Ineffective Coping

Ann Keeley
NANDA
Definition

Inability to form a valid appraisal of internal or external stressors, inadequate choices of

practiced responses, and/or inability to access or use available resources

Defining Characteristics

EditLack of goal-directed behavior or resolution of problem, including inability to attend,

difficulty with organized information, sleep disturbance, abuse of chemical agents, decreased use
of social support, use of forms of coping that impede adaptive behavior, poor concentration,
fatigue, inadequate problem solving, verbalized inability to cope or ask for help, inability to meet
basic needs, destructive behavior toward self or others, inability to meet role expectations, high
illness rate, change in usual communication patterns, risk taking

Related Factors (r/t)

EditGender differences in coping strategies, inadequate level of confidence in ability to cope,

uncertainty, inadequate social support created by characteristics of relationships, inadequate level
of perception of control, inadequate resource availability, high degree of threat, situational crises,
maturational crises, disturbance in pattern of tension release, inadequate opportunity to prepare
for stressor, inability to conserve adaptive energies, disturbance in pattern of appraisal of threat

NOC
Outcomes (Nursing Outcomes Classification)
Suggested NOC Outcomes

EditCoping
EditDecision Making

EditImpulse Self-Control

EditInformation Processing

1
Add entries

Example NOC Outcome with Indicators

Coping as evidenced by the following indicator: Identifies effective and ineffective coping
patterns; modifies lifestyle as needed (Rate the indicator of Coping: 1 = never demonstrated, 2 =
rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently
demonstrated [see Section I].)

Client Outcomes

Client Will (Specify Time Frame):

EditVerbalize ability to cope and ask for help when needed

EditDemonstrate ability to solve problems related to current needs

EditRemain free of destructive behavior toward self or others

EditCommunicate needs and negotiate with others to meet needs

EditDiscuss how recent or ongoing life stressors have overwhelmed normal coping
strategies

EditDemonstrate new effective coping strategies

EditHave illness and accident rates not excessive for age and developmental level

1
Add entries

NIC
Interventions (Nursing Interventions Classification)
Suggested NIC Interventions

EditCoping Enhancement
EditDecision-Making Support

1
Add entries

Example NIC ActivitiesCoping Enhancement

Assist the client in developing an objective appraisal of the event; explore with the client
previous methods of dealing with problems

Nursing Interventions and Rationales

 EditObserve for causes of ineffective coping such as poor self-concept, grief, lack of
problem-solving skills, lack of support, or recent change in life situation. EBN:
Psychological manifestations of ineffective coping can be understood only after a
thorough inquiry into the client's framework for appraisal (Dudley-Brown, 2002).
EditObserve for strengths such as the ability to relate the facts and to recognize the
source of stressors. EBN: Successful adaptation requires a coordination of efforts to fit
the nursing interventions to the client's perception of the threat, personal values and
beliefs, and recognition of personal strengths (Norris & Spelic, 2002).

EditAssess the risk of the client's harming self or others and intervene appropriately.
See the care plan for Risk for Suicide. EBN: The value an individual attaches to a
stressor will affect the level and type of emotional reaction (Norris & Spelic, 2002).
Hopelessness associated with depression is an indicator of a higher risk of suicidal
behavior (Szanto, 2003).

EditHelp the client set realistic goals and identify personal skills and knowledge. EB:
Providing validation of actual stressors and available coping resources and/or strategies
aids in a positive adaptation to stress (Pakenham, 2001). EBN: Efforts to educate
regarding possible and/or potential effects of a specific diagnosis and the resources
available to assist with coping are a positive factor in successful adaptation (Wassem,
Beckham, & Dudley, 2001).

EditUse empathetic communication and encourage the client and family to verbalize
fears, express emotions, and set goals. EBN: A nurse's holistic presence with clients is
considered to be vital (Cote & Pepler, 2002). "The interview process itself can be
therapeutic (Overcash, 2004). "Health professionals could alleviate some psychological
distress by spending time listening to patients and channeling their fears and worries into
meaningful discussions about fatigue (Potter, 2004). Connectedness to others helps with
coping (Lin & Bauer, 2003).

EditEncourage the client to make choices and participate in the planning of care and
scheduled activities. EB: Active involvement in coping plans increases the possibility of a
positive adjustment (Pakenham, 2001). Involving young males in the planning of a clinic
increased its likelihood of success (Raine et al, 2003). EBN: The inclusion of consumer
consultants in preparing discharge planning programs would increase client satisfaction
(Cleary, Horsfall, & Hunt, 2003). Collaborative 'triadic decision-making processes
result in greater effectiveness of care (Dalton, 2003).

