THE INFLUENCE OF HEALTH STATUS, GENDER, AND ANXIETYON THE STRESS AND COPING PROCESSES OF

HOSPITALIZED SCHOOL-AGE CHILDREN

by

Elizabeth Anne Bossert

DISSERTATION

Submitted in partial satisfaction of the requirements for the degree of

DOCTOR OF NURSING SCIENCE

in the

GRADUATE DIVISION

of the

UNIVERSITY OF CALIFORNIA

San Francisco

~ C■ gº klº- - - -

■ º. 4 -º-

Committee in Charge

Deposited in the Library, University of California, San Francisco

Date

Degree Conferred: . ///?o.- - -

University Librarian

The Influence of Health Status, Gender, and Anxiety

on the Stress and Coping Processes of

Hospitalized School-Age Children

Elizabeth Anne Bossert

University of California, San Francisco

School of Nursing

December 20, 1990

copyright 1990

by

Elizabeth A. Bossert

ii

DEDICATION

To my parents,

Robert and Lois Bossert

iii

ACKNOWLEDGMENTS

During the process of preparing for, planning, and executing this

research, I have been blessed by the support and guidance of a number of

persons who have been instrumental in helping me achieve this milestone.

To these people, I want to express my appreciation.

Throughout my life, two people have consistently listened to my plans

and concerns, shared my highs and lows, and encouraged, supported, and

prayed for me. Thank-you, Mom and Dad.

While at UCSF, I have the privilege of studying with many excellent

faculty and appreciate the role of each in contributing to my education.

However, there are four faculty who have had major roles in helping me

develop the skills of a nurse researcher to whom I would like to express

individual thanks.

Bonnie Holaday has served as my advisor throughout the program, has

chaired both the preliminary examination and the dissertation committee,

and has been my sponsor for the NRSA proposal. Through her guidance I

have learned what is needed to develop a sound research plan, a fundable

proposal, a publishable paper, and so much more. Her ability to stimulate

thought, critique written work, her willingness to share knowledge and

resources, and her advocacy has been greatly appreciated. Thank-you,

Bonnie.

Lynn Savedra was the first faculty member with whom I discussed the

possibility of pursuing doctoral education at UCSF and greatly facilitated

my investigation of the program. She consistently has been supportive of

my work as evidenced by her willingness to participate in the preliminary,

qualifying, and dissertation committees, but most importantly, she has

iv.

helped me integrate a Christian viewpoint into secular education. Thank

you, Lynn.

Ida Martinson has also served on all my committees throughout my

course of study and chaired the qualifying examination. In addition, she

has promoted my professional growth by providing the opportunity for

participation in data analysis, publication, and presentation at a

professional meeting. I have appreciated her willingness to listen and to

give suggestions for successfully integrating research into a faculty

role. Thank-you, Ida.

Steve Paul has served as my guide into the world of statistics. His

sense of humor and willingness to answer endless questions has been

greatly appreciated. Thank-you, Steve.

In addition to the faculty at UCSF, I want to extend my appreciation

to my friends among the students and staff. Without your encouragement

and facilitation, this project would not have been completed.

I would also like to express my appreciation to my friends at Loma

Linda University School of Nursing for their encouragement to explore the

possibility of doctoral education and to persevere during the process.

Grateful appreciation is also extended to the persons who facilitated

the process of obtaining access to children at the facilities used for

data collection and also to those who participated in the actual process

of data collection: Debbie Trevithick, Inez Wieging, and Lael Lambert at

the University of California, San Francisco Medical Center; Cheryl

Montague, Paul Maxwell, Nan Ground, Andrea McClean, and Louanne La Fosse

of Shriner's Hospital for Crippled Children, San Francisco; Gene

O'Connell, Artie Glickman, and Barbara Martin of San Francisco General

Hospital and Medical Center; Carolyn Dare, Laurel Kersten, Celia Buckley,

and Margie Crandall of University of California, Davis, Medical Center;

V

Joann Konkel, Debbie Echtenkamp, and Martin Goldsmith of Valley Children's

Hospital; Pat Frost-Hartzer, Nancy Dinsmore, and Cheri Plungy of

Children's Hospital Stanford; and Linda Johnson, Helen Staples, Vera

Durrant, Audrey Burgess, Dee Hart, and Dorthy Neufeld of Loma Linda

University. Appreciation is also extended to the many nurses and staff

personnel who took the time to assist in the process of identifying

potential subjects. Without the support and encouragement of each of

these persons, the process of data collection would have been difficult,

if not impossible.

I also would like to thank the parents who gave me permission to talk

with their children and the children who were willing to talk with me and

share their experiences. I greatly appreciate each one of you.

Appreciation is also extended to the organizations contributing to the

financing of my doctoral education: Loma Linda University, the National

Center for Nursing Research at NIH, University of California, San

Francisco Graduate Division and School of Nursing Century Club Funds, and

the Northern California Affiliate of the Association for Care of

Children's Health.

vi

THE INFLUENCE OF HEALTH STATUS, GENDER, AND ANXIETYON THE STRESS AND COPING PROCESSES OF

HOSPITALIZED SCHOOL-AGE CHILDREN

Elizabeth Anne Bossert

University of California, San Francisco, 1990

ABSTRACT

This study investigated the influence of health status (acutely or

chronically ill), gender, and trait anxiety on the stress and coping

process of hospitalized children, ages 8 through 11. Two aspects were

examined: 1) the specific events appraised as stressful and the coping

behaviors used in response to the events, and 2) the appraised

stressfulness of the global event of hospitalization and the perceived

effectiveness of the coping process. Conceptualization of the study was

guided by Lazarus' theory of stress and coping and Piaget's theory of the

cognitive development of children.

The design was nonexperimental and cross-sectional. The convenience

sample was comprised of 82 children admitted to a pediatric unit in one of

six California hospitals. The children completed six self-report

instruments.

Through content analysis, six categories of stressful events were

identified: intrusive events, physical symptoms, therapeutic

interventions, restricted activity, separation, and environment.

Synthesis of prior research resulted in six categories of coping behaviors

used by hospitalized children: cognitive processing, cognitive

restructuring, cooperation, countermeasures, control, and seeking support.

Based on these categories, analysis of the interviews indicated that of

the six possible relationships between the dependent variables of health

status, gender, and trait anxiety and the independent variables of stress

vii

appraisal and coping behaviors, only the relationship between health

status and stress appraisal was statistically significant; chronically ill

children identified more intrusive events and acutely ill children

identified more physical symptoms as stressful.

Data pertaining to the global hospital experience were examined using

path analysis. As a set, health status, gender, and trait anxiety

accounted for 14% of the variance in the children's stress appraisal;

trait anxiety alone contributed significantly to the model. Trait anxiety

is positively related to appraisal of hospitalization as stressful. As a

set, health status, gender, and trait anxiety accounted for 12% of the

variance in perception of coping effectiveness; both health status and

trait anxiety contributed significantly to the model. Acutely ill

children perceive their coping as more effective than chronically ill

children, and trait anxiety is inversely related to perception of coping

effectiveness. Gender did not have a significant influence in any of the

analyses.

2-2. f 2.z -->(O cºvvv^^{- 4-º'-- 4. /. Z. ~~ º

Bonnie Holaday, Chair 2. Elizabeth Anne Bossert

viii

TABLE OF CONTENTS

CHAPTER ONE: INTRODUCTION

PurposeSignificance

CHAPTER TWO : CONCEPTUAL FRAMEWORK AND LITERATURE REVIEWThe Conceptual Frameworks

The Lazarus Paradigm of Stress and CopingStress

AppraisalThe Coping ProcessAdaptational Outcomes of the Stress and

Coping ProcessPiaget's Theory of Cognitive Development

The Process of Cognitive DevelopmentStages of Cognitive Development

Application of Lazarus' Theory to ChildrenLiterature Review

Research on Sources of Stress during HospitalizationSources of Children's Stress during

Hospitalization Identified by AdultsSources of Stress during Hospitalization

Identified by ChildrenCritique of the Studies of Sources of StressComparison of Adult and Child Identification

of Sources of StressResearch on Coping during Hospitalization

Coping Strategies Reported in the LiteratureSummary of Coping StudiesCritique of the Coping StudiesVariables Influencing Coping as Reported

in the Literature

Conceptual ModelHealth Status

AnxietyGender

Stress AppraisalHypothesesDefinition of Terms

CHAPTER THREE: METHODOLOGYDesign

Strengths and Weaknesses of the DesignResearch SettingsHuman Subject's AssuranceSample

Sample Selection Constraints due to Variablesof Interest

38

4145

4646646974

78798081818284

86868790959697

ix

Page

Inclusion/Exclusion Criteria 99Rationale for Inclusion Criteria 100Rationale for Exclusion Criteria 104

Potential Sources of Uncontrolled Variance 106

Population to Whom Results May Be Generalized 108Sample Size 108Sample Selection 109

Data Collection Methods 110

State-Trait Anxiety Inventory for Children (STAIC) 111Hospital Stress Scale (HSS) and Hospital Coping 114

Scale (HCS)Child Medical Fear Scale (CMFS) 117Coping Response Inventory (CRI) 122Hospital Stress and Coping Interview 125

Data Collection 128The Phases of Data Collection 128The Protocol for Data Collection 130

Description of Data Collectors and Training Process 133Data Analysis 135

CHAPTER FOUR : RESULTS 138

Characteristics of the Sample 138Preliminary Analyses 144

Site of Data Collection 145

Age Differences 145Prior Out-Patient Experience 14.6Prehospitalization Programs 146Parental Rooming-in 147

Analysis of Hypotheses 148Analysis of the Interview Data 148

Stress Categories 148Coping Categories 150Quantification of Interview Data 150Restatement of Theoretical Model 154

Hypothesis 1 155Hypothesis 2 158Hypothesis 3 161Hypothesis 4 164Hypothesis 5 167Hypothesis 6 168Summary of Interview Data Analysis 169

Analysis of the Stress and Coping Word Graphic Scales 170Concurrent validity 171Preliminary Information Regarding Analysis 172Hypothesis 7 172Hypothesis 8 176Revision of Model 180

Summary of Word Graphic Scale Analyses 184Summary of Findings 186

CHAPTER FIVE: DISCUSSIONRevision of the Model

Relation of Results to HypothesesDiscussion of Results Relating to Stress Appraisal

Health Status and Stress AppraisalGender and Stress AppraisalAnxiety and Stress Appraisal

Discussion of Results Relating to CopingHealth Status and Coping BehaviorsGender and Coping BehaviorTrait Anxiety and Coping Behavior

Limitations

Limitations Related to the SampleLimitations Related to Instrumentation

Implications for NursingPersonHealthEnvironment

NursingImplications for Future ResearchConclusion

BIBLIOGRAPHY

APPENDICESA

:

Human Subjects Committee ApprovalUniversity of California, San FranciscoThe State-Trait Anxiety Inventory for ChildrenHospital Stress ScaleHospital Coping ScalePractice ScaleChild Medical Fear Scale

Coping Response InventoryHospital Stress/Coping InterviewUniversity of California, San FranciscoPermission for Child to Be a Research SubjectExperimental Subjects Bill of RightsGeneral Data Form

Summary of Research ResultsConsent to be a Research SubjectChild Assent Form

191191192192196200202204208212213214215217219219221222224227229

232

255255

257258260262264266268270

274276279281

xi

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

LIST OF TABLES

Coping Strategies of Children

Synthesis of Reported Coping BehaviorsItem Contents of Four Fear Scales

Gender and Age of Subjects (in years)

Family Income

Health Status and Condition of Subjects

Description of Subjects by Site

Categories of Stressful Events During Hospital

Categories of Coping Behaviors Used DuringHospital

Events Appraised as Stressful by HospitalizedChildren

Coping Behaviors Used by Hospitalized Children

Interrater Reliability for Content Analysis

Frequency of Stressful Events by Health Status

Frequency of First Stressful Event by Health Status

Frequency of All Coping Behaviors by Health Status

1st Coping Behavior used in Response to IntrusiveEvent by Health Status

Frequency of Stressful Events by Gender

Frequency of First Stressful Event by Gender

Frequency of Coping Behaviors by Gender

1st Coping Behavior used in Response to IntrusiveEvent by Health StatusMean Trait Anxiety Score by Stressful Event Category

Mean Trait Anxiety Score by Coping Behavior Categories

Results of Interview Data Analyses

The Effects of Independent Variables on DependentVariable of Stress

Effects of Independent Variables on DependentVariable of Coping

Revised Effects of Independent Variables on DependentVariable of Coping

Summary of the Effects of Independent Variables onDependent Variables

47

65

121

139

140

141

143

149

151

152

152

153

156

157

159

161

162

163

165

166

167

169

170

173

177

18i

185

xii

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Figure

LIST OF FIGURES

Diagram of the Lazarus Stress and Coping Process

Model of the Relationship Between Three ModifyingVariables and the Stress and Coping Process

Theoretical Model of Relationships Between Variables

Model of Statistical Relationships Between Variables

Theoretical Model of Variables InfluencingStress Appraisal

Theoretical Model of Factors Influencing CopingAppraisal

Theoretical Model of Factors Influencing CopingAppraisal

Theoretical Model of Relationships Between Variables

155

170

174

178

182

184

xiii

CHAPTER ONE

INTRODUCTION

In the hospital you get used to lots of things.

You get used to staying in bed when you don't want to.

And feeling your back itch when you can't scratch it.

You get used to having your bath in bed and even going to thetoilet in a bed pan.

You get used to missing your dog and missing your friends.

Your get used to listening to babies cry, and seeing yourmommy and daddy just when they want to come to visit you.

That's quite a lot of getting used to.

(Shore, 1965, p. 62)

The hospitalized child unquestionably has a lot to "get used to".

Very few of the child's daily routines are conducted in the same manner as

at home. Additionally, many events and situations are encountered that

are unlikely to occur at home. The child may find some of these changes

to be relatively unimportant and ignore the situation or event. Other

changes may cause considerable distress for the child resulting in various

behaviors designed to reduce the stress of the situation or event. While

it is generally accepted that certain common experiences encountered

during hospitalization are stressful for children and that children will

attempt to cope with the situation, little is known about factors that may

influence the individual child's stress and coping responses during

hospitalization.

Purpose

The purpose of this study was to examine the influence of three

selected factors on, first, the child's global reaction to

hospitalization, and second, the child's reaction to specific events

encountered during hospitalization. The specific questions asked were:

1. What is the affect of health status, gender, and trait anxiety

on the school-age hospitalized child's appraisal of the event

of hospitalization as stressful and the resulting perception

of the effectiveness of coping behaviors?

2. What is the relationship of health status, gender, and trait

anxiety on the school-age hospitalized child's appraisal of

events during hospitalization as stressful and on the coping

behaviors used during hospitalization?

Significance

Although numerous researchers have investigated the phenomenon of

children's reactions to hospitalization, as evidenced by the research

literature reviews by Vernon, Foley, Sipowicz, and Schulman (1965), and by

Thompson (1985), there remains a paucity of information available

concerning factors that may be responsible for differences in the

reactions of children. Some previous studies have assumed that all

hospitalized children have similar reactions (Adams & Bergman, 1965;

Gofman, Buckman, & Schade, 1957; Holt, 1968; May & Sparks, 1983). Other

studies have limited the investigation to the reactions of children

admitted for medical reasons (Prugh, Staub, Sands, Kirschbaum, & Lenihan,

1953; Neff, 1978) or more often for surgical procedures (Blom, 1958;

Reissland, 1983; Rose, 1972; Savedra & Tesler, 1981; Timmerman, 1983).

While these studies have provided information that is important in the

quest to understand the hospitalized child, other equally important

variables have not yet been fully explored.

One variable that has received little attention is that of the

child's health status as either acutely or chronically ill. Currently, it

is uncertain if chronically ill children have similar or dissimilar

patterns of stress and coping in response to the experiences of

hospitalization as do acutely ill peers. Although chronically ill

children are a subgroup of the total population of children, and therefore

might be expected to have similar reactions to the event of

hospitalization, it is possible that the prior experiences of this group

with hospitalization may alter their reactions during subsequent

admissions. Considering that between 10 to 15 percent of children are

chronically ill (Perrin, 1985), with 1 to 2 percent severely affected

(Hobbs, Perrin, & Ireys, 1975), and that approximately 36 percent of the

total number of pediatric hospital days are used by chronically ill

children (Butler, Budetti, McManus, Stenmark, & Newacheck, 1985), it is

evident that chronically ill children are hospitalized more frequently

than are healthy children with an acute illness. Thus, it is important to

identify what this group of children perceives as stressful during

hospitalization and how they cope with it. Without this information it is

difficult to plan programs or individualize care that will meet the needs

of these children. The commonalities of chronically ill children's

hospital experiences, despite the precise diagnosis involved, support the

importance of using the noncategorical approach (Pless & Perrin, 1985;

Stein & Jessop, 1982, 1984, 1989) rather than a diagnostic oriented

scheme. Currently, only one research team has published the results of a

comparison between the reactions of acutely ill and chronically ill

children during hospitalization reporting that in preschool children there

are few differences in the number of coping behaviors used by the two

groups, but that chronically ill children do use more coping behaviors

than do acutely ill children (Ritchie, Caty, & Ellerton, 1987; 1988).

A second area of study, investigation of the relationship between

personality variables and the child's stress and coping during

hospitalization, has only begun to be explored. The two factors that have

been examined are locus of control (LaMontagne, 1984, 1987; Rothbaum,

Wolfer, & Visintainer, 1979), and state anxiety (Burstein & Meichenbaum,

1979; Field, Alpert, Vega-Lahr, Goldstein, & Perry, 1988). The

relationship between trait anxiety and the child's reactions to

hospitalization, has not yet been reported in the scientific literature,

although trait anxiety is an easily identifiable and fundamental

personality characteristic.

A third variable needing further study is gender. It is uncertain

whether the gender of the child has a relationship to the appraisal of

stress and resulting coping behaviors during hospitalization. Brown,

O'Keefe, Sander, and Baker (1986), studying the cognitive reactions of

healthy children to stressful situations, found no difference related to

gender, a finding paralleled by a recent study of hospitalized children

(Field et al., 1988). In contrast, other studies (Savedra & Tesler, 1981;

Tesler, Wegner, Savedra, Gibbons, & Ward, 1981; Aisenberg, Wolff,

Rosenthal, & Nadas, 1973) found that gender was a significant factor in .

the type of coping strategy used by school-age hospitalized children.

Further investigation in this area is needed.

Finally, although a few researchers have focused specifically on

school-age children (LaMontagne, 1984; Savedra & Tesler, 1981; Timmerman,

1983; Youssef, 1981), much of the research involving school-age children

has failed to limit the age of the subjects to a recognized developmental

level (Burstein & Meichenbaum, 1979; LaMontagne, 1987; May & Sparks, 1982;

Neff, 1978; Peterson & Toler, 1986; Reissland, 1983; Rose, 1972; Rothbaum,

Wolfer, & Visintainer, 1979), possibly clouding interpretation and

generalization of the results.

It was evident that a study investigating the stress and coping

process of hospitalized school-age children in relation to the variables

of health status, gender, and anxiety would provide a unique contribution

to the knowledge base of pediatric nursing. By filling this gap in the

theoretical base of nursing science, the information generated by the

proposed study will increase the nurse clinician's understanding of the

reactions and behaviors of school-age, acutely ill versus chronically ill

children, boys versus girls, and children with high anxiety versus those

with low anxiety during hospitalization. Rather than assuming that all

hospitalized children have the same concerns and needs, the professional's

awareness of possible differences will be increased, resulting in an

increased ability to design care to meet the needs of specific

populations. Through this awareness, unnecessary stressful situations may

be avoided and support provided to assist the child's coping processes

during the necessary stressful events.

To accomplish the purpose of studying the affect of health status,

gender, and trait anxiety on the stress and coping process of school-age

children during hospitalization, a nonexperimental, cross-sectional design

was used. Qualitative data was collected through an interview with the

child focusing on the events appraised as stressful during hospitalization

and the coping behaviors used in response to that event. Quantitative

data involved administration of standardized instruments to determine the

child's trait anxiety level, medical fears, and coping responses, and word

graphic scales developed for this study to assess the child's stress and

coping responses in relation to the event of hospitalization.

CHAPTER TWO

CONCEPTUAL FRAMEWORK AND LITERATURE REVIEW

Two theoretical frameworks were used to guide the investigation of

factors influencing the school-age child's stress and coping processes

during hospitalization. The first framework was the Lazarus paradigm of

stress and coping. This approach focuses on the cognitive aspects of

stress and coping, rendering it an appropriate framework for studying

psychological reactions to the hospital experience, as contrasted with

either a physiological model, such as that begun by Selye (Mason, 1975a,

1975b ; Selye, 1980), or a sociological model such as proposed by Pearlin

(Pearlin, Lieberman, Menaghan, & Mullan, 1981; Pearlin & Schooler, 1978).

Although the Lazarus model was developed based on research involving

adults, the key concept of individual appraisal of the stressfulness of

events allows appropriate extension to children. Because children's

thought processes differ from that of adults, it was also necessary to

base the research on a theoretical model that considers the mental

development of the school-age child. Piaget's theory of cognitive

development was used for this purpose because of the emphasis on the

cognitive development and functioning of the child. This chapter will

examine these theories, review the literature relevant to the constructs

of stress and coping in child, with emphasis primarily on studies relating

to the hospitalized child, and will describe the model used for this

study.

The Conceptual Frameworks

The Lazarus paradigm of stress and coping will be presented first,

detailing the key points of the theory. Following this will be a

discussion of the elements of Piaget's theory of cognitive development

relevant to this study.

The Lazarus Paradigm of Stress and Coping

The model of stress and coping developed by Richard Lazarus uses a

cognitive phenomenological approach based on three key components: stress,

appraisal, and coping. Each of these constructs will be described as used

in the Lazarus model. A diagram of this process is presented in Figure 1.

Stress

Lazarus defines the concept of psychological stress as "a particular

relationship between the person and the environment that is appraised by

the person as taxing or exceeding his or her resources and endangering his

or her well-being" (Lazarus & Folkman, 1984a, pp. 19). Unlike other

perspectives, stress is not due to interaction with noxious stimuli in the

environment (Selye, 1980; Pearlin et al., 1981), but rather is due to a

transactional process between the person and the environment which results

in stress (Lazarus & Folkman, 1984a). In other words, stress only exists

if that person interprets the environmental events as stressful. As

implied in the above definition, a key element in the Lazarus model of

stress and coping is the process of appraisal.

Personal EnvironmentalVariables Variables

`s _TEvent

|Cognitive Appraisal:

_T Primary SecondaryN ... /Irrelevant Stress

Benign |Harm/Threat/Challenge

|Coping:

Problem EmotionFocused Focused

Reappraisal

Adaptation

Figure 1. Diagram of the Lazarus stress and coping process.

10

Appraisal

Appraisal is defined as, "an evaluative process that determines why

and to what extent a particular transaction or series of transactions

between the person and the environment is stressful" (Lazarus & Folkman,

1984a, pp. 19). Simply, appraisal is the process of assessing whether or

not an event is stressful.

As the definitions of stress and appraisal indicate, the process of

appraisal is dependent on both personal and environmental variables.

Lazarus has identified three general categories of personal factors that

may influence the appraisal process: 1) commitments or motivational

characteristics, 2) belief systems regarding personal control, and 3)

intellectual resources and skills (Cohen & Lazarus, 1983; Lazarus &

Folkman, 1984b). Based on these categories, the personal variables likely

to influence the appraisal process of the hospitalized child would include

the child's commitment to and need for his or her parents, personality

characteristics, and developmental level. Additionally, the child's

appraisal of the situation may be affected by the nature of the child's

illness and type and severity of symptoms, as the physical condition is

likely to impact the child's motivation, perception of control, and

cognitive functioning.

When identifying environmental factors that may affect the appraisal

process, Lazarus focuses on the properties of situations, rather than on

the situation itself, as no one event is appraised as equally stressful by

all persons. Common properties of situations that influence an appraisal

of stress are, 1) the novelty or the extent of prior experience with the

event, 2) event uncertainty or the likelihood an event will occur, 3) the

imminence or period of anticipation of the event, 4) the duration of the

11

event, 5) temporal uncertainty or not knowing when the event will occur,

and 6) ambiguity or a lack of clear environmental clues to the nature of

the situation (Lazarus & Folkman, 1984a). For the hospitalized child, the

novelty of the situation will depend on prior knowledge of the event

through personal experience or vicarious experience such as a family

member, friend, television, books, or preadmission teaching or

preprocedural preparation. Event uncertainty and the temporal elements of

imminence, duration, and uncertainty regarding the timing of the event are

a constant problem during hospitalization since protocols and hospital

policies make it difficult for medical personnel, much less the pediatric

patient, to predict with certainty if and when an event will occur.

Additionally, the child may not be able to interpret the clues that are

available from the environment, resulting in a state of ambiguity.

The relationship of the person and environment in the Lazarus model

is not merely an interaction of the two elements in which the effect of

each separate factor may be determined, but rather it is a two-way

interchange, or transaction. The person acts on and is acted on by the

environment. Both factors, person and environment, merge in the

transaction to form a new entity, different from the original separate

elements (Lazarus & Folkman, 1984 a ; Lazarus & Launier, 1978). As quoted

by Lazarus, "the whole is different from the sum of the parts" (1981, pp.

184). Thus, an event is appraised as stressful, or not stressful, based

on the merging of the unique characteristics of the person and situation

at that specific time.

Cognitive appraisal occurs when the transactional process is

evaluated for relevance to the person. It consists of three components:

primary appraisal, secondary appraisal, and reappraisal. Primary and

12

secondary appraisal take place simultaneously, despite the implied

hierarchy in the names (Lazarus & Folkman, 1984a). Reappraisal follows an

irnitial appraisal process.

Primary appraisal. Primary appraisal is "the process of evaluating

the significance of a transaction for one's wellbeing" (Lazarus, 1981, pp.

192) . The questions are asked, "Am I in trouble or being benefited, now

or in the future, and in what way?" (Lazarus & Folkman, 1984 a, pp. 31).

In other words, the person is determining how and when the situation will

be helpful or harmful.

During primary appraisal it is determined if the event is

irrelevant, benign-positive, or stressful for the individual. An event is

appraised as irrelevant if the person has determined that it has no impact

for their well-being, either positive or negative. A benign- positive

appraisal is one in which the event appears to maintain or increase the

individual's well-being, generally resulting in a feeling of joy, pleasure

or relief. If the event is appraised as stressful, the person perceives

his personal resources as inadequate to deal with the situation. (Cohen

& Lazarus, 1983; Lazarus, 1981; Lazarus & Folkman, 1984a, 1984b.)

An appraisal of stress is further classified as one of harm 'or loss,

threat, or challenge. Harm or loss indicates that the injury, physical,

psychological, or social, has already occurred. Threat indicates a future

occurrence of harm, and is likely to occur when the person perceives the

environment as dangerous and does not believe he is able to master the

situation. Challenge indicates the person believes he may be successful

in dealing with the situation regardless of the problems associated with

it. Whereas with an appraisal of harm or loss the person must cope with

the damage that has happened, an appraisal of threat or challenge allows

13

the person to use anticipatory coping strategies. (Cohen & Lazarus, 1983;

Lazarus, 1981; Lazarus & Folkman, 1984a and 1984b. )

Secondary appraisal. Whereas in primary appraisal the focus is

individual appraisal of personal well-being, in secondary appraisal the

focus is on the appraisal of the resources available for coping (Lazarus

& Launier, 1978). The question being asked is, "What can I do?" (Folkman,

1984, pp. 842). Through an evaluative process that may range from

conscious thought to unconscious reaction (Cohen & Lazarus, 1979), the

person evaluates the potential effectiveness of available resources and

options. Resources would include the individual's physical health and

capabilities; psychological characteristics and functioning; social

support systems; and material assets (Folkman, 1984). Options would

involve behaviors such as information seeking, acceptance, restraint, or

acting to change the situation (Folkman, Lazarus, Dunkel-Schetter,

DeLongis, & Gruen, 1986). The probable effectiveness of the identified

available resources or options in helping the person deal with the threat

to personal well-being will influence the appraisal of the situation as

harmful or challenging. A situation in which the person has a sense of

control is more likely to be appraised as challenging than will

circumstances beyond the control of the person (Lazarus & Folkman, 1984a).

Thus, the processes of primary and secondary appraisal interact and are

highly interdependent (Folkman et al., 1986; Lazarus, 1981).

Reappraisal. Lazarus defines reappraisal as an, "appraisal that

follows an earlier appraisal in the same encounter and modifies it"

(Lazarus & Folkman, 1984a, pp. 38). The transaction between the person

and environment is a dynamic process, subject to change due to feedback

from within the system or from new information outside the system.

14

Whenever a change of this nature occurs, reappraisal of the event is

rhe cessary, essentially beginning a new cycle in the process of appraisal

of stress and coping. (Lazarus, 1981; Lazarus & Folkman, 1984 a ; Lazarus

& Laurier, 1978).

The Coping Process

In this section, four aspects of coping will be discussed. First

the definition of coping as used by Lazarus will be given and analyzed.

Second, the functions of coping will be presented. Third, modes of coping

will be discussed. Finally, the outcome of the coping process will be

briefly addressed.

Definition of coping. Lazarus defines coping as, "constantly

changing cognitive and behavioral efforts to manage specific external

and/or internal demands that are appraised as taxing or exceeding the

resources of the person" (Lazarus & Folkman, 1984a, pp. 141). This

definition encompasses several elements that are essential to

understanding the Lazarus perspective of coping. The first element is

that coping is a process. It involves all that a person actually does to

deal with the situations appraised as stressful. This perspective differs

from coping research that focuses on what the person is likely to do: the

coping style, disposition, or trait (Lazarus & Launier, 1978). The

typical coping style of a person and the coping behaviors actually used

in a situation may differ greatly, due to the transactional nature of

stress appraisal. An a priori determination of coping behaviors cannot be

completely accurate as the unique person-environment situation has not yet

occurred. Because of this, Lazarus encourages naturalistic research,studying coping reactions to stress as it occurs in the person's real

world (Lazarus, 1981).

15

A second important element of the definition is that coping is

dependent on the psychological mediation that occurs during the appraisal

process (Cohen & Lazarus, 1983; Lazarus & Folkman, 1984b). Thus, coping

is contextual, conditional upon the person's appraisal of the demands of

the situation and available resources (Folkman et al., 1986). Only if the

situation has been appraised as stressful and the resources available are

insufficient to meet the demand of the situation will coping occur.

A third element of the above definition is that coping is

differentiated from automatized reactions (Lazarus & Folkman, 1984).

Coping requires effort. Automatized reactions occur without effort.

