1. Introduction
Concepts are the building blocks of a theory that clarifies how something is and how it works. Theory employ concepts to draw meanings in knowledge creation and understanding and plays a critical role in their development and intended meaning generation [1] [2]. Concept analysis, according to Rodgers (1989), is an evolutionary approach of concepts that “addresses contemporary concerns valuing dynamism and interrelationships within reality” [3].
Coping has been identified as an adoptive strategy employed by most parents and family care givers when a relation is taken ill. This is often worst when it so happens the ill person is a baby [4]. The period of admission and staying in the NICU comes with uncertainty, fear and interrupted bonding between mother and baby. Without coping, treatment outcomes, especially in critical, chronic and dilapidating conditions, will be detrimental to the well-being of the patient, parents and family care givers alike.
Ramos et al, 2017, defined coping as actions of self-regulation of emotions, cognition, behaviour and motivational orientation under stress [5]. Coping is a process rather than an event usually involving adjusting to negative events while trying to keep positive self-image and emotional equilibrium. Paediatric hospitalization and treatment trajectory usually have a negative psychosocial effect on the mother and this leads mothers developing various coping strategies to survive the period [6]. Hospitalization of a newborn although increases maternal distress and adjustment to life, it is well documented that most mothers adjust well [7].
Poor coping skills have negative effects on maternal health outcomes. Mother can develop post-partum mood disorders such as depression or baby blues which complicates their recovery and ability to care for the sick baby [8]. Feeling of stress and anxiety are associated with lack of information on medical procedures, interrupted bonding, inability to put baby to breast, unfamiliar NICU environment [7]. The extensive body of coping research has been hampered by a lack of consistency in definition and measurement. The use of multiple terms such as adjustment, adaptations, mutuality, defensive mechanism, and cooperation further complicates this issue.
Coping with stress is a recurrent life activity and it’s observed in daily living. Up to 80% of parents can be expected to develop coping skills concerning their child’s hospitalization and throughout the treatment trajectory [7] [9]. Poor coping contributes to increased psychological and mental health risk for the mother. For example, some mothers can develop post-partum depression which may increase medical cost for the family and delayed bonding of mother and baby [10]. Secondly, initiation and maintaining of lactation is also affected by stress levels of mothers. It is documented that there is a negative correlation between maternal stress after delivery and post-traumatic stress which increases the risk factor for delay in lactogenesis [11].
Long-term effects of poor coping can cause poor postnatal mental health; with appropriate assistance and approach, newborn admission period can be less stressful for the mother and family [12]. It is on this bases that this paper explored the concept of coping and enquire how maternal effective or poor coping strategies impacts maternal and newborns outcomes during newborn admission in the neonatal intensive care unit (NICU).
2. Aim of the Analysis
Concept analysis, according to Walker, 2014, is used to clarify concepts of relevance to the nursing profession that may or may not have been appropriately employed and defined. Using the Avant and Walker framework, the study tries to define, refine, and clarify the idea of coping in nursing practice. To define coping, researchers must examine various applications of the concept in other sectors and describe its characteristics in order to help nurses have a better knowledge and understanding of the concept and make it easier to put it into practice.
3. Selection of the Concept
Coping mostly contain elements relating to patients’ adjustment and their ability to be responsibilities towards the self and other dependents, their role in their treatment process and their collaboration with health care providers to ensure quality behavioral outcomes. The first step in concept analysis, according to Walker, 2014, is concept selection. The paper explored maternal coping with newborn admission. Dealing with the stress of newborn’s admission necessitates a multidisciplinary approach as well as parental participation. Hence, good coping of parents in the treatment of the baby cannot be overlooked. Therefore, the selection of this concept “coping” explore and provides more clarification.
4. Definitions of the Concept-Coping
4.1. Dictionaries Definition of Coping
Dictionaries describe a concept in terms of its widely accepted and universal use. Oxford advanced leaners and Cambridge dictionaries, defined cope as “to deal successfully with something difficult”, “to deal with problems or difficulties especially with a degree of success” or “a long loose piece of clothing worn by priest on special occasion” [13] [14].
