lournu1 of Advanced Nursing, 1989, 14,281-290

Comprehensive health seeking and coping paradigm

Adeline Nyamathi RN PhD Assistunf Professor, School of Nursing, Universify of Culifornia u f Los Angeles, 10833 Le Confe Avenue, Los Angeles, CA 90024-7702, U S A

Accepted for publication 14 April 1988

Journal of Advanced Nursing 14,281-290 Comprehensive health seeking and coping paradigm While scholars in nursing are charged with the responsibility of advancing and structuring a body of knowledge for application in nursing practice, many of the
N Y A M A T H I A. (1989)

currently utilized theories have been borrowed from other disciplines. Until such knowledge is redefined and synthesized according to the perspective of nursing, borrowed knowledge cannot be adequately understood. The purpose of this paper is to present a comprehensive client-orientated health seeking and coping paradigm. This paradigm is theorized to be a function of 12 factors which include: clients situational and personal factors, resources, sociodemographic characteristics, cognitive appraisal, health goals, health seeking and coping behaviours, nursing goals and strategies, clients perceived compliance, clients perceived coping effectiveness, and immediate and long-term health outcome. The Lazarus Schema of Coping and Adaptation and the Schlotfeldt Health Seeking and Coping Paradigm were the parent conceptualizations from which the Comprehensive Health Seeking and Coping Paradigm (CHSCP)was derived. As a nursing-orientated multidimensional framework, the CHSCP will provide a useful framework for nurses interested in altering, enhancing or promoting the health seeking and coping of clients. By providing an intellectual focus for the initial and ongoing assessment of a multitude of variables which influence health seeking and coping, the specification of appropriate strategies can be developed and enhanced. descriptions and explanations of when, why and how people can be helped by nurses. Until knowledge from Scholars in nursing are charged with the responsibility of other disciplines is redefined and synthesized according to advancing and structuring a body of knowledge which will the perspective of nursing, such knowledge cannot be have direct application for nursing practice. While a cadre adequately understood (Crawford et a/. 1979). By asking of nurse scientists are continuously and systematically nursing questions and investigating phenomena that are of discovering knowledge, many of the theories utilized as concern to nurses, borrowed knowledge can have a significonceptual guides for research have often times been cant impact on advancing nursing knowledge and practice. borrowed from other disciplines.The tendency of nurses to Schlotfeldt (1981, 1988) maintains that assisting individrely solely on behavioural science and theories from other uals to cope with illness, life crises, change in life style and disciplines has been limiting, as nursing is not the focus of role represents the ruison defre of nursing. The phenomena the framework (Cox 1982, Schlotfeldt 1975). Moreover, of focus for nursing research are the health seeking Orem (1980)contends that borrowed theory offers little or behaviours, mechanisms and health assets of the human no constructive guidance for nurses that would provide spirit.

INTRODUCTION

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The purpose of this paper is to present a comprehensive, client-orientated health seeking and coping framework that would guide nursing research and practice. It is only until the complex meta-theoretical vista of health seeking and coping is contemplated that relationships among concepts can be tested and evaluated. Theory testing of this nature would lead to the formulation of strategies planned to assist individuals in realizing and actualizing their maximum potential as it relates to wellness and optimum function.

THE EVOLUTION OF THE N O N - N U R S I N G PERSPECTIVE O N C O P I N G

was envisioned as any device that represented minimal disorganization and was therefore equated with how well the person functioned. Similarly, Vaillant (1977) proposed that coping consisted of four classes of defence mechanisms which were ordered based on maturity and pathological import. The progression of low level to high level defences ranged from psychotic mechanisms (denial and distortion of reality) to mature mechanisms (suppression and humour). Researchers directed by these conceptualizations later discovered that coping was inevitably being confounded with adaptational outcome.