Therefore, a situation managed by an automatic reaction or reflex has not

required the use of coping. Interestingly, due to a changes in appraisal,

a situation may require coping at one time, and at another time the

response may be automatic. For example, while driving in a new city a

high level of cognitive and behavioral effort or coping is required, but

after a becoming familiar with the area and traffic patterns, driving

becomes routine or automatized. This automatic behavior will continue

unless a new demand develops, such as road construction, that requires

effort and resumption of coping behaviors. Children's responses to

situations may also fluctuate between automatized reactions and coping

behaviors. For example, beginning school may be a stressful situation for

many children, requiring coping to deal with the unknown routines and

expectations. After a period of time the child becomes familiar with the

experience and automatically reacts according to the immediate situation.

However, a change in the routine, such as moving to a new school or

entering the less structured environment of junior high, places new

demands on the child that cannot be adequately met with former automatic

16

reactions, necessitating the use of coping behaviors until the situation

is no longer appraised as stressful. In sum, situations that can be

managed by routine behaviors do not require coping. It is only when the

situation is appraised as taxing or exceeding the person's resources that

the effort of coping is required.

A fourth element in the definition is that any effort to manage the

situation is considered to be coping, regardless of whether or not the

behavior is effective. A value judgement of "good" or "bad" coping is not

made (Folkman et al., 1986), because it is difficult to accurately assess

the person-environment transaction to determine if the choice of coping

behavior is appropriate.

A fifth point derived from the definition is that emphasis is placed

on the attempt to manage, not master, the situation. Mastery implies that

the person has changed the situation or gained control of it. This

perspective often is not realistic because many situations in life cannot

be changed or mastered, such as illness, injury, and hospitalization.

Instead of mastery, the person does have the option of attempting to

manage the situation by controlling his or her personal response to the

situation through coping behaviors such as minimization, avoidance,

tolerance, or acceptance (Cohen & Lazarus, 1983; Lazarus & Folkman,

1984a).

The final point to be drawn from the definition is the distinction

between coping and adaptation. Coping is the process of dealing with a

situation appraised as stressful. Adaptation is the outcome of this

process. Unlike coping, adaptation may be evaluated as either beneficial

or detrimental to the person. This distinction prevents the confounding

17

of the concept of coping with the outcomes it is used to explain (Lazarus

& Folkman, 1984a; Folkman et al., 1986).

Functions of coping. Lazarus has identified two principal purposes

or functions of coping, problem-focused coping and emotion-focused coping.

Problem-focused coping involves attempts to change the demand that has

resulted in the appraisal of stress. The source of the demand may be

either external, such as a challenging event, or internal, such as

personal expectations. Emotion-focused coping is directed toward managing

the emotional reaction, physical or behavioral, to the stress. Generally,

both modes are used to deal with a stressful situation. A study of

middle-age adults reported using both problem-focused and emotion-focused

coping in 98% of stressful transactions (Folkman & Lazarus, 1980), and a

study of college students facing examinations indicated that both forms of

coping were used 96% of the time (Folkman & Lazarus, 1985). The inter

action of these two functions of coping may be either positive, enhancing

the person's coping process, or negative, counteracting each other and

interfering with optimal usefulness (Cohen & Lazarus, 1983).

Modes of coping. Lazarus and colleagues have theoretically

identified five modes, or categories, of coping that are used in response

to a stressful situation. Information seeking is used to gather

information about the situation and to try to determine appropriate

methods of dealing with it. Direct action includes any behavioral act

directed toward dealing with either the problem or the emotional reaction

to the stress. Inhibition of action is refraining from action. Intra

psychic processes are cognitive activities that may occur consciously or

unconsciously. Turning to others involves seeking support from other

individuals. Early descriptions of the modes of coping include only the

18

first four categories. The need to include the final mode was recognized

in about 1979. (Cohen & Lazarus, 1979; Cohen & Lazarus, 1983; Lazarus &

Launier, 1978. )

Adaptational Outcomes of the Stress and Coping Process

The purpose of examining the process of stress, appraisal, and

coping is to understand the relationship of these elements to the person's

adaptation. Lazarus and colleagues have identified three classes of

adaptational outcomes: physiological, psychological, and social (Cohen &

Lazarus, 1983; Lazarus & Folkman, 1984a).

Lazarus postulates that coping may influence the physiological

status of a person through three pathways: 1) the neurochemical system, 2)

increased involvement with dangerous substances or behaviors, and 3) by

delaying or avoidance of health-care behaviors (Lazarus & Folkman, 1984a).

Similarly, the coping process may affect the psychological well-being of

an individual by: 1) influencing the current emotional status of the

person experiencing a stressful situation (Folkman & Lazarus, 1988), and

by 2) the outcome of the specific stressful transaction on the

psychological well-being person over time (Lazarus & Folkman, 1984a).

Finally, coping processes may influence the social well-being of the

person through the appropriateness of the fit between 1) the person's

primary appraisal of stress and the actual event taking place, and 2) the

person's secondary appraisal of coping resources and the actual demands of

the situation (Cohen & Lazarus, 1983; Lazarus & Folkman, 1984a).

In summary, stress results from a transactional process between the

person and the environment. Appraisal is the cognitive process ofevaluating an environmental situation to determine if it is personally

threatening, a process influenced by variables related to both the person

19

and environment. Coping is the process of dealing with the situation that

has been evaluated as stressful. Two purposes of coping have been

identified: problem solving and emotion-regulation, functions that often

occur simultaneously when dealing with stress. In order to accomplish

these purposes, five types, or modes, of coping may be used: information

seeking, direct action, inhibition of action, intrapsychic process, and

seeking support from others. The outcomes of coping may be determined by

assessing the effect on the psychological, physiological, or social

aspects of the person.

Having carefully examined the major components of the Lazarus

paradigm of stress, appraisal and coping, it is necessary to recognize

that the theory was not developed for the explicit purpose of studying

children. Therefore the child's cognitive functioning must be understood

to determine how the child's cognitive processes of stress and coping

might function. To meet this need, Piaget's theory of cognitive

development will be examined.

Piaget's Theory of Cognitive Development

Jean Piaget's (1896-1980) theory of cognitive development describes

the process of intellectual maturation as evidenced by the child's

understanding of his or her world. Rather than focusing on quantitative

aspects of intelligence, such as measurement and stability of IQ, Piaget

chose to study qualitative characteristics of the child's thinking, such

as common characteristics in the thought processes of children and the

differences between the thinking of children from birth throughadolescence (Brainerd, 1978). Two key concepts of Piaget's theory are the

20

process through which cognitive development occurs and the stages of

cognitive development.

The Process of Cognitive Development

Piaget believed that intellectual development occurs through the

process of growth and change in cognitive structures (Brainerd, 1978);

structures being the internalized, mental operations that constitute the

process of thinking and understanding (Piaget, 1983). Developmental

changes in these structures occur through a process of self-regulation or

equilibration (Piaget & Inhelder, 1969), defined as, "a set of active

reactions of the subject to external disturbances" (Piaget, 1983, pp.

122). As the child becomes aware of external elements in the world that

cannot be understood according to his or her current cognitive structures,

a disequilibrium occurs. Because the basic functions of cognition are

organization and adaption (Brainerd, 1978), the disturbance must be

addressed and equilibrium reestablished.-

The processes through which equilibrium is reestablished are

assimilation and accommodation. Piaget (1983, pp. 106) defines

assimilation as, "the integration of external elements into evolving or

completed structures of an organism." Practically, this means that the

reality of the situation is altered to fit the child's current patterns of

understanding. For example, when a hot water bottle is first encountered,

the child may think it is a type of pillow. However, as the child

observes how the hot water bottle is used by adults, it becomes evident

that the object is different from a pillow, resulting in the need for the

child to change the existing mental structures to incorporate the new

object. This portion of the process, accommodation, is defined by Piaget

(1983, pp. 107) as, ". . . any modification of assimilatory scheme or

21

structure by the elements it assimilates." In essence, the child's

thought patterns have been changed to fit the reality of the situation.

Assimilation and accommodation are considered by Piaget (1952, 1954,

1983) to be complimentary aspects of adaptation, always occurring

together, yet the two processes are in opposition. Assimilation attempts

to maintain the status quo of the child's thinking, whereas accommodation

changes the child's cognitive structures to correspond more directly

reality (Piaget, 1954). As equilibration is achieved through assimilation

and accommodation, the child's cognitive structures are gradually modified

and broadened, resulting in an advancement of the child's cognitive

development (Brainerd, 1978).

As the child develops, the invariant functions of organization and

adaptation remain stable. However, the child's cognitive structures

change due to the adaptive processes of assimilation and accommodation.

Piaget observed that these structural changes occurred in a similar

sequence in different children, an observation that lead to the

formulation of a model of developmental stages of cognitive maturation.

Stages of Cognitive Development

From his observations, Piaget identified distinctive stages in a

child's cognitive development, consisting of behaviors indicative of

differences in the cognitive structure of the child. Basic principles of

this portion of the theory are that the stages are qualitatively

different, that they occur in an universally invariant sequence, that each

stage incorporates and builds on the preceding stage, and that successful

achievement of each stage requires integration of the structures into s

functional whole (Brainerd, 1978). Although support for some of these

22

principles is more theoretical than empirical, Piaget's stages of

development have been widely accepted.

Piaget (1957) identified four stages of a child's cognitive

development: 1) sensorimotor, 2) preoperational, 3) concrete operations,

and 4) formal operations, although at times he combined the second and

third stages under the heading of representative intelligence (Piaget,

1983). For the purposes of this overview, the four stage approach will be

used. It should be noted that the age range provided for each stage is an

approximation. Piaget believed that the actual emergence of the stage

would depend on the child's individual characteristics and environment

(Brainerd, 1978; Ginsburg & Opper, 1988). Although the current study

focuses on children within the age range of concrete-operations, an

understanding of the other stages provides a necessary framework for

understanding the discussion of the findings.

Sensorimotor intelligence. The first stage, sensorimotor, extends

from birth to approximately eighteen months or two years of age. From his

observations, Piaget believed that infants are not capable of internalized

representation (thought), but rather that their behavior indicated a

sequential developmental pattern of motoric schemes or action sequences;

precursors to the development of cognitive structures by older children

(Brainerd, 1978; Piaget, 1957). Two subperiods occur. The first extends

from birth until 7 or 9 months; a period of concentration on the child's

own body. During this time, the child progresses through the first three

substages, moving from simple reflex schemes to a beginning awareness of

the external world. The second subperiod involves objectivization and

spatialization of the child's schemes. During the corresponding last

three substages, the child learns to coordinate schemes, experiment with

23

the schemes to observe differing results, and shows evidence of the

beginning of internalized cognitive functioning (Beilin, 1989; Piaget,

1983). The primary evidence of the precursors of cognitive structure

during this stage is the development of object permanence, the awareness

that an object continues to exist after it is no longer visible (Ginsburg

& Opper, 1988; Crain, 1985; Piaget, 1957).

Preoperational thought. The second stage, pre-operational thought,

extends from approximately two until seven years. During these years the

child develops the cognitive ability of mental representation, "the

internalization of actions into thoughts" (Piaget, 1957, pp. 11). Mental

representation is accomplished through the child's acquisition of semiotic

function, or the ability to use mental symbols to represent a personal,

knowledge of something (Ginsburg & Opper, 1988; Piaget, 1983). Because of

the individualization of the symbols, the child's mental representations

often are somewhat idiosyncratic and may be quite different from that of

the adult, or even of another child the same age.

Although Piaget tended to emphasize what the child in this stage of

development could not yet do, the preoperational child does acquire

several important abilities that give evidence of development of the

cognitive structures. First, Piaget believed that true language, as

semiotic function, emerges during the preoperational period. Earlier

vocalizations of infants do not involve mental representation, and

therefore are not language (Brainerd, 1978; Ginsburg & Opper, 1988).

Second, an understanding of unidirectional functions develops (Beilin,

1989; Piaget, 1983), the ability to understand that if a specific event

occurs, another will follow it, or y - f(x) (Piaget, 1983, pp. 110),

24

an important step in the development of mental functioning. Third, the

child develops the ability to understand correspondences (comparisons)

between objects and event, a necessary precursor to the concept of

conservation, classification, and relations (Beilin, 1989; Ginsburg &

Opper, 1988).

Several characteristics of the preoperational child distinguish this

stage from the next and must undergo gradual restructuring. First,

centration or egocentrism, a difficulty in considering two differing

viewpoints or aspects of a situation at a time, is a typical

characteristic of the preoperational child (Brainerd, 1978). Because of

this, the child's language and play occurs in a parallel, rather than

interactive, pattern. Centration also interferes with the child's

achievement of conservation tasks because the child is able to focus on

only one dimension at a time (Crain, 1985; Ginsburg & Opper, 1988). A

second factor interfering with conservation is the lack of reversibility

(Piaget, 1957). Although the development of the unidirectional function

is fundamental, the child cannot yet mentally reverse the action and

understand that an object or situation may return to its original state,

hindering an understanding of the real world.

Concrete operational thought. The third stage, concrete operations,

begins to emerge about age seven and extends until approximately age

eleven. Operations are reversible mental representations of actions that

are organized into larger systems (Piaget & Inhelder, 1969; Siegler,

1986). The operations are concrete in that the child's thinking is

limited to tangible objects or situations (Ginsburg & Opper, 1988; Piaget,

1957; Piaget & Inhelder, 1969).

25

During the concrete operational stage, the cognitive structure

undergoes a number of important changes. First, the child moves from

centration to decentration, acquiring the ability to think about two or

more aspects of a situation simultaneously (Ginsburg & Opper, 1988).

Second, the child develops reversibility, the ability to mentally reverse

a situation without seeing it done physically. The two key aspects of

reversibility are inversion and reciprocity. Inversion, also called

negation, is the ability to invert an operation, to think through a

situation in one direction and then reverse the thinking process to return

the situation to the original state (Brainerd, 1978; Piaget & Inhelder,

1969). Reciprocity, also called compensation, results in reversibility in

a different manner. This principle is based on the law that for every

action there is a reciprocal action that will compensate or nullify the

first action (Brainerd, 1978; Piaget & Inhelder, 1969). The difference

between these types of reversibility is that inversion reverses the

original process, whereas reciprocity achieves reversibility through a

different process.

The development of decentration and reversibility allows the

concrete operational child to achieve a number of cognitive abilities that

were not present in the preoperational stage including conservation,

classification, and relations. Conservation is the understanding that the

quantitative quality of a substance does not change when the form of the

substance is changed (Brainerd, 1978). Acquisition of this concept begins

around 7 or 8 years with the conservation of substance, illustrated by the

classical liquid or clay experiments, conservation of weight occurs at

nine or ten years, and conservation of volume at eleven or twelve (Piaget,

1957; Piaget & Inhelder, 1969), an example of horizontal decalage

26

(Ginsburg & Opper, 1988). Classification is the grouping of things that

share a similar property accompanied by an understanding of class

boundaries (intension) and membership (extension) (Ginsburg & Opper,

1988). The preoperational child forms graphic collections, a grouping of

objects forming a pattern rather than a class. As the child moves toward

concrete operations, non-graphic collections are made, grouping of objects

according to one or two properties. It is not until 8 years or later that

the child acquires the hierarchial concept of the relationship of a

subclass to its general class (Ginsburg & Opper, 1988; Inhelder & Piaget,

1964; Piaget & Inhelder, 1969). Relations or seriation is the arrangement

of objects according to increase or decrease of a property such as size or

color (Piaget & Inhelder, 1969). Given a set of objects to arrangeserially, the preoperational child may determine the relationship of pairs

of items, but not the whole set simultaneously. Around age seven the

child is able to create a hierarchial arrangement of all the items without

using a trial and error process, evidence that the child is using mental

representation of the objects to determine the serial relationships.

Formal operational thinking. The fourth stage, formal operations,

begins to develop at 11 or 12 years of age and, when achieved at about age

15 (Brainerd, 1978; Piaget, 1957), forms the basis for adult thinking.

Formal operations differs from concrete operations in that the child

develops the ability to think about things beyond his or her own

experience and to formulate alternative options through manipulation of

these mental representations, a process called hypothetico-deductive, or

propositional, thinking (Beilin, 1989; Brainerd, 1978).

The thinking that takes place during the stage of formal operations

is made possible by the combination of the inversion and reciprocity of

S

3.

27

the concrete operational stage into a structural whole (Beilin, 1989;

Piaget & Inhelder, 1969). This new structure is known as the INRC group;

I representing the identity of the group in question, N representing the

inverse operation, R representing the reciprocal operation, and C

representing the correlative operation (Brainerd, 1978; Piaget & Inhelder,

1969). Through the use of these operations the adolescent or adult is

able to consider any possible combination of transformations pertaining to

either a concrete or hypothetical situation.

Because of the emergence of propositional thinking, the adolescent

develops new mental schemes not possible during the concrete stage of

thinking. These include an understanding of 1) proportions: the

equivalence of ratios between quantities; 2) probability: the occurrence

of events by change; 3) double systems of references: the positive or

negative influence of one factor on another, the classical example being

the motion of a snail on a movable board; and 4) mechanical or hydrostatic

equilibrium: Newton's physical principle of action and reaction (Brainerd,

1978; Piaget & Inhelder, 1969).

In summary, Piaget's theory focuses on the process of cognitive

development from infancy through adolescence when patterns of adult

thinking are achieved. The cognitive structures undergo continual change

as the child gradually becomes aware of the real world and adapts his or

her thought processes to it. Adaption is achieved as assimilation and

accommodation act to maintain or reestablish equilibrium. Four

qualitatively distinctive stages of cognitive development were identified

by Piaget: 1) sensorimotor, 2) preoperational, 3) concrete operations, and

4) formal operations. The cognitive structure of the child at each stage

determines the cognitive abilities, such as object permanence during the

28

first stage, uni-directional functions during the second stage,

conservation and classification during the third stage, and propositional

thinking during the fourth stage.

Clearly, children's thinking, as described by Piaget, differs from

that of adults. When proposing the use of the Lazarus paradigm of stress

and coping to study children's reactions during hospitalization, the

question must be asked: May the theory be appropriately applied to

children? This concern will be discussed in the following section.

Application of Lazarus' Theory to Children

Because the basis of Lazarus's stress and coping theory is cognitive

appraisal, and because children's cognitive functioning differs from that

of adults, it was necessary to examine the key elements of the stress and

coping theory to determine if it could be used appropriately to study the

stress and coping of children. Factors considered were the child's

ability to engage in appraisal, the child's ability to determine personal

irrelevance of a situation, and the child's use of problem solving

techniques as a resource for coping.

The first issue addressed was the child's ability to engage in the

process of appraisal. At what age are children able to appraise an event

and is there a relation between appraisal and Piaget's concept of

classification? The question of classification arose because to appraise

an event as benign-positive, irrelevant, or stressful some type of

classificatory function must occur. As noted previously, formal

classificatory ability, involving class inclusion, intension, and

extension, is achieved during the stage of concrete operations (Brainerd,

1978; Ginsburg & Opper, 1988). However, precursors to classification do

29

occur during the sensorimotor and preoperational stages (Piaget &

Inhelder, 1969). In a summary of research concerning classification,

Gelman and Baillargeon (1983) discussed the indications that children as

young as 12 months appear to perceive and classify objects as similar or

different. Therefore it is reasonable to assume that from a very early

age, children are able to classify an object or event, although not

according to the formal properties of the concept.

The process of appraisal, however, is not identical with that of

classification. While general classification of the object or event is

necessary for appraisal, it is not sufficient. The child must also

determine the implications of the event for personal well-being, a element

not involved in classification. A study by Levy (1960) illustrates the

interaction of the classification and appraisal concepts. Observing the

reactions of children receiving injections, Levy noted that children as

young as six months of age who had received previous shots reacted

negatively to the appearance of a needle and syringe. This gives evidence

that the child recognized and classified the object based on prior

experience and then appraised the situation as having personal

implications for well-being. To continue this example, the same six month

old child would likely have reacted positively to the sight of a bottle,

additional confirmation that the very young child is able to appraise the

personal implications of an event for well-being. Although a young child

may not have achieved an understanding of class inclusion properties, he

or she does appear to appraise an event based on the current level of

cognitive functioning. In this manner, appraisal may be considered to be

an age independent function; whether or not an adult would consider a

30

child's appraisal as accurate, if the child appraises an event as

stressful, it is stressful for that child.

A second issue concerning application of the Lazarus theory of

stress and coping to children centers on the child's ability to appraise

of an event as irrelevant to personal well-being. Although children of

all ages have some form of egocentric thought (Inhelder & Piaget, 1958),

it is the child less than 7 years of age, not yet in the stage of concrete

operations, who is incapable of taking another's role or viewpoint

(Piaget, 1959). A child who is unable to take the viewpoint of another

thinks that all events (of which he or she is aware) occur because of him

or for his benefit and therefore will assume that all events have

implications for his personal well-being, either beneficial or stressful.

Therefore, it is likely that the child in the sensorimotor or

preoperational stages is incapable of appraising an event as irrelevant to

their well-being. In contrast, the child who has experienced decentration

in the process of cognitive restructuring will understand that not all

events are personally relevant, and will be more likely to judge some

events as irrelevant to personal well-being. Thus, the appropriateness of

the concept of irrelevant appraisal will depend on the age of the children

being studied.

A third issue when using the Lazarus paradigm to study the process

of stress and coping in children is related to secondary appraisal of

coping resources and the individual's problem solving ability. In

Piaget's research, the process of children's thinking was studied by

observing the child in problem solving activities such as finding hidden

objects, conservation tasks, or establishing equilibrium on a balance

scale. In general, children tended to use trial and error to deal with a

º

31

novel situation until they discovered the principles needed for that

activity. Once the principles were grasped, the child quickly achieved

mastery of the problem, the age of mastery varying with the specific

problem. The trial and error process does require the child to think of

alternative solutions to the problem, but the total range of alternative

actions and the potential effectiveness of one solution as compared to

another is not considered a priori. It is only in the stage of formal

operations that the adolescent becomes able to engage in hypothetico

deductive reasoning, developing propositions and systematically testing

the results of alternative solutions (Inhelder & Piaget, 1958).

Although Piaget's research using problem solving situations did not

involve events likely to result in an appraisal of stress by the child,

the child's process of using the personal resource of problem solving when

dealing with a stressful event would be similar. When confronted with a

stressful event, the child will act according to the most apparent, method

of dealing with the event, rather than selecting the method most likely to

produce the desired outcome as would the adolescent or adult. If the

first method is not successful, an alternative will be used, until either

a successful mode is discovered or the event is over. From experience,

observation of other children, or guidance from an adult, the child may

learn what behaviors are most likely to be effective in coping with a

stressful situation and will selectively use these behaviors in the

problem solving process of secondary appraisal.

In summary, examination of these key elements has demonstrated

several important points. First, the child is able to engage in the

process of appraisal from a very early age, although the result of the

appraisal may differ from that of an adult in the same situation. Because

s

32

appraisal is based on a individual interpretation of the transaction

between the person and environment, if the individual, in this case a

child, appraises as event as stressful, it is stressful to that child,

whether or not an adult, or even another child, would agree. Second, the

ability of the child to appraise an event as irrelevant to personal well

being will be dependent on the child's current thinking in terms of the

concept of centration/decentration. If the child has developed the

understanding that all events do not have implications for personal well

being, then that child will be able to appraise an event as irrelevant.

Acquisition of this cognitive process generally occurs during the

transition period between the preoperational and concrete operational

stages. Finally, from an early age the child is able to use problem

solving techniques to cope with perplexing or stressful events. However,

it is not until the child is able to use propositional thinking that

problem solving is used in a systematic manner. Until that time, coping

behaviors may occur in a haphazard manner or may reflect prior experience

despite the potentially greater efficacy of untried coping behaviors. In

conclusion, because the Lazarus paradigm considers stress to be a personal

phenomenon based on individual's thinking about the event and because

coping is based on the individual's personal resources, such as the

current cognitive approach to problem solving, this theory permits

examination of the unique individual and developmental differences in

stress and coping process, rendering it an appropriate model for use in

studying the stress and coping of children.

ºs*

33

Literature Review

In developing this study, literature pertaining to the constructs of

children's stress and coping was reviewed with an emphasis on research

directly relating to hospitalized school-age children, although other

studies dealing with stress and coping of non-hospitalized child or other

age groups were included as appropriate. The questions guiding this

literature review were, 1) What events during hospitalization do school

age children appraise as stressful?, 2) What coping behaviors do school

age children use during hospitalization, dental care, or other health

related situations?, 3) What variables have been studied in relation to

the child's stress and coping process during hospitalization?

Accordingly, the first section will analyze the information available

pertaining to events or situations children appraise as stressful while

hospitalized. The second section will review studies focusing on the

coping behaviors used by school-age children to deal with stress during

hospitalization or other health care situations. The final section will

examine research relating to the variables responsible for differences in

children's appraisal of stress and the resulting coping behaviors.

Research on Sources of Stress during Hospitalization

A basic premise of this study was that the experience of

hospitalization is psychologically upsetting for a child. Numerous

authors have referred to the disturbing effect of hospitalization on

children. In their classic work on children's emotional reactions to

hospitalization, Prugh, Staub, Sands, Kirschbaum, & Lenihan (1953)

concluded that all the subjects showed some reaction to the event of

34

hospitalization as distinct from the reaction to illness. Later Prugh

(1965) generalized this conclusion to include all hospitalized children.

Sipowicz and Vernon (1965), following a comparison of hospitalized and

nonhospitalized twins, concluded that even a brief hospitalization is

psychologically upsetting to children. Oremland and Oremland (1973) and

Goslin (1978) both describe the event of hospitalization as a life crisis

for a child. Adams (1965) and Illingworth (1958) discuss the trauma

associated with hospitalization, and Erickson (1963) states, "Illness and

hospitalization are traumatic at every stage and age of development" (pp.

47). Erickson also unequivocally identified hospitalization as stressful

for children by entitling a paper discussing anxiety of the pediatric

patient, Stress in the Pediatric Ward (1972), a view that is supported by

both Belmont (1970) and Langford (1961). Finally, in the extensive

literature reviews by Vernon, Foley, Sipowicz, and Schulman (1965) and by

Thompson (1985), the conclusion was reached that research indicates

hospitalization is upsetting to a child."

As the importance of this body of work has been recognized, the

focus of research has shifted toward events thought to be responsible for

the child's psychological upset. Empirical knowledge of the types of

events hospitalized children are likely to appraise as stressful comes

from two sources; indirectly through the observation and interaction with

children and directly from interviewing the child. The majority of

* The concept of psychological upset was defined, based on the workof Gellert (1958) and Chapman, Loeb, and Gibbons (1956), as a situation inwhich the child manifests behaviors such as crying of varying intensities,clinging to parents, eating problems, sleep disturbances, lack of controlof elimination processes, regression, withdrawal, restlessness, anxiety,fear of medical procedures, personnel and hospitals, death fears, tics,excessive concern with bodily functions, and destructive behavior (Vernonet al., 1965, pp. 5, 6).

;º

35

theoretical articles and research reports have been based on the indirect

knowledge, assuming that adults are able to correctly determine which

events will be stressful for the hospitalized child and then proceeding

with guidelines for preprocedural preparation or experimental testing of

various forms of intervention. Only a small portion of the literature

reports what the child actually appraised as stressful during

hospitalization. The sources of stress identified in these two bodies of

literature will be presented and commonalities discussed.

Sources of Children's Stress during Hospitalization Identified by Adults

Studies of children's stress during hospitalization generally have

proceeded on the basis that adults know what events are stressful for the

child. In the literature over three dozen sources of stress for the

hospitalized child have been identified. To analyze this information

common themes will be identified using the five categories of threats

identified by Visintainer and Wolfer (1975) and Wolfer and Visintainer

(1975): 1) physical harm or bodily injury, 2) separation, 3) the strange

or unknown, 4) uncertainty about limits, and 5) loss of control.

The category, physical harm or bodily injury, is perhaps the most

recognized and discussed area of threat and stress for the hospitalized

child. Children fear intrusion into their body (Ritchie, Caty, &

Bllerton, 1984; Ellerton, Caty, & Ritchie 1985) which may occur in the

Process of routine procedures such a temperature measurement and

*dministration of an oral medication (Erickson, 1958a, 1958b), in any

Procedure associated with needles, such as injections, I. V.'s. and

Venipuncture (Eiser & Patterson, 1984; Erickson, 1958a, 1958b, 1972;

Langford 1961), or in any of the multitude of diagnostic or therapeuticProcedures such as surgery, cardiac catheterization, cystoscoP+* *

º

º

36

bronchoscopic exams, paracentesis, or lumbar puncture (Langford, 1961;

Prugh et al., 1953). They fear mutilation during cast removal (Johnson,

Kirchhoff, & Endress, 1975) and during procedures or surgery (Barowsky,

1978; Erickson, 1972; Heavenrich, 1963; Hughes, 1967; Hughes 1982;

Jessner, Blom, & Waldfogel, 1952; Langford 1961; Prugh et al., 1953;

Vernon et al., 1965). They fear pain (Eiser & Patterson, 1984; Gofman,

Buckman, & Schade, 1957; Langford, 1961; May & Sparks, 1983; Rankin, 1988;

Stevens, 1986). They fear death by specific means such as suffocation,

drowning, starvation (Erickson, 1972), drugs (Astin 1977), being crushed

by radiological equipment (Fischman & Friedland, 1986), or death in

general (Erickson, 1972; Hughes, 1967; Prugh et al., 1953; Rankin, 1988;

Vernon et al., 1965).

The second category of threat, separation and abandonment, has been

well documented as a source of stress to the hospitalized child (Bowlby,

1973; Jessner, Blom, & Waldfogel, 1952; Robertson, 1970; Vernon et al.,

1965). Although children between the ages of 6 months and 3 to 4 years

demonstrate the most pronounced effects of separation (Prugh et al., 1953;

Vernon et al., 1965), older children also find separation from parents to

be a difficult experience (Erickson, 1965; May & Sparks, 1983; Prugh et

al., 1965).

The third category of threat or stress for the child is the strange

and the unknown. Heavenrich (1963), Lambert (1984), Meeks (1970), and

Thompson and Stanford (1981), as well as Visintainer and Wolfer (1975),

identify unfamiliarity with the hospital as a source of stress for

children.

The fourth category of potential stress for the child is uncertainty

**&arding limits and unacceptable behavior. Limit setting is a basic

s

º

37

principle of child discipline (Wise, 1986). However, it was mentioned by

only two authors (Lambert, 1984; Visintainer & Wolfer, 1975) in relation

to the hospitalized child. Perhaps uncertainty regarding behavioral

expectations is not as obvious a source of stress for the child as

intrusive procedures or separation from parents, but without such

structure, the child cannot know how to adapt his or her routine actions

to fit the hospital situation. To decrease stress, the child needs to be

told what behavior is acceptable and the reasons for the expectations.

