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Facilitating Children's Coping
NOVEMBER 1985, VOL 42, NO 5
AORN JOURNAL
Facilitating Children’s Coping PREOPERATIVE ASSESSMENTINTERVIEWS
Lynda L. LaMontagne, RN ’urses are responsible for helping patients and their families cope with stressful
N
situations. Although it has been documented that surgery is stressful for children, little is known about how they cope with this stress. This article emphasizes how nurses can assess and facilitate children’s coping preoperatively.
Coping Strategies
A
fter observing and interviewing both children and adults preoperatively, researchers found that children and adults coped with the stress associated with surgery differently.’ Some patients coped by restricting their awareness of the situation and the people around them, by avoidmg information about surgery, or by hesitating to discuss the surgery. These behaviors could be called avoidant. Other patients coped more vigilantly by seeking information about the surgery and what to expect and by readily discussing the surgery. These behaviors could be called active. I studied 51 school-aged children hospitalized for elective, general surgery and classified them according to their predominant use of avoidant and active coping modes? Patients classified as avoiders had limited knowledge about the surgery and the procedures involved. This lack of knowledge was not so much a result of not being offered information as it was that they tended to deny what parents, relatives, physicians, or nurses told them before surgery. These patients also preferred not to have extensive, detailed information about the nature of the surgery, as evidenced 718
by such statementsas “I know all I want to know.” By contrast, active copers were characterized by knowing many details about the surgery and what to expect (including complications and postop erative pain) and by eagerly discusing the surgery. A third group, classified as combination copers, used both avoidance and active coping modes, knew much about the nature of the surgery, but they denied any knowledge of postoperative complicationsand ‘ ‘ . XI the negative aspects of surgery, such as postoperativediscomfort. These patients tended to focus on the benefits of the surgery, as evidenced by such statements as “I won’t have this problem anymore.” Variations in preoperative coping behavior can be viewed from the perspective of Lazarus and colleagues who believe the degree of stress is related to a person’s evaluation of the situation’s effect on his/her well-being and the resources,such as support, available for dealingwith it.3 According to Lazarus,a person consciously or unconsciously determines if a situation is harmful, potentially harmful, or ~hallenging.~ This appraisal affects the coping process and the effectiveness of the coping modes used. In this context, coping is not static. Rather, it is a process that changes according to varying cognitive appraisals. Coping is the action oriented and intrapsychicefforts taken to manage or tolerate the appraised stress. Although surgery may be stressful for all patients, what may be stressful for one patient may not be stressful for another. Knowing how patients appraise an event leads to an understandingof their coping strategies. This information is essential.
AORN JOURNAL
NOVEMBER 1985, VOL 42, NO 5
Assessment Interview
A
ssessment through observing, interviewing, and reviewing the chart is part of the perioperativenursing process. Successful preoperative assessment of coping cannot be conhed to a specific location, such as the surgical unit. The initial assessment could occur in a variety of settings. Through questioning, listening, and clarifying, the nurse gains an understandingof what the pediatric patient is perceiving and how he/ she is coping with the situation. 1 designed an interview to systematically assess children’s preoperative coping. It is adapted from the interview designed by Cohen for use with adults.5 The interview questions assess the extent of the child’s knowledge about the medical problem and surgery, postoperative outcome (benefitsas well as complicationsand discomforts), alertness to the surgical routine and environment, and the emotions associated with surgery. Examples of questions that reflect the above themes are: What did your parents (physician or nurse) tell you about the operation? Did they tell you anything about why it is being done, how the operation will be done, or what good this operation is going to do for you? Where will you be when you wake up? What do you think you will feel like after surgery? After the first day? After that? Whenever a person is going to have an operation, there may be some things he/ she is womed about. What are the main things you are worried about? I categorized each child’s coping strategy by responses to these questions. Specific behaviors differentiatingavoidant, active, and a combination of avoidant-active coping strategies are presented L y h L. ~ ~ g n RN, e DNQ. , is an msthnt profmorof nursingin thegr-program for nursing of children ai Arizona State University, Tempe. She earned her docrorclre ai the University of California, San Francisco. She received her bachelor’s &gree in nursing fram Calijornia State U n i v e w , Las Angeles and m t e r of science &gree fron the University of GUlly0??llil
A child listens to the author’s explanations before going to the operating room.
in Table 1. These behaviors range from avoiding to seeking information and support from others, in addition to minimizing or avoiding verbalizing fears about the threatening aspects of surgery.
