Alternative explanations of coping with stressful experiences associated with physical illness

Coping Processes, Self-Efficacy, and CPAP Use in Adults With Obstructive Sleep Apnea

Background: Coping strategies are predictive of 1 week CPAP use. Coping strategies may predict longer-term CPAP use among adults with obstructive sleep apnea (OSA). Objectives: To investigate the influence of two coping styles (active and passive) and individual coping processes on CPAP use at 1 week and 1 month; and explore the association between self-efficacy and coping on CPAP use. Participants: CPAP-naïve adults (52.3% male, 90.9% White) newly diagnosed with OSA (AHI ≥ 5 events/hr) from two U.S. clinical sleep centers (n = 66). Methods: A post-hoc analysis from a prospective, longitudinal study that examined influential factors on CPAP use among CPAP-naïve patients with newly diagnosed OSA. The Ways of Coping Questionnaire and the Self-Efficacy Measure for Sleep Apnea were completed immediately after CPAP titration polysomnography. Objective 1 week and 1 month CPAP use (mean hr/night) were the primary outcomes. Descriptive analyses and stepwise multiple linear regression analyses modeling for CPAP use (mean hr/night). Results: Active coping was significantly associated with greater CPAP use (mean hr/night) at 1 week, but not at 1 month (p = 0.0397; p = 0.0556, respectively). Higher Planful Problem Solving was significantly associated with greater average CPAP use at 1 week and 1 month (p = 0.0117, p = 0.0378, respectively). Self-efficacy was significantly associated with greater average CPAP use at 1 week (p = 0.0056) and 1 month (p = 0.0056). Conclusions: Self-efficacy and Planful Problem Solving coping are promising behavioral intervention targets to promote CPAP use in newly diagnosed OSA.

Complex Psychological Trauma and Self-Dysregulation: A Theory Synthesis for Nursing

Complex psychological trauma is a phenomenon resulting from severe interpersonal trauma that can negatively affect how individuals experience health care. However, few theories conceptualizing complex trauma exist, and it has received only limited attention in the nursing literature. The purpose of this theory synthesis was to organize two theories of (a) self-regulation and (b) self-dysregulation following complex psychological trauma into a single conceptual framework for use in nursing practice. This article used the theory synthesis approach described by Walker and Avant. The theory has potential to advance nursing science by helping nurses and other health professionals understand how trauma can alter self-regulatory processes and result in unique challenges in care delivery. It also has potential to prevent retraumatization of trauma survivors at the hands of health care providers.

Evaluating the feasibility and effectiveness of a critical care discharge information pack for patients and their families: a pilot cluster randomised controlled trial

OBJECTIVES

To evaluate the feasibility and effectiveness of an information pack, based on self-regulation theory, designed to support patients and their families immediately before, during and after discharge from an intensive care unit (ICU).

DESIGN AND SETTING

Prospective assessor-blinded pilot cluster randomised controlled trial (RCT; in conjunction with a questionnaire survey of trial participants' experience) in 2 ICUs in England.

PARTICIPANTS

Patients (+/- a family member) who had spent at least 72 h in an ICU, declared medically fit for discharge to a general ward.

RANDOMISATION

Cluster randomisation (by day of discharge decision) was used to allocate participants to 1 of 3 study groups.

INTERVENTION

A user-centred critical care discharge information pack (UCCDIP) containing 2 booklets; 1 for the patient (which included a personalised discharge summary) and 1 for the family, given prior to discharge to the ward.

PRIMARY OUTCOME

Psychological well-being measured using Hospital Anxiety and Depression Scores (HADS), assessed at 5±1 days postunit discharge and 28 days/hospital discharge. Statistical significance (p≤0.05) was determined using χ(2) and Kruskal-Wallis (H).