The fifth category that may cause stress in the hospitalized child

is loss of control, both of the environment and of self (Heavenrich, 1963;

Lambert, 1984; Visintainer & Wolfer, 1975). The physical restrictions of

immobilization (Blom, 1958; Erickson, 1965, 1972; Freud, 1952; Thompson,

1985) or confinement, such as isolation (Kueffner, 1975; McGuire,

Shepherd, & Greco, 1978; Powazek, Goff, Schyving, & Paulson, 1978;

Thompson, 1985) are particularly stressful to the child due to hinderingthe child's normal activities and preventing release of stress and tension

through action. Another source of stress related to loss of control is

anesthesia and loss of consciousness (Blom, 1958; Erickson, 1965; Hughes,

1967; Thompson & Stanford, 1981). Children often fear what might happen

to them while under anesthesia, and also what they might do when not in

full control of their impulses (Jessner, Blom, & Waldfogel 1952). This

fear is more prevalent in the late school-age years (Erickson, 1965;

Hughes, 1967).

While the impressions of adults, based on observation and

interaction with hospitalized children, regarding the events children find

**ressful during hospitalization are likely to be accurate, it is possible

that not all possible sources of stress may be identified in this manner.

º,

º

r*

i

º

38

It is important to find out directly from the child what aspects of

hospitalization are stressful.

Sources of Stress during Hospitalization Identified by Children

An extensive literature search resulted in only five studies in

which the school-age child's identification of stressful events during

hospitalization was assessed. The most comprehensive of these was done by

Menke (1972). For the purpose of identifying the stimuli that

hospitalized children perceive as stressful and the relationship between

these stimuli and the variables of age, gender, medical or surgical

diagnosis, length of admission, preparation for hospitalization, and prior

separation from family, the author used a self-developed instrument, based

on projective assessment techniques, to ascertain sources of stress for

hospitalized children, ages 4 to 12 years. One hundred and four children

were asked to respond to a set of 19 cards with pictures of stressful and

nonstressful stimuli relating to hospital procedures (a nurse, doctor.thermometer, hospital gown, hospital bed, medications, syringe, and

stethoscope) or relating to stimuli not normally associated with the

hospital (a man, woman, boy, girl, baby, dog, cat, food, toys, house, and

school). The stressful stimuli were selected based on the researcher's

experience with children, the literature, and a group of expert judges.

The child was asked to pick a card and tell what he or she thought about

the pictured item, a procedure that was repeated until all the cards were

used or the child declined to continue. Following the cards, the children

Were asked open-ended questions about their reaction to being in the

hospital. The children's responses were coded as stressful, nonstressful,* no reaction. All but one of the cards, the picture of toys, "**

identified as stressful by one or more children, and 18 additional

s

.

º

39 º,

stressful stimuli were mentioned during the interview. Analysis of the

data indicated that injections, hospital gowns, thermometers, pain,

confinement in bed, and separation from mother were the most frequently

cited sources of stress for the children. Of the variables examined, only

two factors, length of hospitalization and preparation for

hospitalization, had a significant relationship with the children's

perception of stressful stimuli during hospitalization.

In a partial replication of this study with a sample of 50 children,

ages 6 to 12 years, Menke (1981) focused on the two significant variables

in the previous study, preadmission preparation and length of admission as

related to the hospitalized child's perception of stressful stimuli.

Analysis of the data indicated that 86% of the children considered the

syringe to be stressful, 38% perceived the dog to be stressful, 36%

identified the doctor and food as stressful, and 32% indicated that the

Picture of the hospital gown was stressful. The rest of the pictures were

perceived as stressful by less than 32% of the subjects. The open-ended

questions yielded twenty-three additional sources of stress, such as

confinement to bed, having to remain indoors, pain, absence of parents,

and operations. In this replication the relationship between the

independent variables of preadmission preparation or length of admission

and the dependent variable of perception of stressful stimuli was not

supported.

Similar results were reported by Reissland (1983) in a study of the

relationship between cognitive maturity and the 4 to 13 year old child's

Perception of the hospital experience. Data was collected through an

interview, one segment of which assessed the child's hospital related

fears. Although analysis of these responses was not fully presented, it

s

º

s

40

was mentioned that the children's fears included specific events related

to surgery such as x-rays, injections, anaesthetic mask, and the

operation, as well as general concerns such as sleeping away from home and

branches rubbing on the windows at night.

The remaining two studies identified sources of children's stress in

conceptual categories rather than as specific events. As a measure of the

effectiveness of an inservice education program focused on increasing

awareness of children's needs, May and Sparks (1983) used a self-developed

questi ornnaire to assess the fears and concerns of 36 hospitalized children

between the ages of 7 to 12 years. Concerns identified by the children

included pain, permanence of condition, confinement, the unfamiliar,

**rtainty, socialization, and separation. Similar categories were

*Pºrted by Timmerman (1983) in a study of the preoperative fears of 10 to

12 year old children. Analysis of interviews conducted with 16 subjects

**sulted in nine categories of fears: loss of control, the unknown,in i -"Je stions, pain or discomfort, lagging school achievement, destruction of

body i - - - - -mage, separation, disruption of peer relationships, and death.

Although the categorization scheme used by Timmerman (1983) and Mayand S

- - - - - - -Parks (1983) does not permit direct comparison with the specific

events- - -identified by Menke (1981) and Reissland (1983), several similar

theme- - -5 of stressful events are evident. The most evident theme is that of

fearS f intrusive procedures, primarily in the form of injections or

*Y. A second theme, pain, could be associated with the intrusiveP+ 9 se ea

- - -ures, or may be associated with other aspects of the illness. Thethira

- - - - -theme is that of separation from family, peers, and familiaract i

-*Yities, and the final common theme is confinement to bed or indoors.

41

Critique of the Studies of Sources of Stress

The critique of these studies of sources of children's stress during

hospitalization will be discussed according to the four categories of

threats to validity discussed by Cook and Campbell (1979). These

categories are threats to : construct validity, statistical validity,

internal validity, and external validity.

Threats to construct validity. The primary threat to construct

validity of this group of studies was related to the theoretical framework

and subsequent definition of the construct being studied, that is stress,

fear, needs, or concerns. Of the five studies, only the first of the

Menke (1972) investigations stated a theoretical basis for the study, an

integration of several theories of perception and stress, and provided a

definition of the target construct. Her subsequent work (1981) did not

discuss the framework but did give the same definition of stress. None of

the other authors indicated use of a theoretical framework to guide the

investigation of the children's perception of stress or identification of

fears and concerns or provided a definition of the target construct,

resulting in a possible lack of clarity of the construct and uncertainty

regarding the validity of the information.

An additional threat to construct validity present in all the

studies, although most identifiable in Menke's (1972, 1981) research due

to the inclusion of the "no reaction" coding, was the assumption that the

subjects would identify the major sources of stress or fear. This may be

*n inaccurate assumption as it is possible that some children may have

Perceived selected stimuli as so stressful that they avoided talking about

that situation, possibly resulting in an inaccuracy in identify the

*ources of stress. Although it would be difficult to design a study to

C

y

º

42

circumvent this problem, it should be recognized as a limitation of the

studies.

Threats to statistical validity. The primary threat to statistical

validity was the low power of the most of the studies due to small sample

sizes - None of the studies provided information on statistical power, but

assuming the standard alpha of .05 and a medium effect size coupled with

the sample size of each study, the power of the studies were .21

(Timmerman, 1983), .44 (May & Sparks, 1983), . 57 (Menke, 1981), .64

(Reiss land, 1983), and . 86 (Menke, 1972). Only the original Menke (1972)

study achieved a power above the generally acceptable .80 level (Munro,

Visintainer, & Page, 1986). Interpreted, this means that most of the

***dies had a very low probability of rejecting a false null hypothesis

****1 tirig in a failure to recognize a difference existed if it existed.

Thus, some sources of stress for hospitalized children may not have been

identified.

4A second threat to statistical validity is the use of researcherd *Yeloped instruments. Use of self-developed tools in these studies wasn **essar due to the lack of standardized instruments to examine they

constr- - - - - -Victs; however, the result is a deficit of information regarding

Validi- - - - - -ty and reliability. Of the five studies, all used semi-structured

int **Views, permitting the child to individually identify sources ofstres

- -5 or fear, an approach that is appropriate for exploratory studies.In a cl -cli tion, the Menke (1972, 1981) studies used pictures of predeterminedsti *Ali. somewhat circumscribing the child's report of stressful events,but

**is was balanced by the open-ended questioning regarding additionalSOvl *ses of stress. Ideally, these studies should be replicated and the

43 º,

interview questions refined as needed to develop an interview schedule

that may be tested for validity and reliability.

Threats to internal validity. The internal validity of a study is

of concern in experimental and quasi-experimental research when events

occurring between the pretest and posttest may influence the performance

on the latter (Phillips, 1986). Of the five studies reviewed in this

section, all were descriptive in nature; none examined change in response

over time due to experimental intervention or nature events. Therefore,

no threats to internal validity, such as history, maturation, or repeated

testing occurred.

Threats to external validity. External validity is threatened due

to the failure to control variance of extraneous factors sufficiently

through randomization or the inclusion/exclusion criteria of the samples,

resulting in difficulty generalizing the results to other populations. In

this group of studies, none of the studies were randomized and only Menke

(1972, 1981) stated inclusion/exclusion criteria that attempted to control

extraneous variables. The only control identified by two other

researchers was limiting the investigation to surgical patients

(Reissland, 1983; Timmerman, 1983). The final study (May & Sparks, 1983)

included all children of the designated age admitted to the pediatric

unit. While these approaches have provided necessary basic information

and may have been appropriate for the purposes of the studies, they do not

Provide sufficient basis for generalization to specific subgroups of

*ubjects, such as children with chronic or acute illnesses, males versus

females, or subjects with varying levels of trait anxiety.

A second factor preventing appropriate generalization of the

ºnformation is the broad age range of subjects, 4 through 13 years. None

*

44

of the studies provided rational for the target age group and none focused

on children within one cognitive developmental stage. Menke (1972) did

subdivide the children into two groups, 4 to 7 years and 7 to 12 years

based on Piaget's stages, but did not state which group the 7 year-olds

were assigned to, and did not test for evidence of concrete operational

thinking in these children or for formal operational thinking in the older

subjects. Although Reissland (1983) stated a purpose of examining the

child's reactions to hospitalization according to cognitive maturity, and

her cluster analysis indicated that the subjects under 7 years 3 months

did differ in their responses from subject over 7 years 4 months, this was

not linked to any developmental theory, such as Piaget's cognitive

developmental stages. The assumption that the level of cognitive

development does not influence appraisal of stressful events should not be

made, but rather should be carefully investigated to determine possible

differences in appraisal due to cognitive functioning.-

In general, because research regarding events children appraise as

stressful during hospitalization is in an early stage, the descriptive,

exploratory design of the individual studies appears to be appropriate for

the question. Although the theoretical basis of the studies was weak, the

methodology generally is congruent with the Lazarus concept of individual

*PPraisal of stress as in each study the child was asked what he or she

Perceived to be stressful. The use of interview to obtain baseline

information was appropriate for the age of the subjects (with the possible

exception of Menke's [1972) and Reissland's [1983) inclusion of four year

old children in the general interview process). The generally low

statistical power, and the potential difficulties generalizing the results

emphasize the need for further research in this area. Despite these

■

º

X

** ** -

45

limitations, the studies do provide important information about what

school-age children are likely to appraise as stressful during

hospitalization.

Comparison of Adult and Child Identification of Sources of Stress

Comparison of what children appraise as stressful during

hospitalization and what adults think is likely to be stressful to the

hospitalized child demonstrates striking similarities. Both children and

adults identify intrusive procedures as a source of stress, the child

interpreting these events as a threat to physical well-being, one of the

sub-classifications of stress (Lazarus & Folkman, 1984a). Separation is

identified as a source of stress by both the children and adults.

According to the stress and coping framework, this could result in stress

due to the alteration in the child's resources for coping with altered

person-environment situation (Lazarus & Folkman, 1984a). Similarly, both

groups identify the unknown, uncertainty and loss of control as stressful.

According to Lazarus and Folkman (1984a), these are not direct sources of

stress, but rather are factors that will determine if the person is able

to consider a stressful encounter as a threat or a challenge. Finally,

adults generally assume that hospitalization will be stressful for all, an

assumption that may not be accurate. Because appraisal of stress is an

individual process, it is possible that not all children will consider

hospitalization to be stressful, a possibility that is supported by the

9°casional child who prefers to remain in the hospital rather than face a

*ifficult family or peer situation. In sum, while adults are generally

able to identify the events a hospitalized child will find to be

stressful, only the child can identify the event that he or she has

personally appraised as stressful. Both perspectives are needed to

º

º

º

46

providesupporttothechildduringhospitalization.Ageneralawareness

oftheeventslikelytobeappraisedasstressfulwillhelpthe

professionalsdevelopaphilosophyofpediatriccarethatislikelyto

meettheneedsofmostchildren,whileknowledgeoftheindividualchild's

appraisalofstresswillpermittheprofessionaltoadapttheplanofcare

tomeetthatchild'sneeds.

ResearchonCopingduringHospitalization

Theconstructofcopinghasreceivedattentionfromresearchers

focusingonboththehospitalizedchildandonchildrenexperiencingother

typesofstressfulevents.Theprimaryfocusofthisportionofthe

literaturereviewwillbeonresearchrelevanttopatternsofcopingused

bytheschool-age,hospitalizedchild,withinclusionofotherselected

studiesrelatingtohealthcaresituationsand/orschool-agechildrenasappropriate.First,thecopingstrategiesofchildren,asreport.inthe

literature,willbeexamined(SeeTable1)andthemajorfindingsofthe

studiesgiven.Second,variablesthathavebeennotedtoinfluencethe

typeofcopingbehaviorusedwillbediscussed.

CopingStrategiesReportedintheLiterature

Examinationoftheresearchindicatesthatseveraldistinctive

approacheshavebeenusedtoclassifyoridentifythecopingbehaviors

usedbychildren.Theseare1)Murphy'scategoriesofcoping

(Murphy,1962;Murphy&Moriarty,1976),2)Lazarus'modesofcoping(Cohen

&Lazarus,1979,1983;Lazarus&Launier,1978),3)uni-dimensional

assessmentofcopingbehavior,4)useofcontentanalysistoidentify

47

Table 1

Coping Strategies of Children

Investigator Subjects

Murphy's Categories of Coping:

Murphy, L. B. N: 32(1962) and Age: PreschoolMurphy, L. B., Healthy

& Moriarty, A. E.(1976)

Rose, M. H. N: 14(1972a, 1972b) Age: 18 m to 7 y

Hospitalized forelective surgery orcardiac catheterization

Savedra, M. N: 33& Tesler, M. Age: 6 to 12 years(1981) Hospitalized for

elective surgery

Lazarus Modes of Coping:

Caty, s., N: 39 case studiesEllerton, M. , Age: 20 months to& Ritchie, S. 10 years(1984) Hospitalized

Ritchie, J. A., N: 208Caty, S., Age: 2 to 5 years& Ellerton, M. Hospitalized(1987, 1988)

Coping Strategies

Preparatory steps towardcoping

Active copingPassive coping

Precoping/OrientingActive Copingattempting to controlresistingcooperating or complying

Inactive

Pre-coping or OrientingActive Coping

attempts to controlcooperation

-

resistance

suspendsignoresnegatesattacksmixed

Information-ExchangeAction/InactionIntrapsychic

Information seekingDirect ActionInhibition of action

Seeking or acceptinghelp or comfort from others

IntrapsychicMovement toward independence

or growth

º,

48

Hamner, S. B. ,& Miles, M. S.(1988)

Wertlieb, D.,Weigel, C.,& Feldstein, M.(1987)

N: 15

Age: 4 to 18 yearsBone Marrow Aspiration

N: 176Age: 6 to 9 yearsHealthy

Unidimensional Coping Constructs:

LaMontagne, L.(1984)

LaMontagne, L.(1987)

Field, T.,Alpert, B.,Vega-Lahr, N.,Goldstein, S.,& Perry, s.(1988)

Altshuler, J. L.,Ruble, D. N.(1989)

Burstein, S. ,& Meichenbaum, D.(1979)

Peterson, L.,& Toler, S. M.(1986)

N: 51

Age: 8 to 12 yearsHospitalized for minorsurgery

N: 42

Age: 8 to 18 yearsHospitalized for minorsurgery

N: 56Age: 4-10Hospitalized for minorsurgery

N: 72 (24 per group)Age: 5 to 6 years

7 to 8 years10 to 11 years

Healthy children

N: 20Age: 4.8-8.6 yearsHospitalized fortonsillectomy,adenoidectomy, ormyringotomy

N: 59 children

Age: 5 to 11 yearsHospitalized for minorelective surgery

Action/InactionIntrapsychicInformation-Exchange

Focus : SelfEnvironmentOther

Function: Problem SolvingEmotion-Management

Mode: Information SeekingSupport seekingDirect ActionInhibition of action

Intrapsychic

Avoidant-Active Dimension

Avoidant-Active Dimension

Sensitizer/Repressor

Approach-Avoidant strategiesDirect Emotional Manipulation/tension reduction

Maladaptive strategies

Low defensive/High defensiveWork of worrying/Avoidance

Information-seekingdisposition

Avoidance disposition

49

Coping Behaviors Identified through Content Analysis:

Stevens, M.(1984, 1989)

Neff, E. J. A.(1978)

Youssef, M. M. S.(1981)

Siegel, L. J.,& Smith, K. E.(1989)

Walker, C. L.(1988)

N: 59

Age 12 to 17 yearsHospitalized forsurgery

N: 5

Age: 10-15 yearsHospitalized due tokidney failure andinitiation ofhemodialysis

N: 10Age: 7-11 yearsHospitalized forcardiaccatheterization

N: 80

Age: 8 to 14 yearsHospitalized for minorsurgery

N: 26

Age: 7 to 11 yearsSiblings of childrenwith cancer

DistancingSelf-controlSituational controlInaction

Active copingSeeking social Support

OrientingResisting

aggressionavoidance

Adaptivecooperationparticipationplanningevaluating

Orienting behaviorsSeeking support behaviorsAvoiding behaviorsExpression-of-feelingbehaviors

Distraction

Reinterprets sensationsFantasyMental rehearsal -

Information seekingPositive self-statements

Negative self-statementsCatastrophizing thoughtsAffective expressionAffective inhibitionRelaxation

Seeking help/emotional supportPhysical activitySeeks active termination of

procedurePassive acceptance

Cognitive domains:IntrapsychicInterpersonalIntellectual

Behavioral domains:

Self-focusingDistractionExclusion

K

50

Ryan, N. M. N: 103(1989) Age: 8 to 12 years

Healthy children

Sorensen, E. S. N: 32(1990) Age: 8 to 11 years

Healthy children

Social supportAvoidant activitiesEmotional behaviorsDistracting activitiesCognitive activitiesPhysical exerciseAggressive motor activitiesAggressive verbal activitiesIsolating activitiesHabitual activitiesSpiritual activitiesRelaxation activities

Cognitive-intrapsychicEmotional/sensoryAnalyzing/intellectualizingThought reframingEmotional/external focus

Cognitive-behavioralSubmission/enduranceEmotional expressionsTaking responsibilityRebellion

Behavioral

Problem solvingDistraction

Behavioral reframingAvoidance/flightAggression

-

Manipulation/deceptionImmobilizationSelf-effacing behaviors

IntrapersonalMom and DadOthersPeers

Coping Strategies Identified through other methods:

Curry, S. L., N: 48& Russ, S. W. Age: 8 to 10 years(1985) Well children having

dental work

Categories basedon cognitivebehavioralliterature

Behavioral Coping StrategiesInformation-seekingSupport-seekingDirect efforts to maintaincontrol

Cognitive Coping StrategiesReality-oriented working

throughPositive cognitiverestructuring

Defensive reappraisalEmotion-regulationBehavior-regulationDiversionary thinking

51

patterns of coping behavior, 5) other approaches. The coping research

will be discussed according to these groups.

Murphy's categories of coping. The pioneer researcher in the study

of children's coping was Lois Murphy. In 1953, while working at the

Menninger Foundation, Murphy began a longitudinal study of the ways

normal, healthy children cope with the stresses of life (Murphy &

Moriarty, 1976). Both naturalistic and experimental settings were used to

observe thirty children in a variety of situations over an eighteen year

period. In Murphy's early work, three categories of coping were

identified: 1) preparatory steps toward coping, 2) coping acts, and 3)

secondary efforts needed to manage the results of the precoping or coping

acts (Murphy, 1962), and later she also referred to "passive coping

devices" (Murphy & Moriarty, 1976). In Murphy's later work two global

categories of coping were identified: Coping I and Coping II. Coping I

involves the child's "capacity to cope with opportunities, challenges,

frustrations, threats in the environment; and Coping II, maintenance of

internal integration--that is, capacity to manage one's relation to the

environment so as to maintain integrated functioning" (Murphy & Moriarty,

1976, pp. 117). Examination of these concepts demonstrates a close fit

with Lazarus' concepts of problem focused and emotion focused coping

(Lazarus & Folkman, 1984a), providing additional support that the Lazarus

Paradigm may be appropriately used when studying children.

The earliest study on the coping of hospitalized children was

conducted by Rose (1972a, 1972b). Using Murphy's (1962) work as a

theoretical framework, Rose investigated the coping behaviors of fourteen

children, ages eighteen months to seven years of age, hospitalized for

surgery or cardiac catheterization. The children were observed at home

2

s

52

twice prior to admission, twice after discharge, and one or two times a

day while admitted (range of 5 to 27 in-hospital observations).

Additionally, the mothers were interviewed prior to the child's

hospitalization and after discharge. Analysis of the observations and

interviews indicated that during hospitalization the children used pre

coping or orienting behaviors, defined as, "the process by which the child

familiarizes himself with the environment" (Rose, 1972a, pp. 18), and

active coping, defined as, "the process by which a person deals with

threatening, frustrating, or challenging situations" (Rose, 1972a, pp.

19). Active coping was further subdivided into attempts to control,

resistance, and cooperation or compliance. Using these categories, the

results showed that during hospitalization the children demonstrated an

increase in precoping or orienting behaviors and a decrease in active

coping as compared with prehospitalization behavior. Following discharge

the children's behaviors returned to prehospitalization patterns.”

These findings were partially confirmed by Savedra and Tesler (1981)

(also Tesler and Savedra, 1981). Using a direct coding adaptation of

Rose's protocol”, the subjects, 33 children ages 6 through 12 admitted for

elective surgery, were observed during key stress points of

hospitalization (Wolfer & Visintainer, 1975) for a total of 1,093 five

"inute intervals. The intervals were categorized as inactive, precoping,

°º active coping (subcategorized as attempts to control, cooperative,

resistive, suspends [defined as avoidance), ignores, negates, attacks, and

mixed) according to the frequency of the behaviors. Analysis of the data

*This direct coding adaptation of Rose's coping categories was doneby Bishop (1976) and later used by Stewart (1978). These reports are notincluded in this literature review as the focus was limited to preschoolchildren and does not directly contribute to the foundation of knowledgefor the current study.

53

indicated that preoperatively the children were more likely to use

precoping or orienting behaviors and active-controlling behaviors. Post

operatively the children primarily used controlling behaviors. It was

also noted that multiple forms of coping were used within a short time

frame, emphasizing the dynamic nature of the coping process.

In sum, the studies using Murphy's work on children's coping have

identified two primary categories of coping. Pre-coping or orientating

behaviors are used to gain information about the environment. Active

behaviors are used to deal with a threatening or challenging situation and

have been subcategorized as attempts to control, resistance, cooperation,

suspends, ignore, negatation, and attack.

Lazarus' modes of coping. As an alternate to using Murphy'scategories of coping, a number of researcher's have used Lazarus' modes of

coping to study children's methods of dealing with the stress. In an

early exploration to determine if the Lazarus model could be applied to

children's coping, Caty, Ellerton, and Ritchie (1984) reviewed 39 case

studies of the coping behaviors of hospitalized children, ages 20 months

through 10 years. Through content analysis it was determined that the

reported behaviors of the children could be categorized systematically

using a modified version of the Lazarus modes of coping: 1) information

exchange, 2) action/inaction, and 3) intra-psychic. Reflecting on theprocess of this analysis and a theoretical discussion with Lazarus, it was

recommended that the first category be limited and the second expanded in

future investigations of child's coping behaviors. Accordingly, in

subsequent work by the same group (Ritchie, Caty, & Ellerton, 1987;

Ritchie, Caty, & Ellerton, 1988), the categories used more directly

reflected Lazarus' original five modes of coping: 1) information seeking,

54

2) direct action, 3) inhibition of action, 4) seeking or accepting help or

comfort from others, and 5) intrapsychic, with one additional category,

6) movement toward independence or growth. In this study, the coping of

208 hospitalized children, age 2 to 5 years was observed during low stress

(routine activities of daily living taking place in an unfamiliar

environment such as meals, play, and hygiene) and high stress situations

(illness related activities such as physical assessment, intrusive

procedures, and treatments). Analysis indicated that children use fewer

coping behaviors during high stress situations than in low, and that

chronically ill children with prior experience use more coping behaviors

than do acutely ill children who have had limited prior hospital

experience. This study used the six modes of coping as a vehicle for

examining differences in the responses of children to stress; no further

recommendations for changes in the categorization were given.

Hamner and Miles (1988) used the three category modification (Caty,

Ellerton, & Ritchie, 1984) of Lazarus' modes of coping to study the coping

strategies of fifteen 4 to 18 year old children during bone marrow

aspiration as a part of a cancer protocol. They found the largest

percentage of coping strategies reported by the children were action

inaction behaviors; intrapsychic strategies were reported second most

frequently; and information-exchange was reported least frequently. This

latter finding differs from the high occurrence of information seeking in

the studies based on Murphy's coping concepts. While the children stated

that they wanted the doctors to describe what was being done, the children

seldom reported asking for information. A possible explanation for this

is that all had been in treatment for the disease for over a year and were

familiar with the procedure.

-

55

Another study strongly based on the Lazarus paradigm was conducted

by Wertlieb, Weigel, and Feldstein (1987) to develop a taxonomy of the

coping processes used by children in everyday activities. A semi

structured interview was used to obtain a self-report of stressful events

and the resulting coping behaviors from 176 children ages 6 to 9 years,

the sample obtained from the cliental of a health maintenance

organization. The results were coded according to 1) a focus of self,

environment, or other; 2) a function of problem-solving or emotion

management coping; and 3) a mode of information seeking, support seeking,

direct action, inhibition of action, or intrapsychic. Analysis indicated

that this taxonomy did provide an effective method of categorizing

children's coping behaviors. However, it should be noted that the probes

used during the interview (D. Wertlieb, personal communication, July 7,

1989) were strongly biased toward eliciting responses that would be

congruent with the proposed taxonomy, compounding the methodology with the

OutCOme .

In sum, Lazarus' five modes of coping have been used directly as

delineated by those developing the theory and also have been modified to

a three mode and a six mode version to attempt a better fit with

children's coping behaviors. It appears that the five modes, direct

action, inhibition of action, intrapsychic, information seeking, and

support seeking, represent categories of coping behaviors that are used by

children. Additionally, identification of other modes of coping such as

movement toward independence or growth may be necessary when studying

children's coping behaviors.

Uni-dimensional coping constructs. A third method of categorizing

child's coping behaviors has followed a uni-dimensional assessment of

-

56

coping, focusing on the broad range of one behavior, rather than a multi

dimensional approach such as used by Murphy and Lazarus. This approach

was used by LaMontagne (1984, 1987) in a series of studies examining the

relationship between an avoidant/active coping dimension and the child's

locus of control”. The children's preoperative mode of coping was

determined by interviewing the child and rating the data on a 1 to 10

scale with avoidant coping (little knowledge of the impending surgery and

little tendency to seek such knowledge) at the low end, and active coping

(detailed knowledge of the reason for and procedure of surgery and

willingness to discuss the event) at the high end. As hypothesized,

children who used active modes of coping preoperatively were more likely

to have an internal locus of control than were children who used avoidant

or a combination of avoidant/active coping.

A similar, if not identical, uni-dimensional construct was studied

by Field, Alpert, Vega-Lahr, Goldstein, and Perry (1988). In this study

the dimension was labeled as sensitizer/repressor, sensitizers being those

children whose normal behavior was to actively seek information about a

stressful event, and repressors being those who avoided such information

or used defenses such as denial. Using mother-report, the coping style of

56 children, 4 to 10 years of age, during hospitalization for minor

surgery was determined and compared to their responses to stressful

hospital experiences. Analysis of the data indicated that children rated

as being sensitizers showed more activity, more information seeking, were

*This study was based on the approach-avoidance coping behaviors ofadults (Cohen and Lazarus, 1973; Cohen, 1975). In investigatingchildren's coping, LaMontagne (1984) believed the term active coping moreaccurately reflected the process of a child's coping than the termvigilant coping used by Cohen.

57

more distressed by intrusive procedures, and had shorter ICU admissions

than did children rated as repressors.

Altshuler and Ruble (1989) also used the approach-avoidance

dimension in a study of developmental changes in child's coping with an

unavoidable stressor, incorporating a distinction between complete and

partial avoidance. Seventy-two healthy children were studied, 24 in each

age group of 5 to 6 years, 7 to 8 years, and 10 to 11 years. The children

were told four stories, two depicting positive stress and two negative

stress, and were asked questions pertaining to how they thought the child

in the story might cope with the situation. In the analysis of the data,

two categories were added to the approach-avoidance scheme: direct emotion

manipulation/tension reduction, and maladaptive strategies. Statistical

analysis indicated that the strongly dominant coping strategy of choice

for children of all ages was avoidance, the younger children being more

likely to suggest escape strategies and the older children more likely to

identify methods of decreasing emotional distress through cognitive

distraction. Behavioral distraction, the coping strategy most frequently

reported, was mentioned by children at all ages. Although the sample was

healthy children, because the focus was on children's coping with

uncontrollable situations, the results may have important implications for

the study of the coping behaviors of the hospitalized child.

Burstein and Meichenbaum (1979) studied the dimension of a child's

defensiveness, as well as the characteristic of anxiety, prior to surgery

in relation to coping behaviors. The play of 20 children, ages 4.8

through 8.6 years was observed before and following surgery. The children

were presented with two sets of toys, each set consisting of one toy

relevant to the hospital and one toy of equal interest. Analysis of the

58

play sessions indicated that the children who played with the hospital

related toys prior to surgery, a behavior designated as low defensiveness,

had less post-operative anxiety than did those children demonstrating high

defensiveness by avoiding the stress related toys. The researchers

believed this was indication of coping behaviors similar to the "work of

worrying" and avoidance seen in adults.

