Assessing the coping status of spouses of critically ill cardiac patients: A theoretically based approach Acute cardiovascular disease is an emotionally traumatic event for the patient and family alike. As nurses are concerned with optimizing the health and well-being of patients and families, the nurse's role in assessing coping responses of the spouses is critical for the formulation of appropriate nursing diagnoses and th» development of effective interventions, This article describes the spousal coping instrument, which is based on a conceptual model of nursing and is designed to comprehensively assess the coping responses, factors that influence coping, and outcomes of spouses whose partners have suffered an acute cardiac event. Adeline M. Nyamathi, PhD, RN Assistant Professor School of Nursing University of California, Los Angeles S A MAJOR life-threatening event, cardiovascular disease has consider- able impact on patients and their families. The onset of the event and the individual's perception of the illness as a threat to his or her personal and psychologic well-being are the prime factors responsible for the tremendous impact.’ Over the past two decades, there has been a growing awareness of the effect cardiac disease has on the physical, emo- tional, and social well-being of the spouse. Several authors have identified the con- cerns of the spouses of cardiac patients to be related to personality changes in the patient, role changes in patient and spouse, financial insecurity, resumption of sexual activity, vagueness of the physicians’ in- structions, lack of knowledge and informa- tion about their husbands’ condition, possi- bility of a recurrent event, and dealing with an uncooperative partner.” Moreover, spouses have expressed the need to be comforted, protected, and taken care of during their partners’ acute hospitalization, and to express feelings with their partners despite their fear of upsetting and hurting them. They often feel guilt and blame for causing their partners’ illness, and are overpro- tective toward their recovering partner.*75 12 Dhooper’ discovered in a study of 40 fami- lies of heart attack patients that the sick partner's convalescence was particularly stressful because families were caring for the sick partner, making necessary lifestyle changes, and adjusting to the financial im- pact of the acute illness, During convales- cence, the potential for the manifestation of a crisis event is great. Since nurses are concerned with optimiz- ing the health and well-being of patients and their families, an assessment of the coping responses of the spouses and of factors affecting coping provide a focus for the development and implementation of appropriate nursing strategies effective in enhancing coping. This article describes a theoretically based assessment instrument ] Cardiovasc Nurs 1990:5(1}1-12 {© 1990 Aspen Publishers, Inc, 12 THE JOURNAL OF CARDIOVASCULAR NURSING/OCTOBER 1990 designed to assist nurses in enhancing the coping of spouses of cardiac patients and in maximizing spouses’ physical and psycho- logic well-being. THE SPOUSAL COPING INSTRUMENT The author's revised version of the Spou- sal Coping Instrument (SCI)"* is a 118-item assessment questionnaire designed to com- prehensively assess coping responses, fac- tors that influence the coping process, and adaptive outcomes of spouses of acute car- diac patients, Ninety-eight items request spouses to respond by placing a mark through analogue scales that have descrip- tive end points of “never” or “not at all” and “always,” “very well,” “often,” or “a great deal.” Sample questions from the SCI include the following: “How serious did you consider your partner's condition to be when symptoms first began?” “Have you found out more about the situation so you can handle it better?” “Are you optimistic?” A score is determined by measuring the distance between the end of the line to the subject's mark. Twelve items are multiple choice and eight items are open ended to allow spouses the opportunity to provide detailed information. An additional 24 ques- tions solicit demographic information re- garding age, sex, religion, education, occu- pation, previous marriages, number of children living at home, and medical infor- mation (eg, date of admission, clinical course, diagnosis, treatment planned or per- formed, and surgical procedures planned or performed). Conceptual frameworks in nursing are essential; they provide a focus for develop- ing an organized systematic approach to patient care." The revised SCI is broadly based on conceptualizations of the Lazarus Theoretical Schema of Coping and Adap- tation® and the Schlotfeldt Paradigm of Health Seeking Behaviors.” Nyamathi” combined the solid base of coping theory with a nursing perspective of health seek- ing and coping behaviors to produce a unique and significant conceptualization that has potential for guiding nursing the- ory testing and practice. Fig 1 displays the Comprehensive Health Seeking and Cop- ing Paradigm (CHSCP), which proposes a highly interactive relationship among twelve components. The CHSCP provides a comprehensive