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A mail questionnaire was completed by 171 patients two to 20 months after undergoing coronary artery bypass graft surgery (CABG). The post-CABG period was characterized by fewer working hours, a higher level of physical exercise, a reduction in smoking, and more appropriate nutritional habits, compared with the preoperation period. At the same time, the anxiety level of post-CABG patients was higher than that measured in a community sample. Post-CABG high psychological distress (anxiety and mood states) and low functional national capacity were associated with high levels of pessimism and ineffective emotion-focused coping strategies.. These results may be used by social workers in devising psychological interventions aimed at improving post-CABG patients' quality of life and bolstering their coping strategies.

Key words

coping strategies


open-heart surgery



Coronary heart disease is a major physical illness and one of the main causes of death in Western society (Fitzgerald, Tennen, Affleck, & Pransky, 1993; Trzcieniecka-Green & Steptoe, 1994). People who do not die an early and sudden death may have to consider a major surgical treatment, the most prevalent being coronary artery bypass graft surgery (CABG). More than 350,000 such operations are performed annually in the United States alone (Kulik & Mahler, 1993). This operation prolongs the life of patients in cases of triple-vessel disease (Passamani, Davis, Gillespie, & Killip, 1985). It also improves patients' quality of life (Jenkins, Stanton & Jono, 1994), thus providing them with the opportunity for successful rehabilitation.

The present research investigated physical and behavioral rehabilitation of patients after CABG, assessed by improvements in their functional capacity, daily activities, and life style. The study used patients' anxiety and mood states as distress indicators. The research examined the extent to which these outcomes were associated with dispositional coping and pessimism. Such research findings may contribute to the planning of short-term interventions by social workers and other health professionals for use with patients following CABG.


During the first several weeks after CABG surgery, states of high anxiety or depression are usually observed (see, for example, Pick, Molloy, Hinds, Pearce, & Salmon, 1994; Trzcieniecka-Green & Steptoe, 1994). In long-term research (that is, approximately one year after the operation), the results present a more positive trend in terms of elevation in positive moods (King, Porter, Norsen, & Reis, 1992; King, Reis, Porter, & Norsen, 1993), as well as an increase in quality of life (Kulik & Mahler, 1993). Such outcomes can be accounted for by illness severity factors. In addition, in recent years, the individual's personality and coping characteristics have been investigated as important determinants of post-CABG patients' emotional reactions and rehabilitation.


Lazarus and Folkman (1984) defined coping as the behavioral and cognitive efforts invested by an individual to deal with stressful encounters. Coping is described as having two main components: (1) problem-focused coping, aimed at changing, managing or tolerating the stressful encounter, and (2) emotion-focused coping, aimed at changing or managing the affective and physiological outcomes of the stressful situation, without actually changing the encounter itself. Following Lazarus and Folkman (1984), Carver, Schejer, and Weintraub (1989) developed a classification of coping according to 15 strategies characterized as problem- or emotion-focused strategies and discussed their adaptive and maladaptive values. Problem-focused strategies usually are found to be adaptive or effective when the stressful situation is manageable. The use of emotion-focused strategies seems to be appropriate in the context of uncontrollable situations. However, emotion-focused strategies differ in their presumed effectiveness, and som e, such as ventilation or avoidance, are found to be ineffective even when the stressful occurrence is not under the individual's control (see Ben-Zur, 1999; Carver et al., 1989).

The two components of coping have been extensively investigated, but few studies have dealt with coping strategies and patients' adjustment after CABG surgery. Carver and Scheier (1993) correlated avoidance and vigilant coping in relation to the medical situation, and well-being after CABG. Their results suggest that the use of either type of coping strategy is related to a high distress level and sometimes to a low quality of life and slow rehabilitation.

Dispositional optimism is defined as the generalized expectancies that good outcomes will occur when confronting major problems (Scheier et al., 1989). It is considered to be a determinant of continued efforts to deal with problems, as opposed to turning away and giving up. Scheier et al. (1989) found dispositional optimism to be related positively to situation-specific problem-focused coping, as well as to a high quality of life, six months after surgery. Recently, King, Rowe, Kimble, and Zerwic (1998) found associations of optimism with mood, but not with functional ability, among women who recovered from CABG, with the effects of optimism mediated by the use of cognitive coping strategies.