4.2. Psychology Definition of Coping
Coping is defined as what people do to try to minimize stress which is commonly seen in health psychology. It can be problem focused and directed at reducing the treat and losses of an illness or emotional focus thus directed at reducing negative emotional consequences. From the psychological viewpoint, coping refers to changing one’s behavioural adaptations to overcome unpleasant situation, illness or loss of something vital. Many coping styles have been identified, measured and contrast are made between active and passive coping as well as between behavioural and cognitive coping. Coping strategies exist which demonstrates how people manoeuvre about situations to achieve better outcomes.
The discipline has advance in understanding stress and coping and encourage patients to use self-monitoring coping tools and develop coping strategies. Therapy sections are instituted to help patient rehearse to apply in the real world. This mode of applying coping is very similar to how nurses help patient to deal with stressful situations [15]. While you may have had the option to refuse the request to cope, most people chose to comply. Ones inability to cope with a given situation yields negative outcomes.
4.3. Engineering Definition of Coping
From the engineering viewpoint; coping is the capping or covering of stones, bricks or terracotta placed on exposed top of a wall to prevent seepage of water. It may also be provided on top of compound walls.
4.4. Coping Definition in Architecture
Coping is the capping or covering of a wall. It can be made from varying material of sand or metal.
4.5. Physiology Definition of Coping
From the physiologic viewpoint, coping is the response to stressors. Stressor are events or situations that are in excess the body’s normal adaptation levels. Stress is not a condition experienced during adverse situations but an everyday demand to overcome unpleasant circumstances whether physical or psychological. The body tries to maintain a balance by adopting some changes. These adoptions are referred to as coping. When the body is exposed to stressor either real or imaginary the body responds by alarm, adaptation, exhaustion or recovery. This process is under the influence of hormones like cortisol, adrenaline and nor adrenaline with varying resultant changes in various physical, emotional and behavioral problems. If this persist for long period, leads to serious health condition such as depression or metabolic disorders. Successful recovery is achieved through positive coping mechanisms [16].
4.6. Dentistry Definition of Coping
In dentistry, coping is a metal covering attached to a tooth roof or base which is an accommodation or platform for a crown or bridge placement.
4.7. Definition of Coping in Psychiatry
A constellation of conscious and unconscious response that helps a person adjust to increased external demands without changing the direction or intensity of her goals [17].
4.8. Literature Definitions of Coping in Nursing
Coping is a well-established concept in nursing. It is focused on the thoughts and behaviour mobilised to manage internal or external stressful situations [18]. Coping is the act of dealing with problems in one’s life in order to overcome or work through them, in reaction to stressful stimuli. Horwitz, et al. (2010) describe coping as an active process that involves the use of behavioral or cognitive strategies to handle internal or external sources of psychological stress [19]. Finally, coping is an individual’s changing cognitive and behavioural efforts to manage internal and external demands that are regarded to be overpowering [20].
4.9. Understanding Coping Using the Nursing Diagnosis
Several nursing diagnoses have been created and accepted by the national conference on categorization of nursing disorders. These are linked to individual and family coping with problems of a client’s evolving or changed health status. The NANDA nursing diagnosis Domain 9 details the nursing diagnoses on coping/stress tolerance. Class 2 itemize coping response/diagnoses list as: inefficient coping, defensive coping, compromised family coping, readiness for enhanced coping, ineffective community coping, readiness for enhanced community coping, disabled family coping and readiness for enhanced family coping [21].
Compromised family coping: A situation in which a normally supportive primary family member or close friend provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that the client may need to manage or master adaptive tasks related to his health challenges [22]. Compromised family coping may arise from inadequate or misinformation, inadequate or incorrect understanding by family members or close relatives; temporal or preoccupation by the significant person who is attempting to manage emotional conflict and personal suffering and thus is unable to perceive the clients’ needs or act effectively to meet them. Secondly, prolong disease or progression of the illness or disability that drains the relative’s supportive capacity can result in compromised family coping. Subjective data that could indicate compromised ineffective family coping might include an expression by the relative on a lack of understanding, a description by the significant person of extreme concern with such personal reactions to the clients’ illness or disability as fear, anticipatory grief, guilt, or anxiety [21].
