enough,
the problem will go away.

89%

9%

2%

3.

4.

*DA= disagree, NA/ND= neither agree nor disagree, A=agree

The Internal Coping Patterns subcategory of

72

"Confidence in Family Problem Solving"
contained four
items relating to the families appraisal of problems and

their sense of control in dealing with problems.

Table 9

summarizes the percentage distribution of Internal Coping

Patterns

Confidence in Family Problem Solving"

subcategory items for families.

Table 9
Percentage Distribution of Internal Coping Patterns

Confidence in Family Problem Solving Subcategory, Items

for Families
Specific Subcategory items

DA*

NA/ND*

A*

n=44

1. Knowing we have the power to solve
major problems.

2%

9%

89%

'
2. Knowing
that we have the strength
within our own family to solve our
problems .

7%

7%

86%

3. Facing the problems "head on
and
trying to get solutions right away.

5%

7%

89%

4. Believing we can handle our own
problems.

5%

25%

70%

*DA:

disagree, NA/ND= neither agree nor disagree, A=agree

Data analysis revealed the percentage of agreement

for the four items in this subcategory were close.

These

results indicated the families in this study had utilized

13

these items similarly when dealing with the stressors
associated with CABG surgery.

The statement "Knowing we

have the power to solve major problems"

had the highest

percentage of agreement (89%) and the lowest percentage
of disagreement (2%).

This result indicated that the

families agreed that they had the belief and confidence
within themselves and their abilities to solve problems.
The statements " Facing the problems 'head-on'

and " Trying to get solutions right away" had an 89%
agreement by families.

These results indicated the

families did not avoid or ignore the problems that faced
them.

Instead the families looked for solutions to their

problems.

The statement "Knowing that we have the

strength within our own family to solve our problems" had
an 86% agreement by families.

This result indicated the

families agreed that they had confidence in their

abilities to solve problems within themselves.

This

reflected the families sense of control over the event

and their beliefs in their coping abilities.
The External Coping Patterns subcategories were
analyzed according to the specific items contained in

each of them.

subcategories;

External coping patterns contained five

friends, neighbors, extended family,

church/religious resources, and community resources.

The subcategories of friends, extended family,

74

church/religious resources each contained
four items.
The subcategories of neighbors and
community resources
contained three items each. The responses to each item
were analyzed according to the percentage of distribution

of disagree, neither disagree nor agree, and agree.

Tables 10,11,12,13 and 14 summarizes the percentage

distribution of external coping patterns subcategories

items.
The subcategory of "Friends" related to the support

and encouragement obtained from friends.

The responses

of disagree, neither disagree nor agree, and agree were

analyzed.

Table 10 summarizes the percentage

distribution of the items of the External Coping Patterns

subcategory "Friends".

Data analysis revealed the two items with the
highest percentage of agreement (66%) for this
subcategory relate to the support and encouragement

received and the sharing of concerns with friends.

This

indicated the families agreed that friends had a role in

assisting them in coping with the stressors of the
surgery. Data analysis also revealed that the families

agreed (59%) that information and advice received from
families who faced similar problems was beneficial,
common bond enabled the families to share their

experiences and concerns.

The

In return, this interaction

75

validated to the families that their reactions and

emotions were normal.

Table 10

Percentage Distribution of .External Coping Patterns
Subcategory Friends, Items for Families
Specific Subcategories items
n=44

DA*

NA/ND*

16%

18%

66%

2. Seeking information and advice from
persons in other families who have
faced the same or similar problems.

14%

27%

59%

3. Sharing concerns with close friends.

14%

20%

66%

4. Exercising with friends to stay fit
and reduce tension.

20%

36%

43%

1. Seeking encouragement and support
from friends.

*DA= disagree, NA/ND:

A*

neither agree nor disagree, A=agree

Exercising with friends had the lowest percentage of
agreement (43%) for families in the friends subcategory.
This indicated that this particular coping pattern was

not utilized to the same degree as other items in this
with the stressors
subcategory were used to cope
associated with the surgery. The families in the study

as a means of
did not agree that exercising with friends
as beneficial as sharing
reducing stress and tension was

76

their concerns with or
seeking support from friends.
The data were analyzed according to the percentage
distribution of the items under the External Coping

Patterns subcategory of ’’Neighbors",

This subcategory

contained three items pertaining to the support and
favors received from neighbors.

Table 11 summarizes the

results.

Table 11
Percentage Distribution of External Coping Patterns

Subcategory Neighbors, Items for Families

DA*

Specific Subcategories Items
n=44

NA/ND*

A*

1. Receiving gifts and favors from neighbors
30%
(e.g. food, taking mail, etc.)

25%

45%

2. Asking neighbors for favors and
assistance.

45%

27%

27%

3. Sharing problems with neighbors.

68%

18%

14%

*DA= disagree, NA/ND= neither agree nor disagree, A=agree

Data analysis revealed that receiving gifts and food

from neighbors had the highest percentage of agreement
(45%) for this subcategory.

Less than half of the

families surveyed agreed that gifts and food received
Analysis of the data also
from neighbors was a benefit.

77

revealed sharing of problems with neighbors had the
lowest percentage of agreement (14%) and the highest
percentage of disagreement (68%) for this subcategory.
This indicated the families did not agree that sharing

their concerns with their neighbors would help them cope

with the stressors associated with the CABG surgery.
Many reasons for this high percentage of disagreement may­
exist.

For example, the families may not have felt

comfortable enough to share their problems with their
neighbors .

The data were analyzed according to the percentage
distribution of the items under the External Coping

Patterns subcategory of "Extended Family".

This

subcategory relatws to the support received from

relatives.

Table 12 summarizes the results.

Data analysis revealed sharing difficulties with
relatives had the highest percentage of agreement (59%).
This result indicated the families agreed that sharing

their concerns and problems with their relatives was
beneficial in reducing the stressors associated with the

CABG surgery.

This result was not surprising since the

interconnected and shared
relatives and the families were

common bonds.

78
Table 12

Percentage Distribution of External Coping Patterns
Subcateqory Extended Family, Items for Families
Specific Subcategories Items
n=44

DA*

NA/ND* A*

1. Sharing difficulties with relatives.

27%

14%

59%

2. Seeking advice from relatives
(grandparents, etc.).

39%

23%

39%

3. Doing things with relatives.

20%

25%

55%

4. Asking relatives how they feel
about problems we face.

48%

20%

32%

*DA= disagree, NA/ND

neither agree nor disagree, A=agree

Data analysis revealed that "Asking relatives how

they felt about the problem" had the lowest percentage of
agreement (32%).

This result indicated relatives

perception of the problem was not a significant factor in
helping families in this study cope with the stressors
associated with CABG surgery.

"Doing things with

relatives" had a 55% agreement for families.

The

families in this study agreed being involved in

activities with relatives did help them cope with the
Data
stressors associated with the CABG surgery.

low
analysis revealed seeking advice from relatives had a
This indicated families
percentage of agreement (39%).

79
to a degree sought the advice of relatives to assist them
in coping with the stressors associated with the CABG

surgery.

The families would rather share their problems

with relatives but were not interested in seeking their
advice or perception of the situation.
The data were analyzed according to the percentage
distribution of the items under the External Coping

Patterns subcategory of "Church/Religious Resources".

This subcategory contained related to the religious

beliefs of the families in the study.

Table 13

summarizes the results.

Table 13
Percentage Distribution of External Coping Patterns
Subcategory Church/Religious Resources,Items for Families

Specific Subcategories Items
n=44

DA*

NA/ND*

A*

9%

11%

80%

Participating in church activities.

20%

18%

61%

3.

Seeking advice from a minister.

30%

27%

43%

4.

Having faith in God.

7%

9%

84%

1.

Attending church services.

2.

*DA= disagree, NA/ND- neither agree nor disagree, A=agree

80
Data analysis revealed
that faith in God had the
highest percentage of agreement (84%) for families.
This

indicated that the families in this study relied greatly
on this coping pattern to deal with the stressors
associated with the surgery.

Attending religious

services had an 80% agreement by the families, which

indicated that they sought solace in attending religious
services.

Participating in religious activities had a

61% agreement by the families.

This indicated they

utilized this coping pattern in dealing with the
stressors associated with CABG surgery to a great degree.