Facilitating Coping
0
ne of the goals of preoperative nursing intervention is to facilitate successful coping with the stresses of surgery. There should not be a value judgment placed on a particular coping strategy; avoidant strategies may be as effective as active strategies. What is important is that before intervening the nurse understands how a child is coping with and interpreting the u p m i n g surgery. Effective preoperative preparation must be tailored to the child. There is not a list of ingredients that will prepare all children for surgical procedures. Although children of the same
NOVEMBER 1985, VOL 42, NO 5
AORN JOURNAL
Table 1
Behaviors Typical of Each Coping Strategy Avoidant coping
Active coping
Avoidant-active coping
Restricts knowledge or awareness about the nature of surgery or the procedures involved. Usually knows why the surgery is being done, eg, “to strengthen my eye muscle,” but does not want any more information, eg, “I know all I want to know.” Denies worry or is not specific about what causes worry, eg, “Like I said, Dr Smith will make sure everything is set and nothing is going to happen, so there isn’t anything to worry about.” Focuses on the benefits of surgery, eg,no more illness or the problem will be fixed. Uses parents for support and information, eg, “My mother told me what I need to know” or “I’m not worried as long as my mother is here.” Is hesitant to discuss the surgery and thoughts about it.
Knows many details about the nature of the medical problem, surgery, and procedures involved. Is specific when requesting additional information, eg, “I think I have everything, but I would like to hear again how the doctor will actually do the operation.” Acknowledges worry and is specific about the cam of worry, such as complications or mistakes, eg, “When I heard this surgery could paralyze me I got real nervous, but when the surgeon said he had done thousands of these operations and that it never happened, I felt better, But I still pray it won’t happen to me.” Focuses equally on the positive and negative postoperative outcomes. Seeks support from others. Eagerly discusses the surgery and thoughts about the operation.
Knows a few minor details about the medical problem, surgery, and procedures involved. May want more information, but the information sought is usually general and limited to the procedure, eg, “Um, you’re asking me if I have enough information and yeah, I would say yes because I think everything is straightened out. The only thing I don’t know is how long the operation will be. Do you know?” Acknowledges at least one worry or fear, such as the physician making a mistake, but rationalizes that it won’t happen. Although may mention one or two negative postoperative outcomes like soreness and vomiting, the focus is on the benefits of the surgery. Generates support from others. Talks to parents, siblings, and friends about the surgery. Is open to discussing the surgery and thoughts about the operation.
developmental stage are similar, individual influences, which may affect how they cope with a procedure, make them different from other children of the same age. My preoperative interviews with the school-aged children revealed that each child, although in the same develop mental age group, used different coping strategies! For example, children who cope by denying worry and by limiting knowledge of the procedure may need a nurse or parent present during stressful 122
episodes. Detailed information would probably increase worry. Therefore, it might be best to focus on such minor details as how long the procedure will be, how they can expect to feel after surgery, and what their role will be during the recovery process. Active copers though need detailed information about the procedure and what to expect; therefore, the nature and amount of information given is important to their ability to manage the stress.
AORN J O U R N A L
NOVEMBER 1985, VOL 42, NO 5
Children who combine avoidant and active coping modes show no rigid preference for either strategy. They seek information, but it is usually general in nature and limited to the minor details of the procedure and its positive outcome. These children may acknowledge being worried about a possible complication,but minimize it by stating that the feared outcome will not happen to them. These children need information clari6ed as well as reassurance that the surgical staff is competent. The challenge for the nurse who performs the preoperative coping assessment is to plan preparations that will help the individual child. The nurse is most effective in preparing the child when the plan is based on an understanding of how the child appraises or defines the event and is coping. This understanding comes from a basic knowledge of child development and coping and by observing and interviewing the child. The first step may be to ask the child what he/she knows and wants to know about the situation or procedure. With this information, the nurse can clanfy or provide more information and suggest ways that will help the child manage fears or worries. For example, emphasizing the benefits of the surgery (such as better vision or ability to play sports) or familiarizingthe child with ways the nurses can assist (such as giving pain relieving medications) helps the child effectively cope with the stressful demands of surgery. Preoperative interventions that focus on the details of the surgery may be valuable for children who want this kind of information (and some do), but others may be helped more by supportive interventions that focus on the benefits of the surgery. The only way to know which interventions are appropriate is to understand the child’s coping strategy and appraisal of the surgery. To help children cope effectively requires understanding each patient as an individual. 0 Notes 1. F Cohen, R S Lazarus, “Active coping processes, coping dispositions, and recovery from surgery,” Psychosomatic Medicine 35 (September/October 1973) 375-389; F Cohen, “Psychological preparation, coping and recovery from surgery,” unpublished doctoral dissertation, University of California, Berkeley, 1975; J M George et al, “The effects of psychological factors and physical trauma on recovery from oral surgery,”
