Coping is an emotional process by which the individual attempts to deal with a difficult situation. There are numerous definitions to define coping.
Lazarus and Folkman (1984:141) defines coping as a “constant change in cognitive and behavioural efforts to manage specific external and or internal demands that are appraised as taxing or exceeding the resources of that person”. Snyder and Dinoff (1999) argue that coping is “a response aimed at diminishing the physical, emotional and psychological burden that is linked to stressful life events. These two definitions are similar as they both look into the behavioural and cognitive aspect and how they are affected from a stressful event.
“ For coping to be effective there must be a good match or fit between coping and other agendas such as values, goals, commitment, belief and preferred styles or coping that causes conflict if the necessary coping strategies in a particular encounter are implemented. Coping is not a single event but a series of continuous appraisals and reappraisal of the shifting person environment” Lazarus and Fokeman (1984:142).
There are many ways a person can cope with a difficult situation. Metcalf (1999) states that “coping mechanisms can become overloaded due to the loss of confidence, independence and dignity” Alice’s changes within her health status clearly demonstrated this theory as the alternation within her body image has created a psychological barrier toward how she perceives herself.
Alice, when first admitted onto the ward was generally a fit and active lady with limited medical history. During her cancer treatment she had time to adjust to having cancer but was avoiding understanding about the operation and having an ileostomy bag. Alice was reluctant to discuss the procedure and future treatment or how she was feeling. Manne & Glassman (2000) talks about patients that “lack spouse support have been associated with lower self efficacy and they become more reliance on avoidance coping this is very common in people suffering with cancer.” On the primary Appraisal Alice saw her situation as a stressful appraisal. A stressful appraisal consists of harm, loss, threat and challenge. At the moment Alice see’s her situation as a threat. “A threat is either a harm or loss that has not yet taken place but are anticipated” Lazarus and Folkman (1984:32)
When I spoke to her before the operation she was in a very low mood and found it hard to talk about her emotions, she was in denial about the whole situation and always looked at the negative side. “Denial is the refusal to acknowledge the existence or severity of unpleasant external realities or internal thoughts and feelings” Mind Disorders (2010) this is link in with the avoidance strategy. Avoidance is a “mental mechanism of denial, repression and suppression” Miller (1992:35). Everyone goes through this stage when adjusting to an illness and with the support of friends, family and staff, the patient can come out and accept the whole problem. I think Alice was using avoidance strategies due to fear and self preservation because when the consultant came around to gain consent she asked many questions about the statistic of the cancer spreading to other parts in her body. This made Alice accept the responsibility, blaming her eating habits and life style being the fault of her cancer. Research has shown that “enhancing a patients knowledge of what is happening can help increase a sense of control “Miller (1992:32) her main concern was the change in her body image, this was the hardest problem she had to over come. Lack of control over a patient life can cause a higher incident of depression
However, our assessment has indicated Alice is in the process of accepting having cancer, she was very open about the subject and discussed about her treatment and how it made her feel. It has be recognized by the nursing team that Alice has avoided discussing the operation and the stoma care however, to aid Alice’s recovery these are important psychological issues that need to be addressed. Every time a member of staff asked her question she always changed the subject and switches off.
Everyone copes to a situation differently and it’s the nurse’s role to identify the patient coping styles and strategies to provide a holistic nursing approach Miller (1992:24) nurses need to understand theories about stress responses, appraisals and coping in order to apply knowledge in practice when dealing with patients who are experience a crisis or change Lazarus (1984)
There are many definitions about adjustment and three main models that people follow. Adjustment is a behavioural process by which people maintain emotional equilibrium among their various needs Lazarus & Folkman (1984).
There are many frameworks that are used to explain how individuals adjust to threats to health and serious illness. The three main models of health and adjustment to illness include:
- Biomedical models- empathises on disease it considers disease and illness to be a failure within the body, resulting from infection, accident and inheritance, rather than the social and psychological aspect of illness
- Psychological models of adjustment to illness such as Kuber Ross bereavement models
- Biopsychological models empathises on health, function and well being, it looks at the behaviour emotion and mental process such as Lazarus and Folkman model
The framework I have chosen to use to help aid Alice with adjusting to her Ileostomy bag was Lazarus and Folkman. This framework mixes stress, appraisal and coping theories together to demonstrate the stages an individual react to psychologically stressful situation. In hospitals nurses use this framework to assess, help and evaluate individual coping responses. These theories consist of two appraisal stages and two coping phase’s -problem focus and emotional focus. Lazarus and Folkman (1984)
Appraisal theory “examines the process by which emotions are obtain as a result of an individual's subjective interpretation or evaluation of important events or situations; hence, it is the evaluation of events to determine one's safety in relation to his or her place in the environment ).” There are two types of appraisals primary and secondary. Primary is where a person evaluates a situation as a threat to their well being. Alice demonstrated that she found the stoma a challenge rather than a threat, which had altered her prospective of her care since her original appraisal. The secondary appraisal is when the patient evaluates their own ability to handle the situation. The major step in her adjustment appears to be that she is now seeking advice and guidance. Lazarus (1984) describes this adjustment as the secondary appraisal to his theoretical model.
Her coping strategy has change from avoidance to approacher. Approacher strategy is where a patient has accepted the situation and seeks advice and treatment. This strategy is used to help divert the patients’ attention from the illness like watching television, taking up hobbies, to gain control over the situation. Alice was starting to problem solve, she understand that to be discharged she needs to adjust her life style to cope with the changes within her body images and to learn to manage the care of ileostomy bag.