The lowest percentage of agreement was seeking advice
from a minister (43%).

This indicated families did not

utilize this coping pattern to assist them in coping with
the stressors of the surgery.

The data were analyzed according to the percentage
distribution of the items under the External Coping
Patterns subcategory of "Community Resources".

This

subcategory related to the support received from

Also included in this subcategory

community agencies.

was professional counseling and seeking information for

the physician.

Table 14 summarizes the results.

Data analysis revealed that seeking advice and
information from the
of agreement (82%)

physician had the highest percentage

in this subcategory.

Because anxiety

81
can be heightened by the families'

misunderstanding of the

lack of information or

recovery process from CABG

surgery, educating them can reduce their stress and
fears. The result of data
analysis indicated the
families agreed that the information received from the

physician was important and helped reduce the stress of

the surgery.

Table 14
Percentage Distribution of External Coping Patterns
Subcategory Community Resources, Items for Families

DA*

NA/ND*

1. Seeking assistance from community
agencies and programs.

34%

23%

43%

2. Seeking information and advice from
the family doctor.

14%

5%

82%

3. Seeking professional counseling and
help for the family difficulties.

34%

25%

52%

Specific Subcategories Items
n=44

*DA= disagree, NA/ND

A*

neither agree nor disagree, A=agree

Seeking professional counseling had a 51% agreement
by families.

This indicated professional counseling was

viewed as helpful by

half of the families surveyed.

Professional counseling allowed the families to ventilate

82
their fears and concerns in a
nonthreatening environment
in addition to receiving advice from
an objective source.
Assistance from community agencies and
programs had the
lowest percentage of agreement (43%) for this

subcategory.

This indicated a little under half the

families in the study utilized community agencies to cope
with the stressors of CABG surgery.

Data analysis revealed that the families in this
study utilized a variety of coping patterns to cope with

the stressors associated with CABG surgery.

The families

relied on their religious faith and their confidence in

their problem solving abilities to cope with the

stressors of the CABG surgery.

The families did not

passively deal with the stressors.

They actively looked

for new strategies to adapt to the stressors associated

with the stressors of CABG surgery.
The second research question posed was,

"How did

the adult children of CABG clients cope with the

stressors of the surgery as compared to the spouses of

CABG clients during the six to twelve months following
the surgery?"

The Family Crisis Oriented Personal Evaluation

Scales (F-COPES) (McCubbin , Olson, and Larsen, 1991) were
developed to

identify problem-solving and behavioral

strategies utilized by

families in difficult or

83

problematic situations.

The scale focused on two levels

of interaction identified in the Double
ABCX Model:
1.
Individual to family system
or the internal means of
handling difficult or problematic situations
and
2. Family to social environment
or the external means of

handling problems that emerged outside the family
boundaries.

To determine how each group coped with the stressors

of the CABG surgery, the questionnaires were separated

into the two groups (spouses and adult children).

The

responses of the spouses and the children to the F-COPES
questionnaires were tabulated and given a score.

Total

F-COPES scores for the present study ranged from 76 to

120 for the children and 86 to 137 for the spouses.
These scores were averaged to gain the mean scores for

each group.

Table 15 summarizes the results.

Table 15
F-COPES Mean Scores for the Spouses and Children

Variable

Maximum
Possible
Score

Mean
Scores

Spouses:

(n=16)

150.00

105.75

Children:

(n=28)

150.00

102.54

84
Data analysis revealed
that the mean scores were

close, indicating that both groups had coped with similar
strength. Based on the
mean scores for both groups, it
could not be determined which group coped better with the
stressors associated with CABG surgery.

The spouses' and children's responses to the Family

Crisis Oriented Personal Evaluation Scale (F-COPES Scale)
were divided into Internal and External Coping Patterns

and a score for each category was tabulated.

These

scores were averaged to determine the category's mean
scores for each group.

The scores for each category were

analyzed to determine which coping patterns were utilized
by each group.

Table 16 summarizes the results.

Table 16

Mean Scores on Internal and External Coping Patterns of

Spouses and Children
Maximum
Possible
Score

Category

Mean
Score

Internal Coping Patterns
(n=16)

60.00

39.38

Children (n=28)

60.00

38.18

90.00

61.31

90.00

58.57

Spouses

External Coping Patterns
Spouses

(n=16)

Children (n=28)

85
Analysis of the data revealed that
both groups' mean
scores were close indicating that both
groups utilized
each of the categories of Internal
and External Coping
Patterns similarly. The spouses'
mean scores for both
categories were slightly higher (internal 39.38 and

external 61.31) as compared to the adult children' s mean

scores (internal 38.18 and external 58.57).

This result

indicated the spouses utilized both Internal and External
Coping Patterns to a slightly greater degree than the
children.

To further determine which coping patterns were
utilized by the spouses and children of CABG clients, the

data were analyzed according to percentage distribution
of disagreed (strongly and moderately), neither disagreed

nor agreed (neutral), and agreed (strongly and

moderately) responses on the questionnaire for Internal

and External Coping Patterns by spouses and children.

Table 17 summarizes the percentage distribution of the
responses of disagree, neither disagree nor agree, and
agree by spouses and children for the Internal and

External Coping Patterns.
The percentage of agreement of spouses for Internal

Coping Patterns (59%) and External Coping Patterns (58%)
was higher as compared to the children's percentage of

agreement for Internal Coping Patterns (52%) and External

86

Coping Patterns (49%),

This indicated that the spouses

had utilized more coping patterns in
the Internal and
External categories as compared to the children.

Table 17

Percentage Distribution of Internal and External Coping
Patterns of Spouses and Children

Category

Disagree

NA/ND*

Agree

(n=16)

26%

15%

59%

Children (n=28)

30%

18%

52%

(n=16)

26%

16%

58%

Children (n=28)

27%

23%

49%

Internal Coping Patterns
Spouses

External Coping Patterns

Spouses

*NA/ND= neither disagree nor agree

To determine which specific coping patterns were
utilized by each group, the spouses' and children's

according to the Internal Coping
responses were analyzed
Coping Patterns subcategories, The
Patterns and External
were calculated for the
mean scores each category
Internal Coping Patterns. Table 18
subcategories of
summarizes the results.

87
Table 18

Internal Coping Patterns Mean Scores of
Spouses and
Children
Subcategories

Maximum
Possible
Score

Spouses
(n=16)

Children
(n=28)

Reframing
(13,15,19,24) *

20

17.44

15.50

Family Passivity
12,17,26,28)*

20

7.75

7.64

Confidence in Problem Solving
(3,22,27,11)*
20

16.38

15.21

*Refers to statements in Appendix E

The spouses' reframing mean score (17.44) was higher

than the adult children's mean score (15.50), indicating
that the spouses' relied on this coping pattern more than

the adult children.

••Reframing" reflected the spouses'

and children's abilities to redefine the situation
positively.

"Family Passivity" subcategory had the lowest

7.75 and children
mean scores for both groups (spouses
this subcategory were close. This
The scores in
7.64) .
did not find passivity an
indicated that both groups

assist them in dealing with
effective coping pattern to
The coping patterns in this subcategory were the
stress.
and children.
ones least utilized by the spouses

88

The spouses' mean score
(16.38) and the children's
mean score (15.21) for the
subcategory "Confidence in

Problem Solving" were close as well.

This result

indicated spouses and children utilized this coping
pattern similarly.
"Confidence in Problem Solving"

reflected the spouses' and children's confidence in their
problem solving abilities.
As indicated by the mean scores, the spouses

utilized more coping patterns when compared to the adult
children.

This was evidenced by the mean scores and the

percentage of distribution scores for each group.

Internal Coping Patterns subcategories were analyzed

according the percentage distribution of disagreed,

neither disagreed nor agreed (neutral), and agreed
responses on the questionnaires of the spouses and

children.

Table 19 summarizes the percentage of the

responses of families on the Internal Coping Patterns.

The percentage of agreement for the spouses (92%) in
was higher than the
the subcategory of "Reframing"
This indicated
children's percentage of agreement (73%).
utilized the coping patterns in
the spouses in the study
with the stressors of the CABG
this subcategory to cope

surgery more than the children.