overview of the concept of coping that is appropriate to the nursing profession, The SCI incorporates several compo- nents of the CHSCP—cognitive appraisal, situational and personal factors, health seeking and coping behaviors, coping re- sources, and adaptive outcome. The goal of the SCI is to allow nurses working in acute and outpatient care settings to identify indi- viduals at risk for ineffective coping and, based on the inadequacies identified via the assessment tool, to develop and imple- ment strategies aimed at enhancing coping. For example, individuals with multiple sit- uational demands and a lack of support resources may be at risk for ineffective coping. The early identification of these factors and development of strategies to supplement resources may be of consider- able benefit to a family member. COGNITIVE APPRAISAL The sudden onset of a potentially lethal disease is generally perceived as a crisis event. However, the degree to which a person experiences feelings of harm, threat, or challenge is determined by a cognitive mediating process known as appraisal,1®9 As an ongoing process, appraisal is the means by which the potential outcome of a situation and the coping resources and op- tions available to deal with it are judged or3 Coping Status of Spouses Health | Goals ‘Situational Factors Personal Factors Nursing Goals ociodemographi Resources Factors i and Ss i R A fe + | Cognitive Appraisal 4 — Health Seeking and Coping Behaviors Va E ~N Perceived Compliance Perceived Coping Effectiveness Immediate Healt DY fo h Outcomes i i G 1 E s Health Outcomes Fig 1. Interactive relationship among the 12 components of the Comprehensive Health Seeking and Coping Paradigm. evaluated.“ When an individual per- ceives that the available resources are inad- equate in dealing with the situation, threat is experienced, Because injury to the heart signifies a life-threatening event for pa- tients and their families, the degree of threat experienced may be great. Folkman and Lazarus” maintain there are two types of appraisal—primary and secondary. In primary appraisal, the per- son evaluates the significance of an event as irrelevant, benign-positive, or stressful. Stressful appraisal may be perceived as harm or loss, threat, or challenge. Secon- dary appraisal is the evaluation of what coping options, resources, and strategies are available to respond to the stressor. The degree to which a person experiences harm, threat, or challenge is determined by the relationship between the person and the environment in a specific encounter. It is defined both by the evaluation of “what is at stake” and the evaluation of coping resources and options.) Nyamathi” dis- covered that when the spouses’ appraisal of their partners’ symptoms were related to problems with the heart, coping behaviors were directed at seeking assistance for their partners. Nurses can assist individu- als in understanding the true nature of events and clarify false impressions that4 ‘THE JOURNAL OF CARDIOVASCULAR NURSING/OCTOBER 1990, may be perceived as threatening; thus, an assessment of cognitive appraisal is critical, In the SCI, an assessment is made of cognitive appraisal. Primary appraisal is measured by the degree of seriousness of the partner's condition as perceived by the spouse at the onset of symptoms and at the time of assessment, the degree of concern experienced, and the suspected nature of the illness. Secondary appraisal assesses the options that the spouse believes are available to aid in dealing with the stressor experienced. The spouse's definition of the event can be ascertained through evalua- tion of what he or she feels is at stake and the coping resources perceived as avail- able. SITUATIONAL FACTORS IN COPING ABILITY Situational factors influence coping re- sponses and adaptive outcome. These vari- ables derive from the physical and socio- demographic environment. Physical environment Factors that relate to the physical environ- ment most often influence the coping re- sponses of the individual. In a study’ of spouses of acute MI patients, physical envi- ronmental variables interfered with the spouse's ability to visit during the acute illness and to provide care for the partner. Several questions on the SCI addressed whether the spouse was able to visit with the partner, the degree of comfort experi- enced throughout the visit, and the ability to spend as much time as needed. To the extent that the physical environment is conducive to the individual's plan, adjust ment becomes less difficult.?> Sociodemographic characteristics The SCI solicits sociodemographic ques- tions about sex, age, ethnic origin, religion, employment status, occupation, education, years married, and number of children living at home. The ascribed and achieved personal characteristics of sex, age, educa- tion, and income have been found to influ- ence coping. Pearlin and Schooler” report significant differences between the sexes in their possession and use of effective coping mechanisms. Men were found to possess and employ more action-oriented coping responses that inhibited stress than women. Female patients were found to experience more difficulty coping after an MI than male patients.