The multidisciplinary perspective on coping has undergone extensive restructuring over the years. Currently, Conceptualization of coping as a trait or style coping is viewed within a cognitive phenomenological framework wherein the person and the environment are Folkman & Lazarus (1980) contend that conceptualizing viewed in a dynamic, mutually reciprocal and bidirectional coping as a personality trait (repression-sensitization) or relationship (Folkman & Lazarus 1980).Pearlin & Schooler style (Type A pattern) has been and continues to be a (1978) refer to coping as the things people d o to avoid popular trend. In particular, the association between Type A being harmed by life strains. More specifically, these personality and cardiovascular risk has been widely publiauthors describe coping as any response to external life cized (Friedman & Rosenman 1974, Rhodewalt & Davison strains that serves to avoid, prevent or control emotional 1983).Type A persons have been theorized to have a strong distress. Mechanic (1977) considers coping to include commitment to control situations. Consequently, when instrumental behaviours and capacities for meeting life's control is threatened or frustrated, Type A persons are said goals and demands while Lazarus & Folkman (1984) to become highly emotional, as they alternate between defines coping as constantly changing cognitive and excessive striving to strengthen control and despair over behavioural efforts to manage specific external and/or their lack of control. According to Glass (1977), this leads internal demands that are appraised as taxing or exceeding to surges of catecholamine secretion, and possibly other psychophysiological changes such as increased lipids or the resources of the person (Lazarus & Folkman 1984). While variations in the definition of coping have led to changes in blood clotting time. Folkman & Lazarus (1980) maintain that traits or styles confusion, an even greater conceptual blurring of the term has resulted from the existing multiple conceptualizations are poor indicators of coping as they are based on the assumption that people use the same cognitions and beof coping. haviours consistently across situations. Such a view can be assessed to be a static and unidimensional perspective that Conceptualization of coping a s a defence mechanism does not reflect the multidimensional aspect of coping Historically, coping has been conceptualized in the realm of (Cohen & Lazarus 1979, Folkman & Lazarus 1980, Moos & psychoanalytic ego psychology wherein hierarchically Tsu 1977). organized defence processes were developed and categorized to represent coping (Menninger 1963, Vaillant 1977). Menninger (1963) identified five orders of ego processes Conceptualization of coping as a transactional which were based upon the degree of internal disorganiz- process ation the individual experienced. Those coping devices ranged from superior, top ranking devices such as thinking Lazarus & Folkman (1984) contend that coping is a multiit out, self-control and working off energy to the lowest dimensional concept wherein the degree to which a person order devices which represented total disorganization o f experiences feelings of harm, threat or challenge is deterthe ego. However, based on this conceptualization, when mined by a cognitive mediating process known as apcoping devices of top superiority did not resolve the prob- praisal. As an ongoing process, appraisal is the means by lem, they were no longer considered to be coping devices, which the potential outcome of a situation and the coping and instead, become symptorns indicating a degree of dys- resources and options available to deal with it are judged or control and threatened disequilibrium. As a result, coping evaluated (Folkman & Lazarus 1980, Lazarus ef al. 1974).It
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Health seeking and coping paradigm

is when important goals are not met and threat is said to be experienced that coping processes are set in motion. Numerous authors have recognized that coping processes encompass diverse forms of coping activities which are primarily problem and emotion-focused in nature (Folkman & Lazarus 1980, Lazarus 1966, Mechanic 1977, Monat & Lazarus 1977). Folkman & Lazarus (1980) describe problem-focused coping as activities which function to manage the person-environment relationship that is the source of stress. Emotion-focused coping is an attempt to reduce emotional discomfort associated with the stressor. As a dynamically changing process, coping is influenced by a complex and interrelated series of factors. In the Lazarus Theoretical Schema of Coping and Adaptation (Lazarus & Folkman 1984),causal antecedents and mediating variables are depicted which influence the long-range adaptational consequences. The causal antecedents are environmental variables which include situational demands, timing of the event, ambiguity and social and material resources. Personal variables include the values, beliefs and commitments of the persons as well as their sense of control over their environments. Other antecedent variables are physiological factors such as severity of the illness and the sociological variables of social status, culture and social networks. Mediating variables have also been proposed by Lazarus to affect the relationship between the causal variable and the outcome. These mediating variables include cognitive appraisal of the situation, the problem and emotionfocused coping responses manifested, and perceived social support in terms of emotional, tangible and informational assistance. Finally immediate adaptation is depicted in terms of somatic changes, positive or negative emotions, and quality of outcome while long-term consequences are depicted in terms of chronic illness, morale and social functioning. Lazarus & Folkman (1984) propose that, unlike previous research which studied one antecedent variable and its adaptational consequence, their approach guides the investigation of the mediating processes repeatedly to determine how an environmental demand would be perceived and how it might affect long-term adaptational outcome. Limitations t o the multidisciplinary conceptualizations of coping The previous conceptualizations of coping by behavioural and psychological theorists and researchers have significantly contributed to a current status of theoretical integration. Over the years, researchers have realized that when coping is conceptualized as effective functioning and