RESULTS

158 patients were allocated to: intervention (UCCDIP; n=51), control 1: ad hoc verbal information (n=59), control 2: booklet published by ICUsteps (n=48). There were no statistically significant differences in the primary outcome. The a priori enrolment goal was not reached and attrition was high. Using HADS as a primary outcome measure, an estimated sample size of 286 is required to power a definitive trial.

CONCLUSIONS

Findings from this pilot RCT provide important preliminary data regarding the circumstances under which an intervention based on the principles of UCCDIP could be effective, and the sample size required to demonstrate this.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN47262088; results.

Stress and Psychotropic Drug Use among the Elderly: An Exploratory Model

L'objectif de la présente étude était de tester un modèle de cheminement causal de l'effet du stress et divers autres facteurs sur l'utilisation de psychotropes par des personnes âgées en nous appuyant sur des facteurs d'ordre individuel plutôt que social. Les participants étaient des bénéficiaires d'un service de maintien plutôt que de soins à domicile. Les données sont basées sur une série de deux entrevues (à une semaine d'intervalle) faites au domicile de 99 utilisateurs de médicaments psychotropes provenant d'une banlieue socialement défavorisée d'une grande ville canadienne. Le modèle de cheminement causal initial contribue à une partie appréciable (19%) de la variance dans la consommation de psychotropes. Les prédicteurs qui composent notre modèle final, expliquant 17 pour cent de la variance dans la consommation de médicaments sont l'âge, le sexe, les attitudes envers les psychotropes et les événements de vie. Les personnes plus jeunes consomment plus de psychotropes que les plus vieux. Une attitude positive envers les psychotropes et le fait d'appartenir au sexe féminin est associée à un niveau de consommation élevé. L'analyse de cheminement causal n'a pas confirmé notre modèle de consommation de psychotropes en fonction du stress et a plutôt mis à jour de nouvelles questions liées aux facteurs sociaux. Des explications sont offertes à cet effet. Des suggestions de recherche futures ainsi que les retombées cliniques des données sont présentées dans la conclusion.

The sensory and coping intervention for women newly diagnosed with metastatic breast cancer

Preparatory information at the time of metastatic breast cancer diagnosis can be used to enhance patients' coping ability. Women with metastatic breast cancer evaluated a multimedia educational intervention designed to provide sensory and coping information regarding illness. Twenty women with metastatic breast cancer evaluated the materials. The intervention was evaluated very favorably and women identified the materials as needed information. However, they expressed dislike of content outlining possible concerns suggesting future iterations include only positive content. Findings confirm the acceptability and usability of these materials for further testing and ultimately for integration into cancer care practice.

Nursing interventions to improve the health of men with prostate cancer undergoing radiotherapy: a review

The aim of this study was to investigate what nurses do to improve the health of men who are receiving radiotherapy treatment due to prostate cancer. The method was a literature review using a systematic approach. The Cochrane Library, Medline and CINAHL databases were used in a search that covered the period from January 1994 to April 2006. The screening of 200 abstracts resulted in 14 articles corresponding to the research question, which were assessed according to scientific quality. Two independent reviewers performed the screening and quality assessment process using specific protocols. Two themes emerged: nurse-led care related to radiotherapy treatment and patients' experiences of radiotherapy treatment. The results show that there is strong scientific support for nurse-led follow-up care aimed at assisting patients by means of providing information on how to manage side effects (evidence grade A). In addition, there is moderate scientific support for the need to ensure that this information is structured, objective and concrete and that it can be provided by means of audiotapes or over the phone (evidence grade B) as well as weak scientific support for reporting patients' experiences of radiotherapy treatment (evidence grade C).