“ With regard to age, no difference was found, for there seemed to be a balance in the coping efficacy of younger and older people.” However, indi- viduals who were married or who at- tained higher educational or employment levels*’** were found to be better able to cope. Riegel” noted that family members most likely able to cope best were older; had no history of psychologic problems: and maintained a stable family life, strong social support, and economic stability. With regard to the socioeconomic status of individuals raised in a modern technolog- ical environment, there is no question that patients and spouses who are better edu- cated and more affluent are capable of employing more effective coping efforts. Lazarus” contended that a lack of intellec- tual resources increases the prospects of incorrect evaluations of the situation. More- _ Family members most likely able to cope best were older; had no history of psychologic problems; and maintained astable family life, strong social support, and economic stability. _over, less-educated and poor patients and spouses not only are more exposed to hard- ship, but are also less likely to have the means to fend off the stressors. PERSONAL FACTORS IN COPING ABILITY Researchers agree that the interaction of personal factors with situational variables influences each coping effort21?2*"-* gelf- worth is an especially important personal trait that serves as an ego resource. Self-worth, or self-esteem, is the positive- ness of a person's attitude toward self, Coopersmith refers to self-esteem as “a personal judgment of worthiness that is expressed in the attitudes the individual holds towards himself”**"" and is based on the individual's ability to deal effectively with his or her environment. Lazarus” contends that personality traits affect cop- ing either directly by causing an individual to act in certain ways or indirectly by influencing the individual's appraisal of the situation. In a study of coping responses and self-esteem, Folkman et al’ discov- ered that people sought less social support when their self-esteem was threatened. Thus, persons with high levels of self- esteem avoided help-seeking behaviors that threatened their self-esteem. Nyamathi’ found that women who re- ported a high level of self-worth were more often socially active, were less dependent on their husbands, and reported a need to spend time away from home. On the other hand, women who felt less self-worth clas- sified themselves as emotionally depen- dent on their husbands, were more overpro- tective, and reported greater worry and frustration, The SCI asks spouses to de- scribe their personal attributes in terms of positive and negative qualities as measured by visual analogue scales with the end Coping Status of Spouses 5 points “not at all” and “a great deal.” By understanding family needs for empower- ment and improved feelings of self, nurses may be able to enhance coping behaviors. HEALTH-SEEKING AND COPING BEHAVIORS. Coping behaviors are initiated as a reac- tion to threat appraisal. In the CHSCP, health- seeking and coping behaviorsare the “thoughts and actions individuals engage in to overcome threats to health and life crises with the goal of attaining or retaining optimal health and func- tioning,”""2°5) Coping behaviors help pa- tients and spouses manage the problem causing distress (problem-focused coping) or regulate or reduce emotional distress associated with stress (emotion-focused cop- ing). Problem-focused coping behaviors, such as seeking information and assistance, are more likely to be used when a situation is amenable to change. Emotion-focused coping behaviors, such as crying and with- drawing, are more often used when a situa- tion is not amenable to change.” Geary” reported that the four coping mechanisms commonly used by families of critically ill patients included minimizing the impor- tance of the illness, repeating words to convince themselves of something, acting strong, and remaining near the patients. Schlotfeldt® contends that individuals actively employ health-seeking and coping behaviors in an effort to achieve optimal health and function. Nurses, who are con- cerned with promoting optimum health and harmonious interaction with the environ- ment, must accurately assess the individu- al's ability to interact with the internal and external environment to achieve optimal health.” The SCI asks spouses to specify the de- gree to which they use problem- or emo-6 THE JOURNAL OF CARDIOVASCULAR NuRSING/OcToBER 1990 tion-focused coping responses based on the 40-item Jalowiec Coping Scale (JCS),”” a reliable and valid coping assessment instru- ment. Moreover, the SCI asks spouses to describe any additional coping responses used. (Detailed psychometric information and examples of emotion-focused and prob- lem-focused behaviors identified by the JCS are elaborated in the article by Keck- eisen and Nyamathi, this issue.) COPING RESOURCES Effective social support is thought to result in a positive self-evaluation, increased self- esteem, and mastery over the environment.” Many authors have commented on the crucial impact social support has on health, mortal- ity, enhanced self-esteem, coping, and psy- chologic well-being 9*#520220-48 Caplan characterizes social support sys- tems as long-lasting ties to a group of people who are able and willing to provide emotional strength and assistance in times of need and who share standards and values. Evidence from the literature re- veals that individuals in crisis seek help from other individuals.