defence as ineffective coping, there is an inevitable confounding between the process and the outcome of coping (Lazarus & Folkman 1984). Likewise, conceptualizing coping as a trait or style severely underestimates the complexity and variability of coping efforts. The current conceptualization of coping as a transactional process has been helpful. An understanding of the factors which influence coping and the cognitive processes that intervene between the stressful encounter and the reaction has been invaluable for nurses who are seriously interested in promoting clients health seeking and coping behaviours. As helpful as these conceptualizations have been, it is clear that the focus of nursing has not been evident. And while the impact of the person and the environment have been made clear, the direction for nursing practice is yet to be delineated. How may nurses identify individuals who are at risk for ineffective coping? How may nurses promote and enhance effective coping? Which strategies should nurses implement when individuals are manifesting ineffective coping? These practice-orientated issues are significant as nurses need to assess accurately which coping behaviours support the health goals of the client, the ways to encourage these responses, and to develop strategies for promoting alternative behaviours when activities performed are ineffective or dangerous to the health and well-being of the client. Ellis (1968) maintains that nurses are essential in helping individuals to cope with health problems when their own strength, will or knowledge is insufficient. The development of theories that will significantly influence and guide nursing practice is the appropriate goal for nursing.

THE NURSING PERSPECTIVE O N H E A L T H SEEKING A N D C O P I N G

Schlotfeldt (1981) contends that nurses are concerned with maximizing clients strengths, assets and potentials to attain or to be restored to optimal levels of health function, comfort and fulfillment. This theorists explication of a highly visible, nursing orientated perspective in assisting man to cope with illness, life crises and other anticipated or unexpected stressors in life is portrayed in the Schlotfeldt Paradigm of Health-Seeking Behaviours. In these schema, the health goals of the client, and desired goals of the nurse are mutually concerned with enhancing the individuals motivation to attain and maintain health and function, to avoid disease and disability and to attain or retain the highest possible level of health, function or productivity. Specifically, these goals might
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Figure 1 Comprehensive health seeking and coping

Situational factors

Pe rsona I factors

Nursing goals

Resources

paradigm.
Cognitive appraisal

/ T R

Health goals of client

A
T

___

include: keeping distress within manageable limits, maintaining sense of personal worth, and initiating or maintaining satisfying relations with significant others. The individual attains these goals by employing health seeking and coping behaviours, such as seeking help from family, and learning illness-related procedures. Intervening variables are any factors which alter the health-seeking behaviours of the individual such as availability of resources and the past repertoire of coping responses. Nursing strategies are the means available for compensating for mans health seeking behaviours in some instances, and in others, altering, maintaining or enhancing them through the use of nursing strategies appropriate to each unique nursing situation (Schlotfeldt 1975). These strategies include encouraging, teaching, providing, communicating and nurturing. The Schlotfeldt Paradigm of Health Seeking Behaviours is a fitting conceptual framework which guides the observation, interpretation and organization of nursing knowledge.

