Myocardial infarction: narrations by afflicted women and their partners of lived experiences in daily life following an acute myocardial infarction

Partners' experiences of living with men who have screening-detected abdominal aortic aneurysms: A qualitative descriptive study

AIM

To describe partners' experiences of living with men with a screening-detected abdominal aortic aneurysm (AAA).

BACKGROUND

Diagnosis of a chronic life-threatening disease affects the patients' as well as their partners' lives in different aspects. AAA, with rupture as the major consequence, is a life-threatening disease that can affect the whole family. Screening programmes for AAA have been introduced in several countries to reduce the mortality rate. Although the awareness of having an AAA influences the individuals' quality of life and well-being, it is still unclear how it affects their partners.

DESIGN

Qualitative descriptive design.

METHODS

Twenty-one partners of men with AAA were purposely selected to participate in individual semi-structured interviews between August 2017-February 2018 in Sweden. Data were transcribed and imported into NVivo-12^® . The data were analysed using qualitative content analysis. The study conforms to the COREQ checklist.

RESULTS

Three categories were identified: (a) experiencing the unexpected; (b) being reminded of fragility; and (c) balancing a changing relationship. The partners had a positive attitude towards the screening process and were pleased that their husbands were under surveillance. Nevertheless, at the same time, the diagnosis caused worries and questions. The AAA diagnosis was constantly in the minds of the partners, which sometimes affected and limited daily activities. Furthermore, ambivalent feelings towards surgical treatment were described. The partners tried to support their men and encouraged them to achieve a healthy lifestyle.

CONCLUSION

The partners' well-being and daily lives were impacted by the awareness of the screening-detected AAA. Different degrees of worry were the most common reaction and were pervasive in all three categories.

RELEVANCE FOR CLINICAL PRACTICE

The result highlights the need to review routines or develop new strategies to include the partners in the process of screening and offer supplementary support and information.

Women's experiences of how their recovery process is promoted after a first myocardial infarction: Implications for cardiac rehabilitation care

BACKGROUND

A rapid improvement in the care of myocardial infarction (MI) in the emergency services has been witnessed in recent years. There is, however, a lack of understanding of the factors involved in a successful recovery process, after the initial stages of emergency care among patients, and in particular those who are women. Both preventive and promotive perspectives should be taken into consideration for facilitating the recovery process of women after a MI.

AIM

To explore how women's recovery processes are promoted after a first MI.

METHODS

A qualitative content analysis was used.

FINDINGS

The women's recovery process is a multidirectional process with a desire to develop and approach a new perspective on life. The women's possibility to approach new perspectives on life incorporates how they handle the three dimensions: behaviour, that is, women's acting and engaging in various activities; social, that is, how women receive and give support in their social environment; and psychological, that is, their way of thinking, reflecting, and appreciating life.

CONCLUSIONS

The personal recovery of women is a multidirectional process with a desire to develop and approach a new perspective on life. It is important for cardiac rehabilitation nurses to not only focus on lifestyle changes and social support but also on working actively with the women's inner strength in order to promote the recovery of the women.

Empowered to gain a new foothold in life--A study of the meaning of participating in cardiac rehabilitation to patients afflicted by a minor heart attack

This study aimed to investigate what it means to patients afflicted by a minor heart attack to participate in cardiac rehabilitation (CR). CR is well-established internationally to support patients towards moving forward in satisfying, healthy, and well-functioning lives. Studies indicate that patients achieve improvement in quality of life when participating in CR. However, knowledge of how patients are supported during CR is sparse. Moreover, knowledge of what participating in CR means to patients afflicted by a minor heart attack is lacking. In-depth knowledge in this area is crucial in order to understand these patients' particular gains and needs. In a phenomenological-hermeneutic frame field observations, focus group interviews, and individual interviews were conducted among 11 patients during and after their participation in CR. Field notes and transcribed interviews underwent three-phased interpretation. It was found that patients were supported to gain renewed balance in their lives during CR. Three themes were identified: (1) receiving a helpful but limited caring hand, (2) being supported to find new values in life, and (3) developing responsibility for the remaining time. The patients were carefully guided through a difficult time and supported to continue in healthy everyday lives. They were given hope which enabled them to find themselves a new foothold in life with respect to their own sense of well-being. This guidance and a sense of hopefulness were provided by heart specialists and more seasoned heart patients. In conclusion, patients were empowered to achieve a healthier lifestyle and improve their personal well-being during CR. However, structural barriers in the programme prevented adequate support regarding the patients' total needs. Knowledge of the benefits of CR emphasizes the significance of the programme and highlights the importance of high inclusion. Efforts should be made to develop more flexible and longer lasting programmes and further involvement of relatives must be considered.