*" Support in times of despair has assisted people in dealing with serious illness in the family.*™ More- over, the prevailing literature has identified social support as a protective factor in buffering the effects of stressor factors in the etiology of disease, **-*7 The impact of nursing intervention has been reported to influence spousal coping by providing support, meeting family needs, facilitating absorption of information, en- couraging use of coping skills, and reducing stress and anxiety.” Nyamathi” found that 98% of spouses reported that family and friends positively influenced their ability to cope by assisting with child care, transpor- tation, physical chores, and financial mat- ters and by providing emotional support. For spouses of critically ill cardiac patients, support has come (in order of frequency) from adult children, parents of the patient or spouse, friends, neighbors, other family members, and professionals," Additional resources that enhance cop- ing include physical and mental health, financial and spiritual stability, and a satis- factory relationship with an ill partner. Persons who are frail, tired, or debilitated have less energy to expend on coping than healthy individuals. Spiritual and finan- cial resources provide additional options and ways to perceive threat.*® The SCI solicits data on who was helpful to spouses in dealing with the current situa- tion, the ways they were helpful, the need to talk to people about how they felt, and the ability to ventilate feelings. Further- more, spouses are asked to describe their physical and mental health, concerns cre- ated by financial strain, assistance obtained from religion, and satisfaction of relation- ship with partner. ADAPTIVE OUTCOMES When the stressful situation is managed by effective coping, the uncomfortable feel- ings associated with the threat are allevi- ated and the ability of the individual to maintain the highest level of functioning is preserved." As such, adaptive outcome is measured by emotional and physical dis- tress. Folkman et al” reported a significant relationship between appraisal, coping, and somatic health; when the individual per- ceived the event to be more serious, greater coping was necessary and health outcome was poorer. The SCI elicits the degree to which the spouse has experienced emo- tional distress (eg, depression, anxiety) or physical distress (eg, headache, stomach- ache).The use of the SCI, which is built on a conceptual model of nursing, provides an organized, systematic approach to patient care. The SCI enables nurses to identify the appraisal of threat perceived by spouses as a result of their partners’ illness, situational and personal factors in operation, coping responses manifested, coping resources available, and adaptive outcome. More- over, the framework allows nurses to pre- dict interrelationships among the variables and subsequently to formulate nursing diag- noses from which specific interventions and evaluation strategies can be planned. Before nursing implications are delineated, however, reliability and validity of the nurs- ing assessment instrument is necessary to ensure that the instrument yields the same information on repeated administrations and that the items represent the domain of questions in the hypothetical content universe.* RELIABILITY AND VALIDITY OF THE scl ‘The SCI has been tested on 100 spouses of cardiac patients experiencing acute car- diac illness such as acute ischemia, acute MI, and life-threatening dysrhythmias. Re- liability coefficients of .75 were found for both problem- and emotion-focused coping." The subscales of coping resources, personal factors, and adaptive outcome (emotional and physical distress) demon- strated « coefficients ranging from .67 to .85. As a result of the small number of items, cognitive appraisal reached a Chronbach a of 58.4 Content validity was established to as- sess compatibility with the theoretic frame- work, appropriateness of items for the tar- get population, and clarity of items.” Content validity was established by a criti- cal review of the literature and 100% agree- Coping Status of Spouses. 