Problem focus is a type of coping that allows the person to focus on specific goals (problem solving) It is used to gather information, skills and abilities about the situation, make decisions, gain knowledge. ). Research has shown that the use of problem focus strategies has a much stronger impact to a person psychological adjustment than the use of emotional focus strategies. Walker (2007:162)
To enable Alice to return to a normal life we made a referral to the stoma nurse to empower Alice to take control on the maintenance of her ileostomy bag. The stoma nurse started to rehabilitate Alice by educating her about the importance of cleaning the site and the use of different equipment. “Rehabilitation is used to help patients deal with the combined effect of the surgery” Breckman (2005:318). It’s used to maximise a person ability to function, promote independent and help them adjust to the stoma
The stoma nurse worked alone side the staff nurse to set achievable goals. The objective aims were to accept the stoma as part of her life and not as she perceived it as an external addition, to independently manage her ileostomy bag and to observe and discuss any concerns with the appropriate people. Nurses would prompt Alice to participate in changing her appliance and with the nurse praising Alice this provided psychological support as well. The use of rehabilitation is important for adjustment. Patients go through three main stages to become fully rehabilitated. They need to be able to look after their stoma and manage the equipment. Alice problem was accepting the body change. This can be achieved by adapting the style of clothing worn and having the necessary psychological support provided by the nursing team. Porrett (2005:119) stated that “once a patient return to their old clothes and notice the appliance is not visible this can boost their confidence and self esteem.” The next stage was to encourage the patient to regain normal community activity like going out socialising with her friends, and the final stage was when the patient fully accepted the stoma, this stage can take many years, accepting the change in body image is a slow process.
The reassessment of the nursing care suggest Alice care has indicated that there is a mark improvement in Alice’s psychological welfare as her coping strategies have indicated that she is accepting these changes and coping psychologically
Emotional focused is “based on managing the distress and fear rather than altering the problem. It often involves avoiding having to think about or face up to it or deal with the demand or threat. It’s used to manage the feeling of anxiety” Lazarus, (1984:162)
Black (2000) states that “the psychological effect of a stoma is far greater than the physical effect” Alice still needed help with the emotional strain the ileostomy bag has cause to her body. She felt disgusted and ugly when she first saw the ileostomy bag. Feelings of disgust and shock are identified, especially when seeing the stoma for the first time Persson & Hellstrom (2005). Alice’s nurse Implemented counselling by one to one therapy. This allowed Alice to address her emotions with the understanding of privacy and confidentiality. Alice received confidential one to one therapy from the nurse to allow Alice express her emotions and fears within a privacy and personal environment. With the help of counselling and the nurse’s encouragement Alice started to accept visitors which improve her emotional state. Alice would confine her thoughts and feelings with me when I help change her appliance, which suggested that we had formed a professional nursing/patient relationship. Larsson (2007) stated that a patient sometime share their feeling about a situation as their way to seek emotional social support. I provided Alice with my personal time and listening to her concerns. I talked about the importance of good hygiene to prevent any soreness to the skin and how adjusting her diet can help with the flatulence of the bag this can prevent the embarrassment of unpleasant noises and smells. According to Dewing (1989) there are 4 stages a person goes through to accept altered body image.
- Impact – the initial shock and anger
- Retreat -mourning for the affected part
- Acknowledgement- confronting the problem
- Reconstruction – recognition of the problem and accepting.
At the end of the process we were able to detect Alice was acknowledging the problem and working towards accepting the problem with the help of staff.
To critically analyse the effectiveness of the intervention provided towards Alice’s care. Our main objectives were to implement infection control measures to prevent adverse effect from the surgery to promote good healing. The post operative care was to focus on the care of her stoma and provide stoma care education and to psychologically address the issues relating to the adjustment within the body changes due to the stoma. The interaction from the nurses promoted confidence within Alice to discuss her fears and worries relating to her health issues. The implementing all the various therapies were to promote an overall holistic approach to care. My only criticism can be that the various nursing teams lack communication, which created confusion to the patient. However as the patient had already been through the pre operative stage before I started placement I was unable to comment on the education and information give to help support Alice before the procedure. Pre operative care is to focus on the psychological aspect and help start with the acceptance of the change. You can see throughout this essay the different types of coping strategies Alice went through and how with the help of nurses and staff became confident and accepted the new role of her stoma. I feel Alice has started to accept her ileostomy bag well and with further support after discharge will be able to enjoy her life again.
Conclusion
In conclusion this essay has provided a brief insight into the holistic care provided to Alice after her panproctocolectomy operation. The main aspect of this essay is to focus on the physical and psychological welfare of Alice and her understanding and acceptance of her ileostomy bag. I now understand the impact of body image has on anyone and how to help people accept this change. To ensure this the nurses have followed a theoretical framework of Lazarus and Folkman to enable the correct care throughout the adjustment stage. We have observed many different coping strategies and mechanisms that Alice used throughout the process. To ensure Alice was adjusting to the ileostomy bag nurses provided education, reassurance and listen to her while she expressed her worries and concerns regarding the aftercare, this was done with the help of the stoma nurse providing rehabilitation and education and the counsellor.
I have learnt that one of the most important aspects of nursing is to try and display empathy and autonomy as these skills are essential to develop the therapeutic relationship between patient and family which contribute to promote patient well being as trust between two parties have been accepted. Nurses play an important role in the transition from shock to acceptance and education that focuses on rehabilitation. The more I understand about adjustment the more I can facilitate with the process in the future. To help widen my knowledge of this topic I will need to be involved in future cases.
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