EditProvide mental and physical activities within the client's ability (e.g., reading,
television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports,
games). EBN: Activities that decrease stress and/or increase self-efficacy provide a
positive approach to perceived stressors (Fisher & Laschinger, 2001). Nurses working
with individuals with nonhealing ulcers helped them find ways to normalized their
experience and positively impacted the individuals' adjustment (Hopkins, 2004).
 EditIf the client is physically able, encourage moderate aerobic exercise. EBN:
Exercise is effective in alleviating anxiety (Blanchard, Courneya, & Laing, 2001). EB:
Exercise was found to improve quality of life in female cardiac patients (Tyni-Lenn et al,
2002).

EditProvide information regarding care before care is given. When providing

information take into account the client's individual coping style (Nikoletti et al, 2003).
Before psychiatric clients can make decisions regarding treatment, they must have
appropriate information (Linhorst et al, 2002). EBN: In women with postbreast cancer
lymphedema information is necessary for informed choice with highest potential for a
good outcome (Radina, 2004).

EditDiscuss changes with the client before making them. EBN: Nurses are pivotal in
communicating to clients the information needed to ensure the best outcome. They are
identified by clients as necessary in coordinating all aspects of their care (Hodgkinson &
Lester, 2002). EBN: The nurse's ongoing interaction with individuals with non-healing
ulcers involved honest assessment and communication (Hopkins, 2004).

EditDiscuss the client's and family's power to change a situation or the need to accept
a situation. EBN: An honest assessment of a particular situation as shared by the nurse is
important to the family's sense of what is expected of them in adapting to a health care
change (Weiss & Chen, 2002).

EditUse active listening and acceptance to help the client express emotions such as
sadness, guilt, and anger (within appropriate limits). EBN: Nurses need to provide an
opportunity for clients to address all aspects of the impact of a health status change on
their lives (Richer & Ezer, 2002). "The interview process itself can be therapeutic
(Overcash, 2004). "Health professionals could alleviate some psychological distress by
spending time listening to patients and channeling their fears and worries into
meaningful discussions about fatigue (Potter, 2004). Connectedness to others helps with
coping (Lin & Bauer, 2003).

EditEncourage the client to describe previous stressors and the coping mechanisms
used. EBN: Recounting previous experiences that were perceived by the client as having
been dealt with successfully strengthens effective coping and helps eliminate ineffective
coping mechanisms (Northouse et al, 2002). EBN: Evaluation of pessimism and
optimism in family members of Parkinson's patients can help identify those who are at
greater risk for negative health consequences (Lyons, 2004).

EditBe supportive of coping behaviors; allow the client time to relax. EBN: Sharing
of innermost cares and concerns requires that nurses provide opportunities for clients to
feel safe enough to share (Richer & Ezer, 2002). EBN: The relationship the nurse has
with her patient as a positive effect on the coping of individuals with nonhealing ulcers
(Hopkins, 2004).
 EditHelp the client to define what meaning his or her symptoms might have for the
client. EBN: Exploring the meaning of health status change and the adjustments required
for a successful adaptation within the client's life experience fosters positive growth
(Norris & Spelic, 2002; Richer & Ezer, 2002). "The most positive strategies used by the
participants involved having opportunities to talk about their experience and receiving
explanations about what was happening to them (Potter, 2004).

EditEncourage the use of cognitive behavioral relaxation (e.g., music therapy, guided
imagery). EBN: Relaxation training has been demonstrated to improve overall coping
ability (Tyni-Lenne et al, 2002).

EditUse distraction techniques during procedures that cause the client to be fearful.
Distraction has been demonstrated to be effective in coping with pain of older people
(Blomquist & Edberg, 2002). "Virtual reality, as an emotion-focused distraction
intervention, decreases the symptom distress associated with chemotherapy treatments
(Schneider et al, 2004).

EditRefer for counseling as needed. EBN: Nurses are perceived as the bridge
between the client and all other resources needed to manage an adaptive response to a
health care change (Hodgkinson & Lester, 2002).

