The development of Taiwanese elderly stressor inventory

Copyright

Pergamon

hf. J. Nurs. Stud., Vol. 33, No. I, pp. 29-36, 1996 c 1996 Elsevier Scmm Ltd. All rights reserved Printed in Great Bntain 002&74X9/96 315.00+0.00

0020-7489(95)00034-8

The development of Taiwanese Elderly Stressor Inventory LI-CHAN

LIN, Ph.D., R.N.

Institute qf Clinical Nursing, National R.O.C.

MARIAH

SNYDER,

Yang-Ming University, 155 Li-Nong Street, Section 2, Taipei, Taiwan,

Ph.D., R.N., F.A.A.N.

School qf Nursing, University of Minnesota, Minnesota, U.S.A

ELLEN

C. EGAN, Ph.D., R.N., F.A.A.N.

School of Nursing, University of Minnesota, Minnesota, U.S.A.

Abstract-The purpose of this study was to develop a stressor inventory for use with a population of elderly Taiwanese people that allows the respondent to rate the degree of stressfulnessof each stressor experienced, based on a transactional stressmodel. Thirty-three subjectsidentified stressorsexperienced from age 65 onwards. Seventy-three stressorswere identified and listed in the instrument. Inter-rater agreement on the content was 20.90. The psychometric properties of the instrument was established among 351 elderly Taiwanese subjects. In determining the stability of stressfulness, the generalizability coefficient for the relative decisions was 0.90 and generalizability coefficient for the absolute decision was 0.90. As to stability of stressor frequency, the generalizability coefficients for both the relative and absolute decisions was 0.72. Construct validity of the instrument was provided by a correlation of 0.59 with state-anxiety, of 0.56 with negative affect, and -0.28 with positive affect. Further refinement of the toll is in progress.

Introduction

The quality of nursing care depends in part on the quality of the theoretical base used to explain and manage phenomena such as stress. One significant, theoretical approach to stress for nursing is based on a stress theory that is consistent with beliefs about human 29

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experiences. Lyon and Werner (1987) propose that nursing views human experiences as arising out of dynamic person-environment transactions and focuses on the individualized care needs.The centre of the belief is that there are individual differences in the degreesand kinds of reactions to certain environmental demands or stressors.The transactional stress model allows for individual differences and does not necessitatea normative approach to stress. The transactional orientation to stress is consistent with nursing’s view of human experiences and permits the researchersto focus on individual differences in stressexperiences. The Lazarus transactional stressmodel served as the basis for instrument development in this study. Lazarus and Folkman (1984) defined stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (p. 19). Lazarus identifies two processes,cognitive appraisal and coping, that serve as critical mediators of stressful person-environment relations and their immediate and long-term outcomes. Lazarus emphasizesthat cognitive appraisal is key in determining whether a specific event will be perceived as stressful for an individual. In primary appraisal, the person evaluates whether he or shehas anything at stake in the encounter. In secondary appraisal, the person evaluates what can be done to overcome or prevent harm or to improve the prospects for benefit. Primary and secondary appraisal converge to determine whether the person environment transaction is regarded as significant for his well-being, and whether it is primarily threatening (Folkman et al., 1986; Lazarus and Folkman, 1984). In addition, reappraisal is the feedback process wherein changes in primary and secondary appraisals can be brought about by changes in the adaptational encounter. As the person reacts and the environment counterreacts, these reactions are perceived and appraised by the person, perhaps leading to altered appraisals of the person-environment relationship and an altered emotional response(Lazarus et al., 1980). Cognitive appraisal takes three key forms, representing evaluative judgements or decisions about whether a transaction with the environment is stressful: (a) relevant or irrelevant to one’s well-being; (b) forecasts a positive outcome; and (c) perceived as stressful. In this last type of appraisal, the stressor can be viewed as harm, loss, threat, or challenge (Lazarus, 1985; Lazarus and Folkman, 1984). Cohen et al. (1983) proposed that whether events are considered stressful is determined by personal perceptions. Therefore, stress is the result of the person’s grasp of the meaning of a situation for self, and what the person can do in the situation. Cognitive interpretation of events varies among cultural groups as well as among individuals. Since stressorscan be interpreted and explained in terms of personal experiences, people learn from their own cultural and ethnic backgrounds how to recognize stressors and how to cope with them. The meanings attached to the notions of stressor and coping are related to the basic culture-bound values by which people define a given experience and perception. Although findings from numerous studies (Amster and Krauss, 1974; Brown, 1993; Marcenes et al., 1993) indicate that a relationship exists between stressful life events and the onset of psychosomatic diseases, this relationship has remained controversial. The majority of stressstudies have focused on young adult populations. One conceptualization of stresshas been to measure the occurrence of recent life events. Little attention has been given to the amount and type of stressexperienced by elderly people. Instruments that can be used as measuresof stressin older age groups are needed.