Coming full circle in pharmacovigilance: communicating safety information to patients through patient package inserts

Optimal drug therapy requires that the patient should be informed adequately, unequivocally and in timely fashion. Patient package inserts (PPIs) have an important facilitating role to play in this respect. Patients' confidence in the benefit of a drug treatment and their fear of its side effects are strong determinants of their adherence to that treatment. Yet, the European PPI format does not allow a discussion of the treatment's benefits, which results in an unbalanced focus on side effects. This serious shortcoming may significantly interfere with a patient's compliance. In addition, prescribers are often unaware of the content of the PPI of the products they are prescribing. To rectify this situation, the development is proposed of annotated PPIs providing the scientific background to the PPI message. In conclusion, European PPIs need to be improved. The patient should be informed of the expected benefit of a drug treatment, its likelihood and the expected time course of the effect, and not only of side effects and interactions, which constitutes the present focus. Moreover, prescribers need to be informed about the content of the PPIs for the medicines they prescribe.

A longitudinal study of functional status and correlates following coronary artery bypass graft surgery in women

BACKGROUND

There is limited information available to help women gauge their functional status following coronary artery bypass graft surgery.

OBJECTIVE

This article describes changes in functional status and the influence of comorbidity, household composition, fatigue, and surgical pain on functional status in women during the first 6 weeks at home following coronary artery bypass surgery.

METHOD

A single-group longitudinal design was used for this research. Women were interviewed in person before hospital discharge and by telephone at 2, 4, and 6 weeks after discharge. Functional status was assessed by (a) the Inventory of Functional Status in the Elderly and subscales of the Sickness Impact Profile; (b) comorbid conditions by simple tally; and (c) fatigue and surgical pain by the Energy/Fatigue and Pain Severity subscales of the MOS Patient Assessment Questionnaire.

RESULTS

Women experienced significant gains in functional status over 6 weeks, particularly between 2 and 4 weeks. They engaged most frequently in personal care and low-level household activities during the study period, and most reported improvement in their overall functional status. None of the women were completely recovered or had regained baseline functional status by 6 weeks. The women experienced significant decreases in fatigue and surgical pain, but continued to experience both at 6 weeks. Fatigue and surgical pain were significantly correlated at all time periods.

DISCUSSION

Information about recovery following coronary artery bypass graft, and particularly the finding that recovery is incomplete by 6 weeks, should be incorporated into discharge planning and follow-up for this patient population.

Gender differences in pain characteristics of chronic stable angina and perceived physical limitation in patients with coronary artery disease

Chronic stable angina pectoris, the chest pain associated with reversible myocardial ischemia has detrimental effects on health-related quality of life, particularly in women. The limited research on gender differences in chronic stable angina suggests that angina may be experienced differently in women and that women report greater functional disability related to angina symptoms. No studies have examined gender differences in chronic stable angina from a multidimensional pain perspective or have included reliable and valid measures of pain that would facilitate comparing chronic angina patients with other chronic pain populations. The purpose of this descriptive study was to examine gender differences in characteristics of chronic stable angina using the short-form McGill pain questionnaire (SF-MPQ) and to explore relationships among these pain characteristics and perceived limitation in performing physical activities in patients with coronary artery disease (CAD) (physical limitation subscale of the Seattle angina questionnaire). One hundred and twenty-eight subjects (30.5% women) with stable CAD and angina pectoris documented by a cardiologist completed study questionnaires in an outpatient cardiology clinic. Results of the study suggest that men and women with chronic stable angina had more similarities than differences in chest pain characteristics. No significant gender differences were demonstrated in total sensory or affective intensity scores, the present pain intensity index, or the number of pain words chosen. However, women did report significantly greater pain intensity on the SF-MPQ visual analogue scale. Women were also significantly more likely to describe their chronic angina as 'hot-burning' and 'tender' and to have greater intensity of pain for these two descriptors. Despite the similarities in pain characteristics, women reported greater physical limitation related to anginal pain. The variables of social status and years diagnosed with CAD significantly interacted with gender in predicting physical limitation suggesting that gender-specific models of physical limitation in angina patients need to be explored. To our knowledge, this is one of the first studies that has assessed chronic anginal pain using a reliable and valid generic pain instrument. More research is needed to better understand the nature of gender differences in functional limitation secondary to anginal pain and the physiologic, cognitive-perceptual and psychosocial mechanisms that lead to angina-related functional disability.