1
Add entries

Geriatric

EditEngage the client in reminiscence. Reminiscence activates positive memories and

evokes well-being (Puentes, 2002). EBN: Life review as an intervention had a significant
effect of lowering depression in individuals with cerebral vascular accident (Davis,
2004).
EditAssess and report possible physiological alterations (e.g., sepsis, hypoglycemia,
hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and use
of medications with known cognitive and psychotropic side effects).

EditDetermine if the individual is displaying a change in personality as a

manifestation of difficulty with coping. An older individual's responses to age-related
stress will depend on the balance of personality strengths and weaknesses. EBN:
Negative life events will vary in the degree to which they affect the symptoms observed in
the elderly (Kraaij, 2001).

EditIncrease and mobilize the support available to the elderly client. Encourage
interaction with family and friends. EBN: Relationships are pivotal in supporting coping
in older adults (Cutcliffe & Grant, 2001).
 EditActively listen to complaints and concerns. EBN: The quality of care provided to
elderly chronic pain patients living at home could be improved by active listening
(Blonquist, 2002).

1
Add entries

Multicultural

EditAssess for the influence of cultural beliefs, norms, and values on the client's
perceptions of effective coping. "Healthcare providers must recognize, respect, and
integrate clients' cultural beliefs and practices into health prescriptions (Purnell, 2005).
EBN: The client's coping behavior may be based on cultural perceptions of normal and
abnormal coping behavior (Sterling & Peterson, 2003; Leininger & McFarland, 2002;
D'Avanzo et al, 2001; Doswell & Erlen, 1998). Culture influences perceptions of
stressors and perceptions of potential coping behaviors as well as resources (Cuellar,
2002). EBN: Chinese women may be less likely to seek mental health services for
postnatal depression (Chan, 2002). Gender and age mediate a woman's response to signs
and symptoms of cardiac disease (Lefler, 2004). For Mexican-American adolescents,
positive reinterpretation, focusing and venting emotions, instrumental social support,
active coping, religious, restraint, emotional support, acceptance and planning were all
forms of coping were all associated with positive psychological and physical health
(Vaughn & Roesch, 2003).
EditAssess the influence of fatalism on the client's coping behavior. EBN: Fatalistic
perspectives, which involve the belief that one cannot control one's own fate, may
influence health behaviors in some Asian-American, African-American, and Latino
populations (Chen, 2001). EBN: A study of patients with nonsmall cell lung cancer in
Taiwan yielded that one response was to accept the outcome as fate (Kuo, 2002).

EditAssess the influence of cultural conflicts that may affect coping abilities. EBN:
It may be necessary to help the client to identify and find coping strategies that do not
conflict with cultural expectations (Shibusawa & Mui, 2001).

EditAssess for intergenerational family problems that can overwhelm coping

abilities. EBN: Family assessment is integral to nursing care of clients (Northouse et al,
2002).

EditEncourage spirituality as a source of support for coping. EBN: Many African

Americans and Latinos identify spirituality, religiousness, prayer, and church-based
approaches as coping resources (Abrums, 2004; Coon et al, 2004; Weaver & Flannelly,
2004; Samuel-Hodge et al, 2000). A sense of faith is an important component of
psychosocial well-being in individuals with advanced cancer (Lin, 2003). Spirituality has
a positive effect on coping (Kelly, 2004).
 EditNegotiate with the client with regard to the aspects of coping behavior that will
need to be modified. EBN: As a part of the assessment of coping behaviors, alternate
methods may be introduced and offered to the client as a possible choice in new coping
strategies (Wassem, Beckham, & Dudley, 2001).

EditIdentify which family members the client can count on for support. EBN: In a
variety of different cultures family members are relied on to cope with stress (Aziz &
Rowland, 2002; Donnelly, 2002; Gleeson-Kreig, Bernal, & Woolley, 2002; White et al,
2002).

EditSupport the inner resources that clients use for coping. EBN: African-American
women in one study used inner resources to develop self-help strategies to cope with
reactions following involuntary pregnancy loss (Van & Meleis, 2003).

EditUse an empowerment framework to redefine coping strategies. EBN: Use of an

empowerment framework will allow individuals to redefine behaviors as coping
strategies to confront their environment and connect to natural supports in the
community (Dancy et al, 2001). EB: Empowerment strategies are important for people
with sever mental illness (Linhort, 2002).

1
Add entries

Home Care

EditThe interventions described previously may be adapted for home care use.
EditObserve the family for coping behavior patterns. Obtain family and client history
as possible. EBN: Family assessment is necessary to guide interventions (Weiss & Chen,
2002; Northouse et al, 2002). EBN: The assessment of caregivers coping and
information styles is an important part of nursing care of women with advanced cancer
(Nikiletti, 2003).