Peterson and Toler (1986) examined a narrower segment of the

approach-avoidance dimension of coping in a study focusing on the presence

of an information seeking versus avoidance disposition in children. Data

were collected from 59 children admitted for minor surgery using a variety

of researcher developed tools. The major results indicated that children

do have an information seeking dimension; that children with high

information seeking behaviors are more adaptive during anesthesia, less

distressed following surgery than are children with avoidant behaviors;

and that age and information seeking are positively related.

In sum, five researchers have used a unidimensional approach to

studying children's coping behaviors. Although the labeling differs, it

appears that the same dimension has been examined in all of the studies:

avoidant, repressor, or high defensive behaviors as compared to active,

sensitizer, low defensive, or information seeking behaviors. That these

behaviors occur is evident. Perhaps the primary question is the optimal

method of identifying coping categories: should these behaviors should be

considered as the extremes of one dimension of coping or should they be

considered to represent two or more distinctive modes of coping.

Content analysis. Rather than imposing a predetermined scheme of

coping on the data, a number of researchers chose to use the process of

content analysis to identify categories of children's coping. In one of

59

these studies the category derivation was strongly linked, although not

identical to, a theoretical base, while other researchers developed an

atheoretical categorization scheme.

The study by Stevens (1984, 1989) illustrates the use of content

analysis while retaining a definite link between a conceptual framework

and the identified categories of coping. The coping strategies of 59

adolescents hospitalized for surgery were examined by talking to the

subjects prior to and following surgery using a semistructured interview

based on Lazarus' theory of stress and coping. Content analysis of the

data resulted in six categories of coping: distancing, self-control,

situational control, inaction, active coping, and seeking social support.

While the first three categories are distinct from the modes proposed by

Lazarus, the last three categories reflect the researchers familiarity

with the Lazarus modes of coping, a correspondence that is appropriate

when supported by the data.-

Atheoretical content analysis was used by the remaining researchers

in this category. In two methodologically similar studies conducted by

doctoral students at the University of Pittsburgh, the purpose was to

investigate how children manage and adapt to (Neff, 1978), or their

behavioral responses to (Youssef, 1981), a stressful hospital experience.

Although the term coping was not used, the authors' operationalization of

manage and behavioral responses are congruent with the definition of

coping used in this paper. Neff (1978) examined the adjustment of 5

children, ages 10 to 15 years, to shunt insertion and hemodialysis and

observed three responses used by the children to manage the physical

changes associated with their treatment: orientation, resistive, and

adaptive responses. It was noted that the child's behaviors changed as

60

experience was gained with the procedure with orientation behaviors

decreasing and adaptive behaviors increasing. In the study by Youssef

(1981), observations were made of the behavioral responses of 10 children,

ages 7 to 11 years, undergoing echocardiography and cardiac

catheterization. The four categories of self control identified during

content analysis of the data were orienting, seeking support, avoiding,

and expression-of-feeling. Orienting behaviors, the most frequently

observed behavior, occurred significantly more often during the

echocardiogram than during the catheterization, whereas seeking support,

the second most frequent behavior, occurred significantly more often

during the catheterization than during the echocardiogram. The remaining

two categories were infrequently used and did not have a significant

relationship with any of the variables.

Siegel (Siegel, 1983; Siegel & Smith, 1989) investigated the

relationship between the coping strategies used by hospitalized children

in response to painful and stressful procedures and the child's adjustment

to the hospital. Using a structured interview format, data were collected

from 80 children, 8 to 14 years of age, hospitalized for minor surgery.

Analysis of the responses resulted in fifteen categories of coping: 1)

distraction, 2) reinterprets sensations, 3) fantasy, 4) mental rehearsal,

5) information seeking, 6) positive self-statements, 7) negative self

statements, 8) catastrophizing thoughts, 9) affective expression, 10)

affective inhibition, 11) relaxation, 12) seeking help/emotional support,

13) physical activity, 14) seeks active termination of procedure, and 15)

passive acceptance. It was noted that children who were successful copers

(defined as being cooperative, showing low anxiety, and having high

thresholds for physical discomfort) were more likely to ask questions and

61

used a greater number of coping strategies than did the unsuccessful

copiers. As noted above in the presentation of Lazarus' theory, labeling

coping as good or bad is not appropriate as it is difficult to determine

the effectiveness of the coping and because it confounds coping with

outcome. From the reports of this study it is difficult to determine if

the researcher actually was focusing on the child's adaptation to the

hospital and confused the process of coping with the outcome of

adaptation, or if the purpose was to actually evaluate effectiveness of

the coping behaviors.

The final three studies in this category focus on the coping of

healthy, rather than hospitalized, school-age children, and are included

to provide a broad understanding of children's coping behaviors. In a

study of the coping behaviors of 26 siblings, ages 7 to 11 years, of

childhood cancer patients, Walker (1988) used parent interview, sibling

interview, and a variety of projective tools to develop a taxonomy of

sibling coping. The cognitive domains identified were intrapsychic,

interpersonal, and intellectual, and the behavioral domains were self

focusing, distraction, and exclusion. Thirty-three separate categories

corresponding to the domains were listed. The author reported difficulty

in determining whether a behavior was primarily a cognitive or behavioral

strategy, supporting the findings of Lazarus and colleagues (cited above)

that emotion and problem focused coping generally occur simultaneously and

that one coping behavior may serve both functions. It was also noted that

there was a 44% disagreement in the parent's and child's reports of the

child's coping strategies indicating that the child, rather than the

parent, is the most accurate source of data for this type of study.

62

Ryan (1989) used content analysis to examine the data collected from

103 healthy children, ages 8 to 12 years of age, regarding the strategies

they used to help themselves deal with stressors encountered in daily

living. Group discussion and individual questionnaires were used to

obtain the children's responses to questions designed to tap the process

of coping and the efficacy of the coping. The resulting categories of

coping were: 1) social support, 2) avoidant activities, 3) emotional

behaviors, 4) distracting activities, 5) cognitive activities, 6) physical

exercise, 7) aggressive motor activities, 8) aggressive verbal activities,

9) isolating activities, 10) habitual activities, 11) spiritual

activities, and 12) relaxation activities. Statistical analysis indicated

that the first five categories accounted for two-thirds of the coping

behaviors, that different coping behaviors were used before, during, and

after the stressful event, and that children are able to evaluate the

effectiveness of the coping strategy in helping deal with the stressful

situation.

Finally, Sorensen (1990) used content analysis to examine the daily

coping responses of 32 healthy children ages 8 through 11 years. The

children were interviewed using a sentence completion list adapted from

Walker (1986) and were asked to keep a record of daily stress and coping

responses in a semistructured journal for a period of six weeks. Analysis

of the data resulted in identification of 21 categories (See Table 1)

grouped according to four major themes: cognitive-intrapsychic, cognitive

behavioral, behavioral, and interpersonal. Statistical analyses were

limited to frequency of category occurrence. It was noted that submission

or endurance was the most common response to daily stressors, and that

63

boys were more likely to use physical aggression whereas girls more

frequently reported using emotional forms of coping.

It is more difficult to summarize the categories of coping

identified though content analysis due to the lack of uniformity in

definition of a category, but certain behaviors do appear in most of the

lists. The coping behaviors repeatedly identified through content

analysis are: orienting or information seeking; active coping such as

cooperation or avoidance by attempting to escape the situation either

physically or psychologically; efforts to control the event; and seeking

social support.

Other approaches to categorizing coping behaviors. The remaining

study does not follow any of the previous methods of categorizing coping

behaviors, but it is useful in understanding children's coping behaviors.

Curry and Russ (1985) investigated the coping strategies of 8 to 10 year

old children during dental treatment. A total of forty-eight children,

(Phase I, N-18; Phase II, N-30) were observed during dental treatment and

interviewed following the procedure. Prior to data collection, the work

of major coping theoreticians was examined and synthesized into seven

categories of coping. During the process of data analysis these were

expanded to nine coping categories: 1) information-seeking, 2) support

seeking, 3) direct efforts to maintain control, 4) reality-oriented

working through, 5) positive cognitive restructuring, 6) defensive

reappraisal, 7) behavior-regulating coping cognitions, 8) emotion

regulating coping cognitions, and 9) diversionary thinking. The first

three were considered to be behavioral coping strategies and the last were

classified as cognitive coping strategies. It should be noted that in a

later article (Curry, Fuss [sic], Johnsen, & DiSantis, 1988) applying this

64

categorization to clinical work, defensive reappraisal was not included.

While impressive in the much needed attempt to synthesize the multitude of

coping categorizations, a major difficulty in this taxonomy is the failure

to consider that differences in the conceptual basis may render it

inappropriate to merge the categories from diverse theories, demonstrated

by the authors' inclusion of Lazarus' key construct of appraisal as a form

of coping equivalent to Murphy's (1962) cognitive mastery or Janis' (1958,

1965) work of worrying.

Summary of Coping Studies

The construct of coping has received considerable consideration from

researchers in the recent years. The primary difficulty in synthesizing

this information is the semantical, and sometimes theoretical, differences

in the labeling of coping behaviors and categories. Despite this problem,

several dominant themes repeatedly occur in the reports of children's

coping behaviors (See Table 2). One of the most frequently identified

categories describes the child's behavior when actively taking in the

environment to clarify and understand a situation. This category is

variously labeled precoping (Rose, 1972a, 1972b; Savedra & Tesler, 1981),

orienting (Neff, 1978; Youssef, 1981), information-exchange (Ritchie,

Caty, & Ellerton, 1987, 1988), information seeking (Peterson & Toler,

1986; Siegel & Smith, 1989), approach (Altshuler & Ruble, 1989),

sensitizers (Field et al., 1988) low defensive or the work of worrying

(Burstein & Meichenbaum, 1979), and analyzing/intellectualizing (Sorensen,

1990). A second recurring category is the child's physical or mentalattempts to remove self from the stressful situation identified as

avoidance (Altshuler & Ruble 1989; Burstein & Meichenbaum 1979;

LaMontagne, 1984, 1987; Neff, 1978; Peterson & Toler, 1986; Ryan, 1989;

65

Table 2

Synthesis of Reported Coping Behaviors

Category

Actively takingin theenvironment to

clarify andunderstand asituation

Physical ormental attemptsto remove selffrom thestressfulsituation

Label

Precoping

Orienting

Information-exchange

Information seeking

Approach

Sensitizer

Low defensiveness or

the work of worrying

Analyzing/intellectualizing

Avoidance

Resistance

Suspends

Ignores

Source

Rose, 1972; Savedra &Tesler, 1981

Neff, 1978; Youssef,1981

Ritchie, Caty, andEllerton 1987, 1988

Peterson and Toler,1986; Siegel andSmith, 1989

Altshuler and Ruble,1989

Field et al., 1988

Burstein andMeichenbaum, 1979

Sorensen, 1990

Altshuler and Ruble1989; Burstein andMeichenbaum 1979;LaMontagne, 1984,1987; Neff, 1978;Peterson and Toler,1986; Ryan, 1989;Sorensen, 1990Youssef, 1981

Rose, 1972a, 1972b;Savedra and Tesler,1981

Savedra and Tesler,1981

Savedra and Tesler,1981

66

Behaviorsintended tobring thechild's personalresponse to thestressfulsituation inline withreality

Attempts to dealwith thestressfulsituation bychangingthinking aboutthe situation

Distancing

Distraction

Seeks activetermination of

procedure

Diversionary thinking

Adaptation

Cooperation

Compliance

Reality-orientedworking through

Submission/endurance

Intrapsychic

Direct emotionalmanipulation

Reinterpretation ofsensations

Cognitive activities

Defensive reappraisalEmotion-regulatingcognitions

Positive cognitiverestructuring

Stevens, 1984, 1989

Siegel and Smith,1989; Ryan, 1989;Sorensen, 1990 Walker,1988

Siegel and Smith, 1989

Curry and Russ, 1985

Neff, 1978

Neff, 1978; Rose,1972a, 1972b; Savedraand Tesler, 1981

Rose, 1972a, 1972b

Curry and Russ, 1985

Sorensen, 1990

Caty, Ellerton, andRitchie, 1984; Hamnerand Miles, 1988;Ritchie, Caty andEllerton, 1987, 1988;Walker, 1988;Wertlieb, Weigel andFeldstein, 1987

Altshuler, and Ruble,1989

Siegel and Smith, 1989

Ryan, 1989

Curry and Russ, 1985

Curry and Russ, 1985

Curry and Russ, 1985

67

Control

Turning toothers for helpin coping

Coping throughexpression offeeling

Thought reframing

Control of thesituation

Control of others

Control of self

Control (unspecified)

Seeking social support

Expression of feeling

Affective expression

Emotional expression

Sorensen, 1990

Stevens, 1989

Ritchie et al., 1986;Savedra and Tesler,1981

Ritchie et al., 1986;Stevens, 1989;Youssef, 1981

Curry and Russ, 1985;Rose, 1972a, 1972b;Savedra and Tesler,1981

Curry and Russ, 1985;Ritchie, Caty, andEllerton, 1987, 1988;Ryan, 1989; Siegel andSmith, 1989; Sorensen,1990; Stevens, 1984,1989; Wertlieb,Weigel, and Feldstein,1987; Youssef, 1981

Youssef, 1981

Siegel and Smith, 1989

Sorensen, 1990

º

º

&

68

Sorensen, 1990; Youssef, 1981), resistive behaviors (Rose, 1972a, 1972b;

Savedra & Tesler, 1981); attacks (Savedra & Tesler, 1981) suspends

(Savedra & Tesler, 1981); ignores (Savedra & Tesler, 1981), distancing

(Stevens, 1984, 1989), distraction (Ryan, 1989; Siegel & Smith, 1989;

Sorensen, 1990; Walker, 1988), seeks active termination of procedure

(Siegel & Smith, 1989), rebellion (Sorensen, 1990) and diversionary

thinking (Curry & Russ, 1985). A third category is comprised of behaviors

intended to bring the child's personal response to the stressful situation

in line with reality. These were labeled adaptation (Neff, 1978),

cooperation (Neff, 1978; Rose, 1972a, 1972b; Savedra & Tesler, 1981),

compliance (Rose, 1972a, 1972b), submission/endurance (Sorensen, 1990) and

reality-oriented working through (Curry & Russ, 1985). A fourth category

frequently listed as a coping behavior is the child's attempts to deal

with the stressful situation by changing how he or she thinks about the

situation, identified as intrapsychic (Caty, Ellerton, & Ritchie, 1984;

Ritchie, Caty, & Ellerton, 1987, 1988; Hamner & Miles, 1988; Walker, 1988;

Wertlieb, Weigel, & Feldstein, 1987); direct emotional manipulation

(Altshuler & Ruble, 1989), reinterpretation of sensations (Siegel & Smith,

1989), cognitive activities (Ryan, 1989), though reframing (Sorensen,

1990), and defensive reappraisal, emotion-regulating cognitions and

positive cognitive restructuring (Curry & Russ, 1985). A fifth category

involves control and includes control of the situation (Stevens, 1989),

control of others (Ritchie et al., 1986; Savedra & Tesler, 1981), and

control of self (Ritchie et al., 1986; Stevens, 1989; Youssef, 1981), or

unspecified attempts to control (Curry & Russ, 1985; Rose, 1972a, 1972b;

Savedra & Tesler, 1981). The sixth category of coping used by children is

seeking social support (Curry & Russ, 1985; Ritchie, Caty, & Ellerton,

69

1987, 1988; Ryan, 1989; Siegel & Smith, 1989; Sorensen, 1990; Stevens,

1984, 1989; Wertlieb, Weigel, & Feldstein, 1987; Youssef, 1981). A final

category is coping through expression of feeling (Youssef, 1981) also

labeled affective expression (Siegel & Smith, 1989), and emotional

expression (Sorensen, 1990). Although active coping or direct action are

mentioned a number of times (Caty, Ellerton, & Ritchie, 1984; Hamner &

Miles, 1988; LaMontagne, 1984, 1987; Murphy, 1962; Ritchie, Caty, &

Ellerton, 1987, 1988; Rose 1972a, 1972b; Savedra & Tesler, 1981; Stevens,

1984, 1989; Wertlieb, Weigel, & Feldstein, 1987) as is inhibition of

action (Ritchie, Caty, & Ellerton, 1987, 1988; Wertlieb, Weigel, &

Feldstein, 1987), the coping behaviors that could be classified under

these headings have been included under the more specific categories

listed above such as the second and third categories. Taken as a whole,

these studies provide a good basis for understanding the range of coping

behaviors likely to be used by hospitalized school-age children.

Critique of the Coping Studies

As with the critique of research pertaining to sources of children's

stress during hospitalization, the studies relating to children's coping

will be discussed according to the four categories of threats to validity

discussed by Cook and Campbell (1979). These categories are threats to:

construct validity, statistical validity, internal validity, and external

validity.

Threats to construct validity. Threats to construct validity were

minimal in this group of reports. In contrast to the stress studies, the

use of a theoretical framework was a strength in the coping studies. Of

the 20 studies, 16 were based more or less firmly on a specific

theoretical framework, one could be considered to be a theory generating

70

study, one attempted to synthesize categories of behaviors from a number

coping theories, and only two failed to base the research on a theory of

coping. Thus a consistent theme generally was evident, flowing from the

initial construct of coping to the interpretation of the data.

The design of the studies were non-experimental or quasi

experimental, research. For the questions being examined this was

appropriate. At the time many of these studies were conducted, research

concerning children's coping was still in the early stages and exploratory

studies were needed to determine the broad spectrum of coping used by

children. Data was obtained primarily through observation and/or

interview. Many studies used both approaches, decreasing the chance of

bias due to use of only one method. It should be noted that the

observations were often conducted during an event believed by the

researcher to be stressful to the child, such as Visintainer and Wolfer's

(1975) six stress points" or a cardiac catheterization, dialysis, bone

marrow aspiration, etc., rather than allowing the child to identify events

personally appraised as stressful. Although this approach is not

congruent with Lazarus' construct of appraisal, it is representative of

the alternate view of stress as a generally noxious event, and therefore

did not constitute a threat to the construct validity.

Threats to statistical validity. The major threat to statistical

validity was the low power of the studies. Although none of the studies

stated a power analysis, a rough estimate of the power (based on an alpha

of . 05, a medium effect size, and the individual sample size of the study)

“The six stress points identified by Visintainer and Wolfer (1975, pp.189) are 1) admission, 2) blood test, 3) the afternoon of the day beforesurgery, 4) preoperative medications, 5) before and during transport tothe operating room, and 6) return from the recovery room.

71

ranged from less than . 19 (the lowest value given on the chart [Cohen &

Cohen, 1983]) to .99. Only three studies (Ritchie, Caty, & Ellerton,

1987, 1988; Wertlieb, Weigel, & Feldstein, 1987; Ryan, 1989) were above

the generally acceptable .80 level (Munro, Visintainer, & Page, 1986).

Two additional studies (Altshuler & Ruble, 1989; Siegel & Smith, 1989)

were above .70 and may have been higher if more specific information had

been provided in the study. The generally low power accepted by the

authors threatens the validity of the study as it is possible that the

sampling was not sufficient to determine the actual characteristics of the

group studied.

A second threat to statistical validity is the use of researcher

developed instruments. Because the study of coping in hospitalized

children is still relatively new, no standardized instruments or interview

formats are available, with the exception of the Children's Coping

Strategies Checklist currently being developed for use in observing

hospitalized preschool children (Ritchie, Caty, & Ellerton, 1988).

Therefore, the interviews and observational guides were self-developed by

the researchers. Unfortunately no information regarding pilot testing of

the instruments was given, possibly jeopardizing the reliability of the

data. Of the four studies that did use standardized instruments in

addition to interview and/or observation, only two presented information

concerning the validity and reliability of the tool. While the numerous

similarities in the categories of coping emerging from the data imply that

the instruments are targeting the child's coping behaviors, the study of

children's stress and coping would be strengthened by the development and

use of standardized instruments.

mº-T-

72

Techniques used for data analysis ranged from content analysis and

descriptive statistics through parametric tests such as Pearson's product

moment correlation, independent t-tests, paired t-tests, ANOVA, MANOVA,

and multiple regression; and nonparametric tests such as chi-square and

Spearman rank-order correlation coefficient. Because of the descriptive

nature of the work, the dominant mode of analysis was content analysis and

descriptive statistics. For the studies using inferential statistics it

appeared that the tests were used appropriately, although the information

needed for this determination was at times minimal. Several authors did

mention details such as using multiple regression rather than ANOVA to

take full advantage of the continuous nature of the data, or rationale for

using a .01 or .05 alpha level. In general it appeared that the use of

statistical tests did not threaten the validity of the studies.

Threats to internal validity. Of the studies considered in this

section, only three (Burstein & Meichenbaum, 1979; Rose, 1972; Stevens,

1984, 1989) were of a quasi-experimental nature; examining the coping

behaviors of children before and after hospitalization for surgery.

Because the purpose was to determine the affect of experience on coping,

changes due to maturation of the child was the dependent variable and not

a threat to internal validity. As the studies used observation or

interview, potential enhancement of performance due to repeated testing

was not a threat. However, observer drift in the scoring of the child's

behavior was a possibility. To avoid this threat, Rose (1972a) used

intermittent inter-observer reliability checks during data collection.

Burstein and Meichenbaum (1979) did not mention using such a system. It

is possible that the internal validity of the studies may have been

affected by an extraneous event that took place between the first and last

73

session of data collection, but no mention of this type of historical

affect was noted.

Threats to external validity. Similar to the stress studies, a

major limitation in generalization of the coping research is the age range

considered in the individual studies. Only five studies (Ritchie, Caty,

& Ellerton, 1987, 1988; Stevens, 1984, 1989; Youssef, 1981; Walker, 1988;

Curry & Russ, 1985) limited the subjects to one cognitive developmental

stage, and in several of these it was probable that the some of the

children were in a transitional phase between stages. Additionally, one

study (Altshuler & Ruble, 1989) purposely studied the developmental

differences in the children's coping. The assumption should not be made

that children of various ages use the same coping behaviors, but rather

should be carefully investigated.

A second limitation in generalizing the findings is that fourteen of

the twenty studies specifically focused on focused on coping in response

to intrusive procedures such as surgery, hemodialysis, cardiac

catheterization, injections, or dental work. Thus, while good progress

has been made in understanding how school-age children cope with intrusive

procedures, it is remains uncertain what coping behaviors children are

likely to use in response to non-intrusive situations that have been

appraised as stressful.

In summary, while a variety of methodological problems are present

in the cited research, a critique of the studies indicates that the

theoretical basis and design of the research generally is appropriate for

the state of knowledge in this area. Although the power of the studies,

age factor, and predetermination of a stressful event limit

generalization, the evident similarity in the coping behaviors identified

=m-

74

suggests that synthesis of these studies is likely to provide a reasonably

accurate picture of the coping behaviors used by hospitalized, school-age

children.

Variables Influencing Coping as Reported in the Literature

Although the primary purpose of the studies cited above was to

identify coping behaviors used by children rather than to identify factors

influencing the coping process, occasionally such information was included

as a portion of the demographic analysis. The variables which have been

addressed in this manner are : gender, age, race, diagnosis, and prior

experience. In addition, the personality trait of locus of control (LOC)

has been the variable of interest in several studies, and the relationship

between anxiety and the child's behavior was considered in two studies.

The findings from the previously reviewed studies and other relevant work

relating to these variables will be summarized and discussed.

Of the nine studies reporting the analysis of the correlation

between the gender of the child and the coping behaviors, five reported no

significant relationship (Altshuler & Ruble, 1989; Curry & Russ, 1985;

Hamner & Miles, 1988; LaMontagne, 1984, 1987). The remaining four studies

reported a significant difference between the coping behaviors used by

boys as compared to girls. These studies indicated that boys tend to use

more active coping, including physical activity (Murphy, 1976; Ryan,

1989); use more self-focused coping (Wertlieb et al., 1987); use more

attempts to control (Savedra & Tesler, 1981), and are more likely to be

unable to identify any form of helpful coping (Wertlieb et al., 1987) as

compared to girls. In contrast, girls are more likely to use

environmentally focused coping (Wertlieb et al., 1987); to use emotional

coping strategies (Ryan, 1989); to use pre-coping behaviors (Savedra &

75

Tesler, 1981) and to seek social support as a form of coping (Ryan, 1989),

a trend also noted in Hamner and Miles (1988) study although not

statistically significant. It is difficult to explain the discrepancies

between these results. All the studies were of a descriptive nature and

variety of categorization schemes were represented in both the "not

significant" and in the "significant" findings groups. Clearly more study

is needed in this area.

Eight studies reported on relationship between age and coping

behaviors. Two studies found no significant difference in the coping of

children at different ages (Field et al., 1988; Hamner & Miles, 1988).

Each of these studies included children from two or more stages of

cognitive development. In contrast, six studies found a significant

relationship between age and coping. The relationship most frequently

noted was a positive correlation between age and intrapsychic or cognitive

coping strategies (Altshuler & Ruble, 1989; Curry & Russ, 1985; Ryan,

1989; Wertlieb et al., 1987); as the child ages, and presumably matures

intellectually, there is an increase in cognitive forms of coping. It was

also noted that with increased age there is an increase of emotion focused

coping, seeking support, and inhibition of action (Wertlieb et al., 1987),

and a trend to focus on the positive aspects of the situation (Curry &

Russ, 1985; Brown, O'Keefe, Sanders, & Baker, 1986). Considering the

dimension of active-avoidant coping, it was noted that older children tend

to use more active modes of coping (LaMontagne, 1987). The relationship

between age and information seeking is unclear; Peterson and Toler (1986)

found a positive correlation between these factors, while Curry and Russ

(1985) found a negative relationship. While these results are

inconclusive, it is probable that as the child's cognitive processes

76

change, his or her knowledge of how to cope with a stressful situation

will change. The discrepancies in the findings may be due to the

difficulty in assessing children's coping. Standardized tools are not

available, observational techniques cannot identify the cognitive coping

processes, and, due to the school-age child's difficulty thinking about an

abstract concept such as his own thinking, interviewing also may not

identify the child's coping behaviors fully. Again, further study is

needed in this area.

The remaining demographic variables have only been mentioned by a

few researchers. No significant relationship between race and coping

behaviors has been noted (Curry & Russ, 1985; Knight et al., 1979;

LaMontagne, 1984). Generally, no significant difference between prior

exposure to the stressful situation and coping behavior has been noted

(Curry & Russ, 1985; Field et al., 1988; Knight et al., 1979; LaMontagne,

1984), although one study did indicate that children with prior

experience, in this case chronically ill children, tended to use a greater

number of coping behaviors than did acutely ill children without

experience (Ritchie, Caty, & Ellerton, 1988). Finally, the type of

surgery was not found to have significant relationship to the child's

coping (Knight et al., 1979).

Only two personality characteristics, locus of control (LOC) and

anxiety, have been studied in relation to the coping behaviors of

children. Regarding LOC, research has indicated that an external LOC is

related to avoidant or inward coping behaviors and that and internal LOC

is correlated with active or outward coping behaviors (LaMontagne, 1984,

1987; Rothbaum, Wolfer, & Visintainer, 1979). State anxiety has been

included as an independent variable in two unidimensional studies

77

(Burstein & Meichenbaum, 1979; Field et al., 1988). State anxiety refers

to the situational anxiety as compared to the trait anxiety, the

relatively stable, dispositional aspect of anxiety. Neither study found

a significant relationship between the child's state anxiety and the

coping dimension. Trait anxiety has not been studied in relation to the

child's coping behaviors.

In summary, the reports of the relationship between demographic

variables and children's coping have generally been incidental to the main

purpose of the study. The findings pertaining to the relationship between

gender and coping are inconclusive, although it is possible that there is

a tendency for boys and girls to use different types of coping behaviors.

Regarding the variable of age, it appears probable that coping changes as

the child matures intellectually, evidenced by an increase in cognitive

forms of coping and in self-control. The available research is

insufficient to establish a pattern between ethnicity and coping or prior

experience and coping. Study of the relationship between personality

characteristics and coping has been limited to locus of control and state

anxiety. It appears that an internal locus of control is related to

active coping, and that there is no relationship between state anxiety

levels and coping behaviors. Further research is needed to clarify these

relationships.

As is evident from the literature reviewed, the current knowledge

base concerning sources of stress and the coping of school-age,

hospitalized children provides a basic understanding of these processes.

However, it is evident that little is known about factors that may

influence the differences in appraisal of stress and coping behaviors. If

the available knowledge base is to be of practical use in assisting the

78

child to cope with stressful events, more must be known about the

variables affecting the individual child's responses. Therefore, it is

necessary to carefully select factors to be analyzed in subsequent studies

that will add to the knowledge base in a substantive manner.

Conceptual Model

In the Lazarus paradigm, the appraisal of an event as stressful and

the resulting coping behaviors are dependent on the modifying influence of

personal and environmental variables (Lazarus & Folkman, 1984a). Because

little research has been conducted concerning the influence of such

antecedent variables on the stress and coping process, it was decided to

examine factors that were of a fundamental nature so that the findings

would be of practical use to the nurse clinician. Additionally, the study

of the antecedent variables relevant to the appraisal of stress limits the

problem of circularity that occurs when using a relational definition of

stress (Lazarus & Folkman, 1984a: Lazarus, DeLongis, Folkman, & Gruen,

1985). While there are many variables that may influence the stress and

coping process of the hospitalized school-age child, three personal

variables were selected for investigation in this study: health status as

either acutely or chronically ill, trait anxiety, and gender (See Figure

2).

79

Health Status

Anxiety =~ Nº.

Stress - Coping

_-tº Tº behaviorsGender ~

Figure 2. Model of the relationship between three modifying variables andthe stress and coping process

Health Status

Health status as acutely or chronically ill was postulated to have

an influence on the child's appraisal of stress and coping behaviors due

to the differences in prior experience with hospitalization. The process

of stress appraisal is influenced by prior experience according to the

extent that the situation is novel or familiar to the person (Lazarus &

Folkman, 1984a). Although few situations are completely novel, the child

who has had prior experience as a patient in the hospital will be likely

to have a different knowledge of the meaning of events for his or her

well-being than will the child who's knowledge is derived from the stories

of family members, friends, television or other vicarious sources. A

differing understanding of the hospital experience may result in a

differing appraisal of stress. Similarly, prior experience affects the

coping process by increasing the child's awareness of the extent of

controllability of the event, modifying his or her beliefs in the ability

80

to cope with the current situation (Melamed, Siegel, & Ridley-Johnson,

1988), and through enhancing the child's repertoire of problem solving

skills (Lazarus & Folkman, 1984a). As noted earlier, chronically ill

children are hospitalized more frequently than are healthy children with

an acute illness (Perrin, 1985; Butler et al., 1985). Therefore, it was

thought possible that the stress and coping processes of the chronically

ill child would be different than that of the acutely ill child. As

evident from the above literature review, minimal attention has been given

to this variable in research. Thus, the extent of influence of health

status on the child's reactions and behavior is unknown.