Journal of Behavioral Medicine 3 (September 1980) 291-309; F Rothbaum, J Wolfer, M Visintainer, “Coping behavior and locus of control,” Journal of Personality 47 (March 1979) 118-135; M Savedra, M Tesler, “Coping strategies of hospitalized school-age children,” Westent Journal of Nursing Research 3 (Fall 1981) 371-384; L L LaMontagne, “Children’s locus of control beliefs as predictors of preoperative coping behavior,” Nursing Research 33 (March/April 1984) 76-85; L L LaMontagne, “Three coping statqges used by school-age children,” PediatricNursing 10(January/ February 1984) 25-28. 2. LaMontagne, “Children’s locus of control beliefs as predictors of preoperative coping behavior”; LaMontagne, “Three coping strategies used by schoolage children.” 3. R S Lazarus, Pvchological Stress and the Coping hocess (New York McGraw-Hill, 1966); R S Lazarus, R Launier, “Stress-related transactions between person and environment” in Perspctives in Interactional Psychology, L A Pervin, M Lewis ed. (New York Plenum, 1978) 287-322; R S Lazarus, “The stress and coping paradigm.” Paper presented at the Critical Evaluation of Behavioral Paradigms for Psychiatric Science, Glendon Beach, Ore, November 1978. 4. Lazarus, Pvchological Stress and the Coping PlOCesS.
5. Cohen, Lazarus,“Active coping processes, coping dispositions, and recovery from surgery”; Cohen, “Psychological preparation, coping and recovery from surgery.” 6. LaMontagne, “Children’s locus of control beliefs as predictors of preoperative coping behavior”; LaMontagne, “Three coping strategies used by schoolage children.”
Cancer Survival Longer With Combined Therapy In a study of pancreaticcancer patients treated with radiation and chemotherapy following surgery, survival was significantly prolonged, according to the August Archives of Surgay. Martin H. Kalser, MD, University of Miami, and Susan S. Ellenberg, PhD, of EMMES Corp, Potomac, Md, conducted the study of 21 patients assigned to study and 22 to observational control. The study had to be interrupted because combined therapy was so effective. The median survival rate for the treatment group was 20 months, compared to 11 months for the control group, according to the researchers. I23
AORN JOURNAL
Facilitating Children’s Coping PREOPERATIVE ASSESSMENTINTERVIEWS
Lynda L. LaMontagne, RN ’urses are responsible for helping patients and their families cope with stressful
N
situations. Although it has been documented that surgery is stressful for children, little is known about how they cope with this stress. This article emphasizes how nurses can assess and facilitate children’s coping preoperatively.
Coping Strategies
A
fter observing and interviewing both children and adults preoperatively, researchers found that children and adults coped with the stress associated with surgery differently.’ Some patients coped by restricting their awareness of the situation and the people around them, by avoidmg information about surgery, or by hesitating to discuss the surgery. These behaviors could be called avoidant. Other patients coped more vigilantly by seeking information about the surgery and what to expect and by readily discussing the surgery. These behaviors could be called active. I studied 51 school-aged children hospitalized for elective, general surgery and classified them according to their predominant use of avoidant and active coping modes? Patients classified as avoiders had limited knowledge about the surgery and the procedures involved. This lack of knowledge was not so much a result of not being offered information as it was that they tended to deny what parents, relatives, physicians, or nurses told them before surgery. These patients also preferred not to have extensive, detailed information about the nature of the surgery, as evidenced 718
by such statementsas “I know all I want to know.” By contrast, active copers were characterized by knowing many details about the surgery and what to expect (including complications and postop erative pain) and by eagerly discusing the surgery. A third group, classified as combination copers, used both avoidance and active coping modes, knew much about the nature of the surgery, but they denied any knowledge of postoperative complicationsand ‘ ‘ . XI the negative aspects of surgery, such as postoperativediscomfort. These patients tended to focus on the benefits of the surgery, as evidenced by such statements as “I won’t have this problem anymore.” Variations in preoperative coping behavior can be viewed from the perspective of Lazarus and colleagues who believe the degree of stress is related to a person’s evaluation of the situation’s effect on his/her well-being and the resources,such as support, available for dealingwith it.3 According to Lazarus,a person consciously or unconsciously determines if a situation is harmful, potentially harmful, or ~hallenging.~ This appraisal affects the coping process and the effectiveness of the coping modes used. In this context, coping is not static. Rather, it is a process that changes according to varying cognitive appraisals. Coping is the action oriented and intrapsychicefforts taken to manage or tolerate the appraised stress. Although surgery may be stressful for all patients, what may be stressful for one patient may not be stressful for another. Knowing how patients appraise an event leads to an understandingof their coping strategies. This information is essential.