EditAssess for suicidal tendencies. Refer for mental health care immediately if
indicated.

EditIdentify an emergency plan should the client become suicidal. Ineffective coping
can occur in a crisis situation and can lead to suicidal ideation if the client sees no hope
for a solution. A suicidal client is not safe in the home environment unless supported by
professional help. Refer to the care plan for Risk for Suicide.

EditAssess for affective symptoms after CVA in the elderly, particularly emotional
lability and depression. Refer for evaluation and treatment as indicated. EB: In a study of
elderly with first ever stroke, in the immediate postacute phase, 48.5% of clients showed
evidence of emotional lability, 57.6% showed evidence of depression, while showing
 normal global cognitive level. Prevalence of emotional lability was shown in previous
studies to decrease over the first 6 months post-stroke. Apathy (15.2%) and anhedonia
(6.1%) were significantly and negatively associated with the Barthel Index measure of
functional ability (Piamarta, Iurlaro, Isella, et al, 2004).

EditEncourage the client to use self-care management to increase the experience of

personal control. Identify with the client all available supports and sense of attachment to
others. Refer to the care plan for Powerlessness. EBN: In a study of heart
transplantation clients, personal control was positively associated with optimism, well-
being, and satisfaction with life, and was negatively associated with anger and
depression. Perceived social support helpfulness and attachment were positively
associated with better psychological and functional outcomes (Bohachick et al, 2002).
EBN: Patients experiencing cancer related fatigue report feeling loss of control which
can lead to helplessness (Potter, 2004).

EditRefer to medical social services for evaluation and counseling, which will
promote adequate coping as part of the medical plan of care. If no primary medical
diagnosis has been made, request medical social services to assist with community
support contacts. If the client is involved with the mental health system, actively
participate in mental health team planning. Based on knowledge of the home and family,
home care nurses can often advocate for clients. These nurses are frequently requested to
monitor medication use and therefore need to know the plan of care.

EditRefer the client and family to support groups. EBN: Support groups provide an
essential resource to clients and their families when adapting to health status change
(Fung & Chien, 2002). Support groups have appositive effect on individuals receiving
chemotherapy (Ekman, 2004). EBN: An HIV self-care symptom management program
implemented with African-American mothers produced positive outcomes in mental and
physical health measures (Miles, 2003).

EditIf monitoring medication use, contract with the client or solicit assistance from a
responsible caregiver. Prepouring of medications may be helpful with some clients.
Caregivers in the home benefit from interventions that promote self-efficacy and provide
a nurse for support (Dibartolo, 2002).

EditInstitute case management for frail elderly clients to support continued

independent living. Difficulties in coping with changes in health care needs can lead to
increasing needs for assistance in using the health care system effectively. Case
management combines the nursing activities of client and family assessment, planning
and coordination of care among all health care providers, delivery of direct nursing care,
and monitoring of care and outcomes.

EditThese activities are able to address continuity of care, mutual goal setting,
behavior management, and prevention of worsening health problems (Guttman, 1999).
 EditIf the client is homebound, refer for psychiatric home health care services for
client reassurance and implementation of a therapeutic regimen. EBN: Psychiatric home
care nurses can address issues relating to the client's ability to adjust to changes in
health status. Behavioral interventions in the home can help the client to participate
more effectively in the treatment plan (Patusky, Rodning, & Martinez-Kratz, 1996). EB:
Elderly stroke patients receiving home care were shown to have lower depression scores,
and lower rates of admission to nursing homes (Ricauda et al, 2004).

1
Add entries

Note: All of the previously mentioned interventions may be applied in the home setting. Home
care may offer psychiatric nursing or the services of a licensed clinical social worker under
special programs. Traditionally, insurance does not reimburse for counseling that is not related to
a medical plan of care unless it falls under one of the programs just described. Public health
agencies generally do not have the clinical support needed to offer psychiatric nursing services to
clients. Clients are usually treated in the ambulatory mental health system.