Disables family coping is a nursing diagnosis defined as the behaviour of a family member or other primary caregiver who disables his or her own and the client’s capacities to effectively handle and address tasks that are critical to either person’s adaptation to the health challenge or survival. The family member’s coping response is disabling if it involves short term behaviour that are highly detrimental to the welfare of either the client or the family caregiver. A primary support person’s frequent disabling tendencies include neglectful care of the client in meeting basic human needs and in treatment of illness, extreme denial of the existence of the clients health problem and in the treatment of the illness, intolerance, rejection, abandonment or desertion of the client, taking on the illness signs of the client, decision and action by the family which are detrimental to its economic or social well-being, neglectful relation with other family members and development by the client of helplessness and inactive dependence.
Ineffective individual coping is defined as failure to make a valid assessment of the stressors, insufficient choice of practice responses, and inability to employ available resources. Many pressures in regular life can cause tension and put strain on one’s ability to cope. Situational crises, as well as crises linked with moving through the stages of life, are examples. It includes personal vulnerability, multiple life changes and unhealthy stressful behaviours (which may include inadequate relaxation, failure to take vacations, poor nutrition, lack of exercise, inadequate support system, unmet expectation, work overload, unrealistic perceptions and inadequate method of coping). Ineffective individual coping maybe manifested when a person verbalises an inability to cope or ask for help, is unable to meet basic needs or role expectation, cannot use problem-solving technique, has frequent illness or accidents, exhibits destructive behaviour towards self or others including smoking, excessive eating, drinking of alcohol, high blood pressure, irritable bowel, emotional tension, chronic worry and chronic depression.
Readiness for enhanced family coping is defined as the effective management of adoptive task by family members associated with the client’s health issues, who now demonstrate a desire and readiness for enhanced health in relation to themselves and to the client. The family member is willing and ready to improve his or her self-awareness and relationship with the client to achieve optimal health. Evidence that a family member’s basic human needs are met and his adaptive task is adequately addressed so that goals-related to self-actualization can emerge and shows the possibility of self-growth. An attempt to describe how the client’s health crisis has influenced the family member’s own value, priority, goals, or relationship, evidence that the family member is moving toward a lifestyle that supports and optimizes wellness and expression of interest in contacting another person or group of people who have experienced similar situation are all examples of defining characteristics in readiness for enhanced family coping [23].
4.10. Types of Coping Skills
These coping skills are used to deal with health obstacles based on the approaches used for coping. Problem-focused strategy is used when a person decides to focus on the problem at hand and aim at directly altering the source of discomfort. Some strategies adopted included critically analysing the problem for solutions, working harder, using previous life experiences, talking to experts or people versed in the field where the problem exist [24] [25]. Emotion focused strategy focuses on the emotions evolving from the problem rather than the problem itself. Usually the problem seems to be out of the control of the person or family [24] [25]. Such techniques include ignoring or refuting the existence of the problem, criticizing or not seeking social support, avoidant behaviour, accepting accountability and distancing from the source of the problem.
5. Defining Attributes of Coping
Concepts, according to Walker, 2014, are based on the context in which they are found and have immutable features, which are the characteristics that are most frequently linked with the concept. The ability to adjust to health-related obstacles, flexibility, solutions, control, and enhanced behaviors are the key features of coping. Numerous defining attributes of coping consistently appeared throughout literature. These are modifying, manage, response, problem-focused, emotional-focused, avoidant, cognitive, behavioral, regulate, physiological, and psychological. Therefore, coping can be conceptualized as an adaptive method of dealing with both individual and environmental stressors that involve either a physiological or psychological threat, which may or may not effectively address the problem.