Anxiety

The child's characteristic level of anxiety was postulated to have

an influence on the stress and coping processes. Anxiety has been

conceptualized as having two distinct aspects: trait and state (Endler &

Edwards, 1982). Trait anxiety, the person's predisposition toward

anxiety, is a relatively stable personality characteristic. In contrast,

state or situational anxiety, the transient reaction to an event, follows

the person's appraisal of the stress in a specific situation (Endler &

Edwards, 1982; Folkman & Lazarus, 1988). Therefore, it is the trait

anxiety that may influence the person's appraisal of stress (Klein, 1988)

whereas state anxiety would act as a mediating factor in the coping

process. Trait anxiety would appear to affect stress directly by

influencing the level of threat the individual perceives in the

environment. The level of perceived threat would then result in anxietyindirectly influencing coping by affecting cognitive functioning and the

resulting use of problem-focused coping, such as occurs when high trait

81

anxiety interferes with optimum thinking and problem solving (Lazarus &

Folkman, 1984a, pp. 167). It is also possible that trait anxiety may have

an undetermined direct affect on the child's coping responses.

Gender

Gender also was postulated to have an influence on the stress and

coping processes under consideration. The process of secondary appraisal

of stress may be influenced by gender related personality characteristics,

such as the learned helplessness of girls, and the mastery-orientation

seen more often in boys (Dweck & Wortman, 1982), by determining whether or

not the child believes that resources are available to deal with the

stressful event. Additionally, gender may affect the type of coping

behaviors used by children. Although a portion of the literature found no

gender related difference in coping behaviors (Altshuler & Ruble, 1989;

Curry & Russ, 1985; Hamner & Miles 1988; LaMontagne, 1984, 1987), several

studies did identify important differences in the strategies used by boys

as compared to girls (Murphy, 1976; Ryan, 1989; Savedra & Tesler, 1981;

Wertlieb et al., 1987). Further investigation is needed to gain a better

understanding of this fundamental variable.

Stress Appraisal

The individual's appraisal of stress affects coping behavior.

According to Lazarus (Lazarus & Folkman, 1984a) the type of appraisal

occurring in a situation will influence the resulting coping behaviors.

If the situation cannot be changed or is not controllable, emotion focused

coping is more often used, whereas if the person believes that they may

82

alter the situation, problem-focused modes of coping are more likely to be

used.

It is recognized that many other person and environmental variables

may influence the child's appraisal of stress and resulting coping

behaviors. However; it is believed that these selected variables

represent fundamental and easily identifiable characteristics, and thus

will contribute practical information to the knowledge base.

Hypotheses

Based on the theoretical frameworks of Lazarus and Piaget, on the

current status of knowledge concerning stress and coping of the

hospitalized school-age child, and on the proposed conceptual model, the

hypotheses for this study were:

1. There will be a relationship between health status and the type of

event appraised as stressful during hospitalization.

2. There will be a relationship between health status and the type of

coping behavior used during a stressful hospital event.

3. There will be a relationship between gender and the type of event

appraised as stressful during hospitalization.

4. There will be a relationship between gender and the type of coping

behavior used during a stressful hospital event.

5. There will be a relationship between trait anxiety and the type of

event appraised as stressful during hospitalization.

6. There will be a relationship between trait anxiety and the type of

coping behavior used during a stressful hospital event.-

7. Health status, gender, and trait anxiety will affect the appraisal

of hospitalization as stressful.

83

a . acutely ill children will appraise the event of

hospitalization as more stressful than will chronically ill,

children

b. girls will appraise the event of hospitalization as more

stressful than will boys

C. children with high levels of trait anxiety will appraise the

event of hospitalization as more stressful than will children

with low levels of trait anxiety

8. Health status, gender, trait anxiety, and stress appraisal will

affect the perception of effectiveness of the coping behavior.

a . chronically ill children will perceive their coping behaviors

during hospitalization as more effective than will acutely

ill, children

girls will perceive their coping behaviors during

hospitalization as more effective than will boys

children with low levels of trait anxiety will perceive their

coping behaviors during hospitalization as more effective than

will children with high levels of trait anxiety

children who appraise hospitalization as of low stressfulness

will perceive their coping behaviors during hospitalization as

more effective than will children who appraise the event of

hospitalization as highly stressful.

84

Definition of Terms

In this study key terms will be defined as follows:

Stress: ". . . a particular relationship between the person and the

environment that is appraised by the person as taxing or exceeding

his or her resources and endangering his or her well-being" (Lazarus

& Folkman, 1984a, pp. 19).

Appraisal: ". . . an evaluative process that determines why and to what

extent a particular transaction or series of transactions between

the person and the environment is stressful" (Lazarus & Folkman,

1984a, pp. 19).

Coping: ". . . the process through which the individual manages the demands

of the person-environment relationship that are appraised as

stressful and the emotions they generate" (Lazarus & Folkman, 1984a,

pp. 19).

Health Status: the general state of a person's physical condition, for

this study, specifically either chronically or acutely ill.

Chronic Illness: ". . . a physical . . . condition lasting longer than

three months or necessitating a period of continuous hospitalization

of more than one month" (Pless & Pinkerton, 1975, pp. 90, 91).

Acute Illness: a physical condition that has been present less than three

months, has not necessitated a hospitalization of more than one

month, and that is not normally considered to be a chronic illness.

Trait Anxiety: the "relatively stable individual differences in anxiety

proneness, i.e. to differences among people in the disposition or

tendency to perceive a wide range of situation as threatening..."(Spielberger, 1975, pp. 137)

Gender: The child's sex as male or female.

85

School-age child: a child between the ages of 8 to 11 years of age.

Non-categorical: An approach to studying health related problems that

"focuses on dimensions that vary across disease categories rather

than on disease-specific differences." (Stein & Jessop, 1982, pp.

355)

86

CHAPTER THREE

METHODOLOGY

In the following section the methodology of this study will be

described. This will include the design, description of the research

settings, human subjects assurance, the sample, instrumentation, process

of data collection, and data analysis.

Design

The design selected for this study was nonexperimental and cross

sectional using a nonprobability sample. Nonexperimental is defined as a

"systematic empirical inquiry in which the scientist does not have direct

control of independent variables because their manifestations have already

occurred or because they are inherently not manipulable" (Kerlinger, 1986,

pp. 348). In nonexperimental research, direct control through treatment

or randomization is not attempted, rather the affect of the theoretically

identified independent variable on the dependent variable is inferred from

the observation that the two vary together. Cross-sectional is defined as

a "design that involves selecting a representative sample from the

population of interest and observing all the phenomena . . . of interest

at the same point in time" (Woods & Catanzaro, 1988, pp. 554). In cross

sectional research the variables of interest are assessed once, at a time

determined by the purpose of the study. Nonprobability sampling is a

sampling technique that does not use random sampling (Kerlinger, 1986, pp.119). In nonprobability sampling each potential subject does not have an

equal chance of being in the sample, but rather eligibility is determined

87

through purposive, quota, or convenience sampling. Accordingly, in this

study a convenience sample of subjects were each tested once in the

naturally occurring environment of the hospital; no manipulation of the

setting, subjects, or intervention was involved. This is in keeping with

the purpose of the study to determine the relationship between the

selected independent variables of health status, gender, and trait anxiety

and the naturally occurring dependent variables of stress appraisal and

coping behavior.

Strengths and Weaknesses of the Design

The use of a non-experimental design in the study of stress and

coping has increasingly been recognized as the preferable method of

inquiry (Lazarus, 1981; Lazarus & Folkman, 1984a). Naturalistic research,

rather than experimental investigations, permits the study of the coping

processes that are used in response to actual experiences appraised as

stressful. Use of a non-experimental design in the present study

therefore allows examination of the naturally occurring stress appraisal

and coping processes of hospitalized children. A weakness of using a non

experimental model is the inability to randomly assign subjects to

treatment groups (Kerlinger, 1986). Although less than ideal, this is the

only acceptable alternative when studying the reactions of children to

hospitalization and events occurring while hospitalized. Because the

therapeutic interventions are determined by the child's physiological

needs, it is not possible to randomly assign a subject to a group

receiving a specific, potentially stressful experience such as anintrusive procedure or immobilization. Similarly, use of a model that

would expose a hospitalized child to experimentally induced stressful

88

stimuli would not be ethically acceptable. An alternative, presenting

stressful stimuli to the subjects in story form and asking for their

stress and coping response, would only examine the child's general style

of stress and coping, not his or her actual responses to a real situation.

Thus, use of the non-experimental model to assess the hospitalized child's

appraisal of actual stressful event and their resultant coping behavior

most fully met the purpose of this study.

Use of the cross-sectional design is common in naturalistic research

(Woods & Catanzaro, 1988). One strength of cross-sectional design is that

it permits collection of the independent and dependent variable data at

the same point in time. This characteristic is of great importance when

dealing with a population that is highly transient, such as hospitalized

children. A second advantage of this design is that is allows inter

individual comparison of the variables of interest. Thus, comparisons in

stress and coping may be made across health status groups, gender, and

anxiety. A weakness of the cross-sectional design is the inability to

examine change in behavior over time. Lazarus (Lazarus & Folkman, 1984a)

emphasizes the need to study both the changes in intraindividual stress

and coping behavior through longitudinal designs and the interindividual

differences obtainable through cross-sectional studies. Although

investigating the changes in hospitalized children's stress and coping

over time would contribute valuable information to nursing practice,

inclusion of a longitudinal component in this study was not possible.

Children's admission to the hospital is usually sporadic and

unpredictable. Collection of intraindividual data either would have

necessitated limiting the subjects to children admitted frequently, such

as those on a chemotherapy protocol or would have involved following a

89

large sample of children over a period of years to obtain a sample of

subjects hospitalized several times during childhood. Neither option fit

the purposes of the present study. Therefore, while a design permitting

both interindividual and intraindividual examination would have been

ideal, the use of a cross-sectional design was appropriate to answer the

questions of this study.

It is possible that selection of subjects though convenience

sampling, rather than using randomized selection, may have affected the

generalization of the results of the study. While randomization would

have decreased the possibility of consistent extraneous variables

influencing the data, it was not thought to be a realistic alternative for

this study, as the population of school-aged children admitted to the

hospital is limited. As an alternate method of controlling for variance

in subjects, stringent inclusion/exclusion criteria were developed and

followed (see discussion below).

One additional potential weakness of the design was the exclusion of

a control group. Control groups are a characteristic of experimental or

quasi-experimental research. It would have been possible to design the

current study as quasi-experimental, using children who had not been

hospitalized as the control group, as the presumed intervention is the

experience of hospitalization. However, as discussed above, asking

subjects who had not experienced hospitalization what they thought would

be stressful and how they would cope with it would be assessing the

child's coping trait or style, that is what he or she would be likely to

do. It could not determine the child's coping process or state, what he

or she would actually do when hospitalized, a distinction deemed crucial

to study of stress and coping behaviors (Lazarus & Folkman, 1984b).

90

Additionally, the inclusion of a control group would have asked the

question, is there difference in non-hospitalized and hospitalized

children's interpretation of stress associated with hospitalization and

resulting coping patterns. This would not have allowed examination of the

variables thought to influence the child's stress and coping behaviors

during hospitalization. For these reasons, a control group was not

included in this study.

In summary, a nonexperimental design was used to study the naturally

occurring processes of stress appraisal and coping of hospitalized

children. The cross-sectional aspect of the design was necessary to

gather sufficient data to conduct interindividual comparisons of the

variables in question. Finally, convenience sampling was used due to the

scarcity of the population, but was balanced by inclusion/exclusion

designed to control for variance in the sample. This design provided the

needed structure to investigate factors influencing the stress appraisal

and coping processes of hospitalized school-age children.

Research Settings

Data collection for this study was conducted at seven facilities.

Four of these were large medical centers affiliated with a university and

three were children's hospitals. It was determined that multiple sites

were necessary for the following reasons: 1) use of multiple facilities

would increase the likelihood of obtaining a sample representative of the

target population, thus avoiding an artificial imbalance in chronic versus

acutely ill children and avoiding testing of the subject's reactions tothe milieu of one specific facility; 2) the benefits and burdens of

participation in research would be equitably distributed among

91

hospitalized children in California, rather than limited to a sometimes

overused subgroup in the Bay area; 3) additional sites for data collection

would obviate the potential difficulty obtaining the needed sample size

due to the limited number of children likely to be admitted during the

school year who would meet the selection criteria. To control the

variance in the sample responses, all sites used were designated pediatric

units or hospitals, all allowed rooming-in of the parents according to the

parents availability, and all had a play room available to the children

that was staffed by Child Life Specialists or other trained personnel.

Children admitted to an adult, rather than the pediatric unit, at the

facilities, were not included in the study.

The first setting was the pediatric units of the University of

California, San Francisco, Medical Center (UCSFMC), a teaching hospital

affiliated with a university health science campus. The sixth floor of

the Moffit and Long Hospitals is a designated pediatric hospital within

the medical center and serves as a tertiary referral center for northern

and central California and southern Oregon. There are a total of 75

pediatric beds, including the ambulatory medical and surgical care units,

the PICU, the Pediatric Clinical Research Center (PCRC), and the Pediatric

Transplant unit. The age range admitted to the units extends from infants

through adolescents. For this study, only patients on the ambulatory

medical and surgical pediatric units, and the PCRC were used as subjects.

The medical unit has a high census of children with cancer and as well as

other problems, and has 24 beds, configured as two 4-bed rooms (primarily

used for infants and toddlers), eight 2-bed rooms, and eight private rooms

(often used for immunosuppressed patients). The surgical unit accepts

children with diagnoses ranging from ruptured appendicitis to

º

s

92

neurosurgical and cardiac problems, and also has 24 beds, configured as

two 4-bed rooms (used for the younger patients), eight 2-bed rooms, and

two private rooms. The PCRC has 6 beds and houses children involved as

subjects in medical research who would otherwise be admitted to the

ambulatory medical or surgical units. Primary nursing care is given by

registered nurses. Occasionally student nurses are present on the units.

The playroom is open at designated hours, and a school room and teacher

are located on the floor to work with children experiencing a lengthy

admission.

The second setting is the Shriner's Hospital for Crippled Children,

San Francisco (SHCC). This facility is one of 19 Shriner's Hospitals

providing a philanthropical service for children with orthopedic problems

needing either medical or surgical treatment, for children with spinal

cord injuries, or for children with burn scars needing surgical revision.

The San Francisco unit has three basic units, the spinal cord injury unit,

a boys unit, and a girls unit, with a total capacity of 48 beds. The

patients' ages range from infancy through adolescence. Nursing staff is

composed of approximately 50% registered nurses and 50% nursing

assistants. A team nursing approach is used. A large recreation room is

open at designated hours and provides a variety of activities and crafts.

A school room large enough to provide easy access by wheelchair and gurney

is staffed by teachers and the children are encouraged to attend class on

a regular basis.

The third facility is the pediatric unit of San Francisco General

Hospital Medical Center (SFGHMC). This is a 444 bed facility serving the

lower income residents of the city. The pediatric unit has a capacity of

24 beds, although it is currently budgeted for only 14 beds, and serves

º

º

93

children between the ages of newborn through 17 years having medical,

emergency surgical, or trauma related problems. Most of the rooms have

two beds, although there is a large room with four or more cribs for

infants and toddlers. Primary nursing care is provided by staff comprised

of 75% registered nurses and 25% licensed vocational nurses. Student

nurses are also are involved in care giving several days a week. The

playroom is open at designated hours. Teachers from the school system are

available for children having a lengthy admission, but this is uncommon.

The fourth setting was Children's Hospital at Stanford (CHGS). This

is a 56 bed, non-profit, teaching hospital serving children from infancy

through adolescence. It is located near Stanford University Hospital

(SUH) and interfaces with SUH in coordinating services for children. For

example, CH@S primarily provides services for the children with chronic

physical or psychological problems, while SUH focuses more on the

intensive care and acute care needs. Services such as medical staff and

institutional review board are shared. Three of the four patient care

units at CH@S were used for data collection: the 15 bed Babcock Unit

caring for children of school-age or younger with illnesses such as

gastrointestinal, pulmonary, orthopedic, rehabilitation, and overflow

oncology; the 14 bed McElroy Unit caring for older children with pulmonary

problems, cystic fibrosis patients from early childhood through adults,

orthopedic, and arthritis; and the 13 bed Auxiliary Unit caring for

hematology/oncology patients. The 14 bed Roth Unit, caring for children

with psychosomatic problems, was not used. Each unit has a variety of

single, double, or four-bed rooms. Primary nursing care is provided by

staff consisting of 90 % registered nurses and 10 % nursing assistants.

A recreation department and occupational therapy department are available

Tº- *

/ 7.

94

for the children. There are three school rooms, one each for primary,

intermediate, and high school classes. Teachers also work with children

at the bedside as needed.

The fifth setting was the University of California, Davis, Medical

Center (UCDMC), a 378 bed facility located in south Sacramento. Pediatric

facilities include an ICU, a special care unit, and a 27 bed basic unit.

The rooms on the basic unit house either two or three beds, with the

exception of two infant rooms having room for four or five cribs each.

The hospital is known for its trauma facilities, but also provides

services for chronically ill children. The pediatric nursing staff is

approximately 85% registered nurses and 15% licensed vocational nurses.

The method of care is total care nursing. The playroom is open at

designated hours and a teacher from the school district comes to the unit

as needed.

The sixth setting was Valley Children's Hospital (VCH), located in

Fresno, California. This is a 148 bed facility providing tertiary care to

children in central California from birth through adolescence. In

addition to the usual ethnic mix of California, the Fresno area has a

large population of Southeast Asian refugees, a fact reflected in the

admissions to VCH. Eligible subjects are usually admitted to either the

medical unit or the adolescent unit which takes overflow of older children

from other units as needed. Most patient rooms on the basic units have

two beds. Nursing care is provided by a staff comprised of 86% registered

nurses, 12% licensed vocational nurses, 2% certified nursing assistants,

and periodic rotations of student nurses. The playroom is open at

designated hours, and a school room is located within the facility.

-

2

º

95

The seventh setting was Loma Linda University Medical Center

(LLUMC), a 627 bed, tertiary care facility located in southern California,

approximately 60 miles east of Los Angeles. This is a private, non

profit, teaching hospital affiliated with a health science university.

There are three basic pediatric units, in addition to a pediatric

intensive care unit and a neonatal intensive care unit. Unit 5100 has 26

beds and primarily cares for hematology/oncology patients. Primary

nursing care is given by registered nurses. Unit 5200 has 7 beds for

ambulatory care patients and an 8 bed stepdown unit for patients from

PICU. Team nursing is used to provide care for the ambulatory patients

with a nursing ratio of approximately five registered nurses to one or two

licensed vocational nurses or nursing assistants. The rooms on both units

are semi-private two bed rooms, with each unit also having one or two

three-bed rooms. Unit 5300 has 32 beds and primarily serves NICU

graduates, infants and toddlers and has an all RN staff. Most of the

acutely ill children receive care in a local community hospital. Student

nurses also are involved in the children's care. The playroom is open at

designated hours and arrangements may be made for a teacher to come to the

child's room.

Human Subject's Assurance

Application for Human Subject's approval was made according to the

protocol for each facility and approval obtained. (See Appendix A for a

sample of letter of approval.) Listed below are the institutional review

boards granting approval and the facilities accepting that approval:

1. Committee on Human Research, University of California, San

Francisco, # H1777-05091-01. This approval was accepted by

s

96

University of California, San Francisco, Medical Center; San

Francisco General Hospital and Medical Center; and Shiner's

Hospital for Crippled Children, San Francisco.

2. University of California, Davis, Human Subjects Review

Committee, # 90-309. This approval was accepted by the

University of California, Davis, Medical Center.

3. Stanford University Hospital, Medical Committee for the Use of

Human Subjects in Research, # M1272. This approval was

accepted by Children's Hospital at Stanford.

4). Valley Children's Hospital Human Subject's Committee, (no

number assigned). This approval was accepted by Valley

Children's Hospital.

5. Loma Linda University, Institutional Review Board, (no number

assigned). This approval was accepted by Loma Linda

University Medical Center.

Sample

The following section will discuss the criteria guiding the

selection of the sample for this study. First, the characteristics of

interest will be reviewed and the constraints placed on sample selection

due to the variables will be identified. Second, the specific

inclusion/exclusion criteria used for control of variance in this study

will be delineated. Third, rationale for the criteria will be provided.

Fourth, major potential sources of variance that were not controlled will

be identified and discussed. Fifth, the population to which the results

of this study may be generalized will be described. Sixth, the method of

s

97

determining the sample size will be stated. Seventh, the process of

sample selection will be discussed.

Sample Selection Constraints due to Variables of Interest

The characteristics that were of specific interest in this study

were the child's health status as acutely or chronically ill, the child's

gender, the child's trait anxiety level, and the child's identification of

the stress and coping processes used in relation to hospitalization. The

influence of each of these variables on the sample selection will be

discussed.

The variable of health status was examined by using the

noncategorical approach rather than a diagnostic specific approach. Stein

and Jessop (1982, pp. 355) define this as an method that "focuses on

dimensions that vary across disease categories rather than on disease

specific differences." The argument for using this strategy was that when

working with the psychosocial needs of chronically ill children, there is

more variance within the specific diagnostic groups than between them

(Stein, 1983; Stein & Jessop, 1982, 1984, 1989; Pless & Pinkerton, 1975;

Pless & Perrin, 1985). For the purposes of this study, this principle was

applied to the psychosocial needs of not only the chronically ill child in

the hospital, but also the acutely ill hospitalized child. Regardless of

the diagnosis and specific therapeutic treatment, all children admitted to

the hospital will have similar experiences, such as intrusive procedures,

separation from the familiar home environment, separation from parents

either for brief or lengthy periods of time, realization that parents are

not all-powerful, and loss of personal privacy. Using a noncategorical

approach, rather than the traditional disease specific approach, the

º

-

s

98

commonalities in the stress and coping of hospitalized children may be

examined and variables possibly influencing these reactions may be more

easily studied. As all children admitted to the hospital have either an

acute or chronic condition, inclusion of this variable did not eliminate

any categories of potential subjects from the study.

Similarly, the inclusion of gender as a variable of interest did not

limit the sample of children selected for the study. All hospitalized

children would be either male or female. Therefore, no potential subjects

were excluded due to lack of fit with one of the subcategories of this

variable.

The constraints imposed by the measurement of the variable of trait

anxiety was partially responsible for determining the age of the subjects

in this study. Theoretically, all children would have a typical level of

trait anxiety. However, psychometrically strong instruments to measure

this variable are available only for children from first grade and above

(Reynolds & Richmond, 1978; Spielberger, 1973). Therefore, because the

characteristic of trait anxiety was to be examined, the subjects selected

for inclusion in this study needed to be within the school-age years.

To determine what the child personally appraised as stressful and

the coping behaviors used to deal with the stress, it was necessary to

work directly with the child. Prior research has shown that the agreement

between childrens' and adults' ratings of the stressfulness of childhood

experiences is moderate. Yamamoto and Felsenthal (1982) found a .68

correlation between the adult ratings and the child ratings of the

stressfulness of life events. Lapouse and Monk (1959) found that mothers

underreported the number of their child's fears and worries by 41%.

Similarly, parental identification of coping behaviors used by children

º

99

also fails to identify many of the strategies the child reports using by

about 44 X (Walker, 1988). Based on these studies, it was believed that

the child, rather than the parent or another adult, would be able to

provide the most accurate data regarding the child's appraisal of stress

and coping responses during hospitalization. Therefore, it was decided

that data collection would only involve the child, rather than including

adults familiar with the hospitalized child's experiences such as the

parents, nurse, or child life specialist.

Inclusion/Exclusion Criteria

Because a convenience, rather than random, sample was used,

stringent inclusion/exclusion criteria were developed to control for

variance that could occur due to extraneous factors. Using these criteria

as a control, it was believed a representative sample of hospitalized

school-age children would be obtained. General inclusion criteria for the

subjects in this study were an age range of 8 to 11 years, normal

cognitive ability as determined by age appropriate grade, and minimum

length of admission of 2 to 3 days. Additionally, the chronically ill

children needed to have at least one previous hospitalization, including

overnight stay, in the prior three years, and the acutely ill children

could not have had a hospital admission since two years of age. General

exclusion criteria for the study were an inability of the child to speak

sufficient English to participate in testing, any intensive care

experience during the current hospitalization prior to the time of data

collection, an admission associated with child abuse, any major perceptual

deficits, and terminal phase of the illness.

º

* }

100

Rationale for Inclusion Criteria

The purpose of the inclusion criteria was to control for possible

extraneous factors that might influence the dependent variable: the

child's report of stress appraisal and coping behaviors. The major factor

that was believed to have a possible affect on the responses was the

child's thinking, which is dependent on age and cognitive maturity. In

order to obtain a sample of children with similar thinking processes, it

was decided to use only children likely to be in Piaget's stage of

concrete operational thinking, ages 8 through 11 years. As noted earlier,

the concrete operational stage begins to emerge at about 7 years of age

(Piaget & Inhelder, 1969), but a period of transition occurs as the child

acquires the ability to mentally manipulate the internal representations

of the external, observable world. Therefore, 8 years of age was selected

as the youngest age for potential subjects to increase the likelihood that

the child was indeed using concrete operational thinking. The option of

including some 7 year olds by administering Piage tian tests to determine

the stage of thinking was not used as it would have increased the length

of the testing session, an alternative not feasible when working with sick

children who may become fatigued easily. Eleven years of age was selected

as the upper extreme of age for the subjects. The earliest evidence of

the development of Piaget's stage of formal operations may occur toward

the end of 11th year or during the 12th year (Brainerd, 1978; Ginsburg &

Opper, 1988) and is not well established until the middle of the teen

years. Because a common reaction of children exposed to stressful

situations, such as hospitalization, is regression, it was thought to be

unlikely that 11 year old hospitalized child would use the early

beginnings of hypothetico-deductive reasoning in discussing his or her

! }

101

stress and coping reactions during hospitalization. For these reasons, it

was decided that the subjects would be within the ages of 8 to 11 years of

age. This decision provided more control over possible variance than

would have the broader categorization of "school-age", generally

considered to be ages 6 through 12 years, which would have included

children likely to be in the transitional phases of cognitive functioning.

Because cognitive functioning may not correspond directly with

chronological age, it was also necessary to determine that the subjects be

of normal cognitive ability. This was determined by asking if the child

was in an age appropriate grade in school and by asking if the child

attended any special educational classes. Age appropriate grade was

identified as :

8 years of age -- grade 2 or higher

9 years of age -- grade 3 or higher

10 years of age -- grade 4 or higher

11 years of age -- grade 5 or higher

If the child attended a special education class the reason for this

placement was requested. If it was due to physical limitations, a

learning disability such as dyslexia, or some minor difficulty in a basic

skill, such as needing extra practice and help with reading or math, the

child was considered a potential subject. If the parents response

indicated that the child was receiving remedial help in all academic

areas, the child was not considered a potential subject. Through these

criteria, age of 8 to 11 years and age appropriate grade, it was likely

that the subjects would have similar thinking processes and that possible

variance due to inclusion of children within earlier or later stages of

cognitive development would be limited.

7.

102

A second factor that could be expected to influence the children's

responses and introduce undesirable variance into the results was the

extent of exposure to the hospital environment. It was believed that the

responses of children regarding appraisal of stress and coping behaviors

might be affected by the length of time they had been exposed to the

hospital environment. A child who had been admitted for only a few hours

might have a very different impression than would the child who had been

hospitalized for several weeks, the former having had fewer experiences

and less time to differentiate the potentially harmful events from those

that are personally irrelevant or benign, the latter having had many

experiences and the opportunity to distinguish between personally

stressful and innocuous situations. Therefore it was decided that to

control for this possible source of variance, data collection would need

to be conducted within a set time frame. As all subjects would need

sufficient time to be exposed to a variety of potentially stressful

situations and to use coping behaviors, and because insurance regulations

dictate that the length of hospital admission is kept as short as

possible, it was decided that data collection would occur on the second or

third day of the child's hospital admission. One exception was made to

this criteria, if the child had surgery on the second day of admission,

the period for data collection was extended to the fourth day, as on the

third day the child generally was not alert enough to participate in the

testing. For these children, the fourth day of admission was the third

day in which they were awake and aware of the hospital experience,

rendering it likely that the data from these children would not be

significantly different than that of children tested on the second or

third day. It was believed that this criteria would provide sufficient

º

103

time for all children to experience a variety of potentially stressful

events and use coping behaviors, while controlling for differences that

might occur if comparing children who had been admitted only briefly with

those who had been on the unit for a lengthy period.

An issue related to control of experience during the present

admission is control of prior hospitalization experience. As discussed

earlier, a basic premise of this study was that chronically ill children

are hospitalized more frequently than are healthy children with an acute

illness, and that due to prior experience the chronically ill child may

have different patterns of stress and coping than does the acutely ill

child not having such past experience. It was recognized however that

some chronically ill children, such as a diabetic in good control of his

or her condition, may have only been admitted at the time of diagnosis,

whereas an acutely ill child may have been admitted several times for

unrelated conditions. Essentially then, there were four possible groups

of subjects:

1. chronically ill children with minimal prior hospitalizations

2. chronically ill children with several prior hospitalizations

3. acutely ill children with minimal prior hospitalizations

4. acutely ill children with several prior hospitalizations

Because the number of children in groups one and four were likely to be

limited and inclusion of these children would not provide a clear answer

to the question of the affect of health status on the stress and coping

response of hospitalized children, it was decided that only children in

groups 2 and 3 would be included in the study. No attempt was made to

balance the number of children from the two groups.

-

º

104

Another possible source of variance in the study was the child's

memory of prior hospitalizations. Because the purpose was to examine the

differences between acutely ill children who were unfamiliar with the

hospital environment and chronically ill children who were accustomed to

hospital routines and events, it was decided that the acutely ill subjects

would not have been admitted to a hospital since two years of age and the

chronically ill subjects would have had one or more hospitalizations

within the last three years. This would ensure a comparison between

chronically ill children who know what to expect during hospitalization

and acutely ill children who have no concrete memory of hospitalization,

and thus control for possible variance within groups due to prior

experience in the hospital.

Rationale for Exclusion Criteria

To provide further control for possible extraneous variables, five

exclusion criteria were delimited. Because it was necessary that the

subjects be able to give assent, participate in an interview, and respond

to standardized instruments written in English, it was necessary to

exclude any child with limited communication skills in English. This was

determined by talking with the primary nurse about the child's

communication skills and/or attempting to engage the child is a simple

conversation. If the child was not able to understand and respond to

basic questions relating to age and favorite activities, the child was

excluded from the study.