Client/Family Teaching

EditTeach the client to problem solve. Have the client define the problem and cause,
and list the advantages and disadvantages of the options. EBN: Interventions that support
hardiness and self-efficacy facilitate positive adaptation to stressors (Dibartolo, 2002;
Wassem, Beckham, & Dudley, 2001; Fisher and Laschinger, 2001). Cognitive behavioral
therapy is a useful intervention when working on issues of hope (Collins, 2003).
EditProvide the seriously ill client and his or her family with needed information
regarding the condition and treatment. EB: Clients and families benefit from a sense of
trust in health care providers that is based on honest communication regarding their
condition and options (Fallowfield, Jenkins, & Beveridge, 2002).

EditTeach relaxation techniques. EBN: Relaxation training has been demonstrated

to improve self-efficacy in family caregivers of clients with Alzheimer's disease (Fisher &
Laschinger, 2001). EB: Quality of life is enhanced in women with coronary syndrome X
when they incorporated exercise and relaxation therapy into their coping behaviors
(Tyni-Lenne, 2002).

EditWork closely with the client to develop appropriate educational tools that address
individualized needs. EBN: Educational level may affect the client's level of concern and
ability to process information (Miles et al, 2002). Caregiver and patient coping patterns
may vary (Kershaw, et al 2004).

EditTeach the client about available community resources (e.g., therapists, ministers,
counselors, self-help groups). EBN: Families need assistance in coping with health
changes. The nurse is often perceived as the individual who can help them obtain
necessary social support (Northouse et al, 2002; Tak & McCubbin, 2002). The degree of
 economic impact of the illness on a family will affect their ability to seek out and accept
help from community resources (Mantagnino & Mauricio, 2004).