Patient Experiences of Loneliness: An Evolutionary Concept Analysis

Loneliness is a painful experience for patients. To clarity the concept of patient loneliness, this study undertook an evolutionary concept analysis based on a literature search in the main relevant databases. We identified 7 dimensions in adult patients' experiences of loneliness. These dimensions of loneliness have different causes and theoretical foundations, which have different implications for patient care. Patients may be lonely in their different relationships, including those with nurses and doctors. Loneliness in relation to health care professionals is a new application of the concept of loneliness that provides a useful starting point for future research.

Managing uncertainty in couples living with atrial fibrillation

BACKGROUND

Living with a chronic disease such as atrial fibrillation (AF) not only affects the patient but also has implications for the partner. There is a lack of research on couples living with AF and, in particular, how they experience and deal with the disease.

OBJECTIVE

The aim of this study was to explore couples' main concerns when one of the spouses is afflicted with AF and how they continually handle it within their partner relationship.

METHODS

Classical grounded theory was used throughout the study for data collection and analysis. Interviews were conducted with 12 couples (patient and partner together). There were follow-up interviews with 2 patients and 2 partners separately.

RESULTS

Couples living with AF experience uncertainty as a common main concern. This uncertainty was fundamentally rooted in not knowing the cause of AF and apprehension about AF episodes. Couples managed this uncertainty by either explicitly sharing concerns related to AF or through implicitly sharing their concerns. Explicit sharing incorporated strategies of mutual collaboration and finding resemblance, whereas implicit sharing incorporated strategies of keeping distance and tacit understanding. Time since diagnosis and time being symptom-free were factors influencing afflicted couples' shifting between implicit and explicit sharing.

CONCLUSIONS

Atrial fibrillation affects the partner relationship by bringing uncertainty into couples' daily lives. Even though this study shares similarities with previous studies on couples living with chronic disease, it contributes to the existing knowledge by presenting a set of strategies used by couples in managing uncertainty when living with AF.

The well-being of relatives of patients with atrial fibrillation: a critical incident technique analysis

Background:

The well-being of relatives of patients having chronic heart diseases (CHD) has been found to be negatively affected by the patient’s condition. Studies examining relatives of patients with atrial fibrillation (AF) indicate that their well-being may be affected in a similar manner, but further research is needed.

Aim:

To explore and describe critical incidents in which relatives of patients experience how AF affects their well-being and what actions they take to handle these situations. Design and method: An explorative, descriptive design based on the critical incident technique (CIT) was used. Interviews were conducted with 19 relatives (14 women and five men) of patients hospitalised in southern Sweden due to acute symptoms of the AF.

Results:

The well-being of relatives was found to be affected by their worries (patient-related health), as well as the sacri-ficing of their own needs (self-related health). In handling their own well-being, these relatives adjusted to and supported the patient (practical involvement), along with adjusting their own feelings and responding to the mood of the patients (emotional involvement).

Conclusion:

The well-being of relatives of patients with AF was affected depending on the patients’ well-being. In their attempt to handle their own well-being, the relatives adjusted to and supported the patients. Further research is needed in order to evaluate the effects of support to relatives and patients respectively and together.

Psychosocial complications of coronary artery disease

Background:

Cardiovascular diseases are the leading causes of death around the world. The coronary artery disease (CAD) is one of the most common diseases in this category, which can be the trigger to various psychosocial complications. We believe that inadequate attention has been paid to this issue.

Objectives:

The purpose of the present study was to explore the psychosocial complications of CAD from the Iranian patients’ perspective.

Patients and Methods:

A qualitative design based on the content analysis approach was used to collect the data and analyze the perspective of 18 Iranian patients suffered from CAD, chosen by a purposeful sampling strategy. Semi-structured interviews were held in order to collect the data. Sampling was continued until the data saturation. The data were analyzed using qualitative content analysis approach by MAXQUDA 2010 software.

