Most articles on the families' responses to illness (Keizer, 1 992; Kettunen et aI., 1 999; Minicucci, 1 998) contend that nurses need to be active in including the family during both the acute phase of illness and the rehabilitation process. Failure to involve supporting spouses in rehabilitation programmes result in these spouses not adjusting to the change in lifestyle or supporting compliance with treatment were findings that emerged from a study undertaken by Miller & Wikoff ( 1 989). Stewart et al. (2000) concluded from their research that reliable information about rehabilitative processes was identified as the main strategy that wives used to cope with their husband' s myocardial infarction.
How that information is provided also influences how effective the supportive processes are for the spouse of one who is hospitalised. Medland and Estwing Ferrans ( 1 998) conducted research to test whether a structured communication programme for family members would increase family members' satisfaction with care and improve meeting their needs for communication. These researchers conducted a quasi-experimental study with 1 5 family members in each of the control and experimental groups. A structured communication programme was offered to the members of the experimental group. The programme consisted of a discussion with the nurse 24 hours post admission, an information pamphlet, and a daily telephone call from the nurse caring for the patient. Those that received the structured communication programme made less incoming calls to the unit, and expressed satisfaction with the care the family member received. Less experienced nurses find it difficult to keep the family informed, as their energies are concentrated on caring for the critically ill person, rather than extending their care to incorporate the family (Kosco & Warren, 2000). Anecdotally this tension becomes more apparent as there is pressure to reduce the length of hospital stay.
Length of patient stay is one measurement of resource utilisation that
demonstrates service effectiveness and efficiency (Poutasi, 2000). Therefore, one advantage of innovations of colorectal surgery in New Zealand is that
2002). Furthermore, innovations in heart valve surgery have decreased the post-operative patient acuity. In New Zealand the average length of stay in the critical care units following cardiac bypass graft surgery is only four days (McKay, Bunton, Galvin, Shaw, & Singh, 2002). However, the average length of hospital stay from diagnosis until discharge is 30 days (McKay et aI., 2002); potentially a long time for those who, unless they are residents of the two centres that offer cardiothoracic surgery, would be required to travel out of-town. Ironically, none of these research articles identified the social cost to families during the time of hospitalisation and rehabilitation.
Patients also wish to be actively involved in rehabilitation. For example, while an understanding of the individual's perspective of rehabilitation is essential, little qualitative research addresses this, and this lack of research results in poor understanding of the rehabilitative process (Griffiths & Jordan,
1 998; Nolan & Nolan, 1 998). Griffiths and Jordan ( 1 998) concluded from their grounded theory study based in Britain that when patients suffer acute lower limb trauma they feel a sense of uncertainty that persists throughout the recovery in both the hospital and home. To compensate for this, patients tended to overestimate their ability or under-estimate the pain they actually experienced (Griffiths & Jordan, 1 998). The reason the patient' s perspective is included in this discussion is because of speculation about whether those who are hospitalised in non-local tertiary settings face both external and internal pressure to rehabilitate more quickly in order to go home.
Patients also over-estimate their ability to manage once they are discharged from a hospital setting (Clark, Steinberg, & Bischoff, 1 997). Patients within the age-range of 60-86 years and with a variety of medical diagnoses took part in this Australian research undertaken by Clark et al. The majority of the patients identified that they did not cope as well as they had anticipated on discharge. Of greater concern is the fact that nearly half the patients reported deterioration in their health status and over half required readmission to hospital within three months. In addition the patient's carer rated the patient as requiring considerable assistance to maintain activities of daily living
(Clark et aI., 1 997). This leads to speculation that patients minimise their illness as they attempt to preserve self-image and locus of control (Nolan & Nolan, 1 998). The need to maintain locus of control when dealing with personal illness is supported by Polaschek (2003) who found that New Zealand men on home dialysis adjusted their lives to accommodate dialysis treatment and retain control of their weekly schedule. These men also identified and managed their own ideal weight levels, diet, treatment regimes and on occasion, their medication in order to retain locus of control
(Polaschek, 2003).
As noted previously, fear of dependency is reported to affect the patient's health (Koivula et aI. , 2002). This fear of dependency on care is supported by research conducted by Strandberg, Norberg, and Jansson (200 1), who used hermeneutic phenomenology to determine the experiences of a patient who was dependent on others to meet personal care. In this instance, the researchers found it was a fine balance to differentiate between being dependent on care and becoming dependent on the caregivers themselves. This struggle is supported by research conducted by Strandberg et al. (2002) which concluded that nurses rely on the patient to request care, while the patient is reluctant to request assistance for fear of being a nuisance.
Ironically Strandberg et al. (2002) report that the nursing staff did not view the role of the patient's wife in providing care as significant. Therefore, the need of the patient's wife to have social support is not recognised.