The aim of the present research was threefold: (1) to assess post-CABG patients' rehabilitation and distress; (2) to assess post-CABG patients' recovery from the operation by comparing their anxiety, coping, and pessimism levels with the levels observed in a community sample; and (3) to examine associations between coping and pessimism with post-CABG distress and rehabilitation.

The research hypotheses were that

* emotion-focused coping and pessimism would be associated with higher distress and a lower level of rehabilitation

* problem-focused coping would be associated with lower distress and a higher level of rehabilitation.


Participants and Sampling Procedures

CABG Sample. A convenience sampling was used by selecting 400 Hebrew-speaking patients from the lists of a large medical center that serves the population in the north of Israel. The patients were chosen if they were between the ages of 40 and 70 and had undergone CABG surgery for the first time two to 20 months prior to study initiation.

A questionnaire was mailed to the patients from May through September 1995. The return rate was approximately 50 percent, with 50 of the questionnaires returned uncompleted because of a wrong address. The final sample included 171 people (81 percent men), with a mean age of 61.45 (SD = 6.24). The majority (87 percent) were married, 5 percent were divorced, and 8 percent were widowed; the average number of children was 3.02 (SD 1.79). Most of the respondents had a highschool (42 percent) or higher level of education (26 percent). Fifty-eight percent of the respondents worked during the six-month period prior to surgery, and 42 percent reported working following surgery.

A comparison of the sample with the CABG population from the same time period revealed no differences on gender, education (p [greater than].05), or age distribution (p [greater than].01).

Community Sample. One hundred and fifty community residents (45 percent men) were selected from a large database collected as part of a community research project on stress and coping in everyday life (Zeidner & Ben-Zur, 1994). These participants were selected according to the same age range (40 to 70) as the post- CABG patients (M = 49.33, SD = 7.90). The majority were married (85 percent), with an average number of 3.12 children (SD = 1.63). Most had a high school (51 percent) or higher level of education (32 percent).

Ethical Procedures

The questionnaires were mailed to the post-CABG patients with the assurance

that the study was voluntary and personal details were kept confidential. Accordingly, data were coded and analyzed using code numbers only, and the same procedures applied to the community sample data.


Physiological and Behavioral Rehabilitation. The following data were collected from the post-CABG patients only:

* Functional capacity--A scale including the four descriptions of the New York Heart Association's functional capacity classification was used (O'Rourke, 1994). Participants were asked to indicate the description that best fitted their currentstate. The highest functional capacity was indicated by 1 ("I do not experience pain or have any restrictions in everyday activity"), and the lowestby4 ("I feel disabled and experience pain during periods of rest and when making the smallest effort").

* Daily activity, life habits, and compliance--Respondents were asked to report the number of hours spent on each of the following daily activities, both preceding and following surgery: paid job, volunteer job, hobbies, physical exercise, social/family gatherings, courses/studies, house maintenance, movies/ concerts, television viewing/reading, and sleep. They marked the instructions given by physicians concerning medication and life habits, including physical activity, sexual activity, smoking, appropriate nutrition (low-fat, low-salt, or low-sugar diet). They were also asked whether they took the prescribed medication and engaged in these life habits, both before and after the operation.

Psychological Measures. The following data, except for the current mood scale, are available for both samples:

* Distress--Current anxiety was measured by a five-item State-Anxiety scale, taken from the State-Trait Personality Inventory (Spielberger et al., 1979) and translated into Hebrew (Ben-Zur & Zeidner, 1991). The items were rated on a four-point scale (ranging from 1 = not at all to 4 = very much; [alpha] = .86). A high score, based on the sum of the five items, indicates high anxiety. Current mood and feelings were measured by six new items created for the present study, and rated on the same four-point scale: bad mood, feeling helpless, angry mood, changing mood, depressed mood and sensitization. A composite mood score was created based on a one-factor solution ([alpha] = .88). Since anxiety and mood were highly correlated (r = .84), they were combined to create a general distress score to be used in the correlational analyses.

* Pessimism--The Life Orientation Test (LOT) (Scheier & Carver, 1985) was used in its Hebrew version (Zeidner & Ben-Zur, 1994). It includes eight items, rated on a five-point scale (ranging 1 = strongly agree to 5 = strongly disagree). A high score indicates a pessimistic tendency, and a low score, an optimistic tendency ([alpha] =.59).