Results:

This study revealed the theme of the patients’ challenges with CAD. This theme consisted of: "primary challenges," including doubting early diagnosis and treatment, and feeling being different from others; "psychological issues," including preoccupation, fear of death and surgical intervention, recurrence stress , anxiety and depression; "problems of life," including financial problems, work-related problems, and family-related problems; and "sociocultural issues," including change in perspective of people towards the patient, and cultural issues.

Conclusions:

Although the management of physical problems in patients with CAD is important, psychosocial effects of this disease is more important. Thus, health care personnel should pay ample attention to identify and resolve psychosocial problems of these patients. Results of this study can be used to empower these patients.

The experience of younger adults following myocardial infarction

The aim of this study was to elucidate the meaning of the experience of younger people (< 55 years) during their first year following a myocardial infarction. We analyzed 17 interviews using a phenomenological-hermeneutic method. The core theme and central phenomenon was the everyday fight to redress the balance in life, which encompassed an existential, physical, and emotional battle to regain a foothold in daily life. The aftermath of a life-threatening event involved a process of transition while at the same time creating a new meaning in life. Lack of energy and its impact on the complex interplay of midlife combined with unreasonable demands from employers and health care professionals seemed to color the experience of the informants. The knowledge gained in this study can constitute a valuable contribution to overall quality assurance in nursing care and the development of nursing interventions for the cardiac rehabilitation of younger patients.

Coping with the effects of myocardial infarction from the viewpoint of patients' spouses

The spouse of a patient who has experienced a myocardial infarction (MI) reportedly has psychological and social needs and challenges during the patient's hospitalization but there is a lack of knowledge regarding spouses' coping experiences and resources. The aim of this study was to develop a substantive theory to help explain the coping experiences of the spouse during the patient's hospitalization following an acute MI. Twenty eight spouses of patients in two Finnish hospitals participated in an open-ended interview within 2 to 5 days of the MI and included 12 husbands and 16 wives. The core category "Seeking balance" included the spouses' emotional, cognitive, and social coping experiences following an acute MI. This study adds new information about spouses' coping experiences as well as tensions and problems in interaction between the patient and the spouse. Challenges were reported in talking about serious illness concerns between the spouse and patient and also with other family members.

Couples' thoughts about and expectations of their future life after the patient's hospital discharge following acute myocardial infarction

AIM

To describe and interpret couples' thoughts and expectations about their future life after the patient's discharge following acute myocardial infarction.

BACKGROUND

An acute myocardial infarction is a challenge for both the patient and his/her partner, as it can disrupt family functioning and dynamics. Earlier research has generally focused on either the patient or the partner, and few studies have explored the experiences of the couple.

DESIGN

Qualitative descriptive and interpretative.

METHODS

Fifteen couples took part in individual interviews, 4-8 weeks after discharge. Data were analysed in two phases using qualitative content analysis.

RESULTS

The first phase of the analysis revealed two categories: 'an active approach to the future' and 'a wait-and-see approach to the future', both of which described the participants' thoughts about the future. In the second phase, the couples' stories were interpreted and grouped into four positions: 'the life companions', 'the tightrope walkers', 'the pathfinders' and 'the observers', which illustrated their visions of the future.

CONCLUSIONS

Our results reveal differences in the couples' thoughts about and expectations of their future life, most of them managed the situation by having a positive attitude to life and their future. The couples discovered their resources and compensated for or balanced each other in the early recovery period.

RELEVANCE TO CLINICAL PRACTICE

The results indicate the importance of giving both partners the opportunity to express their views of the situation, as this increases nurses' understanding of the impact of the illness on their life and relationship. However, the results also highlight the significance of seeing the couple and showing them consideration both as individuals and as a unit.

Illness experiences of patients with ischemic heart disease during their transitional phase from hospitalization to discharge in Japan

The purpose of this study was to explore the experience of patients with ischemic heart disease (IHD) during the transitional phase from hospitalization to discharge. Twenty-four patients who experienced IHD for the first time comprised the sample of the study. Semi-structured interviews were conducted during the transitional phase. The results of the qualitative inductive analysis showed two categories of illness experience: (i) the connection of heart attack experience with the self, and (ii) the instability of the self as a patient with heart disease. The participants were found to vacillate between the self as patient with a heart disease and the typical self before the disease onset. The transitional phase is the time when patients experience changes in their symptoms and physical conditions rather than a condition of stability signifying recovery. Patients are expected to manage the symptoms of their heart disease by themselves; however the participants showed signs and symptoms of confusion and anxiety about facilitating their own care. These findings suggest the importance of outpatient nursing practice focusing on the support and emphasis on nursing interventions for patient anxiety and alleviation of confusion through the management of symptoms of heart disease after discharge.