89
Table 19

Percentage Distribution of Internal Coping Patterns
Subcategories for Spouses and Children

Subcategories

DA*

NA/ND*

A*

Refraining
Spouses (n=16)

2%

6%

92%

Children (n=28)

7%

20%

73%

Family Passivity
Spouses (n=16)

67%

23%

9%

Children (n=28)

72%

17%

11%

Confidence in Problem solving
Spouses (n=16)

8%

14%

78%

Children (n=28)

11%

19%

70%

*DA= disagree, NA/ND= neither agree nor disagree, A=agree

Low percentage of agreement on the "Family
Passivity" subscale for both groups reflected the

spouses' (9%) and the children's (11%) negative view of
this subcategory as a means of coping with stress. The
high percentage of disagreement for both the spouses

(67%) and the children (72%) in this subcategory further
supported the spouses

and the children's beliefs this

90

coping pattern was not effective in coping with the

stress of the surgery.

The spouses and children in this

study did not passively deal with the stressors of the

surgery rather they took an active approach in coping

with them.

Further data analysis of Internal Coping Patterns'
subcategories revealed that 78% of the spouses and 70% of

the children agreed that they had confidence in their
problem solving abilities and mastery over the situation.

This result indicated that the spouses agreed that they

had the strength and ability within the family to solve

problems by facing them "head-on" at a higher level than
the children.

The data were then analyzed according to External
Coping Patterns.

The mean scores for each of the five

subcategories of External Coping Patterns were calculated

from the questionnaire responses of the spouses and
children.

Table 20 summarizes the mean scores of spouses

and children for the External Coping Patterns
subcategories.

91

Table 20

External Coping Patterns .Mean Scores of Spouses and
Children
Subcategories

Maximum
Possible
Score

Spouses
(n=16)

Children
(n=28)

Friends
(2,4,16,18)*

20

14.00

14.14

Neighbors
(8,10,29)*

15

7.63

6.75

Extended family
(1,5,20,25)*

20

13.19

12.68

Church resources
(14,23,27,30)*

20

15.63

14.75

Community resources
(6,9,21)*

15

10.88

10.25

*Refers to statements in Appendix E

The scores for the subcategories of "Friends,
Neighbors, Community Resources and Extended Family" were

similar for both groups indicating that they looked for
support in these areas.

The mean scores in the

subcategory of "Church Resources" indicated the spouses

(15.63) utilized this coping pattern to a slightly higher
The spouses
degree than the adult children (14.75).
as a
sought the comfort and support of their religion
means of coping more

often than did the adult children.

the subcategories of "Friends"
The mean scores for

92
(spouses 14.00 and children 14.14),
14.14), -Neighbor,(spouses
7.63 and children 6.75), -Extended Families(spouses
13.19 and children 12.68), and
"Community Resources"
(spouses 10.88 and children 10.25) were close. This

indicated both groups utilized these coping patterns
similarly to cope with the stressors associated with CABG

surgery.
External Coping Patterns subcategories were analyzed

according to the percentage distribution of disagreed

(strongly and moderately), neither agreed nor disagreed
(neutral), and agreed (strongly and moderately) responses
on the guestionnaire of the spouses and children.

Table

21 summarizes the percentage of the responses of families
on the external coping patterns.

Data analysis revealed the spouses' percentage of
agreement scores were higher in the subcategories of
"Neighbors", "Extended Family", "Church and Community

Resources".

Of the 16 spouses, 35% agreed that they

relied on neighbors for support and assistance as

compared to the 25% of the 28 adult children who had

agreed.

In this subcategory, support from neighbors

ranged from picking up the mail, to receiving food, to
asking them for favors or assistance.

The spouses looked

favors more than the
to their neighbors for these
children did.

93

Table 21
Percentage Distribution of External Coping Patterns
Subcateqories for Spouses and Children

Subcategory

DA*

NA/ND*

A*

Friends

Spouses

(n=16)

20%

21%

59%

Children

(n=28)

13%

29%

58%

Neighbors
Spouses

(n=16)

46%

19%

35%

Children

(n=28)

49%

26%

25%

Extended family

Spouses

(n=16)

33%

17%

50%

Children

(n=28)

34%

22%

44%

Church resources

Spouses

(n=16)

16%

8%

76%

Children

(n=28)

17%

21%

62%

Community resources

Spouses

(n=16)

17%

14%

69%

Children

(n=28)

27%

19%

54%

*DA= disagree, NA/ND= neither disagree nor agree, A=agree

"Friends" were an

important means of support for

94
both groups.

This was evident in the
percentage of
agreement scores for the
spouses (59%) and the children
(58%) in this subcategory,

Friends were seen as a source

of support and encouragement and
someone to share
concerns.

In the subcategory of "Extended Families", 50% of
the spouses surveyed agreed that they obtained support

from their extended families while 44% of the adult
children had agreed.

These results indicated support

from the extended family was utilized by the spouses to a

greater degree than the adult children of CABG clients.
Overall, the highest percentage of agreement was in
the subcategory of "Church Resources".

Seventy-six

percent of the spouses agreed that support was gained

from religious/church resources however, 62% of the

children agreed that they gained support from this
resource to help them cope with the stressors of the

surgery.

The 21% of the children who neither agreed nor

disagreed reflected an indifference to religion as a
coping strategy when compared to the spouses (8%).
Nevertheless, in this study, religion played an important

with the stress of the
part in assisting families to cope

situation.
Of the 16 spouses

surveyed, 69% agreed they utilized

of information and
community agencies as a source

95
assistance in dealing with
the situation, while only 54%
of the children agreed.
Community resources consisted of
professional counseling, seeking information from

physicians, and turning to other families'

who have

experienced a similar situation to help cope with the
stress of the event.

Community resources offered an

objective point of view and often provided necessary

information and emotional support.
Based on data analysis it cannot be determined how

the spouses or children coped with the stressors
associated with CABG surgery.

If the hypothesis

(McCubbin, Olson, and Larsen, 1991) holds true (the more
coping patterns utilized the better the adaptation to

stressful events), then data analysis revealed the
spouses coped better than the children.

This finding was

based on the spouses mean scores and percentage of

agreement for the coping patterns identified on the FCOPES scale by McCubbin, Olson and Larsen.

However,

relatively higher scores only indicated the spouses
agreement that the coping patterns identified on F-COPES

(McCubbin, Olson, Larsen, 1991) did assist them in coping
compared to the
with the stressors of the surgery as
did not reflect the
children's score. These scores
coping patterns were in dealing with
effectiveness of the
the stressors of the surgery.

96

Families, like individuals,
differently in times of stress.

have developed and cultivated

coping with stress.

are unique and react
Families over the years

their own unique methods of

Each member of the family plays an

unique role within the family network.

Because of this

uniqueness and individuality of families, there can be no

standardization of coping strategies, used or
recommended.

The role of the nurse is to explore with

families which coping patterns best meet their needs and

to offer support and assistance as needed.

The nurse

needs to continually assess and recommend interventions
as indicated which will strengthen the families' coping
abilities.

Nurses need to remain open and flexible to

meet the needs of each family.
Appendices I and J outline the mean scores of
specific coping patterns as identified by the F-COPES

model of the spouses and the children of coronary bypass
clients in this research study.

Appendix K and Appendix

of the
L summarizes the distribution of percentages
Based on the
spouses and children for the F-COPES model.

analysis of percentage distribution for the Family Crisis

Oriented Personal
McCubbin, Olson

Evaluation Scale (F-COPES Scale) by
and Larsen (1991) , both the spouses and

they responded to difficult or
the adult children agreed
utilizing their internal strength
stressful situations by

97
and coping abilities to direct their
energies at reducing
or eliminating stress.
They accomplished this by

redefining the situation in a more positive
way or
accepting it as part of life, Both groups also had
confidence in their problem solving abilities to face the

challenges of the CABG surgery.

They knew they had the

strength to solve any major problem encountered.

Table

22 summarizes the coping strategies that had the highest

percentage of agreement for spouses and children (> 75%).

Table 22

Coping Strategies with Highest Percentage of Agreement of
Spouses and Children (> 75%).
Strategy

1. Knowing that we have the strength
within our own family to solve
our problems.
2. Facing the problems "head-on" and
trying to get solutions right away.