Contextual variables, emotional state, and current and expected quality of life in breast cancer survivors

PURPOSE/OBJECTIVES

To determine the relationship between contextual variables, emotional state, and quality of life (QOL) now and expectations for the future in survivors of breast cancer.

DESIGN

Descriptive and nonexperimental.

SETTING AND SAMPLE

148 volunteers and women with breast cancer involved in a program by the American Cancer Society. Most subjects were middle-aged (mean = 52.4, SD = 11.56), were married (72%), and had graduated high school (38%). Time since diagnosis was 0.3-19 years (mean = 3.54, SD = 3.61); 74% were diagnosed more than five years ago, 54% were not receiving any treatment, and 66% had localized breast cancer.

METHODS

At home, participants completed a self-report survey for personal and contextual variables, Positive and Negative Affect Scale, QOL Measurement, and Global Life Satisfaction Scale.

MAIN RESEARCH VARIABLES

Time since diagnosis, extent of cancer, emotional state, QOL, and global life satisfaction.

FINDINGS

Women had high positive affect (mean = 37.96) and low negative affect (mean = 17.13). QOL and life satisfaction were high. Time since diagnosis and extent of disease were related weakly to negative affect and QOL (p < 0.001). Positive and negative affect were related moderately to QOL and life satisfaction (p < 0.001). Current personal life satisfaction was significantly greater than breast cancer survivors' estimates for "most people," and survivors expected life satisfaction to increase significantly in five years (p < 0.001). Significant differences in QOL were found between those who were diagnosed recently and those who were diagnosed 10 or more years previously.

CONCLUSIONS

Despite breast cancer, women have positive affect, good QOL, and life satisfaction. Contextual variables were related weakly to outcomes; emotions were related more strongly to outcomes. Survivors were more satisfied with life than they estimated others to be and expected satisfaction to increase in the future.

IMPLICATIONS FOR NURSING

Nurses may use these findings to encourage patients who are newly diagnosed with breast cancer. Women with breast cancer adapt well despite potential negative outcomes, and survivors even report better QOL than they estimate for most people.

Barriers to information access, perceived health competence, and psychosocial health outcomes: test of a mediation model in a breast cancer sample

This study examined the relationship between breast cancer patients' experience of barriers to accessing health information and their psychosocial health outcomes and explored the extent to which this relationship was mediated by patient perceptions of competence in dealing with health-related issues. Study sample consisted of 225 women surveyed within 6 months of diagnosis. Regression analyses suggested that patients who reported greater difficulty in accessing needed information experienced lower emotional (P=0.05), functional (P<0.05), and social/family (P<0.05) well-being as well as lower perceptions of health competence (P<0.001). Also, patient perceptions of health competence mediated the relationship between barriers to accessing information and patient outcomes (emotional well-being, P<0.05; functional well-being. P<0.01; social/family well-being, P=0.01). Breast cancer patients often report dissatisfaction with the extent to which their information needs are addressed by their health care providers. Our findings underscore the need for designing and implementing interventions that would aid providers in better meeting the information needs of their patients.

Expected and reported pain in children undergoing ear piercing: a randomized trial of preparation by parents

This study examined experimentally the effectiveness of preparatory information provided by parents in creating accurate expectations and reducing children's procedural pain. Ear piercing was used as an analogue to minor painful medical procedures. Sixty children, aged 5-12 years, requesting ear piercing and accompanied by their parents, were randomly assigned to a parental information or contact-control condition. Parents in the information group were asked to read their child a description of the procedures and sensations of ear piercing. Parents in the contact-control condition played picture games for the same amount of time. Expected pain was measured on a visual analogue scale (VAS) and the Faces Pain Scale-Revised (FPS-R) before and after the parental information or contact-control procedure. Experienced pain was measured on the same two scales immediately after the ear piercing. Prepared children had more accurate expectations and reported significantly less pain (M=27.3) than non-prepared children (M=49.8). The validity of the measures was supported by strong correlations (r=0.87 to 0.96) between the VAS and FPS-R. The findings suggest that parental provision of preparatory information creates accurate expectations and reduces pain for children.