COMPREHENSIVE HEALTH SEEKING A N D COPING PARADIGM

Components of the Schlotfeldt Paradigm of Health Seeking Behaviours and the Lazarus Theoretical Schema of Coping and Adaptation have been extracted and modified to comprise the Comprehensive Health Seeking and Coping Paradigm. With the solid base of coping theory combined with a nursing perspective of health seeking and coping behaviours, a unique and significant conceptualization has emerged which has great potential for guiding nursing theory testing and practice.
284

As nursing assists, promotes and enhances health seeking and coping behaviours, coping as a response will be expanded to include health seeking and coping behaviours. This expanded title, which accurately reflects the nursing perspective, is defined as the thoughts and actions individuals engage in to overcome threats to health, and deal with life crises encountered, in order to attain or retain optimal health and functioning. The assumptions of this integrated model, which are derived from Schlotfeldt (1975) and Lazarus & Folkman (1984),are: Health seeking and coping is a necessary process which all individuals utilize in various ways throughout their lifetimes; Health seeking and coping is understood as being determined by the relationship between the person and the environment; Health seeking and coping involves problem-focused and emotion-focused behaviours; While individuals have inherent and innate capabilities, some capabilities must be actualized and enhanced through guided learning; Nurses can have a major influence on many aspects of the persons health seeking and coping behaviours and health outcome; The goal of nursing is to utilize knowledge of man relevant to his health seeking and coping behaviours rationally, artfully, and skillfully through use of nursing strategies that assist to realize his maximum potential as it relates to wellness and optimal function. Figure 1 portrays the CHSCP, a complex and multidimensional framework which proposes a highly interactive relationship among its various components and provides a comprehensive overview for the concept o f

Health seeking and coping paradigm coping which is appropriate to the nursing profession. The twelve components of the framework include situational and personal factors, coping resources, sociodemographic factors, cognitive appraisal, health goals of the client and health seeking and coping behaviours. Nursing goals and strategies constitute a major component which can directly influence all other major components, including patient compliance, perceived coping effectiveness and immediate and long-term health outcome. Variables specified under each component are displayed in Table 1.

Table 1 Variables specified under each component

Components Situational factors Variables Environmental constraints Duration Past experience with illness Timing Anxiety/depression/fear Perceived seriousness of event Stimulus ambiguity Perceived self-esteem Perceived control Hardiness Knowledge/cognitive ability Physical health Emotional health Social support Financial security Spiritual security Age Education Marital status Employment status Social class Consideration of threat perceived and resources available Perceived goals in attaining health and
function

Personal factors

Situational factors
Variables which characterize the environment for every individual and influence health seeking and coping are the situational factors. These variables include environmental constraints, duration of the stressor, past experiences with illness and the timing of the event. As depicted in the CHSCP, these factors influence all other components of the model, and consequently represent an important element in nursing assessment. For example, environmental constraints are often identified as barriers to effective coping for patients and family members. These environmental constraints have been known to include entities such as difficulty in getting to the treatment facility, nature of the visiting hours and the ease with which visiting can be accomplished (Haeter 1985, Stillwell 1984).In particular, these factors directly affect the spouses ability to be with their partner, and can influence their perception of the seriousness of their partners illness. As such, these factors have been found to be powerful forces that can influence the health seeking and coping behaviours manifested (Nyamathi 1987). Facilitating the individuals entry into the health care system and manipulating visiting hour policy to benefit the patient and family rather than the physicians and nurses are key strategies nurses can perform to enhance the health seeking and coping behaviours of these individuals. In another example, duration refers to the length of time the stressful event is experienced. A generally long held assumption has been that chronic stresses wear the person down physically and psychologically (Selye 1976)and that the longer the duration of the illness, the poorer will be the adjustment to illness (Shanan et al. 1976). Nurses have learned that the nature of the illness and the strengths and skills possessed by the individual determine the extent of the stressor perceived. In many instances, the presence of a chronic illness can offer the person an opportunity to learn new skills, and specific ways of dealing with its demands. O the situational variables depicted in the CHSCP, f environmental constraint and timing have been depicted as

Resources

Sociodemographic factors

Cogn ifive appraisal

Health goals of client Health seeking and coping behaviour Nursing goals and strategies