3. Knowing we have the power to solve
major problems.
4. Accepting stressful events as a fact
of life.

5. Accepting that difficulties occur
unexpectedly.

6. Seeking information and advice from
the family doctor.
7. Having faith in God.

Spouses
n=16

Children
n=28

100%

89%

94%

86%

88%

78%

96%

68%

100%

90%

94%

75%

88%

82%

98

Analysis of the data
revealed the statements which
had the highest percentage of
agreement for spouses and
children in this study were those
dealing with Internal
Coping Patterns.
The high percentage of agreement for

both groups (spouses 100% and adult children 89%) was
with the statement "Knowing that we have the strength
within our own family to solve our problems".

This

reflected both groups' confidence in their problem
solving abilities and offered a sense of hope.

This hope

gave the family a positive outlook on the situation and

enabled them to move forward.
Spouses agreed (100%) and the children agreed (90%)

with the statement " Difficulties do occur unexpectedly" .
This indicated both groups agreed that life is not
predictable and difficulties can and do occur

unexpectedly without warning.

This belief gave meaning

to a situation in which the family had little or no

control over.
The spouses had a higher percentage of agreement

(96%) when compare to the children's percentage of
"Stressful events are
agreement (68%) with the statement
indicated the spouses
a part of life"* These scores
of life to a greater degree
accepted stress as a part
than the adult children.

family doctor was another
Seeking advice from the

99

area of high P

ntage of agreement with spouses (94%)

ehildrot (75%).
(75,>.

“ compared to

Thle iMicat6d th.

spouses sought information from the family doctor to a
greater degree than the adult children did.
It may have
been the spouse of the ill family member who became the

primary care giver.

Information seeking would have been

necessary in order to understand the illness and its
demands more fully.

Thus, the spouses may have used this

information to plan for family reorganization and gather
resources and support in managing the situation.
Gathering information also may have offered a sense of

control over the situation.

This sense of control may

have positively impacted the family's overall appraisal
Further analysis of the data revealed

of the situation.

that the subcategory "Religious Resources" was frequently

used as a coping strategy by both the spouses and the

adult children.

Eighty-eight percent of the spouses and

82% of the children agreed that "Having faith in God"

helped them cope with the event.

This indicated that the

participants in this study turned to their religious

faith to help them

deal with difficulties and stressors

associated with the surgery,

hope and comfort in

Turning to God gave them

dealing with events in which they

One participant
felt they had little or no control.
the biggest help in
commented that faith in God was

100
getting through the

surgery and continued to be so
through the recovery period.

The coping strategies in which both the
spouses and
children had a high percentage
of disagreement are
summarized in Table 23. These coping strategies fall
under the category of "Family Passivity".

Table 23
Coping Strategies with the Highest Percentage of

Disagreement of Spouses and Children

Strategy

Spouses
n=16

Children
n=28

1. Knowing luck plays a big part in how
well we are able to solve family
problems .

57%

75%

2. Feeling that no matter what we do to
prepare, we will have difficulty
handling problems.

69%

49%

3. Believing if we wait long enough,
the problem will go away

87%

89%

The high percentage of disagreement for both groups

a passive approach
indicated coping patterns dealing with

to the problem were the

least coping strategies used.

this study did not agree with
The spouses and children in
taking a passive approach in dealing with the stress
encountered during

approach to the

the recovery process,

An active

problem provided the opportunity for

101
family involvement in the client's
care and for family
unity and growth. The passive
coping strategies, such as
"Knowing luck plays a
narti
„
n .
y a part in
m solving problems" (spouses

57% and children 75% \

=
' and

a •
Not doing anything will make

the problem go away" (spouses 87% and children

89%) were

the coping strategies least utilized by the spouses and
children.
Strategies used most frquently by the spouses and

children in this study may be useful for families of

future CABG clients.

Based on the distribution and mean

scores and the percentage of agreement revealed in this
research study, the nurse can recommend to spouses and

children of CABG clients interventions which will enhance
both their internal and external coping abilities.

These

interventions need to be directed at strengthening their

problem solving abilities, assisting them with redefining
the situation in a more positive way, and making them

more aware of their strengths to face the challenges
encountered by the surgery. Families may also be
encouraged to seek

relatives.

outside support from friends and

Appropriate religious personel may be

consulted to assist the

family in coping during the

clients' recovery.
As data analysis
of CABG clients coped

revealed, the families and spouses

with the stressors of the recovery

102

process by using a variety of coping patterns.

To

recommend specific coping patterns to CABG clients'

spouses and children would limit the coping abilities of

the family.

The family needs to be given guidance to

utilize a variety of coping patterns.

Each family is

unique with its own set of established rules.

Therefore,

the nurse's role in assisting the family with the
stressors associated with CABG surgery is to assess the

family's established coping patterns to suggest patterns
that have worked for others, and to offer support and

encouragement to the family.

If the family's established

coping mechanisms are not sufficient to help the family

deal with the stressors, then the nurse should explore

new strategies of coping with the family.

CHAPTER V

CONCLUSION

This descriptive comparative research study was

designed to determine patterns of adaptation of the
spouses and family members of coronary bypass graft
clients to the stressors of coronary bypass graft surgery

during the six months to a year following the surgical
event.

The Double ABCX model of Family Adjustment and

Adaptation by McCubbin and Patterson (1983) provides an
organizing framework for the study.

The Family Crisis

Oriented Personal Evaluation Scale (F-COPES) by McCubbin,

Olson, and Larsen (1991) was utilized to determine family
coping behaviors.

The results of the study suggests the

spouses and the children of coronary bypass graft clients
utilized a variety of coping strategies to deal with the

stressors of the surgery.

Both internal and external

coping patterns were utilized to assist the spouses and
the children in adapting to the stressors of the surgical
event.

Discussion

a complex system which provides
The family is
physical, social, .notional, and psychological benefits
103

104

and needs to individuals within the
family unit
(Danielson, Hamel-Bissel,
& Winstead-Fry, 1993). The
structure and function of the family is established by

successfully assigning and performing roles to individual
members. All members are interconnected and
interdependent upon one another.
The roles within the family unit evolve as
individual members mature and change with life

experiences.

illness is an example of a life experience

which requires individuals to make changes within their
lives.

These changes affect the entire system since the

individuals may need to relinquish some of their
responsibilities and roles within the family.

Family

members must be flexible to take on more responsibilities
and assume different roles in order to continue usual
family functioning (Maynard, 1993).

Assuming the added

responsibilities and roles due to illness of a family
member may cause stress within the family.

Coronary artery disease is an example of a stress­

producing illness

which not only affects individuals but

The stress of the
also impacts upon the entire family.
affected individuals require
illness is compounded if the

to treat the effects
coronary artery bypass graft surgery
of the disease.

Coronary artery bypass graft surgery can

within families and
drastically increase the stress

105

disrupt routine functions,

Assessment of the families'

coping skills, problem -solving abilities,
and their needs
is an essential step to
understanding how families will
cope with the stress of the surgery.
It was the purpose of this study to assess the
coping abilities and adaptation process of families of
coronary artery bypass graft clients during the six to

twelve months following CABG surgery.

Although the

research population was small and limited to one agency,

conclusions can be drawn from this quantitative study,
which may provide direction to nurses in assisting

families of CABG clients coping with the stressors during
the six to twelve months following surgery.

The study

revealed the adult children and spouses of coronary
bypass graft clients used a variety of coping patterns
and behaviors during the six to twelve months following a
family member's coronary bypass graft surgery.

These

findings were based on the coping patterns identified by

the Family Crisis Oriented Personal Evaluation Scale (FThe Family
COPES) (McCubbin, Olson, & Larsen, 1991).

Crisis Oriented Personal Evaluation Scale (F-COPES) is an
assessment tool used to

identify the coping patterns and

and children of
behaviors utilized by the spouses
graft clients. The instrument
coronary artery bypass
and behaviors which focus
contains thirty coping patterns

106
on the adaptation portion of the
Double ABCX model of
Family Adjustment and Adaptation
by McCubbin and
Patterson (1983). The instrument
contains coping
patterns which are based on the two levels of interaction

as outlined in the Double ABCX Model Family Adjustment
and Adaptation by McCubbin and Patterson (1983):

(1)

individual to family system or how the family internally
handles difficult situations between its members; and (2)

family to social environment, or how the family

externally handles problems that arise from outside the
family (McCubbin and Patterson, 1983).
By utilizing a variety of coping patterns the

spouses and children were able to gain support from a
variety of resources to help them deal with the stressors

during the six to twelve months following the surgical

event.