Thai Buddhist patients with cancer undergoing radiation therapy: feelings, coping, and satisfaction with nurse-provided education and support

Ninety male and 89 female Thai Buddhist patients with cancer undergoing radiation therapy at a Bangkok hospital outpatient radiation therapy clinic were subjected to a questionnaire study. The purpose of the study was to (i) describe feelings, coping, and satisfaction with nurse-provided education and support and (ii) identify possible gender differences. The results showed that the most common feelings of both genders at first knowledge about radiation therapy were "acceptance/calmness," and the women more often than the men felt "anxiety" and "fright/fear." The most common ways of coping with radiation therapy for both genders were "rest," "talk with family/friends," "visit doctor," and "meditate," and in this regard there were no significant gender differences. The men expressed their highest satisfaction with "nurse has knowledge about disease/treatment" and "nurse listens to patient's problem," whereas the women expressed their highest satisfaction with "patient dares to ask questions" and "nurse likes to explain information." The satisfaction with different aspects of nurse-provided education and support was commonly higher among the men. When oncology nurses are to provide education to radiation therapy patients, it is essential that they are aware of their patients' characteristics, such as the ones identified here, that are related to cultural values and religious beliefs as well as to gender.

Self-regulation theory and coping with physical illness

A self-regulation theory of how patients cope with events that occur during physical illness that has received substantial support from research is described. The theory challenges some traditional thinking about providing patients information and patients' emotional responses to threatening health care events. The use of the theory in practice and suggestions for research to further develop the theory are discussed.

Social comparisons and temporal comparisons after coronary artery surgery

OBJECTIVE

To examine the use and efficacy of social and temporal comparisons used before and after coronary artery surgery.

DESIGN

Secondary analysis of data from a prospective study designed to examine social support.

PATIENTS

141 subjects undergoing surgery.

RESULTS

One third of subjects made spontaneous social comparisons. Most who made a social comparison before and 1 month after surgery viewed themselves as similar to others. Social comparisons were related to mood states only before surgery. The majority of subjects made temporal comparisons 1 year after surgery. Subjects generally saw themselves as the same or better than they were before surgery. Temporal comparisons were related to both emotional and functional outcomes.

CONCLUSIONS

Social comparisons were not consistently related to emotional and functional status; thus whether they can be used to formulate interventions needs further exploration. On the other hand, use of temporal comparisons was related to better mood state and functional status. Enhancing an individual's ability to view self as stable or improved compared with before surgery may be beneficial. Results are discussed in terms of how social comparison theory fits within the overall context of coping with physical illness.

Autologous bone marrow transplantation: the patient's perspective of information needs

Phenomenologic inquiry was used to explore patients' experiences with autologous bone marrow transplantation (ABMT). Interviews were conducted before and after implementation of a clinical pathway that included a teaching protocol for ABMT. Texts were analyzed individually, compared for pre- and postpathway patients to determine if different themes emerged from these two groups, and then combined. Themes common to both groups included (a) a range of needs for information, (b) everybody's different: a fine balance (the challenge of finding a balance when giving information to patients who vary in the amount of information they desire), (c) someone who has been there (the value of talking to someone who has survived an ABMT), (d) and the burden of ABMT patients teaching family. One theme that reflected different experiences of pre- and postpathway patients was that of the need to know detailed information about the ABMT and the fear of knowing too much. Whereas postpathway patients reflected more on the burden of knowing too much, prepathway patients expressed more dissatisfaction about not being told enough about procedures and symptoms to be expected. Suggestions for teaching patients about ABMT include being generally realistic while focusing on the positive, and viewing patient education as a process individualized according to each patient's needs.