Problem-focused coping Emotion-focused coping Encourage ventilation Provide comfort, support and acceptance Encourage hope, refer Clarify misconceptions Teach, organize groups Encourage life-style conducive to health Perceived effectiveness of coping behaviours of client Perceived ability to adhere to prescribed therapy Somatic and emotional health Social changes Optimal physiological and psychosocial functioning Psychosocial adjustment

Perceived coping effectiveness Perceived compliance Immediate health outcome

Long-term health

outcome

causal antecedents in the Lazarus Schema of Coping and Adaptation. However, environmental constraints were often conceived as barriers to the utilization of resources. In
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the CHSCP, environmental constraints represent situations that are likely to occur in the hospital setting and relate to activities which nurses can control. Personal factors An individuals beliefs regarding the seriousness o the f illness and varied personality characteristics are personal factors which may affect coping. In particular, research has indicated that patients identified as depressed or anxious preoperatively suffer a higher mortality rate than patients not as depressed or anxious (Mumford et 01. 1982, Kimball 1977) From a psychological perspective, theorists contend that individuals who are confronted with adisease and who have been labelled as anxious or depressed may just be out of luck, as it is difficult to modify the individuals personality (Singer 1984). However, the perspective of the CHSCP differs in that while nurses recognize that depression and anxiety may be inherent traits of an individual, nurses are knowledgeable about successful strategies which have assisted individuals in coping effectively when they are faced with sudden illness, or the threat of pain, disfigurement, or fear of death from anticipated surgery.Nurses have found that structured teaching can help to increase knowledge levels, decrease postoperative complications and increase postoperative compliance (King & Tarsitano 1982, Milazzo 1980, Rice & Johnson 1984). The assessment of the individuals perception of selfesteem and perceived control assists nurses in identifying individuals who are at risk for ineffective health seeking and coping. Researchers agree that persons with a high level of self-esteem are more likely to cope effectively with their environments than persons with low levels of selfesteem (Coopersmith 1967, Lazarus 1966, Nyamathi 1987). In a nursing study exploring the adjustment of hypertensive patients, Powers & Jalowiec (1987) found that patients who were well adjusted did not perceive their health was under the control of others. By encouraging individuals to increase control over their activities as they recover from illness and emphasizing the aspects of the person that are positive and praiseworthy, nurses can assist individuals in maintaining control over their lives and can foster their perception of enhanced self-esteem. Coping resources Among the vast number of factors which may be considered as resources, physical and mental health, financial and spiritual security and social support are considered the major variables. It has been reported that persons who are
286

frail, sick, tired, emotionally troubled or otherwise debilitated have less energy to expend on coping than healthy persons (Lazarus & Folkman 1984).As a result, by identifying individuals who manifest such problems, nurses can enhance their health seeking and coping capabilities and strengthen their physical and mental health through strategies such as providing specific health information and making referrals to medical and mental health specialists and support groups. The attainment of other resources such as financial and spiritual security, and social support has been shown to enhance their coping capabilities by increasing their available options in stressful encounters. Strategies used included providing more effective access to legal, medical and other professional assistance (Syme & Berkman 1976); assisting the individual in maintaining a positive belief about God and hope for a positive outcome (Lazarus & Folkman 1984); and providing tangible, emotional and informational support and assistance (Cobb 1976, Kaplan et al. 1977, McCubbin 1979). In particular, social support has been crucial in enabling individuals to perceive the situation as less threatening, so that reassurance and security are enhanced and more adaptive coping is demonstrated (Gentry & Haney 1975). In promoting the resources of the individual, nursing strategies should be focused on assisting individuals to realistically evaluate their coping resources and to augment their coping resources by trying out new responses while under the guidance and support of nurses. Lastly, nurses may alter the environment to foster a positive response by strategies such as controlling the noise level to provide an environment conducive to physical and mental recovery. Sociodemographic variables The demographic characteristics of age, sex, socioeconomic class and marital status have reportedly had an effect on the way individuals cope. It has been found that women utilize more emotion-focused strategies than men, have more difficulty adjusting after a heart attack, exhibit a greater degree of anxiety and depression, and manifest a poorer rehabilitative outcome (Folkman & Lazarus 1980, Gentry & Haney 1975, Stern et al. 1977). With marital status, research findings have supported the positive concept of social support, as married men were found to have a better prognosis with cardiac disease than single or divorced men (Hrubec & Zurkel 1971). By acknowledging these individual characteristics, nurses may be guided in identifying individuals at risk for ineffective health seeking and coping behaviour, thus promoting nursing strategies which may overcome such inadequacies.