AORN JOURNAL
NOVEMBER 1985, VOL 42, NO 5
Assessment Interview
A
ssessment through observing, interviewing, and reviewing the chart is part of the perioperativenursing process. Successful preoperative assessment of coping cannot be conhed to a specific location, such as the surgical unit. The initial assessment could occur in a variety of settings. Through questioning, listening, and clarifying, the nurse gains an understandingof what the pediatric patient is perceiving and how he/ she is coping with the situation. 1 designed an interview to systematically assess children’s preoperative coping. It is adapted from the interview designed by Cohen for use with adults.5 The interview questions assess the extent of the child’s knowledge about the medical problem and surgery, postoperative outcome (benefitsas well as complicationsand discomforts), alertness to the surgical routine and environment, and the emotions associated with surgery. Examples of questions that reflect the above themes are: What did your parents (physician or nurse) tell you about the operation? Did they tell you anything about why it is being done, how the operation will be done, or what good this operation is going to do for you? Where will you be when you wake up? What do you think you will feel like after surgery? After the first day? After that? Whenever a person is going to have an operation, there may be some things he/ she is womed about. What are the main things you are worried about? I categorized each child’s coping strategy by responses to these questions. Specific behaviors differentiatingavoidant, active, and a combination of avoidant-active coping strategies are presented L y h L. ~ ~ g n RN, e DNQ. , is an msthnt profmorof nursingin thegr-program for nursing of children ai Arizona State University, Tempe. She earned her docrorclre ai the University of California, San Francisco. She received her bachelor’s &gree in nursing fram Calijornia State U n i v e w , Las Angeles and m t e r of science &gree fron the University of GUlly0??llil
A child listens to the author’s explanations before going to the operating room.
in Table 1. These behaviors range from avoiding to seeking information and support from others, in addition to minimizing or avoiding verbalizing fears about the threatening aspects of surgery.
Facilitating Coping
0
ne of the goals of preoperative nursing intervention is to facilitate successful coping with the stresses of surgery. There should not be a value judgment placed on a particular coping strategy; avoidant strategies may be as effective as active strategies. What is important is that before intervening the nurse understands how a child is coping with and interpreting the u p m i n g surgery. Effective preoperative preparation must be tailored to the child. There is not a list of ingredients that will prepare all children for surgical procedures. Although children of the same
NOVEMBER 1985, VOL 42, NO 5
AORN JOURNAL
Table 1
Behaviors Typical of Each Coping Strategy Avoidant coping
Active coping
Avoidant-active coping
Restricts knowledge or awareness about the nature of surgery or the procedures involved. Usually knows why the surgery is being done, eg, “to strengthen my eye muscle,” but does not want any more information, eg, “I know all I want to know.” Denies worry or is not specific about what causes worry, eg, “Like I said, Dr Smith will make sure everything is set and nothing is going to happen, so there isn’t anything to worry about.” Focuses on the benefits of surgery, eg,no more illness or the problem will be fixed. Uses parents for support and information, eg, “My mother told me what I need to know” or “I’m not worried as long as my mother is here.” Is hesitant to discuss the surgery and thoughts about it.
Knows many details about the nature of the medical problem, surgery, and procedures involved. Is specific when requesting additional information, eg, “I think I have everything, but I would like to hear again how the doctor will actually do the operation.” Acknowledges worry and is specific about the cam of worry, such as complications or mistakes, eg, “When I heard this surgery could paralyze me I got real nervous, but when the surgeon said he had done thousands of these operations and that it never happened, I felt better, But I still pray it won’t happen to me.” Focuses equally on the positive and negative postoperative outcomes. Seeks support from others. Eagerly discusses the surgery and thoughts about the operation.
Knows a few minor details about the medical problem, surgery, and procedures involved. May want more information, but the information sought is usually general and limited to the procedure, eg, “Um, you’re asking me if I have enough information and yeah, I would say yes because I think everything is straightened out. The only thing I don’t know is how long the operation will be. Do you know?” Acknowledges at least one worry or fear, such as the physician making a mistake, but rationalizes that it won’t happen. Although may mention one or two negative postoperative outcomes like soreness and vomiting, the focus is on the benefits of the surgery. Generates support from others. Talks to parents, siblings, and friends about the surgery. Is open to discussing the surgery and thoughts about the operation.
developmental stage are similar, individual influences, which may affect how they cope with a procedure, make them different from other children of the same age. My preoperative interviews with the school-aged children revealed that each child, although in the same develop mental age group, used different coping strategies! For example, children who cope by denying worry and by limiting knowledge of the procedure may need a nurse or parent present during stressful 122
episodes. Detailed information would probably increase worry. Therefore, it might be best to focus on such minor details as how long the procedure will be, how they can expect to feel after surgery, and what their role will be during the recovery process. Active copers though need detailed information about the procedure and what to expect; therefore, the nature and amount of information given is important to their ability to manage the stress.