6. Constructing a Model Case
A case method, according to Walker and Avant (1995), helps in the construction of conceptual meaning for distinct situations or phenomenon. Cases are built in the form of scenarios, which help to illustrate the experience and demonstrate what “not the notion” is [1]. To show, the following three examples were created: model case (which exemplifies coping), borderline case (where some of the attributes are present but not enough to make it truly a case of coping) and contrary case (where coping is not present). Each case uses a health care giver/family care giver interaction to explicate the differences among the model, borderline and contrary cases.
6.1. Scenario for Case Analysis
A client, a 27-year old female, Para 2 delivered a male live infant via spontaneous vagina delivery with APGAR 2/10, 3/10. Baby was diagnoses with severe birth asphyxia and admitted to the NICU. Baby condition was critical initially and was undergoing treatment. Mother was identified to have ineffective coping during the second day of her child’s admission. She refused to visit her baby or get involved in his treatment. She was therefore referred to the hospital psychologists. She has been seeing a psychologist for a little over a week and has been learning cognitive behavioral therapy techniques in an effort to manage her fears surrounding the child’s treatment and becoming involved in his care. In addition, she has been seeing the psychiatric nurse practitioner regularly for psychotherapy management.
6.2. Model Case and Analysis
She has progressively improved her behavior towards the baby since beginning therapy. She reports that she has been using problem-focused coping and has modified her ineffective coping patterns and replaced them with physical activity and good communication with her family and the health professionals in the NICU, which is a healthy response for dealing with stress and this appears to be working well. She is able put her baby to breast, take care of his activities of daily leaving and very hopeful that her baby will survive. Based on the patient’s reports and observation, she appears to be psychologically stable at this point and she will now slowly be weaned off the antidepressant and go on a maintenance counseling schedule. Both mother and baby were discharged successfully and returned for review on a scheduled date.
In the model case, the client demonstrated she is coping well with situations surrounding her child’s illness and possible outcome. She is more involved in caring for her baby and activities at promoting his healing. She also has good interactions with her family and professional healthcare workers who were involved in the care of her baby. She has developed good coping skills and strategies to surmount her current situation.
6.3. Borderline Case and Analysis
She has somewhat improved her behavior towards the baby since beginning therapy. She provides the needed items to care for the baby but is unwilling to do it herself. In addition, she has not been compliant to her treatment. She mostly seems unconcerned about what goes on in the care of her baby.
In the borderline case, not all of the defining attributes are present. She demonstrated a willingness to follow a prescribed therapy for herself and her baby but also refuse self-management behaviors. She negotiates a plan to modify and adjust to the situation by relying severely on family members and health professionals with her little involvement. Though shemodified some aspects of her physiological and psychological behaviour to manage and response to her challenges, she developed avoidant behaviour to adjust.
6.4. Contrary Case and Analysis
Client has abandoned the baby and denied his existence.
In contrary case, none of the defining attributes of coping is demonstrated by the client. This is seen often when patients coping is ineffective and sees it repercussions from her own view which is not ideal. According to (Walker & Avant, 2005a), a contrary case lacks the defining attributes of the concept under study. From the example above, the patient did not comply with any of the treatment and therapy to aid her cope. Though physiologically and physically fit, she is unwilling to comply with her therapist and recommendations from health workers and family.
7. Identification of Antecedents and Consequences
Antecedents as defined by Walker, 2014 are events that occurred prior to the initiation of the concept (coping), and they can include any internal or external stressor that requires an emotional, cognitive, physiological, or behavioral reaction. For ineffective coping to occur there must be a stressful life event that has hampered the individual’s ability to adjust to a situation. The decision to cope effectively with a situation is innate and with good social support and treatment one is able to cover the trails of the time.
Coping also requires a change to be made physically, psychologically and socially. Physiologic coping maintains hemodynamic stability. The extent to which an individual chooses behaviors that coincide with appropriate coping depend on empowerment from professional health workers and clients family [8].