7 ment by a five-member panel of academic and clinical experts in cardiovascular nurs- ing. The self-administered instrument re- quires approximately 30 minutes to com- plete. While the SCI has been used exclusively with spouses of acute-care pa- tients, it is anticipated that after continued psychometric assessment of construct and concurrent validity, the SCI can be used with minor revisions with spouses during the convalescent period as well. IMPLICATIONS FOR NURSING PRACTICE A conceptual framework guides nurses in organizing data, formulating nursing di- agnoses, developing patient interventions, and evaluating outcomes.” The Appendix displays sample segments of the six sub- scales of the SCI: (1) cognitive appraisal, (2) situational factors, (3) personal factors, (4) health-seeking and coping behaviors, (5) coping resources, and (6) adaptive outcome, Relevant nursing diagnoses associated with each subscale are included. By using a comprehensive assessment guide, nurses can identify individuals at risk for crisis and implement strategies to deal with the individual and family, For example, to formulate a nursing diagnosis of Ineffective Individual Coping, the clinician should as- sess factors that affect health-seeking and coping behaviors. Such factors might in- clude inadequate transportation that re- sults in an inability to visit the critically ill partner (situational constraint] and feelings of low self-worth and insufficient informa- tional and emotional support resources (per- sonal constraints). By identifying factors that put patients and spouses at risk for ineffective coping, nurses can develop, im- plement, and evaluate nursing strategi Important nursing strategies include re- laxation of visiting policies to accommodate8 THE JOURNAL OF CARDIOVASCULAR NURSING/OCTOBER 1990 an altered visiting pattern, provision of effective, simple, and meaningful commu- nication, and empathetic touch. Directing the patient and spouse to institutional sup- ports such as clergy and social services and encouraging realistic hopes can enhance a relationship of trust. An understanding of cultural, religious, and social characteris- tics is necessary to personalize the interven- tion plan. The Spousal Coping Instrument is a com- REFERENCES prehensive assessment questionnaire capa- ble of assessing the coping and adaptive outcome of spouses of acutely ill cardiac patients, Alpha reliability coefficients on the clinical sample indicate adequate inter- nal consistency. Content validity has been demonstrated by an expert panel of acade- micians, clinicians, and researchers. The SCI was developed for use in clinical prac- tice as well as research. The instrument provides a comprehensive database on which the clinician can judge the coping and adaptive outcome of the spouse. 1. Bedsworth J, Molen M. 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Cognitive appraisal Primary appraisal Heart-relatedness Perception of seriousness at onset and at present Degree of concern Impact on well-being Secondary appraisal Coping options available 2. Situational factors Physical environment Comfort in unit Ability to visit Sociodemographics Sex Age Ethnic origin Religion Employment status Occupation Education Years married Number of children living at home 3. Personal factors Positive personality characteristics Independent Like responsibility Feel good about oneself Loving Optimistic Negative personality characteristics Moody Nervous Easily depressed ‘Angers easily nursing diagnoses Nursing diagnosis Alteration In Thought Processes, related to perceptual or cognitive impairment Anxiety related to critical illness of a loved one Anticipatory Grieving related to fear of partner's death, sudden financial instability Anticipatory Grieving related to perceived inability to favorably impact the critical event ina realistic manner Impaired Verbal Communication related to lack of comfort in unit Social Isolation related to visiting restrictions Impaired Home Maintenance Management, related to inadequate education, lack of material resources Alteration In Family Process, related to change inrole Disturbance In Self-Concept related to low self-esteem Powerlessness related to personal inadequacy, health care environment12 ‘THE JOURNAL OF CARDIOVASCULAR NURSING/OcTOBER 1990 4, Health seeking and coping behaviors Problem-focused coping Emotion-focused coping 5, Coping resources Social support Individual resources Physical and mental health Financial Spiritual Informational 6, Adaptive outcome Physical distress Emotional distress Ineffective Individual Coping related to inef- fective coping repertoire, negative personal factors, inadequate environmental supports, or inadequate coping resources Social Isolation related to inadequate support Spiritual Distress related to inadequate inner resources Alteration In Thought Processes, manifested by lack of ability to make deliberate and thoughtful judgments, related to sleep dep- tivation Alteration In Health Maintenance, related to inadequate physical and medical capabili- ties, or inadequate financial or spiritual re- source Knowledge Deficit related to inadequate in- formation, barriers to effective learning, informational misinterpretation Alteration In Comfort Pain Alteration In Nutrition related to inadequate food intake Alteration In Bowel Elimination related to stress and anxiety Anxiety related to unmet needs, threat of loved one’s death, change in role function Fear related to loss of support, knowledge def icit, environmental or cultural barriers Anticipatory Grieving related to guilt, denial of potential loss