AORN J O U R N A L
NOVEMBER 1985, VOL 42, NO 5
Children who combine avoidant and active coping modes show no rigid preference for either strategy. They seek information, but it is usually general in nature and limited to the minor details of the procedure and its positive outcome. These children may acknowledge being worried about a possible complication,but minimize it by stating that the feared outcome will not happen to them. These children need information clari6ed as well as reassurance that the surgical staff is competent. The challenge for the nurse who performs the preoperative coping assessment is to plan preparations that will help the individual child. The nurse is most effective in preparing the child when the plan is based on an understanding of how the child appraises or defines the event and is coping. This understanding comes from a basic knowledge of child development and coping and by observing and interviewing the child. The first step may be to ask the child what he/she knows and wants to know about the situation or procedure. With this information, the nurse can clanfy or provide more information and suggest ways that will help the child manage fears or worries. For example, emphasizing the benefits of the surgery (such as better vision or ability to play sports) or familiarizingthe child with ways the nurses can assist (such as giving pain relieving medications) helps the child effectively cope with the stressful demands of surgery. Preoperative interventions that focus on the details of the surgery may be valuable for children who want this kind of information (and some do), but others may be helped more by supportive interventions that focus on the benefits of the surgery. The only way to know which interventions are appropriate is to understand the child’s coping strategy and appraisal of the surgery. To help children cope effectively requires understanding each patient as an individual. 0 Notes 1. F Cohen, R S Lazarus, “Active coping processes, coping dispositions, and recovery from surgery,” Psychosomatic Medicine 35 (September/October 1973) 375-389; F Cohen, “Psychological preparation, coping and recovery from surgery,” unpublished doctoral dissertation, University of California, Berkeley, 1975; J M George et al, “The effects of psychological factors and physical trauma on recovery from oral surgery,”
Journal of Behavioral Medicine 3 (September 1980) 291-309; F Rothbaum, J Wolfer, M Visintainer, “Coping behavior and locus of control,” Journal of Personality 47 (March 1979) 118-135; M Savedra, M Tesler, “Coping strategies of hospitalized school-age children,” Westent Journal of Nursing Research 3 (Fall 1981) 371-384; L L LaMontagne, “Children’s locus of control beliefs as predictors of preoperative coping behavior,” Nursing Research 33 (March/April 1984) 76-85; L L LaMontagne, “Three coping statqges used by school-age children,” PediatricNursing 10(January/ February 1984) 25-28. 2. LaMontagne, “Children’s locus of control beliefs as predictors of preoperative coping behavior”; LaMontagne, “Three coping strategies used by schoolage children.” 3. R S Lazarus, Pvchological Stress and the Coping hocess (New York McGraw-Hill, 1966); R S Lazarus, R Launier, “Stress-related transactions between person and environment” in Perspctives in Interactional Psychology, L A Pervin, M Lewis ed. (New York Plenum, 1978) 287-322; R S Lazarus, “The stress and coping paradigm.” Paper presented at the Critical Evaluation of Behavioral Paradigms for Psychiatric Science, Glendon Beach, Ore, November 1978. 4. Lazarus, Pvchological Stress and the Coping PlOCesS.
5. Cohen, Lazarus,“Active coping processes, coping dispositions, and recovery from surgery”; Cohen, “Psychological preparation, coping and recovery from surgery.” 6. LaMontagne, “Children’s locus of control beliefs as predictors of preoperative coping behavior”; LaMontagne, “Three coping strategies used by schoolage children.”
Cancer Survival Longer With Combined Therapy In a study of pancreaticcancer patients treated with radiation and chemotherapy following surgery, survival was significantly prolonged, according to the August Archives of Surgay. Martin H. Kalser, MD, University of Miami, and Susan S. Ellenberg, PhD, of EMMES Corp, Potomac, Md, conducted the study of 21 patients assigned to study and 22 to observational control. The study had to be interrupted because combined therapy was so effective. The median survival rate for the treatment group was 20 months, compared to 11 months for the control group, according to the researchers. I23