Ramalisa, et al., 2018 described coping as a supportive nurse-patient relationship. The nurse’s role is to assist patients with coping and in turn patients and their family members are expected to participate in the process and demonstrate adequate adjustment [26]. They also emphasized the shared responsibility between patients and health care personnel for health outcomes should be a cooperative relationship that requires communication, care, support, mutual respect and commitment by all parties.
Finally, Ramalisa, et al., 2018 are of the view that for coping to be a positive behavior, patients must be ready for enhanced coping. The nurse thus exploits on the readiness to assist the patient and the family to adjust and exhibit moving toward mutually defined therapeutic goals [26]. Mutuality is a connection with or understanding of another that facilitates a dynamic process of shared exchange between people with common interest. The process of being mutual is characterized by a sense of ownership rather than a commander-subordinate relationship, depicting actions that are shared in common, a sense of moving toward a common goal, and a sense of satisfaction for all involved [27].
8. Consequences
Consequences are the events that occur as a result of coping reactions. They can be good if coping was successful, such as regaining mental balance and equilibrium, or negative if it was unsuccessful, such as depression, self-neglect, or self-mutilating behaviors [2]. If coping has occurred, the following can be expected: happy mood or cheerfulness, confidence in performing duties or empowerment, increased involvement in activities. A sense of self -worth is also integral in each of these events making the client gain control over her life. Lack of ability to cope with adverse events results in lack of control or powerlessness, self-pity, and depression.
The resultant empowerment is a key issue relevant to nursing in health care today for postnatal mothers. Often empowerment is identified as the key to patient involvement, satisfaction and improved quality of life. Powerlessness, on the other hand, implies that one’s lack of willpower to exhibit the desired outcome expected [7]. Also the inability to gain confidence and hope results in helplessness and hopelessness. Therefore, a coping mother, as this analysis implies, is one who has gain his or her ability to do or act. Finally, increased self-worth is expected to occur as a result of effective coping. Self-worth results in demonstration of behaviour that client is confidence and fells useful to herself and her family. In other words, with self-worth enhances client ability to cope.
9. Defining Empirical Referents
According to Walker, 2014, defining empirical referent which is the last stage of concept analysis framework which seeks to either measure the concept under analysis or determine its existence in the real world. “Empirical referents are classes or categories of phenomena that by their existence or presence demonstrates the occurrence of the concept itself” [1]. As a behavioral concept, coping involves complex actions, intentions, emotions and phenomena that may not be directly observable. The concept from this analysis empirically measure empowerment, self-worth, appropriate mood and self-efficacy from the patients’ perspective and the researcher’s observation.
Majority of measures on the studies on coping are from the positivist perspective and may not be sufficiently reliable and valid to holistically understand the concept. Measurement errors generally are biased toward an overestimation of coping. However, the selection of an appropriate measure of coping is complicated by several considerations. Firstly, acute conditions for example, arising from the hypoxic state caused by asphyxia will require different measures from chronic illnesses. Coping may involve multiple behavioral approaches to support the various categories.
Secondly, coping has diverse variants that are interdependent and interconnected with each other. One element of the management plan may not suffice if its success depends on coping with other elements. Thus, a holistic assessment strategy is needed. Coping is an abstract, subjective and complex concept. It can be defined by using other concepts which can be operationalized and measured. The quality of life model and the coping circumplex model are common empirical models that have indicated the empirical structure of the concept of coping for measurement and data generation.
10. Conclusion
Maternal coping analysis will enhance nurses’ skills to integrate coping into practice to achieve better health outcomes for mother, their family and the ill newborn as well as develop outcomes that promote a good image of the nursing profession. Coping requires multidisciplinary approach. Nurses who work neonatal in intensive care units must understand the cognitive changes and stressors that occur during the period of hospitalization for both mother and baby, and how this affects the family’s ability to cope. Nurses must also have the ability to identify and treat individuals who demonstrate maladaptive coping patterns. This concept analysis provides meaning for the word coping and enriches nurses’ understanding of their expected roles associated with the concept to deliver optimum patient care.