The meaning of a consultation with the diabetes nurse specialist

OBJECTIVE

The aim of this study was to elucidate the essential meaning of a consultation between diabetes nurse specialists and patients to gain a deeper understanding of the patients' experiences.

METHODS

Twenty patients with type 2 diabetes were interviewed about their experience of a consultation at an annual check-up with the diabetes nurse specialist. A phenomenological hermeneutic method was used in the analysis and interpretation of the text.

RESULTS

The patient's experience of a consultation was interpreted as manifestation of hold on the disease control. This means a safeguard to continue daily life shown in the four themes being controlled, feeling exposed, feeling comfortable, and feeling prepared.

CONCLUSION

The patients' experiences of a consultation with the diabetes nurse specialist became the basis for a health maintenance process in dealing with critical health-disease aspects. IMPLICATIONS TO PRACTICE: In a consultation, professionals have to take into account the potential emotional turbulence that disease progression can mean to a patient. Diabetes care implies patient dependence on support to avoid a potential self-management insufficiency and call attention to professionals' time for listening to patients' perceptions.

Adaptation Positions and Behavior Among Post—Myocardial Infarction Patients

This study explores myocardial infarction patients' experiences of adaptation to illness consequences after one year, focusing on experiences of “the self.” The study sample consisted of 19 respondents (10 women, 9 men) who have suffered a first-time myocardial infarction. They were interviewed 1 year after the acute heart attack. A constant comparative method for grounded theory provided the strategies used for data collection and analysis. Codes emerged and memos clarified theoretical reflections. The resulting model was able to illustrate possible mechanisms underlying two different behaviors: self-modifying and self-protecting behavior. Four different adaptation positions were identified: put up with current health, struggle for health, ignore illness , and struggle against illness. These categories were related to two core categories: self-agency and coping with illness consequences . This model may clarify the different adaptive behavior observed among post—myocardial infarction patients.

Dyadic benefit finding after myocardial infarction: a qualitative investigation

OBJECTIVE

The aim of this study was to explore the process of dyadic benefit finding after myocardial infarction.

METHODS

For the purposes of the study, a qualitative methodology using intepretative phenomenologic analysis was used. Semistructured interviews were conducted with 11 couples. Patients were predominantly male, aged between 50 and 70 years, and partners were aged between 45 and 64 years. All couples were married.

RESULTS

In terms of the patients, the following themes emerged: a catalyst for change/wake-up call; change of life philosophy; being protected/being invincible; humanistic attitudes. With regard to the spouses, the following themes emerged: active search for benefit/failure to find benefit and improvement of relationship.

CONCLUSION

The study revealed no compatibility in the process of benefit finding between patients and spouses. Clinical implications for cardiac rehabilitation interventions are discussed.

Managing consequences and finding hope--experiences of Swedish women and men 4-6 months after myocardial infarction

Research has focused more on symptoms, risk factors and treatment, than on individuals' experiences of illness and recovery after myocardial infarction (MI). Therefore, the aim of the study was to describe the experiences of present everyday life of women and men 4-6 months after MI and their expectations for the future. Semi-structured interviews were conducted with 20 women and 19 men from January 2000 to November 2001. Data were analysed with content analysis. Two themes, 'Managing consequences of MI' and 'Finding a meaning in what had happened', were generated. The first theme reveals that many of the patients had not established a stable health condition, even if symptoms and emotional distress had diminished over time. They had to manage health problems, lifestyle modifications, emotional reactions and changes in social life. The support from their social network encouraged them to move on. The second theme shows that patients also found positive consequences of what they had gone through, new life values and hopes in the future. The conclusions were that most of the patients moved on and began to regain a balance in everyday life, but some patients still struggled hard to find this balance. Those patients experienced large difficulties with managing their everyday life and felt a lack of support from their social network. Health professionals can be an important resource in helping patients in their adaptation to changes if they are more sensitive to patients' needs of support both in a short- and long-term perspective.