Similarly, because the study was dependent on the child's ability to

respond to verbal and written questions, children with any major

perceptual deficits were not considered potential subjects. This was

determined by talking with the child's nurse and/or attempting to engage

º

105

the child in a simple conversation or determine the extent of visual or

hearing impairment. If the child's deficit was such that it would hinder

his or her ability to participate fully in the data collection, the child

was not considered to be a potential subject.

Three additional groups of children were excluded from the study due

to experiences that could potentially increase the child's appraisal of

stress during hospitalization and alter the coping behaviors. The first

of these was the exclusion of children who had been admitted to the

intensive care unit during the current hospitalization. Because the child

admitted to the intensive care unit is likely to experience and observe

many more stressful events and because the physical condition of the child

would decrease the options available for coping, it was believed the

experiences of this child would be sufficiently different from that of the

child admitted to a general medical or surgical unit to result in

undesirable variance in the responses of the child. Therefore, children

having been admitted to ICU during the current hospitalization prior to

data collection were excluded from the study.

The second group having an experience that could potentially

introduce extraneous variance into the study was children admitted for a

diagnosis related to child abuse. It was thought possible that an abused

child might appraise events differently than an child that had not been

abused. Additionally, it is possible that the child who has been abused

has learned to use different coping behaviors in response to a stressful

situation. Therefore, to control for this possible source of variance,

children admitted to the hospital due to abuse were not included in the

study.

º

106

Similarly, children who were considered to be in the terminal phase

of their illness were not considered potential subjects. Because the

dying child is generally aware that the end of life is nearing, the

relative importance of events may be altered, resulting in differences in

the appraisal of stressful events. To control this source of extraneous

variance, the chart was read and the nurse consulted to determine the

child's condition. If a "do not resuscitate" order was written or it was

apparent that vigorous curative treatment had been stopped and palliative

care was being provided, the child was excluded from the study.

The above inclusion and exclusion criteria were developed to

reduce the variance in the subject's responses that may have occurred due

to use of a convenience, rather than random, sampling. Despite these

rigorous criteria, several relevant extraneous variables were not

controllable and may have increased the source of error variance.

Potential Sources of Uncontrolled Variance

Although many potential sources of uncontrolled variance could be

identified, four dominant factors should be recognized. The first of

these would be the multitude of specific diagnostic or therapeutic

experiences that might be encountered by an individual subject.

Obviously, only a child who had experienced a bone marrow aspiration or a

bronchoscopy would be likely to identify that event as stressful.

Therefore, despite the similarities in the experiences of all hospitalized

children, individual events uncommon to the population will occur and may

act as a source of uncontrollable variance. A second extraneous variable

would be the child's knowledge about the hospital acquired through

indirect, rather than direct, experience. Possible sources for such

-

107

information would include books, television, family or friends, and pre

hospitalization programs. This knowledge could function to either

increase or decrease the child's appraisal of events as stressful, and

thus would contribute to uncontrollable variance in the child's responses.

A third source of variance would be the child's prior positive or negative

experiences in a medical office, clinic, or emergency room. Although

these events would be of limited length, the child may have developed an

opinion about the stressfulness of a physical exam, of the measurement of

the blood pressure, or of intrusive procedures such as injections. These

previous experiences would be likely to influence the child's reactions to

similar events during hospitalization. A fourth major source of variance

would be the ability of the parents to provide reassurance and support to

the child during hospitalization through their presence. While it is

likely that most parents will attempt to spend time with the child during

hospitalization, the actual number of hours the parent is able to be

present would vary greatly. It is possible that children appraise the

stressfulness of an event differently according to whether the parents are

available or unavailable. Thus, the child's responses may vary depending

on the presence or absence of the parents during potentially stressful

events.

While it would have been ideal to control for all possible sources

of extraneous variance, such an option is not possible in nonexperimental

research. It is recognized that the inability to control all extraneous

independent variables that may influence the dependent variables could

pose a threat to the internal validity of the study. The affect of the

uncontrolled extraneous variables may mask the true affect of the

independent variables on the dependent variable. Accordingly, while the

*

108

results of this study should provide a reasonable representation of the

influence of health status, gender, and trait anxiety on the stress and

coping of hospitalized, school-age children, the results are study

specific. It is probable that a replication would yield somewhat

differing results due to fluctuations in the influence of the uncontrolled

variables.

Population to Whom Results may be Generalized

Because randomization and a sampling framework was not used in this

study, the external validity of the study may have been threatened and it

should not be assumed that the findings are representative of all

hospitalized children. Rather, generalization must be made only to

children similar to the sample obtained for the study. However, due to

the use of a noncatagorical approach and the use of clinical facilities

throughout California the ability to generalize the results is broad.

Succinctly, the findings may be generalized to English speaking, 8-11 year

old children of normal cognitive and sensory functioning, living in

California, hospitalized for any condition other than child abuse, or a

critical or terminal illness.

Sample Size

Sample size was determined through a power analysis based on an

alpha of . 05, power of .80, and an estimated medium effect size. The

standard alpha and power were used as this was a descriptive psychosocial

study and more stringent parameters were not needed as might have been the

situation if the study had been testing differences in new, and possibly

109

costly, interventions. The medium effect size was based on clinical

intuition that the variables have a moderate influence on the child's

stress and coping behaviors during hospitalization. No previous research

was available on which to base this judgement. Using these parameters,

the necessary sample size for a regression analysis involving the maximum

of four independent variables influencing one dependent variable was 82

subjects (Cohen, 1988).

Sample Selection

As stated above, convenience sampling was used to obtain the

subjects for this study. Each child meeting the inclusion criteria and

admitted to the participating facilities was considered a potential

subject. At all facilities except one”, the admission list or Kardex was

checked daily or every other day by the data collector to determine if any

children between the ages of 8 to 11 years had been admitted to the unit.

If so, the chart was checked to determine if the child met the

inclusion/exclusion criteria. The data collector then spoke with the head

nurse, charge nurse, or primary nurse to verify the information and to

determine the child's current physical and psychosocial status and the

appropriateness of approaching the parents and child regarding the study.

Occasionally, the nurses would suggest or request that the data collector

wait a few hours as the child had just been medicated or was very tired.

*At Shriner's Hospital for Crippled Children, the Head Nursespreferred to screen for potential subjects as children were preadmitted tothe hospital. The researcher contacted the nurses several times a weekregarding subject availability and the nurses would provide names andsuggest the best time to contact the parent and approach the child fordata collection. Eligibility was verified by the researcher by readingthe child's chart and talking with the nurses and parents.

~"

ºº

110

Following this preliminary determination of eligibility, at three

facilities* the physician was then contacted for permission to approach

the parents and child about the study. Finally, if any questions

regarding eligibility remained, such as the child's grade in school, the

parents were contacted, a brief overview of the study given and the

additional information obtained. If the child met all the

inclusion/exclusion criteria the process of obtaining informed consent

(described below) from the parent and child was begun.

Data Collection Methods

Data collection consisted of a combination of standardized

instruments, graphic rating scales, and semi-structured interview.

Six instruments were used. To measure the independent variable of trait

anxiety, Spielberger's State-Trait Anxiety Inventory for Children, A-Trait

scale was used. To measure the dependent variables of a child's appraisal

of the event of hospitalization as stressful and the accompanying

perception of the effectiveness of the coping behaviors, the Hospital

Stress Scale and the Hospital Coping Scale were used. Because these are

new measures, concurrent validity was assessed using the Child Medical

Fear Scale and the Coping Response Inventory, instruments measuring

similar, but not identical, constructs. Finally, the Hospital Stress and

Coping Interview was used to assess the dependent variables of the child's

*Individual physician consent was required by the PCRC at theUniversity of California, San Francisco Medical Center, due to possibleconflicts with other ongoing research; by two of the five services atChildren's Hospital at Stanford, the orthopedic service and thehematology/oncology service; and by the private physicians admittingchildren to Valley Children's Hospital. At all other facilities, generalpermission was given for data collection by the chief of pediatrics, thechief of the service, or the medical director of the unit.

*** *---as

111

sal of events during hospitalization as stressful and the coping

.ors used in response to these events. Each of these instruments

ye described.

State-Trait Anxiety Inventory for Children (STAIC)

The purpose of the STAIC, or the "How I Feel Questionnaire", is to

le a measure of the state and trait anxiety of children. State

y is defined as the , "subjective, consciously perceived feelings of

ºn, apprehension, and nervousness . . . that may vary in intensity

uctuate over time as a function of the stresses that impinge on the

sm (Spielberger, 1975, pp. 137). Trait anxiety, "refers to

vely stable individual differences in anxiety proneness . . . the

;ition or tendency to perceive a wide range of situations as

:ening and to respond to these situations with differential

ions in state anxiety (Spielberger, 1975, pp. 137). For the

es of the present study only trait anxiety, as a measure of the

indent variable, was assessed, as trait anxiety would be an

dent to appraisal of stress, modifying the transaction between the

and situation, whereas state anxiety would be a mediating variable

incing the child's reactions during the event.

The STAIC form C-2 or A-Trait scale was developed to measure the

anxiety of children between the ages of 9 through 12 years

berger, 1973), although the author reports that it may be used

riately with children as young as 6 years of age if the items are

o the child (Spielberger, 1989). The self-report scale consists of

items scored on a three point Likert scale of 1 - hardly-ever, 2 -

mes, 3 - often. The child is asked to choose the response that

º

112

ibes how he or she usually feels. The scores are added, resulting in

jective determination of interval data.

The items for the STAIC were developed based on examination of other

ty inventories for children and on the previously developed State

Anxiety Inventory (STAI) for adults and adolescents. Criterion for

tion of items were concurrent validity with the Children's Manifest

ty Scale (CMAS) (Castaneda, McCandless, & Palermo, 1956) and the

al Anxiety Scale for Children (GASC) (Sarason, Davidson, Lighthall,

, & Ruebush, 1960) and internal consistency based on item-remainder

lations, therefore, although additional details regarding the

ptual development of the tool would be helpful, it appears likely

the content and construct validity of the STAIC are good.

Normative data was based on testing of population of over 1500

n, fifth, and sixth grade children from 5 counties in Florida during

arly 1970s. Approximately 35 to 40 percent of the children tested

Black; the ethnicity of the remainder of the sample was not given.

1thor reports that concurrent validity has been established through

risons with other measures of anxiety: in a sample of 75 children,

»rrelation of the STAIC A-Trait with the Children's Manifest Anxiety

(Castaneda et al., 1956) and the General Anxiety Scale for Children

son et al., 1960) were .75 and .63 respectively (Spielberger, 1973).

retest reliability over an eight week period, estimated on a 246

5up of the original sample, was moderate, .65 for boys and . 71 for

The internal consistency for the scale, based on Cronbach's alpha,

78 for boys and .81 for girls. In sum, the both the validity and

>ility of the A-Trait scale appear to range from moderate to good.

Appendix B for a copy of the instrument.)

º

º

º

113

The STAIC was selected for use in this study because the

psychometric properties appear to be equal to or better than those of

other anxiety inventories for children and because the length of the STAIC

was shorter than the other tools, an advantage when working with ill

children who may have limited energy and a short attention span. Of the

other instruments that appear to measure the child's trait anxiety, the

Child's Manifest Anxiety Scale, developed in the early 1950s, consists of

53 items and had a .90 test-retest reliability over a one-week period

(Castaneda et al., 1956). The Revised Children's Manifest Anxiety Scale

has 37 items, an KR-20 reliability of .85 (Reynolds & Richmond, 1978), and

test-retest correlation of . 68 over nine months (Reynolds, 1981). The

construct validity of two other instruments is uncertain. The Child

Anxiety Scale by Gillis is a 20 item, self report inventory with a KR-20

reliability of .73, and a one-week test-retest coefficient of .81.

However, construct and concurrent validity have not been established for

the tool, and reviewers do not recommend the use of the instrument at this

time (Maxwell, 1985; Sterling 1985). The Junior Manifest Anxiety Scale by

Joshi (1974) is a 40 item inventory with a reported test-retest two week

reliability of .86 based on 200 children. Content validity as judged by

two experts was . 88, and concurrent validity believed to be good as

determined by comparing the scale with the theoretically opposite trait of

neuroticism (Johnson, 1976). Further validity and reliability studies are

needed prior to using this instrument. One final instrument, the Observer

Rating Scale of Anxiety by Melamed and Lumley (1988) states a purpose of

measuring overt state anxiety, rather than trait anxiety. Because of the

length of the potentially appropriate instruments or the weaknesses of the

114

available short inventories, the STAIC presented the best combination of

properties for use in the current study.

Hospital Stress Scale (HSS) and Hospital Coping Scale (HCS)

The purpose of the Hospital Stress Scale was to provide a measure of

the degree of stress the child perceived in relation to being

hospitalized. Stress, as discussed earlier, occurs as a result of a

person-environment transaction that is appraised as threatening the well

being of the person. Because no instrument was available to measure the

child's stress in relation to the hospital environment, the Hospital

Stress Scale was devised by the researcher based on Savedra and colleagues

(Tesler, Savedra, Wilkie, Holzemer, Ward, & Paul, 1989) findings in

developing a tool for assessing children's pain (see discussion below).

The HSS is a word graphic rating scale consisting of a 10 centimeter line

with five verbal descriptors in order of ascending degree of stress at

equal intervals along the line. Because prior work by Elwood (1987)

indicated that fourth grade children generally use the term "upsetting"

rather than stress or stressful, and because Menke (1981) found that

school-age children used "upset" as a synonym for stress, the word "upset"

was used on the scale. Accordingly, the verbal descriptors were: not

upset, little upset, medium upset, large upset, and worst possible upset.

The child was asked to place a single, vertical mark on the scale to

indicate how upsetting the event of hospitalization was . The point at

which the mark intersected the line was measured in millimeters from the

left side of the scale and used as continuous data. (See Appendix C for

a copy of the instrument.)

115

Similarly, the purpose of the Hospital Coping Scale was to provide

sure of the child's perception of the effectiveness of the coping

iors used in response to the event of hospitalization. Coping, as

in this study, is the process of attempting to manage a situation

has been appraised as stressful. Again, because no instrument was

able to measure the child's perception of the effectiveness of his or

oping with the stress of hospitalization, the Hospital Coping Scale

evised by the researcher based on the work of Savedra and colleagues

discussion below). The HCS is a word graphic rating scale consisting

10 centimeter line with five verbal descriptors in order of ascending

e of perceived effectiveness at equal intervals along the line. The

1 descriptors were: no help, little help, medium help, large help,

est possible help. The child was asked to place a mark on the scale

dicate how much the things they did to take care of the upset really

d. The point at which the mark intersected the line was measured in

meters from the left side of the scale and used as continuous data.

Appendix D for a copy of the instrument.)

Because the subjects were not likely to be familiar with the use of

d graphic scale, a practice word graphic scale was used prior to the

istration of the HSS and HCS. The practice scale asked the child to

ify his or her favorite class in school, least favorite class, and

ther class. The verbal descriptors on the ten centimeter line were:

like class at all, like the class a little, like the class a medium

t, like the class a lot, and like the class best of all. The concept

class in school was chosen as it represented an activity with which

:hild would be familiar, but something that was not physically

ete such as favorite food or game would have been. In this way the

:

c

* * *-

116

child was encouraged to think about rating an intangible event as would be

necessary with the HSS and HCS scales. The purpose of asking the child to

indicate three classes ranging from the class liked best to the class

liked least was to demonstrate that the mark could be placed anywhere on

the 10 centimeter line. (See Appendix E for a copy of the instrument.)

Because these instruments are researcher developed, there is no data

available on the reliability and validity of the scales. Concurrent

validity was determined through correlation with scales measuring similar

constructs; the results of the HSS being correlated with the Child Medical

Fear Scale, and the HCS correlated with the Coping Response Inventory (see

discussion below). The objectivity of the scoring of these instruments

was likely to be good, as it only required the measurement of the

placement of the child's mark on the 10 centimeter line. The same

measuring device was used to determine the placement of the marks for all

subjects.

The word graphic scale has been used in other research with children

with good results. It has been reported that children as young as five

years of age have used the graphic rating scale effectively (Ross & Ross,

1988). Additionally, the responses of school-age children to self-report

rating scales have been carefully analyzed in the development of a tool

for pain assessment in children (Tesler, Savedra, Wilkie, Holzemer, Ward,

& Paul, 1989). Comparing five types of scales, it was found that

hospitalized children preferred the word graphic rating scale to a color

scale, visual analogue scale, graded graphic rating scale, or magnitude

estimation scale. Test-retest reliability for the pain assessment word

graphic rating scale, determined by having the subjects mark identical

scales at separate intervals of one testing session, was .91, indicating

R

117

strong reliability in this use of the scale. Construct validity was

demonstrated by the decrease in children's markings of pain intensity over

a five day post-operative period. Correlations between the five scales,

ranging from .68 to .97, demonstrate concurrent validity for the pain

scale. It was evident that the word graphic rating scale has been shown

to be reliable and valid when used to assess self-reports of school-age

children's pain intensity. Therefore, it was reasonable to believe that

a word graphic scale used to assess other situations of self-report in

school-age children might also have similar potential for reliability and

validity, such as in the measurement of the target constructs of stress

and coping during hospitalization.

Child Medical Fear Scale (CMFS)

The purpose of including the Child Medical Fear Scale (Broome,

Hellier, Wilson, Dale, & Glanville, 1988) in the current study was to

provide a test of concurrent validity for the Hospital Stress Scale. Fear

was conceptualized by the authors of the CMFS as, "a temporary reaction

and an emotional response to specific real or unreal danger" (Broom et

al., 1988, pp. 203), whereas the construct of stress, as identified in

this study, occurs as the result of a person-environment transaction that

is appraised as threatening the well-being of the person. Appraisal of an

event as stressful precedes the emotional reaction of fear to the event.

While these constructs are not identical, because the appraisal of stress

must be made before fear is experienced, the determination of a child's

fear in relation to medical events should provide a measure of the degree

of stress the child perceives in the situation.

118

The CMFS was developed to provide a measure of children's

fearfulness of medical experiences. The original 29 item self-report

scale used a three point, forced choice format. The responses are scored

not at all - 1 point, a little = 2 points, and a lot - 3 points, for a

possible total score ranging from 17 to 51, the low scores reflecting low

fearfulness and the high scores indicating high fearfulness. Because the

scoring only involves a simple calculation of the child's responses, the

objectivity of the scoring process is good. The items for the

instrument were developed by interviewing 146 children, ages 6 to 11

years, about medically related concerns and fears. The sample consisted

of 48% males and 52% females, and 71% were white. The ethnicity of the

remaining 29% was not stated. From this data the items for the instrument

were developed, resulting in probable good content validity of the

measure. Three child health experts were asked to rate the relevance of

the items, resulting in a content validity index of .78%. Criterion

validity was established by a .71 correlation with the Medical Fear

Subscale of the Fear Survey Schedule for Children (Scherer & Nakamura,

1968). However, an expected relationship between the child's age and

score on the CMFS was not demonstrated (Broome et al., 1988).

Reliability testing was conducted using a separate group of healthy

84 children, ages 5 to 11 years. The sample was 38% male and 62% female;

88% Caucasian and 11% Black. Internal consistency was demonstrated by a

Cronbach's alpha of .93; a test-retest coefficient of . 84 over a two week

period; and an intercorrelation of the theoretical subscales of . 69,

indicating that the test measures one factor: children's fears of medical

experiences. Following additional testing it was decided to revise the

CMFS to eliminate items that showed little variability and to combine

119

similar or redundant items. The revised version consists of 17 items,

scored as described above for the original version. Preliminary testing

of the revised CMFS is currently in process. Data is available for a

sample of 12 well children, ages 5-12 years, and their parents, and 23

sick children and their parents. Internal consistency estimates were: for

the mothers of well children, .75; for the well children, .82; for the

mothers of ill children, .90; and for the ill children, . 83. Correlation

between the ratings of the well child and parent was .67, and between the

ill child and parent was .46. The test-retest validity for well children

over a two week period was .81. The total scores for the well children

and ill children were not significantly different (M. E. Broome, personal

communication, November, 27, 1989).

Although psychometric testing of the revised CMFS is still in

process, the validity of the instrument should not have been affected by

the changes and the early estimates of reliability remain good. Because

less time is needed to complete the revised version, thus reducing the

length of the data collection session and decreasing the possibility of

causing unnecessary fatigue for the hospitalized children, the 17 item

revision of the CMFS was used in this study. (See Appendix F for a copy

of instrument.)

Four alternate medical fear scales were considered for use in this

study. The first was the medical fear subscale of the Fear Survey

Schedule for Children by Scherer and Nakamura (1968). Using factor

analysis, 11 of 80 items were assigned to the medical fear subscale (See

Table 3). Six items were possibly relevant to medical fears and five were

In Ot. An internal consistency of .94 was reported for the totalinstrument. A second scale was a revision of Sherer and Nakamura's tool:

120

the medical fear subscale of the Revised Fear Survey Schedule for Children

by Ollendick (1983). Again, using factor analysis, a medical fear scale

was identified, consisting of seven items (See Table 3), five possibly

related to medical situations and two unrelated. For the total instrument

validity was claimed because girls indicated a greater number of fears

than did boys, a positive correlation with trait anxiety was noted, and an

inverse relation with self-concept and locus of control was identified.

Reliability was established by an internal consistency of .94 and a test

retest of .55 over a 3 month period. The third scale was the Hospital

Fears Rating Scale by Melamed. This twenty-five item tool consists of the

first eight fears for the Scherer and Nakamura (1968) medical fears

subscale, eight additional items considered by the author to have face

validity as hospital fears, and nine other nonmedical fear items (See

Table 3). Additional support for validity is stated to be the change in

children's scores on the scale following hospital experience or structured

hospital preparation programs. One study showed a test-retest reliability

of .75 as determined immediately before and after viewing a hospital

related slide tape (Melamed, Dearborn, & Hermecz, 1983). The fourth

scale, the Hospital Fear Questionnaire, was developed by Roberts, Wurtele,

Boone, Ginther, and Elkins (1981) and consisted of five items considered

to have face validity for child's fears during hospitalization (See Table

3). Although used in three studies to evaluate the effectiveness of

prehospitalization programs (Roberts et al., 1983; Elkins & Roberts, 1984,

1985), no information was given regarding any additional determination of

validity or reliability of the instrument.

121

Table 3

Item Contents of Four Fear Scales

Sherer andNakamura (1968)

Sharp objects

Having to go tothe hospital

Getting a shotfrom the nurseor doctor

Going to thedentist

Going to thedoctor

Getting ahaircut

Deep water orthe ocean

Getting carsick

My feelings gethurt easily

My feelings gethurt easilywhen I amscolded

I get tiredeasily

Ollendick

(1983)

Riding in theCar

Having to go tothe hospital

Talking on thetelephone

Getting a shotfrom the doctor

Going to thedentist

Going to thedoctor

Getting carsick

Melamed and

Lumley (1987)

Sherer andNakamura'sfirst 8 items

plus:Germs or

gettingseriously ill

The sight ofblood

Being alonewithout yourparents

Having anoperation

Getting a cutor injury

Getting sick atschool

Not being ableto breathe

Persons wearingmasks

Spiders

Making mistakes

Going to bed inthe dark

Strange or meanlooking dogs

Flying in anairplane

GettingpunishedThunderstorm

Ghosts or

spooky things

Falling fromhigh places

Roberts etal. (1981)

Having anoperation

Taking medicineDoctors andnurses

Blood-test

X-ray

(Note: This wasadministered

with, butconsidered

separate fromSherer andNakamura'sfirst 8 items)

122

These instruments for measuring children's fears related to

hospitalization have four major weaknesses. First, the items for the

scales were identified theoretically by adults. Children were not asked

to identify sources of fear during hospitalization. Second, with the

exception of the Hospital Fear Scale by Melamed, the instruments are

relatively short, indicating a strong probability that they do not

adequately sample the range of children's fears during hospitalization.

Third, the scales borrowing items from the Scherer and Nakamura (1968)

medical fear subscale included items that do not have a logical

relationship, or face validity, for the hospital experience. Therefore,

the validity of the instruments for measuring what children actually fear

is jeopardized. Finally, the reliability estimates for the instruments

has remained inadequate. For these reasons, and because the Children's

Medical Fear Scale by Broom et al. (1988) has strong evidence of validity

and reasonable early reliability estimation, the CMFS was selected for use

as a measure of concurrent validity in the present study of children's

stress and coping during hospitalization.

Coping Response Inventor CRI

The purpose of the Coping Response Inventory was to provide a test

of concurrent validity for the Hospital Coping Scale. The construct of

coping, as used in this study, is the process of attempting to manage a

situation that has been appraised as stressful. The question asked by

both the HCS and CRI is how effective has the coping been in helping

manage the stressful event. Because the CRI is not specific for use with

hospitalized children, it could not be used as a direct measure of this

123

iable, but rather was used to estimate the validity of the newly

sloped HCS.

The CRI was developed by Elwood (1987) to provide a measure of the

activeness of children's coping responses to situations they have

raised as stressful. The author interviewed children both singly and

groups to determine what types of events were perceived as stressful

typical coping behaviors. Children from five fourth grade classes and

n five seventh grade classes representing a cross-section of

ioeconomic levels were interviewed. The total number in these groups

not given, nor was the geographic or ethnic mix of the subjects

ted. Based on the children's discussion, three inventories were

*loped for each age group: a major event inventory, a daily has sle

2ntory and a coping response inventory. These inventories were then

ted for reliability by administering the tools to a group of 156 fourth

le children and 147 seventh grade children. It was not stated if these

* the same children initially interviewed, and again geographic

ation and ethnicity were not given.

For the purposes of the present study to determine the concurrent

idity of the HCS, the coping response inventory for grade four children

used, as more subjects would be likely to be in or near this grade

, the seventh grade. The fourth grade CRI is a 14 item, self-report

ºntory. The child is asked to read the item and decide if he or she

I that behavior when an upsetting situation occurred. If the answer is

the child indicates on a four point Likert scale how much the

lvior helped solve the situation, the responses being: 1 - made it

;e, 2 – no change, 3 – helpful, and four - very helpful. The children

instructed to skip any items they did not use. The scores are summed

-*

124

and divided by the total possible for the number of items answered,

yielding a percentile indicating the child's perception of the

effectiveness of their coping response. Calculation of the score in this

manner will result in a high degree of evaluator objectivity.

The content validity of the instrument appears to be strong as it

was based on what children have identified as coping behaviors rather than

on what adults assume children do to cope with a stressful situation.

Additionally, the content validity was further strengthened by

administering early versions of the inventory to a grade-appropriate group

of children, revising the tool based on the subject's responses, and

readministering the inventory until the CRI results strongly reflected the

children's comments during an interview. Construct validity was

established by comparing the fourth grade inventory to the seventh grade

inventory and examining the responses to determine that the developmental

changes expected between the two groups were reflected in the instruments.

Test-retest reliability on a subgroup of 17 fourth grade children showed

no significant change across a two week period although the upsetting

event to which the child was referring may not have been the same (Elwood,

1987). No additional reliability scores were given for the CRI. (See

Appendix G for a copy of instrument.)

Although the CRI is new and is still in the process of being tested,

it was the best instrument available for use in the present study. Two

other instruments were considered. The Coping Inventory, by Zeitlin

(1980, 1985) is an observational instrument designed for use in

educational and therapeutic planning. The author states the tool is based

on the work of Murphy's study of children's coping, Lewin's Field Theory,

Piaget's model of cognitive development, a transactional model of child

125

development, Chess and Thomas's study of temperament, Burton White's study

of competency, and Coelho's and Haan's model of coping. In short, because

of theoretical differences in the conceptualization of the coping process,

such as a confounding of coping with adaptation and the assumption that

coping behaviors may be categorized as adaptive or maladaptive, the

Zeitlin tool not appropriate for use in a study based on the Lazarus

theory of stress and coping. The second available coping tool is the

Assessment of Coping Style, by Boyd and Johnson (1981). This is a

revision of the earlier School Picture - Story test and uses a projective

approach to assess coping styles used in interpersonal interactions with

peers and authority. The author has developed the instrument based on six

coping styles: externalized attack, avoidance, and denial, and

internalized attack, avoidance, and denial (Stone, 1985; Zarske, 1985).

Again, the theoretical basis is not congruent with the Lazarus model and

therefore is not appropriate for use in this study. In sum, the Coping

Response Inventory by Elwood (1987) is the only instrument available for

use in assessing children's coping behaviors that is congruent with the

Lazarus conceptualization of coping. Therefore, the CRI was selected for

use in estimating the concurrent of the Hospital Coping Scale.

Hospital Stress and Coping Interview

The purpose of the Hospital Stress and Coping Interview was to

identify the events occurring during hospitalization that school-age

children appraise as stressful and the resulting coping behaviors. The

*evel of the data obtained with this instrument is categorical. The

format developed by Wertlieb, Weigel, and Feldstein (1987) to assess the

*tress and coping of nonhospitalized school-age children was adapted for

126

use with the hospitalized child resulting in an interview consisting of a

series of open ended questions designed to elicit the events the child has

appraised as stressful during hospitalization and the actual coping

behaviors used in response to that event. Following assurance that there

were no right or wrong answers, and a reminder that the interview would be

tape recorded (previously discussed with the child in the assent process),

the child first was asked a non-threatening question about the positive

aspects of being in the hospital to decrease the child's anxiety and

facilitate the child's responsiveness. The child then was asked what has

happened in the hospital that has been upsetting (see above for discussion

of the term "upsetting"), followed by a question designed to elicit the

coping process, what the child did or thought when the upsetting event

Oc curred. In the event the child had difficulty understanding the

questions on stress and coping, follow-up probes were included to help the

child answer the questions without providing suggestions for specific

answers (Holaday & Turner-Henson, 1989; Woods & Catanzaro, 1988). To

Provide a therapeutic closure to the interview, the child was asked what

could be done by the nurses or doctors to make it easier to manage the

*Pse tting things. (See Appendix H for copy of instrument.)

The interview has been identified as the optimal method of studying

the school-age child's world (Deatrick & Faux, 1989) and it is generally

*&ree d that school-age children are able to provide reliable information

through interviewing (Faux, Walsh, & Deatrick, 1988; Gorman, 1980; Yarrow,

1999) , but careful planning is needed to obtain reliable and valid data.