Health seeking and coping paradigm

Cognitive appraisal

PERCEIVED C O P I N G EFFECTIVENESS
The individuals perception of coping effectiveness is a unique and vital concept which assists nurses in evaluating the success of behaviours manifested. McNett (1987) reported that the perceived availability of social support, and not the use of social support was significantly and positively related to coping effectiveness. By assessing the success of health seeking and coping behaviours, the nurses and clients can begin to develop and identify a repertoire of effective responses for future utilization while at the same time, acknowledging ineffective responses.

As the mediating cognitive process between the event and

coping responses, cognitive appraisal determines to what extent a particular transaction between the person and environment is stressful. There is some evidence that nurses can eliminate known stressors before they can be perceived and interpreted as threatening. For example, Hansel1 (1984) describes the relationship between noise in the ICU, lack of sleep and resultant behavioural alterations in critically ill patients. Nursing interventions which decrease the amount of personal communication that occur over a patients bedside and limit unnecessary interactions with other staff and patients are two interventions that can have a favourable impact on patient recovery.

Health seeking and coping behaviours

These responses refer to the behaviours and cognitions in which people engage when actually contending their life crises (Pearlin & Schooler 1978). In an investigation of cardiac surgical patients, King (1985)found that information seeking and attention-deployment responses were used to a great extent before surgery, while social support, turning to family and friends, and imagery-rehersal-vigilance were coping responses used most often during the postoperative period. Positive thinking was a coping response that did not change over time. The study supported the notion that coping processes change over time. As nurses begin to identify the individualsresponses to disease, particularly as they are influenced by multiple personal and environmental factors, an understanding of the typical health seeking and coping behaviours utilized and resultant health outcome will be gained. This understanding will be useful in assisting nurses to design interventions for individuals suffering from particular disorders.

HEALTH GOALS OF THE CLIENT

By closely monitoring the constantly changing health goals of the client, nurses are best able to evaluate the appropriateness of the health seeking and coping behaviours manifested. For example, a newly diagnosed patient with an operable malignancy may strive for recovery and resumption of usual activities. Nurses caring for this individual would expect to see behaviours such as information seeking related to the impending surgery, and learning skills related to adequate ventilation and activity after surgery. O n the other hand, an individual who has received news that an inoperable cancer has metastasized and that their prognosis is grave would have significantly different goals, focused on managing financial issues and procuring a power of attorney. By assessing the goal of the individual and other factors in the person-environment constellation, nurses can effectively evaluate the appropriateness of the health seeking and coping behaviours manifested.

NURSING GOALS A N D STRATEGIES

Nurses, throughout history have been aware of how crucial their presence, thoughts and actions have been in assisting individuals to cope with stressful events. Through the use of skilled communication, the nurse can facilitate the individuals expression of thoughts and feelings. By means of skilled interventions such as providing information, enhancing social support and offering specialized instruction in behaviours that will alleviate pain, reduce anxiety and enhance postoperative function, nurses have assisted individuals in altering and enhancing health seeking and coping behaviours. For example, in a comprehensive review of the coping literature, Clark (1987) reported that the use of a nursing intervention successful in reducing stress of patients preparing to transfer from CCU has resulted in fewer cardio287

Perceived compliance

A strong, positive correlation has been demonstrated

between denial and non-compliance with the medical regimen, particularly in the areas of smoking cessation, rest, return to work and decreasing the number of hours worked (Croog & Levine 1977). While it is important that nurses support the clients denial in the early stage of recovery, assisting clients in utilizing alternative coping responses during the later convalescence will positively influence immediate and long-term health outcomes. One strategy nurses have used is engaging the family in the clients teaching programme. Such involvement can enhance the health seeking and coping behaviours of clients and families alike (Dracup el al. 1984).