Impact of cardiac disease on couples' relationships

AIM

This paper reports a study to describe meanings that couples mutually assign to, and practices they develop, after the onset of cardiac disease and to understand the impact of the illness on the couples' relationships in everyday life.

BACKGROUND

Patients as well as partners are affected by the onset of cardiovascular disease. Social support within intimate relationships has been shown to be important for patient survival and well-being, and couples' coping strategies are pivotal for well-being and adjustment to the chronic condition in both patients with cardiovascular disease and their partners.

METHOD

Twenty-four couples participated in this phenomenological study. Data were collected during 2003. Participants were interviewed after having been hospitalized due to an acute event and having participated in a rehabilitation programme. Three in-depth interviews were obtained for each dyad: one couple interview and two individual interviews with each partner of the dyad. Paradigm cases were sought and thematic analyses conducted.

FINDINGS

All couples experienced a 'brush with death' at the onset of heart disease, which called for changes in lifestyle. Three distinct patterns of dealing with the illness emerged. The first revealed that some couples assess the illness as a positive, transformative experience in their lives, bringing them closer together. The second showed that a proportion of couples experience the illness as a threat which imposes fear on both partners. The challenges are faced as mutual tasks and new routines are developed. The third pattern revealed couples who experience a missed opportunity to change. These couples are disenchanted about each other but return to life as usual.

CONCLUSIONS

Nurses can use the information gained from this study to support couples in their attempts to come to terms with the illness, and can enhance their supportive role in rehabilitation efforts.

Preparing for the worst while hoping for the best: the relevance of hope in the heart failure illness trajectory

BACKGROUND

Patients with heart failure have higher mortality rates than those with most malignant diseases. The heart failure illness trajectory is one of gradual decline characterized by unpredictable events such as acute decompensation of heart failure or a sudden cardiac death. Health professionals have an obligation to give patients and their families concise and honest information concerning their prognosis. The challenge exists to give what ostensibly may seem a bleak prognosis within a context of hope and optimism.

AIM

To explore the role of hope in heart disease and the potential utility of this construct in the development of nursing interventions.

METHODS

The electronic databases CINAHL, MEDLINE, EmBASE, and PSYCHlit were searched from 1982 to August 2004 using the key words "hope," "hopelessness," "heart disease," and "heart failure." Articles were subsequently sorted to meet the inclusion criteria of (1) a philosophical discussion of the construct of hope and/or (2) investigation of hope in heart disease.

RESULTS

This search retrieved 768 articles, and 24 met the inclusion criteria. Key findings from the review indicate that "hope" and "hopelessness" are underdeveloped, yet important constructs and conceptually linked with depression and spirituality. Intriguing findings from descriptive, observational studies have demonstrated the positive impact of expression of hope on cardiovascular outcomes. These findings need to be validated in randomized controlled trials.

CONCLUSIONS

This critical literature review has determined that "hope" is strongly associated with the individual's future orientation. Increased understanding of this concept may assist in refining patient-focused interventions and developing therapeutic strategies to enhance hope.

Stress in women's daily life before and after a myocardial infarction: a qualitative analysis

BACKGROUND

Little is known about women's perceptions of their daily life before and after a myocardial infarction (MI), especially with regard to stress, which is a risk factor for coronary heart disease (CHD).

AIM

To describe and explore women's perceptions of stress before and after an MI.

METHOD

Two interviews with women who suffered an MI, the first at the hospital (n = 20) and the second 4-10 months after the MI (n = 14), were analysed using a phenomenographic approach.

FINDINGS

The stress emanated either from within themselves (personal traits) or as an effect of their immediate surroundings. The period before the MI was stressful due to the different roles they had to maintain in their private and professional lives. They lost control over their daily life. After hospital discharge they both wanted and needed support, as they were terrified when they returned home. They did not know how much they could do and neither did their relatives, while little or no support was provided by the healthcare professionals.

CONCLUSIONS

To prevent CHD in daily life and avoid reinforcing stress, it is important to place greater emphasis on stress as an important risk factor. An understanding of this phenomenon can assist primary healthcare, coronary care unit (CCU) and rehabilitation nurses in supporting these women as well as their partners to adapt their daily lives both before and after an MI. It is essential to formulate and implement individualised treatment plans and to provide support groups for women.