* enhance the validity of the interview data the following elements were

**t into the interview process: 1) privacy during the interview (Holaday

& *rner-Henson, 1989; Faux et al., 1988; Rich, 1968), 2) focus on recent

127

events (Faux et al., 1988), 3) questions structured to move from the easy,

positive, or nonthreatening to potentially stressful concepts (Faux et

al., 1988; Holaday & Turner-Henson, 1989; Rich, 1968; Sattler, 1988;

Yarrow, 1960), 4) use of age appropriate words and concepts (Faux et al.,

1988; Holaday & Turner-Henson, 1989; Rich, 1968; Sattler, 1988; Yarrow,

1960), 5) use of action oriented words rather than abstract words, such as

"what did you do" rather than "what did you feel" (Faux et al., 1988;

Rich, 1968), 6) provision of periodic reassurance that the interview is

proceeding satisfactorily (Amato & Ochiltree, 1987; Sattler, 1988), 7)

minimization of socially desirable responses by acknowledging that

everyone finds something in the hospital upsetting (Faux, 1988; Rich,

1968; Yarrow, 1960), 8) audio recording of the interview to avoid

interruptions for transcription that may cause the child to loose interest

(Amato & Ochiltree, 1987) (Note: audio recording is considered to be a

nonreactive technique due to children's familiarity with such equipment

[Faux et al., 1988; Webb et al., 1981]), and 9) limiting the length of the

interview to avoid fatigue which may result in less than optimal answers

(Faux et al., 1988; Yarrow 1960). Additionally, content validity was

established by basing the interview on the work of Wertlieb et al. (1987)

and through comparison with other stress and coping interviews in the

current literature. Consensual validity was determined through a review

of the instrument by three pediatric nursing experts. Construct validity

was assessed through a pilot test of the instrument with five subjects

meeting the inclusion-exclusion criteria. The children's responses were

analyzed and revisions made as necessary to enhance their understanding of

the questions. Interrater reliability for the categories developed from

128

the content analysis portion of the data analysis will be reported in the

next chapter.

Data Collection

The process of data collection, including the preliminary trial, the

pilot study, and the final protocol used for data collection, including

obtaining informed consent, will be detailed in this section. A

description of the persons participating in data collection will also be

given.

The Phases of Data Collection

Two preparatory phases, the preliminary trial and the pilot study,

preceded data collection. A separate group of children was used in each

of these phases, so that data were collected from each subject only once.

Data from the preliminary trial and pilot study were not included in the

final data analysis.

Following the selection of instruments needed to obtain information

regarding the variables of the investigation and development of the

interview, a preliminary trial of the instruments was conducted during

November 1989. The purpose of this trial was to gain a sense of the

responses of the children to the instruments and estimation of the length

of time needed to complete the process. Three children, ages eight, ten,

and eleven years, who had experienced a medical or dental procedure within

the last year were interviewed in their homes. The parents, friends of

the investigator, were given a copy of the consent form, both to obtain

appropriate consent and to gain feedback regarding the clarity of the

129

consent. All parents stated that the consent form was clear and easily

understood. The children responded well to the interview and answered the

questionnaires easily within about a thirty minute session.

While the preliminary trial indicated that the protocol was

appropriate for use with eight to eleven year old children who were

currently healthy, it was necessary to determine if it would be reasonable

for use with hospitalized children of the same age. Therefore, following

approval of the Committee on Human Research at the University of

California, San Francisco and the Nursing Research Committee of the same

facility, a pilot study was conducted during January 1990. Parental and

child consent was obtained, and five children meeting the

inclusion/exclusion criteria were interviewed and completed the

questionnaires and scales. While the children were able to complete the

interview and questionnaires without difficulty, it was evident that minor

modifications were needed. First, the wording of the interview was

awkward. Accordingly, the questions were restructured to create a more

natural flow to the process. Second, use of both direct questioning to

determine the children's stress and coping processes and indirect

questioning to verify the responses appeared to be confusing or irritating

to the children. After being asked what they found upsetting and what

they did to take make it less upsetting, an indirect probe was asked

regarding what they would tell a friend about upsetting things in the

hospital and how to manage them. The subjects repeated the answers given

in direct questioning and gave nonverbal messages of impatience in

repeating the answers. Because of this, and because the ill children

tended to tire toward the end of the session, the interview was shortened

to four questions with suggested probes (See Appendix H). The third

130

phase of data collection, the actual study, was conducted from February

through August 1990. During this time data were collected from 82

subjects meeting the inclusion/exclusion criteria following the protocol

described below.

The Protocol for Data Collection

Following the identification of potential subjects, the parent (s) of

the child were approached, given a brief explanation of the study, the

reason their child had been selected, and asked if they would be willing

to listen to more information about the study. If so, the parents'

consent form and the Experimental Subject's Bill of Rights (See Appendix

I and J for copies of the University of California, San Francisco consent

form. Consents for other facilities contained the same information, but

in the format required by that facility. ) was given to the parent(s) and

each step of the protocol explained. The parent(s) were asked if they

would like time to consider the information before signing. If so, the

consent was left with them and the researcher returned in approximately

one-half hour to ask for their decision. Generally, however, the parents

stated they did not need any additional time and were willing to give

permission immediately. An attempt was made to discuss the study away

from the child's hearing, but this was not always possible. Parental

consent was obtained whenever it was possible to contact the parents

following admission of the child to the facility. At the time of consent

the parents were requested to complete a demographic form pertaining to

the child (See Appendix K) and given the opportunity to request a summary

of the research results, if so desired (See Appendix L).

131

Following parental consent, the study was be explained to the child

and assent for participation requested. The child's assent form (See

Appendix M) was given to the child. For most children it was read to or

with the child, but a few older children purposely held the form away from

the researcher's view and read it independently. All children were

reassured that there were no right or wrong answers to the questions and

the rights of privacy, with the exception that the parent might request to

see the child's answers, and withdrawal of assent were reinforced before

asking if the child was willing to participate. The child's consent was

obtained immediately before proceeding with the data collection on the

second or third day of admission.

Data collection was conducted in the child's hospital room or

another nearby quiet location. During the consent process it was

explained to the parents that children tend to expect parents to answer

questions for them, so it would be helpful if the parent would leave the

room during the data collection. If the parent was hesitant to do so, or

if the child wanted the parent to stay, the parent was asked not to coach

the child's answers, and the data collector attempted to position herself

so that the child was not looking directly at the parent during the data

collection.

The instruments were grouped and administered as follows:

1. Hospital Stress and Coping Interview

2. in random order:

STAIC A-Trait scale

As a set: the Practice Scale, Hospital Fear Scale, and

Hospital Coping Scale

Coping Response Inventory

132

3. Child Medical Fear Scale

The rationale for administering the interview first was to provide the

necessary frame of reference for the child to understand the concepts

being tapped in the Hospital Fear and Coping Scales and Coping Response

Inventory, moving from the concrete to the abstract, a principle of

interview development (Faux et al., 1988) that was reasonable to apply to

the general data collection process. The rationale for administering the

Practice Scale, Hospital Fear Scale, and Coping Scale as a set was the

similarity of format and logical flow of questioning. The Hospital Fear

and Coping Scales, the STAIC A-Trait Scale, and the Coping Response

Inventory were administered in random order to correct for unrecognized

interaction between the tests. The Child Medical Fear Scale was

administered last to avoid suggesting possible sources of stress to the

children.

The interview was recorded on audio tape, transcribed, and the tapes

permanently erased at the completion of the study. To control for

probable variations in reading level, an attempt was made to read the

instruments aloud to the subjects, however, some older children were

resistive to this, and read the instruments independently. All children

did respond independently in answering the items. The total testing time

ranged from twenty minutes to one and one-half hours, depending on how

talkative the child was and how many interruptions occurred.

Interruptions occurred for a variety of reasons. The most common

was the entrance of hospital personnel for necessary assessment or

treatment. These episodes included the nurse taking the child's vital

signs, giving medicine, resetting the I. V., the physician checking the

child, or the physical therapist repositioning the child. Occasionally,

133

the parent arrived during the session, and a break was taken so the child

could greet and talk with the parent. Finally, on a few occasions, the

child tired during the session and was given a chance to rest before

continuing.

Description of Data Collectors and Training Process

Because of the geographical distance between the participating

facilities, research assistants collected the data at several of the

facilities. All of the data collectors were female, registered nurses and

had a minimum of one year experience working with hospitalized children.

Of the six research assistants, four had an earned Master's degree in

Nursing one of whom was working toward a doctorate in public health; one

was working on her Master's degree; and one was in the process of applying

for admission to a Master's program. These persons conducted the data

collection at UC Davis Medical Center, Children's Hospital at Stanford,

Valley Children's Hospital, and Loma Linda University Medical Center. The

primary investigator collected the data at UC San Francisco Medical

Center, Shriner's Hospital for Crippled Children, and San Francisco

General Hospital Medical Center.

To ensure that all data was collected using the same procedure, and

thus minimize the potential variance that could occur due to having the

data collected by seven individuals, the primary investigator developed a

manual entitled, Instructions for Data Collection. The following areas

were discussed in this manual: background and purpose of the research,

definition of key terms, responsibilities of the data collectors, the

materials needed for each session, identification of potential subjects,

the process of informed consent, a description of each instrument with

134

guidelines for proper administration, guidelines for interviewing

children, and answers to common questions that could occur. Each data

collector received and read a copy of the manual and a sample packet of

consent forms and instruments before the researcher came to the facility

to conduct a training session.

Training sessions were held at each facility where research

assistants would be collecting the data. During the session, an overview

of the Lazarus theory of stress and coping was presented to give the

nurses a better understanding of the theoretical basis of the study to

enable them to participate intelligently in the data collection and

understand the importance of allowing the child to independently identify

sources of stress during hospitalization. The process of identifying

potential subjects was reviewed and the importance of following the

inclusion/exclusion criteria was emphasized. Examples were given of types

of patients that would or would not be eligible. Because all data

collectors were pediatric nurses familiar with the purpose and process of

obtaining consent it was not necessary to explain the legal necessity of

obtaining consent from parents; rather the emphasis in the training

session was placed on the initial approach to the parent, how to describe

the protocol in lay terms, and answers to common questions that might be

asked. Each instrument was reviewed with the data collectors and

suggestions given for facilitating the child's participation, such as

during the interview jotting notes of the "upsetting" things identified by

the child to guide the next question on coping. Each nurse was asked to

use the sample packet of instruments on a non-hospitalized child by

focusing on an experience in the doctor's or dentist's office or emergency

room, and then report back to the researcher. At that time any questions

135

were clarified and suggestions given as needed. Following the first data

collection session, the primary investigator again talked with the data

collector and provided feedback on the session. This procedure was

repeated intermittently throughout the process of data collection.

To further control the variance that could occur when data is

collected by multiple persons, data collection packets consisting of all

forms needed were precollated and numbered. Numbered cassette tapes were

provided corresponding to the numbers of the data collection packets. A

ruler-shaped piece of poster board was provided to help the children track

the line for the items and responses on the various instruments. Tape

recorders and batteries were provided. Finally, a supply of colorful

"thank-you" stickers were given to each data collector.

Periodic telephone calls and on-site visits indicated that the data

collectors followed the protocol for subject identification and data

collection very carefully. All data collected by the assistants was

reviewed by the primary investigator before inclusion in the study. Data

collected by the assistants from eight subjects were eliminated from the

final analysis due to questionable eligibility for the study.

Data Analysis

The plan for data analysis is presented below. Descriptive

statistics were used for preliminary examination of the data, and

inferential statistics for testing the hypotheses and drawing conclusions

from the data.

Descriptive statistics were used to determine the measures of

central tendency and variation for the variables of gender, health status

group, trait anxiety, stress appraisal associated with the event of

136

hospitalization, perceived satisfaction with coping behaviors during

hospitalization, and for the categories of stress and coping used during

hospitalization. In addition, the demographic data of age, ethnicity,

prior experience with hospitalization, prior experience as an out-patient,

participation in a prehospitalization program, and extent of parental

rooming-in during hospitalization were examined by the same procedures to

determine any unexpected variations in the sample.

Hypotheses 1, 2, 3, 4, 5, and 6, examining the relationship between

health status and the child's identification of stressful events and

coping behaviors; between gender and the stressful events and coping

behaviors; and between trait anxiety and the stressful events and coping

behaviors, were analyzed using a two part process. First, the data

obtained during the interview with the child was examined through the

process of content analysis (Asher, 1983), reducing the qualitative data

to mutually exclusive categories. For the purpose of statistical

analysis, only the child's first response to the stress probe and the

coping probe was included in this portion of the statistical analysis.

Second, Chi square analysis, or analysis of variance, as appropriate, was

used to determine the relationship between each independent variable and

the categories, resulting in three analyses for each set of categories:

health status by stress categories, gender by stress categories, trait

anxiety by stress categories, health status by coping categories, gender

by coping categories, and trait anxiety by coping categories.

Hypothesis 7, the affect of health status, gender, and trait anxiety

on the child's appraisal of hospitalization as stressful, and Hypothesis

8, the affect of health status, gender, trait anxiety, and stress

appraisal on the child's perception of effectiveness of the coping

137

behavior, were analyzed using the statistical technique of path analysis

because of the fit between the proposed question and this technique.

Theoretically, the purpose of path analysis is to calculate the direct and

indirect influences of the independent variables on the dependent variable

(Kerlinger, 1986). In this study, as in most nonexperimental research, it

was probable that the independent variables were related, requiring use of

multiple regression techniques (Kerlinger, 1986). Additionally, use of

multiple regression techniques made full use of the continuous nature of

the data.

At each stage of the model, multiple regression was used to evaluate

the effect of the independent variables on the dependent variable. The

categorical variables of health status and gender were dummy coded for

quantitative analysis. For the analysis of Stage I, the relative effects

of health status, gender, and trait anxiety on stress appraisal were

determined. Stage II examined the relative effects of health status,

gender, trait anxiety, and stress appraisal on coping behavior.

The Pearson product moment correlation coefficient was calculated

for the necessary tests of concurrent validity. The results of the

Hospital Stress Scale were correlated with the results of the Child

Medical Fear Scale, and the results of the Hospital Coping Scale were

correlated with the results of the Coping Response Inventory.

138

CHAPTER FOUR

RESULTS

In this chapter, the results of the data analysis will be presented.

First, the demographic characteristics of the sample will be described,

providing information regarding the age of the subjects, ethnicity,

residence in an urban or rural setting, family income, health status and

diagnostic groupings, any ongoing therapeutic interventions, prior

hospitalization, and description of subjects by site of data collection.

Additionally, the subjects that refused to participate in the study will

be described. Second, the preliminary analyses of the data to determine

unexpected differences in characteristics will be described. Factors to

be considered are site of data collection, age, prior out-patient

experiences, prehospitalization teaching programs, and parental rooming

in. Third, the hypotheses will be discussed in numerical order, according

to two naturally occurring subgroups: Hypotheses 1 through 6, addressing

the analysis of the interview data in relation to health status, gender,

and trait anxiety; and Hypotheses 7 and 8, addressing the analysis of the

stress and coping word graphic scales in relation to health status,

gender, and trait anxiety. The results of each subgroup of hypotheses

will be summarized and schematically portrayed using the theoretical model

described in Chapter 2.

Characteristics of the Sample

Data were collected from 82 children, the sample size needed to

achieve the desired power of . 80. The convenience sample was comprised of

139

41 (50%) males and 41 (50%) females. The average age was 9.6 (s.d. l. 2)

years; 9.63 (s.d. l. 2) for males and 9.65 (s.d. l. 2) for females. Table

4 provides the number of subjects by age and gender.

Table 4

Gender and Age of Subiects (in years)

8 9 10 11

Gender n (%) n (%) n (%) n (%) Total

Males 11 (13.4) 7 ( 8.5) 9 (11.0) 14 (17.1) 41 ( 50%)

Females 9 (11.0) 9 (11.0) 10 (12.2) 13 (15.6) 41 ( 50%)

Total 20 (24.4%) 16 (19.5%) 19 (23.2%) 27 (32.9%) 82 (100%)

The ethnicity of the subjects was : 52 (63.41%) Caucasian, 13

(15.85%) Hispanic, 10 (12.2%) Black, 2 (3.66%) Asian, and 4 (4.88%)

"Other" consisting of two Portuguese and two of mixed heritage, as

indicated by the parent on the demographic data sheet. Thus, all major

ethnic groups were represented in the sample. Seventy-one percent of the

children resided in an urban area (within the city limits), and 29 percent

in a rural location (outside the city limits). Family income is

summarized in Table 5.

Regarding the health status of the children, 21 (25.6%) were

admitted to the hospital for an acute illness and 61 (74.4%) for a chronic

illness, as defined previously. Table 6 provides information regarding

140

Table 5

Family Income

Range N Percent

less than $ 9,999 15 19.2%

$ 10,000 to $ 19,999 12 15.4%

$ 20,000 to $ 29,999 15 19.2%

$ 30,000 to $ 39,999 14 18.0%

$ 40,000 and higher 22 28.2%

the subjects's health status by condition requiring hospitalization. The

use of the non-categorical approach provided a wide range of diagnostic

conditions. Included in the category of cardiac disorders were diagnoses

of congestive heart disease and pending surgical correction of cardiac

defects. The category of gastrointestinal disorders included children

with appendicitis, gastric or intestinal surgery, ulcerative colitis,

Crohn's disease, and pancreatitis. Hemopoietic disorders included

diagnoses of idiopathic thrombocytopenia, sickle cell anemia, neutropenia,

and aplastic anemia. Neurological disorders included children with spina

bifida admitted for surgery to release a tethered spinal cord.

Oncological disorders included leukemias, lymphomas, and a variety of

solid tumors. Orthopedic disorders included open reduction of fractures,

surgical intervention for non-union of fractures, osteomyelitis,

corrective surgery for orthopedic anomalies, osteogenesis imperfecta, and

Legg's Perthes Disease. The category of reconstructive surgery included

141

Table 6

Health Status and Condition of Subiects

Acute Chronic

Condition N (%) N (%)

Cardiac Disorder 0 (0%) 2 (2.4%)

Gastrointestinal Disorder 9 (11.0%) 6 (7.3%)

Hemopoietic Disorder 1 (1.2%) 9 (11.0%)

Neurological Disorder 0 (0%) 2 (2.4%)

Oncology 0 (0%) 13 (15.9%)

Orthopedic Disorder 7 (8.5%) 9 (11.0%)

Reconstructive Surgery 0 (0%) 7 (8.5%)

Renal Disorder 0 (0%) 5 (6.1%)

Respiratory Disorder 0 (0%) 6 (7.3%)

Other 4 (4.8%) 2 (2.4%)

Total: 21 (25.6%) 61 (74.4%)

children admitted for burn scar revision and correction of congenital

structural

diagnoses

correction

transplant

fibrosis.

defects, such as malformed ears. Renal disorders included

of nephrotic syndrome, ureter reimplantation, surgical

of congenital abnormalities, and evaluation of possible renal

rejection. Respiratory disorders included asthma and cystic

Conditions not directly related to the above categories were

grouped under the label of "other" and included trauma not involving

142

orthopedic injuries, arterio-venous malformation, systemic lupus

erythematosus, and children admitted for rehabilitation training.

During data collection, 61 (74.4%) of the children were experiencing

some sort of mechanical device used for ongoing assessment or

intervention. Forty-four children (53.7%) had an IV or heparin lock.

Eleven children (13.4%) had a cast. Five (6.1%) had a central line. Five

(6.1%) had a naso-gastric tube. Four (4.9%) were receiving oxygen by mask

or nasal cannula. Two (2.4%) had a urinary catheter. Two (2.4%) were on

cardiac monitoring. One child (1.2%) was in traction.

Considering prior experience with hospitalization, of the acutely

ill children, only 2 of the 21 subjects (9.5%) had been previously

admitted to the hospital. As stipulated in the eligibility criteria,

these admissions occurred when the child was less than two years of age.

For the chronically ill children, the number of prior hospitalizations

ranged from 1 to 100, with a mean admission rate of 9.8 (s.d. - 15.9). It

is possible that this range is skewed toward the high side, as the

parental response to number of admissions appeared to be rounded to a

convenient estimate after 16 admissions. It was not possible to verify

this information as old charts were not readily available and the children

had often been admitted to more than one facility.

Of the seven clinical facilities described in chapter 3, data were

collected at only six of the hospitals. No subjects were obtained from

Children's Hospital at Stanford. This was due to an unusually low

admission of children between eight and eleven years of age that met the

inclusion/exclusion criteria at that facility during the period of data

collection. The research assistant reported that during the entire period

of data collection, only three potential subjects were identified, and all

143

were unwilling to participate in the study. Therefore, all analyses will

be based on the remaining six facilities. The total number, age in years,

gender, and health status of the subjects obtained from each facility is

reported in Table 7.

Table 7

Description of Subjects by Site

UCSF" SHCC” UCDMC" VCH* LLUMC" SFGH"

Variable N N N N N N

Total N 42 14 7 6 8 5

Age in years

8 10 3 2 1 2 2

9 9 2 O 3 2 O

10 11 2 2 1 2 1

11 12 7 2 1 2 2

Gender

Male 20 8 2 3 5 3

Female 22 6 5 3 3 2

Health Status

Acute 7 l 5 5 O 3

Chronic 35 13 2 1 8 2

"UCSF - University of California, San Francisco Medical Center;SHCC - Shriner's Hospital for Crippled Children;UCDMC - University of California, Davis Medical Center;VCH - Valley Children's Hospital;LLUMC - Loma Linda University Medical Center;SFGH = San Francisco General Hospital and Medical Center

144

Information on potential subjects that refused to be in the study,

was kept by the data collectors at all of the seven facilities. During

the period of data collection, 18 potential subjects declined to

participate in the study. This group was comprised of 13 (72.2%) males

and five (27.8%) females, 11 (61.1%) chronically ill and 7 (38.9%) acutely

ill, with an average age of 9.4 years. In nine cases the parent refused

permission, in seven the child was not interested in participating, and in

one the physician denied permission as the child was exhibiting behavioral

problems. Reasons for not participating were that the child was too

tired, was grouchy, was nauseated, that the child didn't want to talk

about the hospital experience, hoarseness due to surgery, imminent

discharge, and in two cases no reason was given. Three of the children

were reapproached during a subsequent admission when feeling better and

were then willing and even eager to participate.

At each facility, periods of time elapsed during which no data were

collected, due to illness, vacation, or work schedule of the data

collector. Due to the difficulty of gathering post hoc data to determine

if children admitted during these periods met the eligibility criteria,

the number and characteristics of missed potential subjects is not known.

Preliminary Analyses

It was possible that subgroups of the total sample may have had

subtle differences in factors that could influence the results of the

study. In order to determine if the subjects could be treated as a total

sample, preliminary analyses were conducted to examine the data for

possible differences due to site of data collection, age, prior out

145

patient experiences, prehospitalization teaching programs, and parental

rooming-in.

Site of Data Collection

Although each site used for data collection met the stipulations of

being a pediatric unit, allowing rooming-in of parents, and having a

staffed playroom, it was possible that differences existed in the

psychosocial support provided for the children that could result in

differences in the degree of stressfulness experienced by the children and

the perceived effectiveness of the coping behaviors. To examine for this

possibility, one-way analysis of variance was run on site by Hospital

Stress Scale scores and on site by Hospital Coping Scale scores. The

results indicated no significant differences in the dependent variables

between the six different sites. Therefore, it was appropriate to combine

the subjects from the six facilities as a total sample for data analysis.

Age Differences

In order to obtain a fairly homogenous group of children with

similar thought processes, the age range of 8 to 11 years, was used.

However, it was possible that even within the stage of concrete

operations, children's appraisal of stress and perception of their coping

could differ due to cognitive level. To check for this possibility, a

one-way analysis of variance was run comparing the subjects's age in years

with their responses to the dependent variables of the Hospital Stress

Scale score and the Hospital Coping Scale score. There was no significant

difference in the children's responses to these scales when examined by

146

age in years. Therefore it was not necessary to examine these groups

separately.

Prior Out - Patient Experience

Prior experience in a clinic or medical office with in the last year

ranged from 0 visits to 1000. Eliminating the subject on whom the parent

indicated 1000 visits, assuming that this was an overstatement as that

number of appointments within a 365 day period is highly unlikely, the

number of clinic or office visits ranged from 0 to 104, with a mean rate

of 10.4 (s. d. 15. 7). As would be expected, the parents of the chronically

ill children reported a significantly greater number of clinic and office

visits, with a range from 0 to 104, a mean of 13.3 (s. d. 17.4) than did

the acutely ill children. The acutely ill children had a range of 0 to 10

clinic appointments, with a mean of 2.3 (s. d 2.35). Therefore, the

chronically ill child was much more likely to have gained some knowledge

of health care procedures through office or clinic appointments than was

the acutely ill child. Although prior out-patient experience was not

included as a independent variable in this study, this preliminary finding

supports the assumption that the health care experiences of chronically

ill children differ from that of acutely ill children.

Prehospitalization Programs

Another source of prior experience with hospital situations might be

gained through prehospitalization teaching programs. Of the total sample,

only 16 (19.5%) had participated in such a program, 57 (69.5%) had not

had such an experience, and the parents of 9 children (11%) were uncertain

147

if their child had this type of an opportunity. Interestingly, all of the

children who had participated in a prehospitalization program were

chronically ill; none of the acutely ill children had been exposed to this

source of knowledge. A comparison of the scores on the Hospital Stress

Scale of children having participated in such as program as compared to

those who had not was statistically not significant. Therefore it was not

necessary to examine these two groups separately.

Parental Rooming-in

The number of hours per day in which the parent was able to stay

with the child ranged from 0 to 24 with a mean of 17.5 hours. The mean

for the acutely ill children was 18.3 hours (s. d - 6.1), and for the

chronically ill group was 17. 1 hours (s. d - 8.6), a difference that was

statistically not significant. Therefore it was not necessary to examine

these two groups separately.

In sum, five extraneous factors that could have potentially

influenced the children's stress appraisal and coping behaviors were

assessed. These factors were: site of data collection, age, out-patient

experience, prehospitalization programs, and parental rooming-in. None of

these caused a significant difference in the children's perception of the

stressfulness of the hospital or their perception of the effectiveness of

their coping behaviors. Therefore, it was appropriate to consider the

sample to be a homogenous group for the statistical analysis of the

hypotheses.

148

Analysis of Hypotheses

Discussion of the analytical strategies used for data analysis will

be presented in two sections. First, the approach used to analyze the

interview data in relation to the independent variables will be discussed

and the results presented. Second, the results of analyzing the data

obtained from the stress and coping word graphic scales will be described.

Within these two groups, the hypotheses will be examined in numerical

order.

Analysis of the Interview Data

The children's responses to the interview were examined using the

process of content analysis to develop categories of stressful events and

coping behaviors. This was followed by statistical analysis of the

quantification of these categories.

Stress Categories

Content analysis has been defined as, "a research methodology that

utilizes a set of procedures to make valid inferences from text" (Weber,

1985, pp. 9). For this study, the set of procedures used to analyze

stressful events was: 1) careful analysis of the interview data to

identify stressful events according to the definition of this concept used

in this study (see chapter 2); 2) identification of specific events stated

by more that one subject; 3) grouping of the specific events into a

conceptually similar categories; 4) development of an operational

definition for each category; 5) selection of a label representative of

the events included in the category; and 6) identification of events

representative of the category. Table 8 lists the stressful event

149

Table 8

Categories of Stressful Events During Hospital

Label Operational Definition Examples

Intrusive Any event involving entry Injections, blood workeVents into the body through the Intravenous insertion,

skin or a natural body surgery, pills,orifice nasogastric tubes,

suppositories

Physical Any physical symptom or Pain, nausea, sidesymptoms sensation relating to the effects of medications

illness or treatment such as blurry eyes,dizziness, burning ofintravenous medication

Therapeutic Any activity relating to Physical exam by doctor,intervention treating or assessing the palpation of abdomen,

physical status of the walking after surgery,patients vital signs taken at

night, dressing andremoval of stitches

Restricted Limitation of normal or Bed rest, holding stillactivity desired activity due to during x-rays,

illness or hospital rules not allowed to leaveunit, can't go outside

Separation Any expression of concern Parent's leaving,due to separation from miss friends, pets, etc.family, friends, pets, etc.,due to hospitalization

Environment Any physical or interpersonal Cords and wires onaspect of the child'senvironment

walls look like monstersat night, changingrooms, unpleasant ornoisy roommates;impatient or "mad"doctors and nurses

categories and operational definitions developed during the process of

content analysis and provides examples of the event.

150

Coping Categories

Content analysis was also employed to identify the coping behaviors

the children reported using during hospitalization. However, the

development of the categories differed somewhat from that of the stress

categories. The procedure used to analyze the coping behavior data was:

1) careful analysis of the interview data to identify coping behaviors

according to the definition of this concept used in this study (see

chapter 2); 2) identification of specific behaviors stated by more that

one subject; 3) assignment of the specific behaviors into one of the

coping categories derived from the synthesis of prior research relating to

coping of hospitalized children (see chapter 2); 4) selection of a label

representative of the category; and 5) identification of events

representative of the category. Table 9 lists the coping behavior

categories and operational definitions and provides examples of the event.

Quantification of Interview Data

A total of 337 stressful events were identified, with a mean of 4.1

(s.d. - 2.6), and a range of 0 to 16. Three children could identify no

stressful events. A total of 347 coping behaviors were identified, with

a mean of 4.2 (s. d - 3.2), and a range of 0 to 18 behaviors. Four

children did not identify any coping behaviors, the three who were unable

to state any stressful events and one additional child. Table 10 lists

the frequency with which a stress category was mentioned and the

percentage relative to the total number of stressful events. As is

evident from this table, the most frequently occurring category was that

of intrusive events, named more than twice as often as the next most

frequent category. Table 11 provides the frequency with which a coping

category was mentioned and the percentage relative to the total number of

151

Table 9

Categories of Coping Behaviors Used During Hospital

Label Operational Definition Examples

Cognitive Actively taking in or seeking Thinking about theprocessing information to clarify and situation, asking

understand a situation questions aboutthe event

Cognitive Any attempt to deal with the The shot will feelrestructuring stressful situation by like a mosquito

changing thinking about the bite, the surgerysituation was good because I

will get well

Cooperation Any behavior intended to bring I let them do it,the child's personal response I held still, Iin line with reality drank so I

wouldn't have to

get an IV

Countermeasure Any physical or cognitive Don't let them doattempts to remove self from it, ignoreor mitigate the effect of the doctors, sleep,stressful situation don’t think about

it, watchtelevision

Control Any attempt to influence the Relaxationsituation to control the techniques such asstressful event tapes or deep

breathing

Seeking Turning to others for help Wanting parentssupport in coping present, holding

someone's hand,calling friends onphone, talkingwith roommate

152

Table 10

Events Appraised as Stressful by Hospitalized Children

Categories Frequency (N–337) Percentage

Intrusive events 131 38.9

Physical Symptoms 56 16.6

Therapeutic Interventions 39 11.6

Restricted Activity 40 11.9

Separation 24 7.1

Environment 47 13.9

Table 11

Coping Behaviors Used by Hospitalized Children

Categories Frequency (N-347) % of subjects

Cognitive Processing 15 4.3

Cognitive Restructuring 34 9.8

Cooperation 32 9.2

Countermeasure 117 33.7

Control 76 21.9

Seeking Support 72 21.0

153

coping behaviors. The three most commonly mentioned categories were, in

decreasing rank order, countermeasures, control, and seeking support; the

remaining categories occurred with far less frequency.