A.Nunmathi
vascular complications. Simple interventions can consist of having a nurse from the receiving unit visit the patient in the CCU before transfer, to answer questions and instruct the patient on the physical layout of the unit, nursing routine and visiting hours (Schwartz & Brenner 1979). In another well-known example, when nurses attend to the concerns and needs of families, coping becomes more effective. Specific interventions found successful in enhancing the health seeking and coping of spouses of critically ill family members included an orientation of the spouse to the CCU environment, arranging for one phone call at home to give an update on the patients condition, talking with the spouse for 15 minutes away from the bedside, and identifying one or two nurses per shift who would be the primary caregivers for the patient. It was observed that families with whom the care plan had been used experienced fewer symptoms of crisis (Dracup & Breu 1978). were the health seeking and coping behaviours, nursing goals and strategies and the health goals of the client. 3 An expansion of the nursing perspective on coping resulted in the integration of additional clientorientated components such as perceived compliance, perceived coping effectiveness, and immediate and long-term health outcome. 4 Unlike previous conceptualization of coping and adaptation, the CHSCP is a highly integrative model which proposes continuous and concurrent interaction among many of the concepts. As a nursing-orientated multidimensional framework, the CHSCP will provide a useful framework for nurses interested in altering, enhancing or promoting the health seeking and coping of clients. By providing an intellectual focus for the initial and ongoing assessment of a multitude of variables which influence health seeking and coping, the specification of appropriate strategies can be developed and evaluated.

Health outcome
Research findings demonstrate that perceptual and personal factors such as the fear of precipitating another MI and the presence of emotional disturbance often influence the individuals eventual return to work and social functioning. With demonstrated findings that as many as 46% of post-myocardial infarction patients do not return to work (Wishnie eta]. 1971),an understanding of the influential factors relevant to the individuals immediate and longterm health outcome is significant.

IMPLICATIONS FOR THEORY TESTING A N D A D V A N C E M E N T OF NURSING PRACTICE

While much clinical research data has demonstrated relationships between concepts of this multidimensional framework, continued theory testing is mandatory as the advancement of nursing practice can only be based upon validated knowledge. To test the theory, continued studies need to be conducted to examine the relationships among the major components of the theory, particularly as it relates to health seeking and coping behaviours and health outcome. To accomplish this, the development of empirical referents becomes a necessary first step for nurses. Folkman & Lazarus (1984) contend that studies dealing with the aspect of how individuals cope with stressors are exceedingly difficult, as the question is difficult to pose, and the self-report nature of the findings may be biased. This is particularly the case as stressful situations often affect cognitive functioning and recall of cognitive and behavioural responses. Most importantly, the multiple instruments sought would have to assess the many intervening variables which may influence the health seeking and coping process in a non-redundant fashion. A promising coping assessment instrument has been constructed which assesses many of the influencing variables. While reliability and validity are being established at this time, the initial psychometric analysis of the data is very promising (Nyamathi et al. 1987).

S U M M A R Y OF DERIVED THEORY
The CHSCP represents a newly synthesized framework for nursing, the focus of which is the health seeking and coping of individuals experiencing significant stressors. This framework is theorized to be a function of 12 factors which include: clients situational and personal factors, resources, sociodemographic characteristics, cognitive appraisal, health goals, health seeking and coping behaviours, nursing goals and strategies, clients perceived compliance, clients perceived coping effectiveness, and immediate and long-term health outcome. The Lazarus Schema of Coping and Adaptation and the Schlotfeldt Health Seeking and Coping Paradigm were the parent conceptualizations from which the CHSCP was derived. Modifications of the parent theories consisted of the following: 1 The overriding perspective of coping and adaptation was changed from that of a psychological and behavioural science orientation to a nursing orientation. 2 Nursing-orientated concepts incorporated from the Schlotfeldt Paradigm of Health Seeking Behaviours
288