Long-term chest wall discomfort in women after coronary artery bypass grafting

OBJECTIVE

The purpose of the study was to determine the occurrence of long-term chest wall discomfort in women after coronary artery bypass grafting.

DESIGN

Prospective repeated-measures design.

SETTING

Posthospitalization.

SAMPLE

Fifty-one women who had undergone coronary artery bypass grafting. Data were collected at 12 and 18 months by self-report and data collection instruments.

INSTRUMENTS

Life Orientation Test, Satisfaction with Life Scale, Profile of Mood States, Sickness Impact Profile, interview schedule, and discomfort scale 0 to 10.

RESULTS

Women who had an internal mammary artery graft had significantly (p = 0.003) more discomfort. Most discomforts were intermittent and did not interfere with daily activities. However, the feelings of numbness and itchiness tended to be continuous.

Creating information messages for reducing patient distress during health care procedures

Health care providers want strategies which they can use to assist patients in decreasing their distress during threatening health care procedures. Concrete objective information has been shown in laboratory and clinical studies to be effective in reducing negative emotional responses. Concrete objective information is a message, given before a health care event, which describes the experience from the patients' point of view in unambiguous, concrete, and objective terms. According to self-regulation theory, this type of information facilitates coping by decreasing the difference between expectations and actual experience and by increasing patients' understanding of their experience. However, little emphasis has been placed in the literature on the process of creating the message. This paper will describe a four-stage process that permits systematic development of comprehensive and accurate concrete objective information messages to prepare patients for health care procedures.

The effects of a discharge information intervention on recovery outcomes following coronary artery bypass surgery

This quasi-experimental study tested the effects of a discharge information intervention on physical and psychological outcomes 1 month following coronary artery bypass surgery (CABG). Recovery outcomes were compared between two groups of patients: those receiving an audiotape of information focusing on expected physical symptoms and their management in addition to usual care, and those receiving a usual cardiac discharge information protocol. The nonprobability sample of 82 patients were men and women and had a mean age of 64 years. The outcome measurements included psychological distress, measured by the Profile of Mood States, and physical functioning, measured by the Sickness Impact Profile. The audiotape intervention produced positive effects on physical functioning [F(1,80) = 6.37, p < 0.01]; the effects were maintained when age and post-operative length of stay were statistically controlled. No differences in psychological distress were found. Findings suggest that audiotapes containing discharge information about expected recovery experiences are a feasible and effective approach to enhancing the physical recovery of CABG patients.

CABG discharge information: addressing women's recovery

Women's descriptions of the coronary artery bypass surgery recovery experience were elicited for development of a preparatory discharge information intervention. In a convenience sample, 20 women (mean age = 67 years) were interviewed about the physical sensations, emotions, and concerns they experienced after CABG at three measurement points: discharge, 2 days after discharge, and 3 weeks following discharge. Many of the recovery experiences reported by women in this study are not addressed in traditional CABG discharge information.

Postmastectomy pain syndromes

Pain associated with cancer and its treatment continues to be a significant concern for those persons diagnosed with the illness. This article will focus on pain syndromes associated with surgical interventions for women with breast cancer. Postmastectomy pain syndromes including postaxillary dissection pain and phantom breast pain will be described in terms of their nature, incidence, and temporal course based on current literature findings. Treatment strategies and implications for nursing interventions employed in caring for these women will also be discussed. Nurses can use information about postmastectomy pain syndromes to educate their patients, to cooperate in successfully managing effects of the disease and treatment, and to help women cope after breast cancer surgery.

Personality, appraisal, and adaptational outcomes in HIV seropositive men and women

A cross-sectional exploratory design was used to assess the relationships of personality, socioeconomic status, and appraisal with functional and emotional outcomes in 77 men and 50 women with HIV infection. Multiple regression analysis showed that, among men, socioeconomic status moderated the negative relationship between self-esteem and disruption in usual activities. Consistent with Lazarus and Folkman's (1984) theory, appraisal of HIV threat mediated the negative relationship between self-esteem and mood disturbance for men and women, and the positive relationship between self-esteem and purpose in life for women. Appraisal did not mediate between personality variables and disruption in usual activities or life satisfaction for men or women.