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The researchers reviewed several stressor inventories for use with elderly subjects (Amster and Krauss, 1974; Holmes and Rahe, 1967; Mensh, 1983; Murrell et al., 1984; Pai et al., 1987; Stokes and Gordon, 1988). The criteria for evaluating these tests included (a) Age: Are the items appropriate for an elderly population? (b) Culture: Are the items consistent with a Taiwanese background? (c) Psychometric properties: Does an instrument have a reliability coefficient of 0.7 or larger? (Lynn, 1985) (d) Model: Does the theoretical framework fit with the transactional stress model? (e) Items generated: Methods for developing items are literature review, a combination of literature review with experts and patient interviews, and item selection from existing scales (Mishel, 1989). If items were selected from existing scales, is the concept congruent with the original scale? No stressor inventory was found that met these criteria. The purpose of this study, therefore, was to develop a stressor inventory for the Taiwanese elderly that meets the above criteria and allows the respondent to rate the degree of stressfulness of each stressor experienced.

Method

The instrument development occurred in three phases: identification of stressors and development of items, determination of content validity of the instrument, and establishment of reliability and construct validity of the instrument. Ident@ation

of stressors

A convenience sample of 33 elderly Taiwanese subjects were interviewed to determine stressors experienced. Subjects were attendees at a senior centre for the purposes of participating in recreational activities or continuing education classes. Additional subjects were obtained from persons who lived in a public living assistance facility, from persons who sought free blood pressure readings at a health station, and from a community health nurse’s case load. Criteria for inclusions were: understand Mandarin or Taiwanese; live in their own home or living assistance facility; capable of self-care; can leave their home when desired; are 65 years of age or older. Since those unable to self-care were thought to have specific stressors especially focusing on physical symptoms, in order to obtain homogenous subjects sampling criteria excluded those with disability. The sample was predominantly male (63.6%) with an age range of 6683 years with a mean age of 70.2 years. Due to convenience sampling, this result did not reflect the gender distribution of elderly Taiwanese people. The interview guide consisted of two sections. The first section contained open-ended questions in which the subject was asked to identify events they perceived as being stressful since they turned 65. Subjects were asked to describe in detail stressful situations they had experienced including pleasant and unpleasant events. Stressful situations were defined for the subjects as events that are disruptive to the normal course of living. The second section consisted of specific questions to draw attention to areas not already addressed by the respondents. This included family composition, living arrangements and visiting patterns and how subjects perceived these The interview and the other data collection took 6&90 min. The interviews were tape recorded and then transcribed. Content analysis was used to analyse the interview data. Seventy-three stressors were categorized from the interviews. From discussions with an expert, re-marriage was included in the scale, although it had not been mentioned in the

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interviews, Thus, 74 items constituted the original version of Taiwanese Elderly Stressor Inventory (TESI). Each item included three parts: whether subjects experienced the events in the past half-year, how often the events occurred, and how much stresseach caused. Determination of content validity

Three human service scienceprofessionals were instructed to check whether they regarded those listed items as stressors experienced by elderly Taiwanese people. They were not required to change words in the items. They rated each item on a 4-point rating scale: (1) not relevant; (2) somewhat relevant; (3) quite relevant (relevant but needsminor alteration); (4) very relevant and succinct (Lynn, 1986). When experts did not rate an item as “very relevant and succinct”, they were asked simultaneously to give their opinion about how to change the wording. The content validity index (CVI) score was computed by summing the percentage of agreement of all items that were given ratings of ‘3’ or ‘4’ by the experts (Waltz et al., 1991). The CVI for the three experts was 0.97. Based on the suggestions received, several items were collapsed and several items were added. For example; ‘Children with alcoholism’ (#27) and ‘Gambling of children’ (#30) were collapsed into the item ‘Bad habits (e.g. gamble, alcoholic or drug abuse) of family member’. In addition, stressors were circumscribed to have a ‘starting’ and/or ‘ending’ point. The following items, ‘Disharmony of child’s marriage’ (#I l), ‘Vision blurred’ (#40), and ‘Hearing loss’ (#41) were deleted becausethey were progressive and it was not possible to describe when these situations started. In contrast, ‘Friction between your married daughter and her in-law’ could be described when or how many times they had conflict. Two items were added: ‘Foreclosure of mortgage or loan’ and ‘Birthday’. The former was added becausemost elderly had a lower economic status than that of younger adults and ‘Foreclosure of mortgage or loan’ might be a stressor. The latter was added since concern about death was not an event which had a ‘starting’ and/or ‘ending’ point. Therefore, ‘Birthday’ was used as an indicator of concern about death becausebirthday might induce the concern of death. The revised TESI was comprised of 7 1 items. The definition of stressor, criteria of sampling, method of item generation and the revised TESI were given to a further two experts. They were asked to evaluate the content validity of the 71 items of the TESI, using the samerating method as before and revise the wording of items. The content validity index was 0.90. Based on the suggestion of the two raters, the wording of 13 of the 71 items of the TESI was changed. Two items were added, ‘Deterioration in residential neighborhood’ and ‘Unsatisfied sexual need’ were two stressors on the Pai, Wen, Lu and Kuo scalethat the experts suggestedadding (Pai et al., 1987).This provided a scale with 73 items. Establishment of reliability