A variety of resources available to the spouses

and children may have assisted them with maintaining

homeostasis within the family unit.

This was consistent

with the Double ABCX Model of Family Adjustment and
hypothesized that families using
Adaptation (1983) which
behaviors obtained from the
more of coping patterns or
would adapt more successfully
two levels of interactions
situations (McCubbin and Patterson, 1983).
to stressful
number of coping patterns
Yet simply, determining the
families will cope with stress.
cannot predict how

107

Assessing the number of
copmg patterns identified by
families will give an indication
of the wide variety of
coping patterns and behaviors
from which they have chosen
and therefore is a measure of potential flexibility in
meeting the demands of the stressor.

Thus they will have

a greater probability for successful adaptation to the

stressor.
A second finding in the study is spouses and
children coped similarly during the six to twelve months

following the surgical event.

This is evident by similar

F-COPES percentage of agreement for both groups.

Because

there may be parent-children combinations who responded
to the questionnaire, coincidences in similar coping

patterns may not be accidental.

Parent-child

combinations would have similar value systems, beliefs,

and coping methods and resources,
coping abilities would be similar,

Therefore, their

However, the data

that were gathered provides no way of linking a specific
parent and child.
A third finding in this study is the high percentage
of agreement by the spouses

and the children to the items

identified on the Family Oriented Personal Evaluation
Scale (F-COPES) (McCubbin, Olson, & Larsen, 1991),
subcategories of
relating to internal coping patterns
in problem solving. Reframing
reframing and confid®nce

108
reflected the spouses

and the children's ability to

redefine the situation positively.

The spouses and the

children in this study agreed that they responded to
difficult or stressful situations by utilizing their

internal and external strengths and coping abilities to
direct their energies at reducing or eliminating the

stressor.

They accomplished this by redefining the

situation in a more positive way or accepting it as a

part of life.

Both groups also had the confidence in

their problem solving abilities to face the challenges of
the CABG surgery.

They knew they had the strength to

solve any major problems encountered. Thus they were able
to effectively manage the stressor of the surgery.

Confidence in problem solving abilities may also
have reduced the stress and anxiety associated with
coronary bypass graft surgery, as evidenced by the high
percentage of agreement by spouses and children in this
area.

Confidence in problem-solving reflected the

confidence in their abilities to
spouses ' and children's
effectively meet the demands of the stressors associated

with coronary bypass graft surgery.
inner strength and power

They relied on their

to face the challenges of the

surgery.

A fourth finding

of the study is the high percentage

of agreement for three of the five external coping

109
patterns subcategories

friends, church/religious

resources and community resources.

External coping

patterns are resources the family uses outside the

immediate family unit (McCubbin, Olson, & Larsen, 1991) .

The spouses and children viewed friends as a source

of support and encouragement and with whom they could

talk over the stressful event and obtain advice from
outside the family.

Friends may have provided many

benefits to the spouses and children:

emotional support,

a feeling that they are cared for, esteem building, and a

feeling that they are respected and valued (Cobb,1976).
This mutual trust relationship helped to reduce the

stress associated with the coronary bypass graft surgery.
Community resources and support were used by the

spouses and the children in this study to cope with the
stressors associated with the surgery.

Resources and

support include a range of services, such as medical,
community, or professional counseling services.

Medical

resources (such as talking with the physician) were very
Studies have
important to the spouses ■and children.

for information regarding their
listed the families' need
of the top priorities during the
loved ones as being one
(Leske, 1986; Molter,1979). The
illness experience
the condition, the prognosis, and
families needed to know
loved ones (Leske, 1986). Based
the progression of their

110
on that information, th^v =
y are able to make decisions
regarding the long term
care of the clients and any
changes in roles or
responsibilities needed within the
family.
The spouses and children in this
study agreed
that seeking information from physicians was an important
source of support for them.

The role of the nurse may be

in facilitating a dialogue between the physician and the

families.

In addition to this facilitating role, the

nurse is also a teacher, a communicator, and a patient

care manager.
Also included in External Coping Patterns

subcategory " Community Resources" is the use of
A community agency from which the

community agencies.

study drew participants from was the phase II Cardiac
This program offered classes

Rehabilitation Program.

regarding lifestyle changes and risk factor modification.

Clients and their families were encouraged to attend

these classes.

Informally, these classes were a source

of support and encouragement.

were able to meet others
compare their progress

The clients and families

with similar situations and

and share their concerns.

This

helped the clients and their
informal support may have
associated with coronary
families cope with the stressors
bypass graft surgery.

The subcategory

"Church Resources

is also contained

Ill
in the External Coping Patterns
subcategory community
resources.
Church resources had the highest
percentage
of agreement for spouses and children. Both groups
agreed that their religious convictions helped them cope
with the stressors associated with the coronary bypass

graft surgery.

This belief in religion or spirituality

may have offered the spouses and children a sense of
hope, gave them the confidence in their problem solving
abilities, and enabled them to move forward and confront

the stressors associated with the surgery.

Spirituality is often overlooked as an area for
intervention by nurses because these beliefs are deemed

personal and private.

Spirituality may be an area where

nurses may explore with families its significance in

family coping.

If families deem it a significant source

of potential comfort, then the nurse may encourage, and

if needed, facilitate spiritual interventions in the
coping process.

The six months to a year following the coronary

bypass graft surgery may still be a critical and
and families. The event
vulnerable time for clients
undergo sudden and often
causes clients and families to
the demands and stressors
drastic changes because of
It is important that health care
encountered.
the families' coping patterns and
professionals assess

112
use this knowledge to determine strategies for
intervention . By assessing coping patterns and gaining
an insight into family functioning, nurses can gain

insight into what is important to individual families.
Establishing harmony between the old and new
patterns of coping is a process occurring over time.
Families may struggle with fitting these new patterns of
coping into their already well-developed coping systems

because change is required as they assimilate the new
coping patterns.
It is at this point that families are most

vulnerable.

Nurses must be aware of each family's

vulnerability and assist them in coping with stressors or
demands they face.

Change is necessary within the family

system for them to adapt to the stressors of the surgery.

These changes should be made in an environment which
promotes stability and predictability (Danielson, Hamel-

Bissel, & Winstead-Fry, 1993).

The effectiveness of the

new coping patterns depends on the meaning each family

attaches to them.

Coping and problem solving may be

directed at reducing or

eliminating stress, acquiring new

demands of the system while
resources and balancing the
External resources from the
maintaining integrity.
health care professionals, can
community, including
maintain harmony and cohesiveness in the
assist families

113
adaptation process.
Unfortunately, community agencies dealing
specifically with
coronary bypass graft clients and their
families are limited in some communities.
Yet a cardiac
rehabilitation program with a focus of assisting clients

with initiating and continuing an exercise regime and

informational sessions relating to dietary restrictions,
risk factors modification, and lifestyle changes seems

critical.

Family support sessions may also benefit many

families.

Support sessions specifically for families of

CABG clients would enable the family to tap into new

coping resources thus assisting them in adaptation

process.
Conclusion
Data about the coping patterns of the spouses and
adult children of coronary bypass graft surgical clients

suggested the following conclusions:
1.

2.

3.

Spouses
Spouses and children of CABG clients in the
six months to twelve months following the
surgical event used a variety of coping
patterns to cope with the stressors
associated with the event.
The spouses and children of coronary
artery bypass graft clients' relied on .
internal coping patterns such as reframing
tnd having confidence in their problem
solving abilities to cope with the stress
of the event.

The .nnnses
spouses and children of coronary artery
bypass graft clients sought encouragement

114
and r--- • from friends t
dealing with the stressorsto assist them in
j associated with
the event.

4.

Spouses and children of CABG clients
t^zed community resources such as an
established cardiac rehabilitation program
and information obtained from their
p ysician to cope with the surgical event.

5.

The spouses and children of coronary artery
bypass graft clients relied on their
beliefs in religion or a higher power to
cope with the stressors of coronary bypass
graft surgeries.

Recommendations
Based on the results of this research study, the
following recommendations are made:

1.

This study be replicated using a larger
sample and not limited to one agency.

2.