1
Add entries

References

1. Abrums M: Faith and feminism: how African American women from a storefront church
resist oppression in healthcare, ANS Adv Nurs Sci 27(3):187-201, 2004.
2. Antoni MH: Stress management effects on psychological, endocrinological, and immune
functioning in men with HIV infection: empirical support for a
psychoneuroimmunoligical model, Stress 6(3):173-188, 2003.
3. Aziz N, Rowland JH: Cancer survivorship research among ethnic minority and medically
underserved groups, Oncol Nurs Forum 29(5):789-801, 2002.
4. Blanchard CM, Courneya KS, Laing D: Effects of acute exercise on state anxiety in
breast cancer survivors, Oncol Nurs Forum 28(10):1617-1621, 2001.
5. Blomquist, K, Edberg AK: Living with persistent pain: experiences of older people
receiving home care, J Adv Nurs 40(3):297-306, 2002.
6. Bohachick P, Taylor MV, Sereika S et al: Social support, personal control, and
psychological recovery following heart transplant, Clin Nurs Res 11:34-51, 2002.
7. Chan SW, Levy V, Chung TK et al: A qualitative study of a group of Hong Kong Chinese
women diagnosed with postnatal depression, J Adv Nurs 39(6):571-579, 2002.
8. Chen YC: Chinese values, health and nursing, J Adv Nurs 36(2):270-273, 2001.
9. Cleary M, Horsfall J, Hunt GE: Consumer feedback on nursing care and discharge
planning, J Adv Nurs 42(3):269-277, 2003.
10. Coon DW, Rubert M, Solano N et al: Well-being, appraisal, and coping in Latina and
Caucasian female dementia caregivers: findings from the REACH study, Aging Ment
Health 8(4):330-345, 2004.
11. Cote JK, Pepler C: A randomized trial of a cognitive coping intervention for acutely ill
HIV-positive men, Nurs Res 51(4):237-244, 2002.
12. Cuellar NG: A comparison of African American and Caucasian American female
caregivers of rural, post-stroke, bedbound older adults, J Gerontol Nurs 28(1):36-45,
2002.
13. Cutcliffe JR, Grant G: What are the principles and processes of inspiring hope in
cognitively impaired older adults within a continuing care environment? J Psychiatr
Ment Health Nurs 8(5):427-46, 2001.
14. Dancy BL, McCreary L, Daye M et al: Empowerment: a view of two African American
communities, J Natl Black Nurses Assoc 12(2):49-52, 2001.
15. Davis MC: Life review therapy as an intervention to manage depression and enhance life
satisfaction in individuals with right hemisphere cerebral vascular accidents, Issues Ment
Health Nurs 25(5):503-515, 2004.
16. D'Avanzo CE et al: Developing culturally informed strategies for substance-related
interventions. In Naegle MA, D'Avanzo CE, editors: Addictions and substance abuse:
strategies for advanced practice nursing, St Louis, 2001, Mosby.
17. Dalton JM: Development and testing of the theory of collaborative decision-making in
nursing practice for triads, J Adv Nurs 41(1):22-33, 2003.
18. Dibartolo M: Exploring self-efficacy and hardiness in spousal caregivers of individuals
with dementia, J Gerontol Nurs 28(4):24-33, 2002.
19. Dombeck MT: Chaos and self-organization as a consequence of spiritual disequilibrium.
1996, Clin Nurse Spec 16(1):42-47, 2002.
20. Donnelly TT: Contextual analysis of coping: implications for immigrants' mental health
care, Issues Ment Health Nurs 23:715-732, 2002.
21. Doswell W, Erlen J: Multicultural issues and ethical concerns in the delivery of nursing
care interventions, Nurs Clin North Am 33(2):353-361, 1998.
22. Dudley-Brown S: Prevention of psychological distress in persons with inflammatory
bowel disease, Issues Ment Health Nurs 23:403-422, 2002.
23. Ekman I, Bergbom I, Ekman T et al: Maintaining normality and support are central issues
when receiving chemotherapy for ovarian cancer, Cancer Nurs 27(3):177-182, 2004.
24. Fallowfield LJ, Jenkins VA, Beveridge HA: Truth may hurt but deceit hurts more:
communication in palliative care, Palliat Med 16(4):297-303, 2002.
25. Fisher PA, Laschinger HS: A relaxation training program to increase self-efficacy for
anxiety control in Alzheimer family caregivers, Holist Nurs Pract 15(2):47-58, 2001.
26. Fung WY, Chien WT: The effectiveness of a mutual support group for family caregivers
of a relative with dementia, Arch Psychiatr Nurs 26(3):134-144, 2002.
27. Gleeson-Kreig J, Bernal H, Woolley S: The role of social support in the self-management
of diabetes mellitus among a Hispanic population, Public Health Nurs 19(3):215-222,
2002.
28. Hodgkinson R, Lester H: Stresses and coping strategies of mothers living with a child
with cystic fibrosis: implications for nursing professionals, J Adv Nurs 39(4):377-383,
2002.
29. Howell D, Fitch MI, Deane KA: Women's experiences with recurrent ovarian cancer,
Cancer Nurs 26:10-17, 2003.
30. Kershaw T, Northouse L, Kritpracha C: Coping strategies and quality of life in women
with advanced breast cancer and their family caregivers, Psychol Health 19(2):139-155,
2004.
31. Kraaij V, de Wilde EJ: Negative life events and depressive symptoms in the elderly: a life
span perspective, Aging Ment Health 5(1):84-91, 2001.
32. Kelly J: Spirituality as a coping mechanism, Dimen Crit Care Nurs 23(4):162-168, 2004.
33. Kuo TT, Ma FC: Symptoms distresses and coping strategies in patients with non-small
cell lung cancer, Cancer Nurs 25(4):309-317, 2002.
34. Lefler L, Bondy KN: Women's delay in seeking treatment with myocardial infarction: a