Development of discharge information for recovery after coronary artery bypass surgery

Descriptions of coronary artery bypass graft (CABG) recovery experiences were elicited for development of a preparatory discharge information intervention. A convenience sample of 15 men and 5 women were interviewed about the concerns, emotions, and physical sensations they experienced after CABG and the actions they found most useful to manage the recovery at three time points: (a) discharge; (b) 2 days after discharge; and (c) 3 weeks after discharge. Concerns of subjects centered on pain management and return to independence in activities of daily living. Reports of negative emotions increased over the first month of recovery and included depression, anger, and anxiety. Subjects most frequently reported physical sensations associated with fatigue, chest incision, sleeping, leg incision, shoulder and neck muscles, and coughing. Descriptions of the CABG recovery experience provided data for development of discharge information, that focused on concrete experiences from the viewpoint of the person having CABG surgery and included orienting information about the onset, sequence, and duration of the experiences.

Patients' responses to postponement of coronary artery bypass graft surgery

The purpose of this study was to determine the thoughts and feelings of patients (n = 24) awaiting coronary artery bypass graft (CABG) surgery and, in particular, the thoughts and feeling of those patients (n = 17) whose surgical procedure was postponed. On average these patients waited four additional days before the surgery could be performed. Patients reported that the most difficult part of CABG surgery was the wait itself. Those whose CABG surgery was postponed expressed anger and disappointment, had additional tests, procedures and medication, extended hospital stays and increased costs.

The colposcopy experience: what do women know?

A study of 149 first-time colposcopy women was undertaken to determine their level of knowledge about female anatomy, abnormal pap results, and the colposcopy procedure. Factors which influenced their knowledge were also explored. Results suggest that women are missing fundamental knowledge about the experience; for example, location of the cervix (39.6%), site of pap smear (44.3%), meaning of pap result (38.9%), and the purpose of colposcopy (32.4%). Older women with a university education knew more. Women's perception of information gained through personal contacts and this information combined with that obtained through written material had a significant impact on what they knew. Women identified the type, source and preferred timing of additional information that would be helpful. The data provide valuable insights for nurses who practise in ambulatory settings and doctors' offices.

Living with chronic illness: social support and the well spouse perspective

Progressive neurologic disease has a significant impact on family members, particularly those living with and caring for a homebound adult. Focus groups were conducted with women who were the primary caregiver for their disabled husband. The women described themselves as being restricted to the home by caregiving requirements. Multiple sclerosis was a critical personal hardship for them, involving persistent struggle that often resulted in anger and frustration. Because of the social isolation created by their caregiving responsibilities, these women depended on their disabled husband for support. Yet, never having time away from the husband strained the marital relationship and threatened the supportive nature of the relationship. The women in this study found it necessary to have personal time and space away from their husband. They created space for themselves by setting apart a place in the home that was theirs or by declaring time out for themselves. These strategies helped them avoid or reduce negative outcomes of the social support received from their husband.

Theories used in patient/health education

Patient and health education programs may need to use a multitheory approach to promote health behaviors such as cancer prevention and early detection practices and decrease negative responses such as anxiety, distress, pain, and use of damaging alternative treatments. Multiple intrapersonal, interpersonal, organizational, and community approaches are required. For example, a strategy for breast cancer education should be characterized by an understanding of the target population's attitudes and beliefs about breast cancer, communication of information, education regarding specific facts about breast health and breast cancer, social influence strategies to promote acceptance of the target behaviors, and organizational and community-based interventions to reach the widest audience. Nurses should design education programs that carefully integrate theories to obtain predicted result for the largest number of people for whom the results are desirable. Intervention strategies designed to alter the identified influential factors will have the most successful impact and optimal chance of attaining program goals.