The guestionnaire be expanded to include:

a

Information about the marital status,
the number of children, and
employment status of the adult children
and spouses, as well as to account for
parent-child combinations.

b. Information regarding the a9e/
employment status, and the number of
children under the age of 18 years of
the CABG client's spouse.
r

3.

Information regarding the postoperative
recovery of the CABG clients; i.e. were
there any complications relating to the
surgery?

ThiA study should be replicated using the
This stuay
oriented Personal Evaluation
McSbbln, Olson, and Larsen a. a.
adjunct to a tool which would elicit

115
information about how each
group coped
with the surgical event.

4.

Alter the Likert scale on the F-COPES to a
4 point scale (l=strongly disagree,
2=disagree, 3= agree, 4=strongly agree).

Implications for Nursing
The results of this study reinforces this author's
belief that nurses, as part of the health care team, have
an important role with families in the recovery phase of

coronary bypass graft clients.

The coronary bypass graft

surgery not only affects clients but entire families.

Families are often forgotten once the coronary bypass
graft clients are discharged from the hospital.

Many

established programs exist for CABG clients, but many do

not include family members.

Families need continued

support both emotionally and educationally to help them

during the recovery process.

In order to provide

holistic care for clients, families
met.

needs must also be

Meeting these needs will enable the family members

to maintain homeostasis and reestablish family
cohesiveness.

By

assessing the coping patterns of

families, the nurse can gain an understanding of family

. .
•
recovery and assist them in coping
behavior in illness
that are encountered
with the stressors and role changes
with coronary bypass surgery.

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APPENDICES

Appendix A

123

EDINBORO UNIVERSITY
OF

PENNSYLVANIA

October 14, 1993

Department of Nursing
Edinboro, PA 16444
(814) 732-2421

Dr. H. McCubbin
1300 Linden Drive
University of Wisconsin
Madison, WI 53706

Dear Dr. McCubbin:
I am enrolled as a graduate student in the Master of
Science of Nursing program at Edinboro University of
Pennsylvania.
I am writing to ask permission to use your
Family Crisis Oriented Personal Scales (F-COPES) and your
framework of T-Double ABCX Model of Family Adjustments
and Adaptation in the preparation and implementation of a
master in nursing thesis requirement.
Any information and/or suggestions that you may have
about the application and implementation of the T-Double
ABCX Model of Family Adjustments and Adaptation would be
greatly appreciated.

I await your reply and thank you for your time.
Sincerely,

Mary Alice Nash B.S.N., R.N.
Master candidate in the Science in Nursing

A member of the State System of Higher Education

_

Appendix!B

UNIVERSITY of

WISCONSIN
M A D I S

1

o

I

124

n

I

i

November 9, 1993

Mary Alice Nash
917 West 30 Street
Erie, PA 16508
Dear Ms. Nash:
I am pleased to give you my permission to use the Double ABCX Model in your work.

When using the Double ABCX model the correct reference is McCubbin, H.I. and J.
Patterson (1983). “The Family Stress Process: The Double ABCX Model of Adjustment
and Adaptation.” In H. I. McCubbin , M.B. Sussman, and J.M. Patterson (Eds.)
Advances and Developments in Family Stress Theory and Research. New York:
Haworth Press.

If I comd,

of any further assistance to you, please let me know.

Sincerely,

Iton I. McCubbin

HIM/kme

Enclosures

Office of the Dean
School of Family Resources and Consumer Sciences
1300 Linden Drive

Madison, Wisconsin 53706-1575

608/262-4847

FAX: 608/262-5335

125

Appendix C

EDINBORO UNIVERSITY
OF

PENNSYLVANIA
Department of Nursing
Edinboro, PA 16444
(814) 732-2421

March 6, 1994
Dr. H. McCubbin
1300 Linden Drive
University of Wisconsin
Madison, WI 53706

I

Dear Dr. McCubbin,

I*

I wrote to you last November asking permission to use
your Family Crisis Oriented Personal Scales (F-COPES) and
your framework of Double ABCX Model of Family Adjustments
and Adaptation in preparation and implementation of a
master in Nursing thesis requirement.

I

)

I

If you recall I* am currently a student at Edinboro
University of Pennsylvania.
i have received your
permission to use the Double ABCX Model in my thesis, I
am writing to you now requesting permission to use the
Family Crisis Oriented Personal Scales (F-COPES) in my
research study.' For your convenience I have enclosed a
self addressed envelope.

I await your reply and. thank you for your time.
Sincerely,

I

I

Mary Alice Nash, B.S.N., R.N.
Master in Nursing Candidate

A member of the State System of Higher Education

Appendix p

U-N I v e

r sTt y o f

WISCONSIN
A D I S O N

126

April 25, 1994

Maiy Alice Nash
Edinboro University
Department of Nursing
Edinboro, PA 16444
Dear Ms. Nash:
I am pleased to give you my permission to use the F-COPES: Family-Crisis Oriented
Personal Evaluation Scales (McCubbin, H., Olson, & D., Larsen, A.) instrument.
We have a policy to charge $5.00 (one time charge only) per instrument to individuals
who seek permission. We apologize for..this necessity. We also ask that you please fill out
the enclosed abstract form and return it to this office.

The manual, Family Assessment Inventories for Research and Practice, Second
Edition should be cited when using the instrument. The publication is currently out of
print while a new edition is being compiled. However, we are making packets available for
the instrument including scoring, psychometric data and theoretical information at a cost of
$15.00 per packet. It is not advisable to use the Family Inventories manual by David
Olson to score the instrument due to errors in its scoring section.
A sample copy of the instrument is enclosed. Additional copies can be obtained at this
address for 10 cents each. When large quantities are requested, the cost of postage is also
added to the order.

If I could be of any further assistance to you, please let me know.
Sincere™

H;

ilfon I. McCubbin
te

Enclosures

Office of the Dean
School of Family Resources and Consumer Sciences

1300 Linden Drive

Madison. Wisconsin 53706-1 575

PAY- Ano/icn coor

Appendix-

e

<< OF

fAMILY STRESS COPING ANO HEALTH PROJECT

1300 Linden Drive
iinivtrtlty ot Wltconeln-U&dlton
WI53706

Farn',y form pr<x,,am

■q

F-COPES

H McCubbm
^AOISO^

127

FAMILY CRISIS ORIENTED PERSONAL SCALES
HamUton L McCubbin

David H. Olson

Andrea S. Larsen

PURPOSE

The Family Crisis Oriented Personal Evaluation Scales is designed to record effective problem­
solving attitudes and behavior which families develop to respond to problems or difficulties.
WRECT1OH8

First, read the list of "Response Choices" one at a time.
Second, decide how well each statement describes your attitudes and behavior in response to
problems or difficulties. If the statement describes your response very well, then circle the
number'5 indicating that you STRONGLY AGREE; if the statement does not describe your response
at all, then circle the humber 1 indicating that you STRONGLY DISAGREE; if the statement
describes your response to some degree, then select a number 2, 3, or 4 to indicate how much
you agree or disagree with the statement about your response.

e

c

CJ
©

Q
x

c

E cn

© ©
■u •

o
WHEN WE FACE PROBLEMS OR DIFFICULTIES IN OUR FAMILY, WE RESPOND BY:

i?
<5

>»

OT

o>

c

2?

<
>-

<

©

•q

c

“ o

o

C

o

zZ

z

3)

1

2

3

4

5

2 Seeking encouragement and support from friends

1

2

3

4

5

3 Knowing we have the power to solve major problems

1

2

3

4

5

4 Seeking information and advice from persons in other families who have
faced the same or similar problems---------- - ---------------

1

2

3

4

5

5 Seeking advice from relatives (grandparents, etc.)

1

2

3

4

5

6 Seeking assistance from community agencies and programs designed to help
families in our situation

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

Sharing our difficulties with relatives

7 Knowing that we have the strength within our own family to solve our
prob1ems

___________ ________ ___________

_8 Receiving gifts and favors from neighbors (e.g.food, taking in mail, etc.)
9 Seeking information and advice from the family doctor

10 Asking neighbors for favors and assistance

------------

128

©

o

s
Q
>.
O>

o

WHEN WE FACE PROBLEMS OR DIFFICULTIES IN OUR FAMILY, WE RESPOND BY:

>»
S ©

ii

o

o
o
Z

co

2?