and construct validity

Criteria for sampling in this phase were the sameas in phase one. Convenience sampling was used. According to Nunnally’s suggestion (Nunnally, 1978), the sample size should be estimated at five people per item. Thus, 351 subjects were included. In this phase, participants were asked to check whether they had experienced each of the listed stressorsin the past 6 months, to indicate how often these events had occurred, and how much stress the events caused them. A 4-point (l-4) rating scale (range from seldom occurred to always occurred) was used for the stressor frequency subscale. The most frequent stressors were

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‘Taking bus’ (#37), ‘Political issue, e.g. assertion about independence of Taiwan’ (#65) and ‘Change in your sleeping habits’ (#l 1). Stressfulnesswas rated on a 7-point rating (range from not stressful to extremely stressful). However, most subjects were unable to rate the degree of stressfulness by using a number. In order to increase the subjects’ concrete thinking ability, seven disc-like metal circular frames of varying diameters were used with the smallest disc equating to no stressfulnessand the largest disc meaning that the situation was highly stressful. The most stress items were ‘Friction with children’ (#51) with a mean value of 4.88; ‘Divorce or separation of your children’ (#46) with a mean value of 4.6; and ‘Your remarriage’ (#16) which had a mean value of 4.5. Two weeks after the first administration, the same inventory was again administered to 62 subjects to test stability of the TESI. In order to control event clusters and to avoid inflating the number of events described, events were combined if multiple occurrences happened within the same2-week period as all referred to the sameepisode. At the time of the first administration, demographic details were obtained and the State-Anxiety from the State Trait Anxiety Inventory (STAI) developed by Spielberger et al. (1970) and the Positive and Negative Affect Schedules(PANAS) developed by Watson et al. (1988) were administered. Ye (1990) translated the STAI into Chinese. Cronbach alphas of Chinese version of the STAI were from 0.85 to 0.98. The internal consistency of PANAS was assessedin 33 subjects phase one. For the positive affect scale, coefficient alpha was 0.90. For the negative affect scale, coefficient alpha was 0.79. The STAI and PANAS scaleswere used to determine the construct validity of the TESI. Generalizability theory was used to determine the stability of both stressfulness and stressor frequency. The advantage of this method is it allows the source of measurement error to be ascertained (Shavelson et al., 1989). In determining the stability of stressfulness, the generalizability coefficients for the relative decision was 0.90 and the generalizability coefficients for the absolute decisions was 0.90. As to stability of stressor frequency, the generalizability coefficients for both the relative and absolute decisions was 0.72. Lazarus and Folkman (1984) emphasized the importance of repeated intra-individual observations in studying stress and coping, becauseit could help researchers to understand intra-individual variability and stability. High stability of stressfulnessreflects that subjects rated the stressorsthey experienced at a similar level of stressfulnessbetween two administrations. The construct validity of the TESI was investigated by assessingcorrelations between stressfulness, positive affect (PA), negative affect (NA), and state-anxiety. The degree of interrelationship between state-anxiety, PA, NA, and stressfulness was determined by Pearson product-moment correlation coefficients. There was a modest negative correlation (Y= -0.28) between stressfulness and PA. A high positive correlation (r= 0.56) was obtained between stressfulnessand NA. A high correlation was also found between stressfulness and state-anxiety (r=0.59). These findings support the construct validity of the TESI. NA and state-anxiety are positively related to stressfulness,whereas PA is negatively related to stressfulness. Discussion The TESI was developed because instruments for assessinglife events developed by Stokes and Gordon (1988), Amster and Krauss (1974) and Pai et al. (1987) did not include the spectrum of stressorsexperienced by elderly Taiwanese people. The following stressors