meta-synthesis, J Cardiovasc Nurs 19(4):251-268, 2004.
35. Leininger MM, McFarland MR: Transcultural nursing: concepts, theories, research and
practices, ed 3, New York, 2002, McGraw-Hill.
36. Linhorst DM, Hamilton G, Young E et al: Opportunities and barriers to empowering
people with severe mental illness through participation in treatment planning, Soc Work
47(4):425-434, 2002.
37. Lyons KS, Stewart BJ, Archbold PG et al: Pessimism and optimism as early warning
signs for compromised health for caregivers of patients with Parkinson's disease, Nurs
Res 53(6):354-362, 2004.
38. Miles MS, Burchinal P, Holditch-Davis D et al: Perceptions of stress, worry, and support
in black and white mothers of hospitalized, medically fragile infants, J Pediatr Nurs
17(2):82-88, 2002.
39. Miles MS, Holditch-Davis D, Eron A et al: An HIV self-care symptom management
intervention for African American mothers, Nurs Res 52(6):350-360, 2003.
40. Montagnino BA, Mauricio RV: The child with a tracheostomy and gastrostomy: parental
stress and coping in the homea pilot study, Pediatr Nurs 30(5):373-401, 2004.
41. Nikoletti S, Kristjanson LJ, Tataryn D et al: Information needs and coping styles of
primary family caregivers of women following breast cancer surgery, Oncol Nurs Forum
30(6):987-996, 2003.
42. Norris J, Spelic SS: Supporting adaptation to body image disruption, Rehabil Nurs
27(1):8-12, 38, 2002.
43. Northouse L, Walker J, Schafenacker A et al: A family-based program of care for women
with recurrent breast cancer and their family members, Oncol Nurs Forum 29(10):1411-
1419, 2002.
44. Overcash JA: Using narrative research to understand the quality of life of older women
with breast cancer, Oncol Nurs Forum 31(6):1153-1159, 2004.
45. Pakenham KI: Application of a stress and coping model to caregiving in multiple
sclerosis, Psychol Health Med 6(1):13-27, 2001.
46. Patusky KL, Rodning C, Martinez-Kratz M: Clinical lessons in psychiatric home care: a
case study approach, J Home Health Case Manag 9:18, 1996.
47. Piamarta F, Iurlaro S, Isella V et al: Unconventional affective symptoms and executive
functions after stroke in the elderly, Arch Gerontol Geriatr Suppl(9):315-323, 2004.
48. Puentes WJ: Simple reminiscence: a stress-adaptation model of the phenomenon, Issues
Ment Health Nurs 23(5):497-511, 2002.
49. Purnell LD, Paulanka BJ: Guide to culturally competent health care, Philadelphia, 2005,
FA Davis Company.
50. Radina ME, Armer JM, Culbertson SC et al: Post-breast cancer lymphedema:
understanding women's knowledge of their condition, Oncol Nurs Forum 31(1):97-104,
2004.
51. Raine T, Marcell AV, Rocca CH et al: The other half of the equation: serving young men
in a young women's reproductive health clinic, Perspect Sex Reprod Health 35(5):208-
214, 2003.
52. Ricauda NA, Bo M, Molaschi M et al: Home hospitalization service for acute
uncomplicated first ischemic stroke in elderly patients: a randomized trial: J Am Geriatr
Soc 52:278-283, 2004.
53. Richer MC, Ezer H: Living in it, living with it, and moving on: dimensions of meaning
during chemotherapy, Oncol Nurs Forum 29(1):113-119, 2002.
54. Samuel-Hodge CD: Influences on day-to-day self-management of type 2 diabetes among
African-American women: spirituality, the multi-caregiver role, and other social context
factors, Diabetes Care 23(7),928-33, 2000.
55. Schneider SM, Prince-Paul M, Allen JJ et al: Virtual reality as a distraction intervention
for women receiving chemotherapy, Oncol Nurs Forum 31(1):81-88, 2004.
56. Shibusawa T, Mui AC: Stress, coping and depression among Japanese American elders, J
Gerontol Soc Work 36(1/2):63, 2001.
57. Sterling YM, Peterson JW: Characteristics of African American women caregivers of
children with asthma, MCN Am J Matern Child Nurs 28(1):32-38, 2003.
58. Tak YR, McCubbin M: Family stress, perceived social support and coping following the
diagnosis of a child's congenital heart disease, J Adv Nurs 39(2):190-198, 2002.
59. Tyni-Lenne R, Stryjan S, Eriksson B et al: Beneficial therapeutic effects of physical
training and relaxation therapy in women with coronary syndrome X, Physiother Res Int
7(1):35-43, 2002.
60. Van P, Meleis AI: Coping with grief after involuntary pregnancy loss: perspectives of
African American women, J Obstet Gynecol Neonatal Nurs 32(1):28-39, 2003.
61. Vaughn AA, Roesch SC: Psychological and physical health correlates of coping in
minority adolescents, J Health Psychol 8(6):671-683, 2003.
62. Wassem R, Beckham N, Dudley W: Test of a nursing intervention to promote adjustment
to fibromyalgia, Orthop Nurs 20(3):33-45, 2001.
63. Weaver AJ, Flannelly KJ: The role of religion/spirituality for cancer patients and their
caregivers, South Med J 97(12):1210-1214, 2004.
64. Weiss SJ, Chen JL: Factors influencing maternal mental health and family functioning
during the low birth-weight infant's first year of life, J Pediatr Nurs 17(2):114-125, 2002.
65. Wengstrom Y, Haggmark C, Forsberg C: Coping with radiation therapy: effects of a
nursing intervention on coping ability for women with breast cancer, Int J Nurs Pract
7(1):8-15, 2001.
66. White N, Bichter J, Koeckeritz J et al: A cross-cultural comparison of family resiliency in
hemodialysis clients, J Transcult Nurs 13(3):218-217, 2002