< «5

s© «« 55
T) «

w

©

<

c

2

11

Facing the problems "head-on" and trying to get solution right away

1

2

3

4

5

12

Watching television

1

2

3

4

5

13 Showing that we are strong

1

2

3

4

5

14 Attending church services

1

2

3

4

5

15 Accepting stressful events as a fact of life

1

2

2

4

2

16

Sharing concerns with close friends________

1

2

3

4

5

17

Knowing luck plays a big part in how well we are able to solve family
problems_________________ __ ________________

1

2

3

4

5

18

Exercising with friends to stay fit and reduce tension

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

2

3

4

5

1

2

3

4

5

X

2

1

A

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

19 Accepting that difficulties occur unexpectedly

20 Doing things with relatives (get-togethers, dinners, etc.)
21

Seeking professional counseling and help for family difficulties

22

Believing we can handle our own problems

23

Participating in church activities

Defining the family problem in a more.positive way so that we do not
become too discouraged
about problems we face
25 Asking relatives how they feel
we will have difficulty

24

26 Feeling that no matter what we do to prepare.
handling problems___
27 Seeking advice from a minister
28 Believing if we wait long enough
29 Sharing problems with neighbors
30 Having faith in God

—

129

Appendix F

Dear ,
I am ra nursing student at Edinboro University.
As part
of my graduate
studies
-------at Edinboro University, x QU1
I am
conducting a study on the coping behaviors of family
members
= of coronary artery bypass graft patients. My
My
purpose in writing to you, is to ask if you are willing
to assist me in this study.

I am requesting information from family members of
coronary artery bypass graft patients who have
participated in the cardiac rehabilitation program
offered by the Diagnostic and Cardiac Rehabilitation
Program. Your husband recently underwent coronary
artery bypass graft surgery and participated in the
cardiac rehabilitation program. I would appreciate that
you assist me in my study by completing the yellow
questionnaire. I also ask that you assist me by
forwarding the green questionnaire to your children who
are over the age of 18 years. The children can be sons,
daughters, sons-in-laws, and daughters-in-laws. By
completing and returning the questionnaire, I hope to
gain more information on how families cope after coronary
bypass graft surgery. The results in return will assist
nurses in helping other coronary artery bypass graft
families cope with the event.
Enclosed is a consent form and a questionnaire about some
of the coping strategies used by families during times of
part in the study will take
stress..Yourfamily's
--approximately 30 minutes of their time, to complete the
questionnaire. Your family's privacy will be protected.
Their identity and yours will be absolutely confidential.
Neither their name nor yours, will appear on the
questionnaire or in the report.

130

If your family is willing to participate, have them
complete the enclosed questionnaire and return it by mail
in the postage paid envelope by April 8, 1994. If you
need any extra green forms for family members please feel
free to contact me and I will forward the forms to you.

Thank You for your cooperation.

Sincerely,

Mary Alice Nash, BSN, RN
,
Master candidate in the Science in Nursing

131
Appendix G

-Consent Form

signing this document, I am giving my consent to
Participate in a research study by a graduate nursing
student in Pennsylvania. I understand that I will be
part of a research study that involves the problem­
solving and behavioral strategies utilized by me as a
family member following coronary bypass graft surgery of
a family member. This study will provide guidance to
nursing in assisting families of coronary bypass graft
surgery patients deal with the stressors encountered in
the recovery process.
My participation in this study is granted freely, I
understand that participation in this study is entirely
voluntary, and that even after the research begins I can
refuse to participate and terminate my participation at
any point.
I have been told that the results of this study will
not be given to anyone else and no reports from this
study will ever identify me in any way. I have also been
informed that my participation of refusal to participate
will have no effect on the services that I or any member
of my family may receive from this program.
This study will help nursing education in better
preparing to meet family needs in the six to twelve
months following coronary bypass surgery of a family
member. However, I will receive no direct benefit as a
result of this participation.
I understand that the results of this research study
will be given to me if I ask for them.

Respondent's Signature

Date

Researcher's Signature

Date

(

132

Appendix H

Dear

Last week a questionnaire was mailed to you seeking your
opinions about coping behaviors of families.
If you have already completed and returned it to me,
please accept my sincere thanks. If not, please do so
today. Because it has been sent to a small sample of
families, it is extremely important that yours also be
included in the study if the results are to accurately
represent the families of open heart patients.

The yellow
or husband
green ones
daughters,

questionnaire is to be completed by the wife
of the coronary bypass graft patient and the
are to be filled out by the family members sons, daughter-in-laws, and son-in-laws.

If by some chance you did not receive the questionnaire,
or it got misplaced, please call me and I will get
another questionnaire in the mail to you or your family
members today.
Sincerely,

Master^candidate in the Science in Nursing

HDpendix I

133

Spouses distribution and taean scores ipr the Family Crisis Oriented Personal Scales
n=16

SD

ND

NA/ND

HA

1. Sharing our difficulties with relatives

3

1

1

6

5

3.80

2. Seeking encouragement and support from friends

1

2

3

6

4

3.72

3. Knowing we have the power to solve major problems

0

0

2

8

6 4.71

4, Seeking information and advice from persons in other
families who have faced the same or similar problems

1

2

2

7

4 3.93

5, Seeking advice from relatives (grandparents, etc.)

5

4

3

2

2 2.66

6. Seeking assistance from community agencies and
programs designed to help families in our situation

4

0

3

4

5 3.60

7. Knowing that we have the strength within our own
family to solve our problens

0

0

0

6

10 4.93

8. Receiving gifts and favors froe neighbors (e.g. food,
taking mail, etc.)

4

0

3

8

1 3.33

9. Seeking information and advice froo the family doctor

1

0

0

5

10 4.73

10. Asking neighbors for favors and assistance

5

2

4

5

0 2.73

11. Facing the problems "head-on” and trying to get
solution right away

0

0

1

12. Watching television

8

1

5

0

2 2.33

13. Showing that we are strong

0

0

4

6

6 4.40

14. Attending church services

1

0

1

3

11 4.57

15. Accepting stressful events as a fact of life

1

0

0

9

6 4.53

16. Sharing concerns with close friends

2

2

2

7

3 3.67

17. Knowing luck plays a big part in how well we are able
to solve family problems

6

3

5

1

1 2.40

3D=strongly disagree, Moderately agree, NA/ND= neither agree no disagree,
MA=fioderately agree, SA= strongly agree

3

SA Mean

12 5.00

134

Appendix I (con't)

SD

HD

NA/ND

MA

SA Mean

18. Exercising with friends to stay fit and reduce tension

2

1

6

5

2 3.46

19. Accepting that difficulties occur unexpectedly

0

0

0

8

8 4.80

20. Doing things with relatives (get-together, dinners, etc,)

1

0

4

4

7 4.26

21, Seeking professional counseling and help for family
differences

3

0

4

6

3 3.60

22. Believing we can handle our own problems

0

0

3

7

6 4.46

23. Participating in church activities

2

1

0

6

7 4.20

24. Defining the family problem in a more positive way
so that we do not become too discouraged

0

0

0

6

10 4.93

25. Asking relatives how they feel about problems we face

4

3

3

4

2 3.00

26. Feeling that no matter what we do to prepare, we
will have difficulty handling problems

8

3

3

1

1 2.13

27. Seeking advice from a minister

2

3

3

5

3 3.46

28. Believing if we wait long enough, the problem will
go away

13

1

2

0

0 1.40

29. Sharing problems with neighbors

10

1

2

2

1 2.06

1

0

1

1

13 4.86

30. Having faith in GOD

SD=strongly disagree, HD=ioderately agree, NA/ND= neither agree no disagree.
HA=iioderately agree, SA= strongly agree