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identified by Taiwanese elderly were not found in the instruments developed by the American investigators: ‘Providing care for your daughter or daughter-in-law postpartum for one month home confinement’; ‘Going back to Mainland China to visit your relatives’; ‘Unsuccessful in arranging meeting between your child and prospective mate’; ‘Taking care of grandchildren’; ‘Friction between your married daughter and her in-law’; ‘Asking living expensesor allowance from children’; ‘Taking bus’; ‘Children refusing to allow you to live with them’; ‘Reconciling having immediate families in Mainland China and Taiwan’; ‘Request for grandchildren rebuffed’; and ‘Political issue(e.g. assertion about independence of Taiwan)‘. The stressor reported most frequently in the previous 6 months was ‘Taking bus’ (#37). Because it is related to daily living and social welfare policy in Kaohsiung, it was not surprising that ‘Taking bus’ was the most frequently noted stressor. In Kaohsiung, the government provides a card for transportation to senior citizens who then do not pay the transportation fee. However, because bus drivers obtain a bonus for how many paid passengersthey carry, those travelling free are not the bus drivers’ favourite passengers. Bus drivers often see elderly people waiting in the station, yet pass them by without stopping. If they are fortunate enough to make it on the bus, drivers often move before they are seated,causing them to fall down. The stressor with the highest mean rating for stressfulnesslevel (4.88) was ‘Friction with children’ (#51). Again it is understandable why this stressor was highly stressful for these Taiwanese subjects. Traditionally, elderly Chinese want to live at home with their families and the extended family is a kind of glory. The older family members usually have the final authority. The advantage of three generations living together is that the new generation can take care of the oldest one. However, the more contact they have, the greater the conflict that may occur. Due to rapid change in social values, young people sometimes rebel against authority. Older people feel upset because they have lost their status and authority. This may be one reason why this item had such a high stressfulnessrating. The third highest mean stressfulnessrating was ‘Your remarriage’ (#16). In contrast, the Stokes/Gordon StressScale(SGSS),remarriage was the second lowest stressor (rank 34th). The researchers recognized that remarriage in Taiwan was very stressful because of the conservative social values and that the older people are regarded as being asexual. The implication of different item ratings is that stress perception is influenced by culture. Therefore, assessmentof stress needs to include the meaning each stressor has for an individual based on that person’s culture. The strengths of this study include considering the cultural beliefs within a transactional stressframework to develop an instrument to determine the stressorsexperienced and their degree of stressfulness for an elderly Taiwanese population. An aim was to have the instrument be compatible with nursing’s perspective of the human health experience. These factors had not been considered in the existing instruments for life stressors among the elderly that were reviewed (Amster and Krauss, 1974; Holmes and Rahe, 1967; Mensh, 1983;Murrell et al., 1984;Stokes and Gordon, 1988).Besidesthe above strengths, beginning psychometric properties of the TESI were established. Based on the process of instrument development and the findings, the TESI fits with criteria established for an acceptable stressor inventory; age specific, culture sensitive, adequate psychometric properties, model fits with transactional stress,and items were generated from an appropriate sample. The TESI was developed for future use in clinical practice and research. Even though the TESI has high stability and construct validity, the length and ability of respondents to

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conceptualize stressfulness in varying degrees may make this inventory inappropriate for clinical application. A shorter version of the TESI will be developed for use by nurses. However, at this time the TESI can provide guidance to practitioners to select interventions to reduce the impact of the stressors experienced or to plan interventions to help avoid the stressfulness of impending stressors for individual patients. In this study, subjects were asked to recall stressors that had occurred in the past 6 months and this resulted in several problems. Stressors may have excluded or included clients’ limitation of recall. The use of convenience sampling to generate items and to determine reliability and validity limits the representativeness of items generated and restricts the generalization of the results. The experts used to determine content validity were limited due to the availability of only a few people in Taiwan who had research experience in gerontology or stress. This is reflected also in the minimal literature on stress and coping which exists in Taiwan, which limited comparison between the contents and characteristics of TESI and similar instrument in the validation process. In sum, the TESI fits the criteria of age specificity, culture sensitivity, psychometric rigorous, theoretical model, and item generation. However, validation is a never-ending process. Benson and Clark (1982) asserted that “the validation of a newly developed instrument is never accomplished through one study or by one researcher. It requires numerous research efforts and must be considered an ongoing process” (p. 798). Therefore, continuing work to revise the instrument includes removing the 6 months time limitation, reducing number of items, and including physiological measures of stress to support construct validity.

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