* Coping strategies--The COPE scale (Carver et al., 1989) was used in its shortened Hebrew form (Zeidner & Ben-Zur, 1994). Respondents mark their use of each of the coping options in dealing with stressful encounters in everyday life on a scale ranging from 0 = not at all to 3 = great extent. The Hebrew scale includes 15 subscales, each composed of the sum of two items per subscale. Following factor analysis, two main scales were computed: (1) a problem-focused scale composed of active coping; planning, positive reinterpretation, instrumental social support, suppression of competing activities, and restraint, and (2) an emotion-focused scale composed of emotional/social support, religion, ventilation of emotion, mental disengagement, behavioral disengagement, and alcohol or substance use (the COPE includes an additional three subscales that did not form a scale--humor, acceptance, and denial). Alpha levels were .80 and .72 for the problem-focused and emotion-focused scales, respectively.

Data Analysis

In light of the number of statistical operations performed on the data, we used a conservative p = [less than].01 level of significance.


Physical and Behavioral Rehabilitation in the CABG Sample

Functional Capacity Following CABG, 30 people reported the highest level of functional capacity, 55 a medium level, 46 a low level, and 24 reported the lowest level. Frequencies of functional capacity for the general population of patients during the period preceding surgery in 1995 and 1996, as assessed by physicians on the same scale used for participants, were, from highest to lowest, 6, 189, 243, and 267. Thus, more than 50 percent of the post-CABG patients showed high to medium capacity compared with fewer than 30 percent in the pre-CABG population [[chi].sup.2](3,l50) = 138.2, p [less than] .0001]. These data imply an improvement following the CABG surgery.

Daily Activities, Life Habits, and Compliance. As can be seen in Table 1 after the operation, the average number of working hours was greatly reduced (t = -7.12, p [less than] .0001; these data do not include retired or disabled respondents), whereas number of hours spent on physical exercise increased (t = 3.31,p [less than] .005).

Overall scores for life habits before and after surgery were created by summing up all answers given in a positive direction. A positive overall change in life habits following the operation was observed (t = 6.56, p [less than] .0001) (Table 2). Positive changes in nutrition were reported most frequently, whereas sexual activity showed a small change in the opposite direction.

When asked about instructions pertaining to medication, 98 percent reported receiving instructions to take medication after surgery, and 93 percent reported compliance with these instructions (Table 2). Respondents reported receiving instructions on the following daily life habits: smoking (78 percent), dietary habits (93 percent), physical exercise (82 percent), and sexual activity (63 percent).

To measure compliance, the data for engagement in each life habit after surgery were crossed with the data pertaining to instructions concerning the habit. The percentages of people reporting that they received instructions and followed them are given in Table 2. The highest levels of compliance were found for the nutrition and smoking habits.

Comparisons between CABG and Community Samples

Anxiety. The anxiety mean of the CABG participants was compared with the mean of the community sample in a two-way, sex ( sample analysis of covariance (ANCOVA), controlling for age. Significant effects for both sample and sex, with no interaction, were found: Women reported higher anxiety than men, with corrected means of 10.48 and 9.29, respectively, [F(l, 282) =6.22, p = .01]. More important, the post-CABG patients were more anxious than the community sample, [corrected means of 10.62 and 9.15, respectively, F(1, 282) = 6.09,p = .01].

Coping Strategies and Pessimism. No differences were observed between the two samples on either the emotion- or the problem-focused coping subscales, or on pessimism. A clear trend was observed in our sample, as was noted in earlier research (Zeidner & Ben-Zur, 1994), to report a more frequent use of problem-focused strategies compared to emotion-focused strategies [M = 3.54 (SD = 1.20) and 2.11 (SD = l.10),respectively; t = 14.68, p [less than] .00011.

Association among Distress, Rehabilitation, Coping, and Pessimism

Pearson correlation analyses showed positive correlations between distress and emotion-focused coping or pessimism (r = .52, p [less than] .0001). Emotion-focused and problem-focused coping were correlated differentially with pessimism ( r .40, p [less than].001 and r = -.22,p [less than].01, respectively). Of the demographic variables, people with less education reported on a high level of emotion-focused coping, a high level of pessimism, and a low level of problem-focused coping (r = -.24, -.28, and .20, respectively, p [less than] .01).

