For most persons, everyday life includes shares of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends in part on the persons coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources.
Socio-cultural and religious factors may influence how people view and handle their problems. Some cultures may prefer privacy and avoid sharing their fear in public, even to health care providers. As resources become limited and problems become more acute, this strategy may prove ineffective. Vulnerable populations such as patients, those in adverse socioeconomic situations, those with complex medical problems such as those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors. Such problems can occur in any setting (e.g., during hospitalization for an acute event, in the home or rehabilitation environment as a result of chronic illness, or in response to another threat or loss).
NANDA define ineffective individual coping as an inability to form a valid appraisal of the stressors, inadequate choices of practical responses, and/or inability to use available resources. Stimuli likely to cause ineffective coping in illness, pain and incapacitation, lack of sleep, stressful hospital environment and treatment procedures, loss of control over whats happening to self, loss of hope, lack of meaningful contact with loved ones, uncertain future.
Conditions and stimuli to cause ineffective coping are perception on a harmful stimulus or cues that a harmful stimulus is imminent, perception that the harmful stimulus threatens the individuals goals or values and perception that the patients resources arent equally to coping with the threat.
The period of impact begins immediately after injury and is characterized by shock, disbelief and feelings of being overwhelmed. The client and family members may be aware of what is happening but may be coping to the situation poorly.
Black and Hawks, 2004; Gulanick, 2007; Doenges, et al, 2002; Holloway, 2004
Intervention and Rationale
I: Review pathophysiology affecting client and extent of feelings of hopelessness/helplessness/loss of control over life, level of anxiety; perception of situation.
R: Indicators of degree of disequilibrium and need for intervention to prevent or resolve the crisis. Studies suggest that up to 85% of all physically ill people are depressed to some degree. Impairment of normal functioning for more than 2 wk, especially in presence of chronic condition, may reflect depression, requiring further evaluation.
I: Establish therapeutic nurse-client relationship.
R: Client may feel freer in the context of this relationship to verbalize feelings of helplessness/powerlessness and to discuss changes that may be necessary in clients life.
I: Note expressions of indecision, dependence on others, and inability to manage own ADLs.
R: May indicate need to lean on others for a time. Early recognition and intervention can help client regain equilibrium.
I: Assess presence of positive coping skills/inner strengths, e.g., use of relaxation techniques, willingness to express feelings, use of support systems.
R: When the individual has coping skills that have been successful in the past, they may be used in the current situation to relieve tension and preserve the individuals sense of control. However, limitations of condition may impact choices available to client; e.g., playing musical instrument to relieve stress may not be possible for individual with tremors or hemiparesis, but listening to tapes/CDs may provide some degree of comfort.
I: Encourage client to talk about what is happening at this time and what has occurred to precipitate feelings of helplessness and anxiety.
R: Provides clues to assist client to develop coping and regain equilibrium.
I: Evaluate ability to understand events. Correct misperceptions, provide factual information.
R: Assists in identification and correction of perception of reality and enables problem solving to begin.
I: Provide quiet, non stimulating environment. Determine what client needs, and provide if possible. Give simple, factual information about what client can expect and repeat as necessary.
R: Decreases anxiety and provides control for client during crisis situation.
I: Allow client to be dependent in the beginning, with gradual resumption of independence in ADLs, self-care, and other activities. Make opportunities for client to make simple decisions about care/other activities when possible, accepting choice not to do so.
R: Promotes feelings of security (client will know nurse will provide safety). As control is regained, client has the opportunity to develop adaptive coping/problem solving skills.
I: Accept verbal expressions of anger, setting limits on maladaptive behavior.
R: Verbalizing angry feelings is an important process for resolution of grief and loss. However, preventing destructive actions (such as striking out at others) preserves clients self-esteem.
I: Discuss feelings of self-blame/projection of blame on others.
R: Although these mechanisms may be protective at the moment of crisis, they eventually are counterproductive and intensify feelings of helplessness and hopelessness.
I: Note expressions of inability to find meaning in life/reason for living, feelings of futility or alienation from God.
R: Crisis situation may evoke questioning of spiritual beliefs, affecting ability to cope with current situation and plan for the future.
I: Promote safe and hopeful environment, as needed. Identify positive aspects of this experience and assist client to view it as a learning opportunity.
R: May be helpful while client regains inner control. The ability to learn from the current situation can provide skills for moving forward.
I: Provide support for client to problem-solve solutions for current situation. Provide information and reinforce reality as client begins to ask questions; look at what is happening.
R: Helping client/SO to brainstorm possible solutions (giving consideration to the pros and cons of each) promotes feelings of self-control/esteem.
I: Provide for gradual implementation and continuation of necessary behavior and lifestyle changes. Reinforce positive adaptation/new coping behaviors.
R: Reduces anxiety of sudden change and allows for developing new and creative solutions.
I: Refer to other resources as necessary (e.g., clergy, psychiatric clinical nurse specialist/psychiatrist, family/marital therapist, addiction support groups).
R: Additional assistance may be needed to help client resolve problems/make decisions.
Doenges, et al, 2002; Gulanick, 2007; Kruse, et al, 2003