Striving for balance in daily life: experiences of Swedish women and men shortly after a myocardial infarction

AIM

The aim is to describe experiences of daily life of women and men during the first four to six months after a myocardial infarction. The focus is on problems, managing problems and support from their network.

BACKGROUND

A cardiac event is traumatic and may influence well-being during a significant period of time. Few qualitative studies have investigated experiences of both women and men after a myocardial infarction and remarkably little research has been conducted on men's experiences.

DESIGN

The study design was descriptive, retrospective and qualitative.

METHODS

Semi-structured interviews were conducted with 20 women and 19 men from January 2000 to November 2001. Data were analysed using qualitative content analysis.

RESULTS

Three themes were generated from the analysis: 'Threatening ordinary life', 'Struggling for control' and 'The ambiguous network'. Physical symptoms and emotional distress were the most commonly described problems during the first months after a myocardial infarction. The informants manage the problems by negotiating with themselves, relying on their own capabilities, changing attitudes and behaviours and taking their own decisions and actions. The network was generally supportive but rather often the informants also experienced communication problems when they interacted with their network.

CONCLUSIONS

Women and men strive for balance between problems and resources in daily life after a myocardial infarction. How well they succeeded depends on how secure they feel how well they communicate their needs to their network and how sensitive their network is to their spoken and unspoken needs.

RELEVANCE TO CLINICAL PRACTICE

The findings provide an insight into what kind of problems women and men may experience after myocardial infarction and how caregivers can aid them to increase security in their daily life. Some risk characteristics that may have increased their problems in daily life are suggested, for women and men respectively.

Readjustment 5 months after a first-time myocardial infarction: reorienting the active self

AIM

This paper reports on an interview study exploring the self-regulation process in women and men, 5 months after a first-time myocardial infarction.

BACKGROUND

Somatic, psychological and social factors affect readjustment after a first-time myocardial infarction, and studies have demonstrated substantial rates of depression in patients after myocardial infarction Women report poorer mental health and physical condition than do men. Reconstruction of the self begins when disease poses novel problems and is more likely to occur in cases of long-lasting and disruptive illnesses. Experiencing myocardial infarction is likely to alter a person's mental representation of self. However, the self-regulation process following first-time myocardial infarction is not yet fully understood.

METHOD

Twenty-one people (11 women, 10 men) were interviewed 5 months after first-time myocardial infarction. The grounded theory method provided the strategies for data collection and analysis.

FINDINGS

Interviewees' definition of themselves as active was threatened by fatigue and other health problems that kept them from taking part in activities as they had done before the heart attack. Although reorienting the active self was central to the process of recovery from myocardial infarction, reorienting was restricted by illness perception and coping.

CONCLUSION

Participants had not established a stable health condition 5 months after first-time myocardial infarction. They mainly preferred to moderate rather than radically change their daily life activities. They needed more knowledge and support. Nurses can help with information and advice on managing daily life activities, including dialogue about lifestyle changes at this phase of readjustment.

‘The intruder’: spouses’ narratives about life with a chronically ill partner

AIM

The aim of this study was to illuminate the meaning of middle-aged spouse's experiences of living with a chronically ill partner. A purposive sample of four female spouses was selected for interviews using a narrative approach.

BACKGROUND

When someone is diagnosed with a chronic illness, it is easy to understand that a considerable number of devastating consequences follow, both for the afflicted as well as for the family. Families often feel neglected and that their problems and needs are underestimated, if they do not personally draw attention to this fact.

METHODS

A phenomenological hermeneutic method, inspired by the philosophy of Ricoeur, was used when interpreting the interview text.

RESULTS

The experiences of spouses living with a chronically ill partner often brought a feeling of detachment from their partner's lives. The women experienced changes in their relationships because of their partners' disabilities; they had emotions of loneliness, despite living together as a couple. Through their actions, the women sought reassurance and support in order to maintain a meaningful partnership with their spouses and this is expressed in three themes: feelings of limitation, the struggle of everyday life and a striving for normalization.

CONCLUSIONS

Middle-aged women living with a chronically sick partner are still of an active disposition and regard themselves as still being in mid-life. They wish to be loved as a wife and not as a care provider.

RELEVANCE TO CLINICAL PRACTICE

The findings from this study can help increase the knowledge and understanding of the problems and concerns encountered by middle-aged spouses living with chronically ill partners and can be useful in the education and supervision of nurses and in relationship with relatives.