Ineffective coping: An advanced nursing practice approach
Ineffective coping is an applicable nursing diagnosis evident in several of the patients I have come in contact during my practice and time at TG’s oncology. This case presentation will explore different instances of ineffective coping, applicable nursing interventions, and outcomes from an advance practice nurse perspective. The NANDA definition of ineffective coping is “an inability to for a valid appraisal of stressors, inadequate choices of practiced responses, and/or inability to use available resources”.
Coping mechanisms are usually conscious methods that the individual uses to overcome a problem or stressor. They are learned adaptive or maladaptive responses to anxiety based of problem solving, they may lead to changed behavior
Inappropriate coping mechanisms can be changed because the patient is usually aware of using them.
EX: Talking out problems with others
Expressing emotion—yelling, crying, laughing
Seeking comfort from friends, food, treasured objects,
smoking, or mind-altering substances
Using humor to relieve tension in a way that avoids fully
acknowledging a difficult situation
Exercising
Avoidance of upsetting situation or confrontation
Using step-by-step approaches to resolution of the problem.
The nurse’s psychosocial assessment of the patient and family should focus on the effect of the illness rather than the physical symptoms.
Assess: Lifestyle information and personality style
Normal coping patterns
Understanding of current illness
HX of psych disorders
Recent/current life change/stressors (other than illness)
Major issues raised by current illness
Mental status examination:
-changes in appearance, emotions, memory, thought processes
and reasoning, behaviors.
Patient A Patient B
65 yr old female, diabetic with recent BKA and infectious complications. Long hospitalization awaiting prothesis and physical therapy rehabilitation. An extended hospitalization (3 months) has contributed to marked changes in mood, affect, ADL performance, and rehab potential. Patient does have a daughter living near by who visits everyday.
PATIENT PROFILE & SHARED NURSING DIAGNOSIS:
INEFFECTIVE INDIVIDUAL COPING 42 year old female battling cervical cancer with renal complications and metastasis to the lymph nodes. Eighteen months full of chemotherapy treatments and increasing constant pain have also affected her mood, ADL performance, and individual coping mechanisms. Patient B also has a S.O. who seems to be attentive and caring, but who also seems need emotional support
Lack of goal directed behaviors;
Fatigue; Inability to meet basic needs; Use of coping mechanisms that impede adaptive behavior; Change in usual communication patterns; APPLICABLE DEFINING CHARACTERISTICS: Lack of goal-directed behaviors; Sleep disturbance; Fatigue; Verbalized inability to cope; Destructive behavior to self/others; Inability to meet basic needs; Inability to meet role expectations; Use of coping mechanisms that impede adaptive behavior;
Inadequate level of perceived control; Disturbance in pattern of tension release; Inability to conserve adaptive energies; Situational crises RELATED FACTORS
Inadequate level of confidence in ability to cope; Inadequate level of perceived control; inadequate resources available ($$); High degree of threat;
• Demonstrates coping AEB identifies effective and ineffective coping patterns and modifies lifestyle as needed
• Verbalizes ability to cope and asks for help when needed.
• Communicates needs and negotiates with others to meet needs
• Discusses how recent life stressors have overwhelmed normal coping strategies
DESIRED OUTCOMES
COPING ENHANCEMENT • Demonstrates coping AEB identifies effective and ineffective coping patterns and modifies lifestyle as needed
• Verbalizes ability to cope and asks for help when needed.
• Remains free of destructive behavior toward self and others
• Communicates needs and negotiates with others to meet needs
• Discusses how recent life stressors have overwhelmed normal coping strategies
• Observe for causes of ineffective coping: poor self-concept, grief, lack of problem solving skills, lack of support
• Use empathetic communication, and encourage client/family to verbalize fears, express emotions, and set goals
• Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping.
NURSING ASSESSMENT
P. 254-260
ACKELY AND LADWIG
5TH ED • Observe for causes of ineffective coping: poor self-concept, grief, lack of support
• Monitor for risk of suicide
• Use empathetic communication, and encourage client/family to verbalize fears, express
• Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping.
• Discuss with patient/family the perceived and actual power to change or accept a situation
• Help client set realistic goals
• Provide mental and physical activities within the client’s ability.
• Discuss changes in treatment or environment before making them (involve the patient as much as possible) INDEPENDENT NURSING INTERVENTIONS
COPING ENHANCEMENT
P. 254-260
ACKELY AND LADWIG
5TH ED
• Discuss with patient/family the perceived and actual power to change or accept a situation
• Help client set realistic goals
• Be honest; avoid false reassurance or trite statements.
• Discuss client’s/family’s power to change or accept a situation.
• Provide critically ill patients/families with needed information regarding their condition and treatment.
Reassess the behaviors and feelings of the patient OUTCOMES EVALUATION
Role of CNS
As a CNS, the nursing process takes on several different roles diversifying the types of interventions to be made. For example, the CNS working as a direct expert caregiver would perform many of the same assessments and interventions listed by NANDA, NIC, and NOC. These would be done with enhanced critical thinking and collaborative interventions.
As an educator of patients, the CNS may be able to take time with the patient and family to further assess the situation and help formulate a plan for enhancing coping mechanisms. The CNS as a staff educator can educate nursing staff about the importance of recognizing ineffective coping mechanisms and other psychosocial responses to stressors. REFERENCE THE LUNNEY ARTICLE!!
This study by Lunney et al. examined the prevalence and accuracy of nurses’ assessment and nursing diagnosis of psychosocial responses. The researchers followed 62 nurses from 3 different hospitals, and asked them to assess and diagnose the psychosocial problems of their patients. The nurses’ assessments were followed by two trained raters to check the nurses’ accuracy in their assessment and diagnoses. “They found that the nurses’ diagnoses were not sufficiently accurate. This result told the researchers many things, but most importantly, it showed that low accuracy is a problem that needs to be addressed by APNs and educators. The researchers concluded that inaccuracy of ND may increase costs because resources may be used for unnecessary or ineffective interventions. CNSs should be involved in “developing the broad base of intellectual, interpersonal, technical, and perceptual skills needed for achieving accuracy in NDs. CNSs and educators need to also promote critical thinking skills and collaboration with other members of the health care team. This will help nurses feel more comfortable validating the meaning of cues and inferences with patients, families, and other providers.” (SEE LAST PAGE OF ARTICLE!!!)
“Inaccuracy simply shows that some patient data may be misinterpreted and creates opportunities for improved patient outcomes to be missed.”
Ineffective coping occurs in staff as well. Charles Kemp author of Terminal Illness: a guide to nursing care has a chapter devoted to the stress of health care providers. He discusses several sources of stress such as the nature of the work, involvement with patients and families, and personality variables. He also suggests several strategies for coping with stress. I believe that these strategies can be facilitated by an APN.
References
Dellasega, D., & Zerbe, T. M. (2002). Caregivers of frail rural older adults: Effects of an advanced practice nursing intervention. Journal of Gerontology, 28(10), 40-.
Ackley,B. J., Ladwig, G. B. (2002). Nursing diagnosis handbook: A guide to planning care. 5th Ed. Mosby: St. Louis.
Gorman, L.M., Raines, M. L., Sultan, D.F. (2002). Psychosocial Nursing for General patient Care 2nd Ed. F.A. Davis Company: Philadelphia.) p.13 and 16
(from Gordon, M. (2002) Manual of Nurisng Diagnosis 10th ed. Mosby: St. Louis
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