Difference scores were used for overall changes in life habits and in hours spent on daily activities (not including sleep). The compliance measure was based on the sum of combinations of receiving instructions in relation to life habits and engagement in these habits.

Distress was highly correlated with functional capacity, and both measures were negatively related to changes in life habits, with distress related to changes in activity levels (Table 3). Thus, people who experienced high distress also reported low functional capacity, less activity and less positive changes in life habits. Distress and functional capacity after surgery were correlated highly with emotion-focused coping and pessimism. It should be noted that surgery-related variables, or time elapsed between operation and questionnaire completion, did not correlate with any of these variables.

The preceding analyses show emotion-focused coping to be positively related to distress and functional capacity. Therefore, we investigated correlations between these outcomes and the specific emotion-focused strategies. High distress was found to be mainly associated with ventilation, alcohol or substance use, and behavioral disengagement (r = .62, .35 and .33, p [less than] .001), as well as emotional support, religion and mental disengagement (r= .28, .26 and .21,p [less than] .01). Low functional capacity was related to religion (r= .30,p [less than] .001), ventilation, and emotional support (r = .28 and .27,p [less than] .01).

Multiple Regressions and Hypotheses Testing. Table 4 presents five regression analyses. Each of the five main outcome measures (that is, distress, functional capacity; compliance, life habits difference, and activities difference scores) was regressed on the coping and pessimism scales, as well as education, sex, martial status, and age. Emotion-focused coping is related significantly to high distress and low functional capacity, and pessimism is related to high distress and small activities changes. These results support the first hypothesis in regard to distress and some of the rehabilitation measures. Problem-focused coping is related only to high levels of compliance, and therefore the second hypothesis is not supported for distress and most of the rehabilitation measures.


Rehabilitation and Distress of Post-CABG Patients

The present research focused on distress and rehabilitation of individuals following CABG surgery. On the one hand, participants' reports indicated a very high level of compliance concerning medication and physician follow-up, with a large positive change in nutrition habits, and with positive changes in smoking and physical exercise. On the other hand, very small changes were noted in daily activity, with a major reduction in hours spent on paid work. Moreover, the anxiety of respondents was higher than that of a comparison sample and did not change over time, in a cross sectional testing.

The fact that the distress of postsurgery patients is not reduced over time is alarming insofar as it may interfere with rehabilitation, impair quality of life, and affect health. Several possible explanations can be offered in regard to this finding. First, although the operation was successful for these patients and their functional capacity was improved, it still consisted of a major life-threatening event, with long-term trauma leading to anxiety and other mood changes that are difficult to overcome. Moreover, these patients may have realized their vulnerability for the first time, and the possibility of death may have become more concrete than ever before. Second, patients might have hoped that their level of functioning would be highly improved and their hopes were not entirely fulfilled. Such disappointment may underlie their continued anxiety and mood changes, and may lead to uncertainty concerning future health.

Distress and Rehabilitation as Correlates of Coping and Pessimism

Our results concerning associations between low pessimistic tendency and life style changes are in accordance with earlier findings (Scheier et al., 1989). In addition, those who reported low postsurgery functional capacity also reported a high level of emotion-focused coping. In contrast, problem-focused coping was not correlated highly with rehabilitation and life-change measures. In addition, distress was associated mainly with certain emotion-focused coping strategies considered to be ineffective--that is, the ventilation or avoidance strategies (Carver et al., 1989), which were found to correlate with post-CABG distress in other studies (Carver & Scheier, 1993).

Although postsurgery distress, functional capacity, pessimism, and emotion-focused coping were found to be strongly associated in this study, it should be remembered that the investigated variables are reciprocally determined. Thus, distress may affect and be affected by functional capacity and may augment the use of emotion-focused coping and pessimism; emotion-focused coping and pessimism, in turn, may elevate distress and prevent improvements in functional capacity.

Methodological Limitations

First, all postsurgery data were based on patients' self-reports, including postsurgery functional capacity. Second, the changes in anxiety over time were assessed by a cross-sectional and not by a within-individual test. Third, all data were collected at one time point. Nevertheless, the comparisons made between the CABG and community samples showed no differences on the coping and pessimism measures, suggesting that these tendencies might indeed be stable enough not to be affected by CABG and its related physical and psychological effects. However, future studies should include pre- and postsurgery psychological and medical assessments made during several time points.