Health seeking and coping paradigm

The continued development and testing of the CHSCP would enable nurses to design more effective interventions to enhance health seeking and coping behaviours of individuals experiencing a variety of acute and chronic illnesses and other life stresses. As revisions are made and empirical data collected, the findings will contribute to the understanding and exploration of relationships among concepts, so that continued advancement of nursing practice can be actualized. In particular, nurses are in an ideal position to conduct such research, as they are directly involved in assisting individuals to cope with life stresses brought on by illness and other misfortunes (Fagin 1987). Schlotfeldt (1975) contends that much knowledge is needed about mans typical health-seeking and coping behaviours as they are manifested during illness, injury, deprivation and life crises. Empirical studies of mans health-seeking behaviours can reveal how coping efforts are affected b y situational, personality, and perceptual factors and will permit valid generalizations about the healthseeking behaviours of man. A greater understanding of the health seeking and coping processes of individuals will contribute to the base of nursing knowledge and will enable nurses to develop and implement the most effective nursing strategies possible. Fagin C. (1987) Stress: implications for nursing research. Image 19(1),38-41. Folkman S. & Lazarus R. (1980)An analysis of coping in a middleaged community sample. Journal of Health and Behavior 21, 219-239. Friedman M. & Rosenman R. (1974) Type A Behavior and Your Heart. Knoft, New York. Gentry W. & Haney T. (1975) Emotional and behavioural reactions to acute myocardial infarction. Heart t? Lung 4(5), 738-745. Glass D. (1977) Stress, behaviour patterns and coronary disease. American Scientist 65, 177-187. Haeter B. (1985) Nursing responsibilities in changing visiting hour restrictions in the intensive care unit. Heart t? Lung 14, I8 1-1 86. Hansel1 H. (1984) The behavioural effects of noise on man: the patient with intensive care unit psychosis. Heart 0 Lung 13, 59-65. Hrubec Z. & Zurkel W. (1971) Socioeconomic differentials in prognosis following episodes of coronary artery disease. Journal of Chronic Disease 23, 881-889. Kaplan B., Cassel J. & Gore S. (1977) Social support and health. Medical Care 15, 47-58. Kimball C. (1977) Psychological responses to the experience of open-heart surgery. In Coping with Physical Illness (Moos R. ed.), Plenum, New York, pp. 113-134. King K. (1985) Measurement of coping strategies, concerns and emotional responses in patients undergoing coronary artery bypass grafting. Heart 0 Lung 14(6),579-586. King I. & Tarsitano B. (1982) The effect of structured and unstructured pre-operative teaching: a replication. Nursing Research 31,324-329. Lazarus R. (1966) The stress and coping paradigm. In Theoretical Basis for Psychopathology (EisdorferC., Cohen D., Kleinman A. & Maxim P. eds), Spectrum, New York, pp. 177-214. Lazarus R. & Folkman S. (1984) Stress, Appraisal and Coping. Springer, New York, pp. 117-180. Lazarus R., Averill J. & Opton E. (1974) The psychology of coping: issues of research and assessment. In Coping and Adaptation (Coelho C., Hamburg D. & Adams J. eds), Basic Books, New York. McCubbin H. (1979) Integrating coping behavior in family stress theory. Journal of Marriage and the Family 41,237-244. McNett S. (1987) Social support, threat, and coping responses and effectivenessin the functionally disabled. Nursing Research 36(2),98-103. Mechanic D. (1977) Illness behavior, social adaptation and the management of illness. Journal of Nervous and Mental Diseuse 165, 79-87. Menninger K. (1963) The Vital Balance: The Life Process in Mental Health and Illness. Viking, New York, pp. 153-250. Milazzo V. (1980) Study of the differences in health knowledge gained through formal and informal teaching. Heart t? Lung 9, 1079-1082. 289

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A. Nyamathi
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