Appendix J

135

Adult Children distribution and mean scores for the Fatally Crisis Oriented Personal Scales
n=28

r

SD

HD

NA/ND

MA

SA Mean

1. Sharing our difficulties with relatives

2

6

5

11

4

6.20

2. Seeking encouragesent and support froa friends

2

2

5

15

4

7.13

3. Knowing we have the power to solve major problems

1

0

2

13

9

7.53

4. Seeking information and advice from persons in other
families who have faced the same or similar problems

1

2

10

12

3 6.53

5. Seeking advice from relatives (grandparents, etc.)

5

3

7

9

4 5.86

6. Seeking assistance froo community agencies and
programs designed to help families in our situation

6

5

7

4

6 5.53

7, Knowing that we have the strength within our own
family to solve our problems

1

1

1

13

12 7.86

8. Receiving gifts and favors fro® neighbors (e.g. food,
taking nail, etc.)

6

3

8

9

2 5.47

9. Seeking information and advice from the family doctor

2

3

2

8

13 7.40

10. Asking neighbors for favors and assistance

9

4

8

6

1 4.67

11. Facing the problems Bhead-onu and trying to get
solution right away

0

2

2

14

10 7.73

13

9

4

2

0 3.40

13. Showing that we are strong

3

2

8

10

5 6.40

14. Attending church services

2

1

4

9

12 7.47

15. Accepting stressful events as a fact of life

1

1

7

12

7 7.13

with close friends
16. Sharing concerns

0

2

7

15

4 7.00

14

7

5

1

1 3.47

12. Watching television

17. Knowing luck plays a big part in how well we are able
to solve family problems

nqly disagree, MD=moderately agree, NA/ND= neither agree nor disagree,
Moderately agree, SA= strongly agree

136

Appendix J (con'tj

SD

ND

NA/ND

MA

SA Mean

18, Exercising with friends to stay fit and reduce tension

1

5

10

9

3 6.13

19, Accepting that difficulties occur unexpectedly

0

0

2

17

8 7,87

20. Doing things with relatives (get-together, dinners, etc.)

2

3

5

5

1 6.13

21. Seeking professional counseling and help for family
differences

5

2

7

7

7 6.20

22. Believing we can handle our own problems

0

2

8

12

5 7.10

23. Participating in church activities

2

4

8

7

7 6.46

24. Defining the family problem in a more positive way
so that we do not become too discouraged

0

1

5

14

25. Asking relatives how they feel about problems we face

7

7

6

7

1 4.80

10

3

8

6

1 4.60

6

2

9

7

4 5.66

28. Believing if we wait long enough, the problem will
go away

18

7

2

1

0 2.80

29. Sharing problems with neighbors

13

6

6

3

0 3.66

2

0

3

4

19 8.13

26. Feeling that no matter what we do to prepare, we
will have difficulty handling problems
27. Seeking advice from a minister

30. Having faith in SOD

SD=strongly disagree, MD=moderately agree, NA/ND= neither agree no disagree,
MA=aoderately agree, SA= strongly agree

8

7.53

Appendix K

137

Spouses Percentage Distribution for the Family Crisis Oriented Personal Scales
n=16

SD

HD

NA/ND

19'Z

67

67

38Z 317,

2. Seeking encouragement and support from friends

67.

137.

197

387 257

3, Knowing we have the power to solve major problems

07

07

137

507. 387.

4. Seeking information and advice from persons in other
families who have faced the same or similar problems

67.

137

137

447. 257

1. Sharing our difficulties with relatives

MA

SA

5. Seeking advice from relatives (grandparents, etc.)

317

257

197

137. 137.

6. Seeking assistance from community agencies and
programs designed to help families in our situation

257.

07.

197

257 317

07

07

07

387. 637

8. Receiving gifts and favors from neighbors (e.g. food,
taking mail, etc.)

257.

07

197

507. 67

9. Seeking information and advice from the family doctor

67

07

07

317. 637.

317

137.

257

11, Facing the problems Bhead-onB and trying to get
solution right away

07.

07

67

197. 757

12, Watching television

507

67

317

07 137

13, Showing that we are strong

07

07

257

387, 387

14. Attending church services

67

07

67

137 697

15, Accepting stressful events as a fact of life

67.

07

07

567 387.

with close friends
16. Sharing concerns

137.

137

137

447 197

^TT^TTluck plays a big part in how well we are able
to solve family problems

387

197

317

67.

7. Knowing that we have the strength within our own
family to solve our problems

10. Asking neighbors for favors and assistance

----- idisagree, MD=moderately agree, NA/ND= neither agree no disagree,
^"aodeVtely agree, SA= strongly agree

317.

07

67.

138

Appendix X (con't)

SD

HD

NA/ND

18. Exercising with friends to stay fit and reduce tension

137.

6X

38%

317. 13X

19. Accepting that difficulties occur unexpectedly

OX

OX

OX

507. 50X

20. Doing things with relatives (get-together, dinners, etc.)

67.

OX

257.

257. 447.

19%

OX

25’.

38X 197.

OX

07.

19X

447. 3BX

13X

6X

OX

387. 447.

OX

OX

OX

387. 637.

25. Asking relatives how they feel about problems we face

257.

19X

19X

257. 13X

26. Feeling that no matter what we do to prepare, we
will have difficulty handling problems

507.

19X

197.

67.

27. Seeking advice fros a minister

13X

197.

19X

317. 19X

28. Believing if we wait long enough, the problem will
go away

81X

6X

13X

07.

OX

29. Sharing problems with neighbors

637.

6X

137.

137.

6X

6X

07.

6X

21. Seeking professional counseling and help for family
differences

22. Believing we can handle our own problems
23. Participating in church activities
24. Defining the family problem in a more positive way
so that we do not become too discouraged

30. Having faith in GOD

SD=strongly disagree, MD=moderately agree, NA/ND= neither agree no disagree,
HA=moderately agree, SA= strongly agree

HA

SA

67.

67. SIX

Appendix L
Adult Children Percentage Distribution

139

for the Family Crisis Oriented Personal Sraies
n=28

SD

ND

NA/ND

KA | SA

1. Sharing our difficulties with relatives

77

217

187

39Z 147

2, Seeking encouragement and support from friends

77.

7Z

187

547. 147

3. Knowing we have the power to solve major problems

47.

07

7Z

467. 327

4. Seeking information and advice fros persons in other
families who have faced the same or sisilar problems

47.

77

367

437 117

5. Seeking advice from relatives (grandparents, etc.)

18Z

117

257

327 147.

6. Seeking assistance froa cosaunity agencies and
prograss designed to help families in our situation

217

187

257

147. 217

47

47

47

467 437

8. Receiving gifts and favors fro® neighbors (e.g, food,
taking mail, etc.)

217.

117

297

9. Seeking infonaation and advice from the fafflily doctor

77

117

77

327.

147

07

77

12. Watching television

467

13. Showing that we are strong

7. Knowing that we have the strength within our own
family to solve our problems

10. Asking neighbors for favors and assistance

327

77

297 467

297 | 217

471

77

I 507

367.

327.

147

77

07

117

77

297

14, Attending church services

77

47

15, Accepting stressful events as a fact of life

47

47.

257

437. 257

16, Sharing concerns with close friends

0Z

77

257

547. 147

I 507

257

11. Facing the problems l’head-anH and trying to get
solution right away

17. Knowing luck plays a big part in how well we are able
to solve faaily problems
'

SD=strongly
Moderately
agree, MD= neither aoree
nnr
HA=moderatelydisagree,
agree, SA=
strongly agree
9
’ lsa9'BBJ

147

367 187
327. 437

187 ! 47

47

140
Appendix L (con't)

SD

ND

NA/ND

MA I SA

18. Exercising with friends to stay fit and reduce tension

47.

18X

367

327. 117

19. Accepting that difficulties occur unexpectedly

07.

07

77

617. 297

20. Doing things with relatives (get-together, dinners, etc.)

77

117

187

187

21. Seeking professional counseling and help for family
differences

187

77

257

257 257

22. Believing we can handle our own problems

07

77

297.

437 187

23. Participating in church activities

77

147

297

257 257

24. Defining the family problem in a more positive way
so that we do not become too discouraged

07

47

187

507. 297

25. Asking relatives how they feel about problems we face

257.

257

217

257.

47

26. Feeling that no matter what we do to prepare, we
will have difficulty handling problems

367

117

297

217

47

27. Seeking advice from a minister

217

77

327

257. 147.

28. Believing if we wait long enough, the problem will
go away

647

257

77

47

07

29. Sharing problems with neighbors

467

217

217

117

07

77

07

117

147. 687

30. Having faith in GOD

SD=strongly disagree, MD=moderately agree, NA/ND= neither agree no disagree,
MA=soderately agree, SA= strongly agree

47