The present results indicate strong associations between postsurgery distress, functional capacity, and dispositional emotion-focused coping strategies, whereas distress and changes in life habits and daily activity reveal an association with pessimism. In addition, positive changes in life habits and changes toward more activity following the operation were shown to be related negatively to high distress and a low level of functional capacity.

These results suggest that after CABG surgery, patients who possess a tendency toward either high pessimism or high emotion-focused coping are at a high health risk emanating from both high distress and a slow rehabilitation process. This calls for the creation of intervention procedures that will aid patients and their families in the postCABG adaptation period by changing their outlook on life and teaching effective coping strategies. Such a perspective presents a challenge for social workers to develop patient intervention programs for the specific population of highly anxious and pessimistic CABG patients. The aim of these programs would be to implement cognitive and behavioral techniques (see Cameron & Meichenbaum, 1982; Home, Vatmanidis, & Careri, 1994) for changing individual coping strategies in dealing with anxiety, as well as for focusing on personal motivation to change unhealthy life habits.

Several facets of these interventions can be delineated: First, credible and positive information should be provided, both before and after CABG. Earlier studies have shown positive effects of preoperative health care relevant information on indices of postoperative pain, distress, and recovery (Devine, 1992; Johnson, 1999). The postoperative information should emphasize the patient's active role in the recovery and rehabilitation process and aim at creating feelings of control and mastery. It can be based on written material covering topics such as risk reduction activities and ways toward safe recovery (Thomas, 1995) as well as a graphic or video presentation of a model patient (Burish, Snyder, & Jenkins, 1991) that went through the various stages of surgery successfully. The provision of such information is intended to lower patients' anxiety, feelings of helplessness, and overindulgence in either emotional expression and ventilation or in mental and behavioral disengagement.

Second, short-term intervention programs can be devised using cognitive-behavioral preparation methods such as relaxation and cognitive coping strategies. CABG patients participating in a program including relaxation, information, and counseling reported on general improvements in emotional state, functional level, and social activity (Trzcieniecka-Green & Steptoe, 1994). Thomas (1995) found that a collaborative patient-staff educational intervention lowered CABG patients' anxiety at hospital discharge. This program offered opportunities to identify individual needs regarding recovery and presumably strengthen the patients' sense of power, choice, and control through active involvement.

Third, patients' participation in social support groups sessions should be recommended. Such groups have been used with people with chronic illnesses, the evidence suggesting that this type of intervention helps patients cope (Taylor & Aspinwall, 1993). Furthermore, several studies have shown that for cardiovascular patients social support is important in smoking cessation, weight loss, and exercise maintenance (Crossman & Eyjolfsson, 1991). Thus, support through patient group sessions can be used to strengthen effective coping strategies and compliance with treatment recommendations.

These proposed interventions can be implemented by medical social workers in the various stages of diagnosis, treatment, and recovery of CABG patients. However, the best results in terms of rehabilitation probably can be achieved if an interdisciplinary team that includes social workers, physicians, occupational therapists, and nurses cooperate in the effort to strengthen the appropriate messages. Such a team can best direct patients toward the type of actions that are most effective in lowering distress, bolstering optimism, and developing coping strategies, and consequently, improving their quality of life.


Hasida Ben-Zur, PhD in psychology, is senior lecturer, School of Social Work, and staff member, Ray D. Wolfe Centre for Study of Psychological Stress, University of Haifa, Haifa, Israel; e-mail: RPPS3O2@UVM.HMFA.AC.IL. Batya Rappaport, MSW, is senior medical social worker, and Ronny Ammar, MD, is senior surgeon, Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa; Gideon Uretzky, MD, is head and professor, Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa. The authors thank Moshe Zeidner for his agreement to the use of the community sample data in the present research. Sharon Cohen and Yfat Ravid were most helpful in data coding. We also thank the medical and nursing staff of the Department of Cardiothoracic Surgery of Carmel Medical Centre for their help during various stages of the research. This work was supported by the Ray D. Wolfe Centre for Study of Psychological Stress, University of Haifa.


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Author:Ben-Zur, Hasida; Rappaport, Batya; Ammar, Ronny; Uretzky, Gideon
Publication:Health and Social Work
Geographic Code:1USA
Date:Aug 1, 2000
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