Interrater reliability was determined by comparing the above

categorizations with those of two pediatric nurse researchers who

separately reviewed 10% of the interviews, randomly selected. The

correlation in the number of identified stressful events, the number of

identified coping behaviors, the percentage of agreement in the

categorization of the items, as determined by Cohen's Kappa, and the

number of significant findings in the comparison of assignment to the six

categories is presented in Table 12.

Table 12

Interrater Reliability for Content Analysis

P.I./1st" P.I/2nd” 1st/2nd”

Stress

r for number of events .9842 .9845 . 99.35

mean Ž of category agreement 62.5% 70.8% 68.75%

# of significant comparisons 2 of 6 2 of 6 4 of 6

Coping

r for number of behaviors . 9928 . 9772 . 98.91

mean X of category agreement 56.25% 66.67% 70.8%

# of significant comparisons 1 of 6 6 of 6 4 of 6

ºr - - - - -Comparison of primary investigator and first reviewerºr ºr - - -Comparison of primary investigator and second reviewerºr ºr - - -

ºr Comparison of first and second reviewers

154

The correlation between raters for the identification of stress

items and coping items was very high, all above .97. The mean percentage

of agreement in assignment to categories was determined by calculating the

average percent of agreement between each pair of raters for the six

stress categories and then for the six coping categories. For the stress

categories the mean percent of agreement was moderate, ranging between

62.5% to 70.8%, the individual comparisons ranging from 62.5% to 100%.

The number of significant comparisons between the raters ranged from two

to four of the six possible results. The mean rate of agreement in

assignment to the categories among all raters was : Separation, 100%;

Restricted activities, 70.85; Physical symptoms, 62.5%; Environment,

62.5%; Intrusive events, 54.2%; and Therapeutic interventions, 54.2%. For

the coping categories the mean percent of agreement also was moderate,

ranging between 56.25% and 70.8%, the individual comparisons ranging from

37.5% to 87.5%. The number of significant comparisons between the raters

ranged from one to six of the six possible results. The mean rate of

agreement in assignment to the categories among all raters was: Cognitive

processing, 75%; Seeking Support, 75%; Cooperation, 70.8%; Cognitive

restructuring, 62.5%; Countermeasure, 58.3%; Control, 45.8%.

Restatement of Theoretical Model

Before beginning analysis of the individual hypotheses, the

theoretical model (first introduced in Chapter 2) will be briefly reviewed

to regain an overall perspective of the study. To reiterate, the model

schematically illustrates the proposal that health status, anxiety, and

gender influence stress appraisal, and that all four factors are related

to coping behaviors. For ease of referral, the entire model is reproduced

below (Figure 3).

155

Health Status

Anxiety -~ Nº.Stress T* Coping

- mº- -appraisal Tº behaviors

Gender ~.

Figure 3. Theoretical model of relationships between variables.

Hypothesis 1

The first hypothesis postulated that there would be a relationship

between health status and the type of event appraised as stressful during

hospitalization. The descriptive statistics for this question were

examined by determining the frequency and percentage of each category of

stressful event by health status (see Table 13). These statistics were

based on N - 78, one acutely ill child and two chronically ill children

did not identify any stressful events associated with hospitalization.

Acutely ill children identified a total of 81 stressful events, with a

mean of 3.9 per child (s.d.- 3.0), and a range of 0 to 14 events.

Chronically ill children identified a total of 256 stressful events, with

a mean of 4.2 per child (s.d.- 2.4), and a range of 0 to 16 events. The

difference in the mean number of stressful events of the two groups was

not statistically significant at a .05 level. A comparison of the

percentage for each category between groups demonstrate that there is

little difference except in two categories: intrusive events in which the

156

Table 13

Frequency of Stressful Events by Health Status

Acute (N-20") Chronic (N-59")

Category Number Percent Number Percent

Intrusive events 22 27.2 109 42.6

Physical symptoms 22 27.2 34 13.3

Therapeutic interventions 10 12.3 29 11.3

Restricted activity 12 14.8 28 10. 9

Separation 5 6.2 19 7. 9

Environment 10 12. 3 37 14.5

Total events identified 81 257

" Three children, one acutely ill and two chronically ill, were unable toidentify any stressful events associated with hospitalization.

chronic group identified more events, and physical symptoms, in which the

acute group identified more events.

To determine if there was a statistically significant difference

between the responses of the acutely ill and chronically ill children in

the type of stressful events identified, the Chi-square test of

independence was used. Because this test assumes that the responses are

independent, that is that each subject contributed only one score to the

analysis, only the first responses of the subject were considered in this

analysis (see Table 14). The first response was chosen as it is likely

that the first item mentioned is the most dominant stressful event for

that child.

157

Table 14

Frequency of First Stressful Event by Health Status

Acute (N–20") Chronic (N-59")

Category Number Percent Number Percent

Intrusive events 8 40.0 39 66.1

Physical symptoms 9 45. 0 5 8.5

Therapeutic interventions O 0.0 6 10. 2

Restricted activity 1 5. 0 3 5.1

Separation O 0.0 4 6.8

Environment 2 10. 0 2 3.4

Total stressful events 20 59

" Three children, one acutely ill and two chronically ill, were unable toidentify any stressful events associated with hospitalization.

For the test of the relationship between health status and the type

of events appraised as stressful, the value of the Chi Square statistic

was 17.6342, d.f. - 5, p < 0.01, statistically significant. It should be

noted that 9 of the cell expected frequencies were less 5, resulting in a

possible inaccuracy of the statistic. To determine if the small cell

frequencies influenced the significance of this finding, similar

categories were collapsed, such as combining therapeutic intervention with

restricted activity and merging separation and environment. reexaminationof the Chi-square statistic indicated that the findings remained

significant at the .01 significance level. Therefore, it is reasonable to

158

conclude that, despite the less than ideal cell frequencies, the

relationship between health status and the categories of stressful events

is significant.

To determine in which categories there was a significant difference

between acutely and chronically ill children's responses, the test of

differences of proportion was used. Based on an alpha of .05, the

percentage of acutely ill children citing an intrusive response was

significantly lower than was that of chronically ill children. Also, the

percentage of acutely ill children citing a physical symptom was

significantly higher than that of chronically ill children. The remaining

four categories were not examined due to possible instability related to

low cell frequency.

Hypothesis 2

The second hypothesis postulated that there would be a relationship

between health status and the type of coping behavior used during

hospitalization. The descriptive statistics for this question were

examined by determining the frequency and percentage of each category of

coping behavior by health status (see Table 15). These statistics were

based on N - 77; the three children who could not identify a stressful

event were not questioned regarding coping behaviors and one additional

chronically ill child was unable to identify any coping behaviors used in

response to stressful events associated with hospitalization. Acutely ill

children identified a total of 69 coping behaviors, with a mean of 3.3 per

child (s.d.- 2.6), and a range of 0 to 11 events. Chronically ill

children identified a total of 278 stressful events, with a mean of 4.6

per child (s.d.- 3.3), and a range of 0 to 18 events. The difference in

the mean number of coping behaviors of the two groups was not

159

Table 15

Frequency of All Coping Behaviors by Health Status

Acute (N-20)." Chronic (N-58)"

Category Number Ž Number 7.

Cognitive Processing 3 4.3 12 4.3

Cognitive Restructuring 12 17.4 22 7. 9

Cooperation 4 5.8 28 10.1

Countermeasure 22 31.9 95 37.1

Control 18 26.1 58 22.7

Seeking Support 10 14.5 63 24.6

Total 69 278

* One acutely ill child and three chronically ill children were unable toidentify any coping behaviors used during hospitalization.

statistically significant at a .05 level. A comparison of the percentage

for each category between groups demonstrated that there is little

difference except in two categories: cognitive restructuring in which the

acute group reported more behaviors, and seeking support, in which the

chronic group reported more behaviors.

To determine if there was a statistically significant difference

between the responses of the acutely ill and chronically ill children in

the type of coping behavior identified, the Chi-square test of

independence was used. Because the concept of coping must always be

160

considered in relation to a specific stressful event, it was believed that

the theoretical basis for analyzing the coping behavior would be strongest

if the response to a specific category of stress was analyzed. As the

category of intrusive events received the largest number of first

responses, this category was selected for analysis of the child's coping

response. This technique avoids comparison of coping behaviors elicited

by diverse stressful situations such as intrusive events, restricted

activity, and separation, that logically could produce very different

coping behaviors. Again, only the first coping behavior stated in

response to the intrusive event was used to maintain the Chi Square

assumption of independence. Although the category of intrusive events was

the most frequently cited stressful category only 16 acutely ill children

and 48 chronically ill children were able to identify a coping behavior

used in response to an intrusive event, thus the total N for this analysis

was 64. (See Table 16 for descriptive statistics on the first response

data).

For the test of the relationship between health status and the type

of coping behavior used in response to an intrusive event, the value of

the Chi Square statistic was 5. 3484, d.f. - 5, p > 0.5, statistically not

significant. The expected frequencies of 7 cells in the 2 x 6 table were

less than 5, therefore the data were further examined by collapsing

conceptually similar categories, such as combining cognitive processing

and cognitive restructuring, both a form of cognitive coping, and

counteraction and control, both behavioral coping. Although the results

of these Chi-square analyses moved toward the .05 level, the results

remained not significant. Therefore, despite the difficulty with cell

size, it is clear that in this sample there was no significant

161

Table 16

1st Coping Behavior used in Response to Intrusive Event by Health Status

Acute (N-16)." Chronic (N-48)"

Category Number Ž Number Ž

Cognitive Processing l 6.5 3 6.3

Cognitive Restructuring 3 18.8 4 8. 3

Cooperation 1 6. 3 7 14.6

Countermeasure 4. 25. 0 15 31. 3

Control 4 25. 0 4 8.3

Seeking Support 3 18.8 15 31. 3

" The N's for this table represent only the children who identified anintrusive event as stressful and who verbalized a coping behavior usedin response to the intrusive event.

relationship between health status and the type of coping behavior used by

school-age children during hospitalization.

Hypothesis 3

The third hypothesis postulated that there would be a relationship

between gender and the type of event appraised as stressful during

hospitalization. The descriptive statistics for this question were

examined by determining the frequency and percentage of each category of

stressful event by gender (see Table 17). These statistics were based on

N - 78, one male and two females did not identify any stressful events

associated with hospitalization. Males identified a total of 155

162

Table 17

Frequency of Stressful Events by Gender

Male (N-40") Female (N-39")

Category Number 7. Number 7.

Intrusive events 57 36.8 74 40.7

Physical symptoms 28 18.1 28 15.4

Therapeutic interventions 16 10.3 23 12.6

Restricted activity 27 17.4 13 7.1

Separation 8 5.2 16 8.8

Environment 19 12.3 28 15.4

Total N 155 182

* One male and two females did not identify any stressful events associatedwith hospitalization.

stressful events, with a mean of 3.7 per boy (s.d.- 2.4), and a range of

0 to 14 events. Females identified a total of 182 stressful events, with

a mean of 4.4 per girl (s.d.- 2.7), and a range of 0 to 16 events. The

difference in the mean number of stressful events between the two groups

was not statistically significant at a .05 level. A comparison of the

percentage for each category between groups demonstrated that there is

little difference except in the category of restricted activity that the

boys reported more frequently.

163

To determine if there was a statistically significant difference

between the responses of the males and females in the type of stressful

events identified, the Chi-square test of independence was used. Again,

because this test assumes that the responses are independent, only the

first responses of the subject were considered in this analysis (see Table

18 for descriptive statistics on the first response data).

Table 18

Frequency of First Stressful Event by Gender

Male (N-40") Female (N-39")

Category Number 7. Number 7.

Intrusive events 25 62.5 22 56.4

Physical symptoms 6 15. 0 8 20.5

Therapeutic interventions 3 7.5 3 7.7

Restricted activity 3 7.5 1 2.6

Separation 1 2.5 3 7.7

Environment 2 5.0 2 5.1

* One male and two females did not identify any stressful events associatedwith hospitalization.

For the test of the relationship between gender and the type of event

appraised as stressful, the value of the Chi Square statistic was 2.4549,

d. f. - 5, p > . 05, statistically not significant. Because the frequency of

164

eight of the cells was lower than the expected frequency of 5, the

statistic was reexamined by collapsing conceptually similar categories,

such as therapeutic interventions and restricted activity, and separation

and environment. Although these measures moved the p-value toward the .05

level, statistical significance was not achieved. Therefore, it is

evident that in this sample there was no significant relationship between

the gender of the child and the type of stressful event first mentioned in

relation to hospitalization.

Hypothesis 4

The fourth hypothesis postulated that there would be a relationship

between gender and the type of coping behavior used during

hospitalization. The descriptive statistics for this question were

examined by determining the frequency and percentage of each category of

coping behavior by health status (see Table 19). These statistics were

based on N = 77; the three children who could not identify any stressful

events were not questioned regarding coping behaviors and one additional

male was unable to identify any coping behaviors used in response to

stressful events associated with hospitalization. The males identified a

total of 151 coping behaviors, with a mean of 3.7 per child (s.d.- 2.4),

and a range of 0 to 11 events. The females identified a total of 196

stressful events, with a mean of 4.7 per child (s.d.- 3.7), and a range of

0 to 18 events. The difference in the mean number of coping behaviors of

the two groups was not statistically significant at a .05 level. A

Comparison of the percentage for each category between groups demonstrated

that there is little difference except in one category, countermeasure,

reported more frequently by the boys than by the girls.

-

Z.º.

-

165

Table 19

Frequency of Coping Behaviors by Gender

Male (N–39)." Female (N–39)."

Category Number 2. Number 7.

Cognitive Processing 5 3.3 10 5. 1

Cognitive Restructuring 15 9.9 19 9.7

Cooperation 15 9.9 17 8.7

Countermeasure 60 40.4 57 29.1

Control 27 17. 9 49 25. 0

Seeking Support 29 19.2 44 22.4

Total 151 196

* Two males and two females were unable to identify any coping behaviorsused during hospitalization.

To determine if there was a statistically significant difference

between the responses of the males and females in the type of coping

behavior identified, the Chi-square test of independence was used. Again,

because the concept of coping must always be considered in relation to a

specific stressful event, the category of intrusive events was selected

for analysis of the child's coping response. Only the first coping

behavior stated in response to the intrusive event was used to maintain

the Chi Square assumption of independence. Although the category of

intrusive events was the most frequently cited stressful category only 29

166

males and 35 females were able to identify a coping behavior used in

response to an intrusive event, thus the total N for this analysis was 64.

(See Table 20 for the descriptive statistics on the first response data.)

Table 20

1st Coping Behavior used in Response to Intrusive Event by Health Status

Male (N-29)." Female (N–35)."

Category Number 7. Number 7.

Cognitive Processing 1 3.4 3 8.6

Cognitive Restructuring 2 6.9 5 14.3

Cooperation 4 13.79 4 11.4

Countermeasure 12 41.4 7 20. 0

Control 4 13.8 4 11.4

Seeking Support 8 29.0 12 34.3

* Twelve males (29.27%) and six females (14.63%) did not state any copingbehaviors used in conjunction with an intrusive event.

For the test of the relationship between gender and the type of

coping behavior used in response to an intrusive event, the value of the

Chi Square statistic was 5.0837, d.f. - 5, p >.05, statistically not

significant. Because the frequency of eight of the cells was lower than

the expected frequency of 5, the statistic was reexamined by collapsing

conceptually similar categories, such as cognitive processing and

167

cognitive restructuring and counteraction and control. Although these

measures moved the p-value toward the .05 level, statistical significance

was not achieved. Therefore, it is evident that in this sample there was

no significant relationship between the gender of the child and the type

of coping behavior first described in connection with an intrusive event.

Hypothesis 3

The fifth hypothesis postulated that there would be a relationship

between trait anxiety and the type of event appraised as stressful during

hospitalization. Because the trait anxiety score provided interval data,

the descriptive statistics examined were the mean and the standard

deviation (see Table 21).

Table 21

ean Trait Anxiety Score by Stressful Event Category

Category N Mean StandardDeviation

Intrusive events 47 39.1 6.6

Physical symptoms 14 37.3 6.9

Therapeutic interventions 6 33. O 5.9

Restricted activity 4. 34.5 8.6

Separation 4. 36.7 4.1

Environment 4 38.8 5. 7

Total 79

s

º

>

168

To determine if there was a relationship between the trait anxiety

scores and the number of stressful events identified by the children, the

correlation between the variables was determined. The test was not

significant at the .05 level.

To determine if there was significant difference in the trait

anxiety scores between the six stress categories, the one-way analysis of

variance was used. As an assumption of this test is that the groups are

mutually exclusive, only the first responses of the subjects were

considered in this analysis. The total N was 79, because three subjects

were unable to identify any stressful events associated with

hospitalization. The one-way analysis of variance was not significant at

dif = 5, 73, F = 1. 231.

Hypothesis 6

The sixth hypothesis postulated that there would be a relationship

between trait anxiety and the type of coping behavior used during

hospitalization. The descriptive statistics for this question were

examined by determining the mean and standard deviation of trait anxiety

for each category of coping behavior (see Table 22).

To determine if there was a relationship between the trait anxiety

scores and the number of coping behaviors reported by the children, the

correlation between the variables was determined. The test was not

significant at the .05 level.

To determine if there was significant difference in the trait

anxiety scores between the six coping categories, the one-way analysis of

variance was used. Again, because the concept of coping must always be

considered in relation to a specific stressful event, the category of

7...",^--

-

169

Table 22

Mean Trait Anxiety Score by Coping Behavior Categories

Category N Mean Standard Deviation

Cognitive Processing 4 41.2 9.7

Cognitive Restructuring 7 39.9 4.9

Cooperation 8 38.2 6.9

Countermeasure 19 38.9 8.0

Control 8 37.2 7.3

Seeking Support 18 37.2 5.9

Total 64

intrusive events was selected for analysis of the child's coping response,

and only the first coping behavior stated in response to the intrusive

event was used to maintain the assumption of independence. Because 18

subjects did not identify any coping behaviors used in relation to

intrusive events, the total N for this portion of the analysis was 64.

The one-way analysis of variance was not statistically significant at d■

- 5, 58, F - 0.356 at dif - 5, 58.

Summary of Interview Data Analysis

Analysis of the data for Hypotheses 1 through 6 demonstrated one

significant relationship and five non-significant relationships. Table 23

summarizes these findings. Figure 4 schematically illustrates these

relationships.

170

Table 23

ult terview ta Analyses

Hypothesis Statistical Result Significance

1 (health status by stress) X* - 17. 6342, d.f. - 5 p < 0.01

2 (health status by coping) X* - 5.3484, d.f.- 5 N. S.

3 (gender by stress) X* - 2.4549, d.f. - 5 N. S.

4 (gender by coping) X* - 5.0837, d.f.- 5 N. S.

5 (anxiety by stress) F - 1.241, d. f. - 5, 73 N. S.

6 (anxiety by coping) F - 0.356, d. f. - 5, 58 N. S.

Health Status

NS>.O1

Anxiety -

NS Stress Tº Copingappraisal _- behaviors_º-

Gender ~. NS

Figure 4. Model of statistical relationships between variables.

Analysis of the Stress and Coping Word Graphic Scales

Analysis of the data provided by the word graphic scales proceeded

in two phases. First, concurrent validity of the word graphic rating

scales was determined. Second, the examination of Hypotheses 7 and 8 was

conducted using multiple regression and path analysis.

171

Concurrent validity

Because the Hospital Stress Scale and the Hospital Coping Scale were

new instruments developed for use in this study, it was necessary to

examine the validity of the instruments. As described in Chapter 3, the

Child Medical Fear Scale (Broome et al., 1988) was selected to examine the

validity of the Hospital Stress Scale, and the Coping Response Inventory

(Elwood, 1987) was selected to examine the validity of the Hospital Coping

Scale. These instruments purport to measure similar, although not

identical, constructs. Because all four tools provide interval level

data, the Pearson Product Moment Correlation Coefficient was used to

determine the relationship.

Based on the sample of 82 subjects, the correlation between the

Hospital Stress Scale and the Child Medical Fear Scale was .3388, The

statistical significance of this correlation is low positive. This

indicates that the instruments do measure similar constructs, but that the

overall relationship between the instruments is not strong. Although a

stronger relationship would have been preferred, the low correlation may

be acceptable in this case as the tool used for concurrent validity is

newly developed and is still, itself, in the process of having validity

examined. Additionally, the Children's Medical Fear Scale measures the

emotion of fear, rather than stress itself. Fear may be generated in a

stressful situation, but not all stressful situations result in fear.

Therefore, achievement of a positive correlation, although it may have

been low, may be interpreted as evidence that the Hospital Stress Scale

does appear to assess children's appraisal of the stressfulness of the

hospital experience.

172

The correlation between the Hospital Coping Scale and the Coping

Response Inventory was .3448. Again, the statistical significance of this

correlation is low positive. The two instruments do appear to measure

similar constructs, but the relationship is not strong. The construct of

coping as used in the Coping Response Inventory appears to be congruent

with that of the current study, but the instrument was developed for use

with healthy, rather than ill, children and may not have adequately

represented coping behaviors used by the hospitalized child. Again, the

positive, although low correlation, may be interpreted as evidence that

the Hospital Coping Scale does appear to assess children's perception of

the effectiveness of their coping behaviors during hospitalization.

Preliminary Information Regarding Analysis

In determining the path coefficients through multiple regression,

several methods may be used to enter the data into the equation. It was

of interest to know how much variance was contributed to the model by each

variable, regardless of the significance of the factor. Additionally,

there was no theoretical basis for examining the independent variables

separately. Accordingly, for this investigation, the method used was

simultaneous regression analysis. It is also important to note that a

residual analysis was performed to check for evidence of deviations such

as curvilinearity, outliers, and homogenous variance that would violate

the assumptions of the regression procedure. Examination of the residuals

indicated that all assumptions were met.

Hypothesis 7

Hypothesis 7 postulated that health status, gender, and trait

anxiety would affect the appraisal of hospitalization as stressful in that

173

a) acutely ill children would appraise the event of hospitalization as

more stressful than would chronically ill children; b) girls would

appraise the event of hospitalization as more stressful than would boys;

and c) children with high levels of trait anxiety would appraise the event

of hospitalization as more stressful than would children with low levels

of trait anxiety. This hypothesis comprised the first stage of the

theoretical model.

Simultaneous regression analysis was used to test this first portion

of the model, with all three variables being entered in one step. The

results of this analysis are presented in Table 24. The cumulative R* of

. 14, due to the three independent variables, indicates that together they

explain a significant (<.01) proportion of the variance in Stress

appraisal. Examination of the unique contribution attributable to each

variable indicates that only trait anxiety had a significant (<.001)

influence on stress appraisal.

Table 24

The Effects of Independent Variables on Dependent Variable of Stress

Variable df Cumulative R* Unique R* F p-value

Independent variables 3 0.1426 4.323 <. 01

Health status 1 . 0104 0.948 N. S.

Gender 1 .0002 0.015 N. S.

Trait anxiety 1 . 1310 11. 919 <. 001

Residual 78

174

Before addressing the subhypotheses of Hypothesis 7, it is necessary

to determine the nature of the relationship between the independent

variables and the dependent variable. This information is provided by the

standardized beta weights, and is graphically shown in Figure 5, the

portion of the theoretical model relevant to this hypothesis.

Health Status

. 104

Anxiety → * >_*—

Stressappraisal

Gender

Figure 5. Theoretical model of variables influencing stress appraisal.

The first subhypothesis proposed that acutely ill children would

appraise the event of hospitalization as more stressful than would

chronically ill children. To interpret the above data it is necessary to

note that the coding for health status was as follows: 1 - acute

condition, 2 - chronic condition. It is also necessary to recall that the

higher the score on the Hospital Stress Scale, that is the closer to 100

on a scale of 0 to 100, the greater the degree stressfulness appraised by

the child. The standardized beta of . 104 indicated that the relationship

was in a positive direction. This implies that a child who was assigned

a higher score on the variable of health status (chronic condition) had a

tendency to score higher on the variable of stress appraisal, although the

strength of the association was not strong. In sum, the chronically ill

child was somewhat more likely to appraise the event of hospitalization as

175

stressful than was the acutely ill child. However, the unique portion of

variance attributable to this variable was not statistically significant.

Therefore, Hypothesis 7. a. was not supported.

The second subhypothesis proposed that girls would appraise the

event of hospitalization as more stressful than would boys. To interpret

the above data it is necessary to note that the coding for gender was as

follows: 1 - male, 2 - female. Again, it is necessary to recall that the

higher the score on the Hospital Stress Scale, the greater the degree of

stressfulness appraised by the child. The standardized beta of . 013,

indicated that the relationship was in a positive direction. However,

this result was so close to zero that it cannot be stated that a trend was

evident. As would be expected, the unique portion of variance

attributable to this variable was not statistically significant.

Therefore, Hypothesis 7.b. was not supported.

The third subhypothesis proposed that children with high levels of

trait anxiety would appraise the event of hospitalization as more

stressful than would children with low levels of trait anxiety. To

interpret the above data it is again necessary to note that the trait

anxiety scale of the State-Trait Anxiety Inventory for Children is scored

so that the higher the score, the greater the degree of trait anxiety.

The scoring of the Hospital Stress Scale follows the same pattern, the

higher the score, the greater the degree of stressfulness appraised by the

child. The standardized beta was . 378, indicating that the relationship

was in a positive direction. The child who was assigned a higher score on

the variable of trait anxiety was more likely to score higher on the

variable of stress appraisal. In sum, the child who scored high in the

personality characteristic of trait anxiety was more likely to appraise

176

the event of hospitalization as highly stressful than was the child who

scored low in trait anxiety. The unique portion of variance attributable

to this variable was statistically significant at the .001 level.

Therefore, for this sample, Hypothesis 7. c. was supported.

Hypothesis 8

Hypothesis 8 postulated that health status, gender, and trait

anxiety would affect the perception of effectiveness of the coping

behavior in that a) chronically ill children would perceive their coping

behaviors during hospitalization as more effective than would acutely ill

children; b) girls would perceive their coping behaviors during

hospitalization as more effective than would boys; c) children with low

levels of trait anxiety would perceive their coping behaviors during

hospitalization as more effective than would children with high levels of

trait anxiety; d) children who appraise hospitalization as of low

stressfulness would perceive their coping behaviors during hospitalization

as more effective than would children who appraise the event of

hospitalization as highly stressful. This hypothesis comprised the second

stage of the theoretical model. It is important to note that stress

appraisal is treated as an independent variable in this phase of the

model, rather than as a dependent variable as in the first phase.

Simultaneous regression analysis was used to test this second

portion of the model, with all four variables being entered in one step.

The results of this analysis are presented in Table 25. The cumulative R2

of . 14, due to the set of four independent variables, indicated that

together they explain a significant (<.05) proportion of the variance inperceived coping effectiveness. Interestingly, an examination of the

unique contribution to the variance in coping of any one characteristic,

177

Table 25

Effects of Independent Variables on Dependent Variable of Coping

Variable df Cumulative R* Unique * F p-value

Characteristics 4 0.1437 3. 230 <. 05

Health status 1 . 0.391 3.513 N. S.

Gender 1 . 0.063 0. 564 N. S.

Trait anxiety 1 . 0334 3.007 N. S.

Stress appraisal 1 . 0240 2. 157 N. S.

Residual 77

after the contribution of the remaining three characteristics was held

constant, indicated that no one variable accounted for a unique

contribution above and beyond that which it shared with the other

characteristics.

Before addressing the subhypotheses of Hypothesis 8, it is necessary

to examine the nature of the relationship between the independent

variables and the dependent variable. This information is provided by the

standardized beta weights, and is graphically shown in Figure 6, the

portion of the theoretical model relevant to this hypothesis.

The first subhypothesis proposed that chronically ill children would

perceive their coping behaviors during hospitalization as more effective

than would acutely ill children. To interpret the above data it is again

necessary to recall that the coding for health status was as follows: 1 -

acute condition, 2 - chronic condition. It is also necessary to recall

178

Health Status

Anxiety -

StreSS -. 167 - CopingO8 appraisal Tº behaviors-.O8 1

Gender -

Figure 6: Theoretical model of factors influencing coping appraisal

that the higher the score on the Hospital Coping Scale, that is the closer

to 100 on a scale of 0 to 100, the greater the perceived effectiveness of

the child's coping behaviors. The standardized beta of -. 203 indicated

that ine relationship was inverse. This implies that a child who was

assigned a lower score on the variable of health status (acute condition)

had a tendency to score higher on the variable of perception of coping

effectiveness. In sum, the acutely ill child was more likely to perceive

his or her coping as effective than was the chronically ill child.

However, the unique portion of variance attributable to this variable was

not statistically significant. Thus, Hypothesis 8. a. was not supported.

The second subhypothesis proposed that girls would perceive their

coping behaviors during hospitalization as more effective than would boys.

To interpret the findings it is again necessary to note that the coding

for gender was as follows: 1 - male, 2 - female. It is also necessary to

recall that the higher the score on the Hospital Coping Scale, the greater

the perceived effectiveness of the child's coping behaviors. The

179

standardized beta was - .081, indicating that the relationship was inverse.

This result was so close to zero, that it cannot be stated that a trend

was evident. As would be expected, the unique portion of variance

attributable to this variable was not statistically significant.

Therefore, Hypothesis 8.b. was not supported.

The third subhypothesis proposed that children with low levels of

trait anxiety would perceive their coping behaviors during hospitalization

as more effective than would children with high levels of trait anxiety.

To interpret the above data, it is necessary to recall that the trait

anxiety scale of the State-Trait Anxiety Inventory for Children is scored

so that the higher the score, the greater the degree of trait anxiety.

The scoring of the Hospital Coping Scale follows the same pattern, the

higher the score, the greater the perceived effectiveness of the coping.

The standardized beta was - .205, indicating that the relationship was

inverse. This implies that the child who scored lower on the variable of

trait anxiety was more likely to score higher on the perceived coping

effectiveness. In sum, the child who has a low level of trait anxiety was

more likely to perceive his or her coping behaviors as being effective

than was the child who scored high in trait anxiety. However, the unique

portion of variance attributable to this variable was not statistically

significant. Therefore, Hypothesis 8. c. was not supported.

The fourth subhypothesis proposed that children who appraise

hospitalization as lowly stressful would perceive their coping behaviors

during hospitalization as more effective than would children who appraise

the event of hospitalization as highly stressful. To interpret the data

relevant to this proposition, it is necessary to recall that the Hospital

Stress Scale is scored so that the higher the score, the greater the

18O

appraisal of stress related to hospitalization. The scoring of the

Hospital Coping Scale follows the same pattern, the higher the score, the

greater the perceived effectiveness of the coping. The standardized beta

was - . 167, indicating that the relationship was inverse. The child who

scored lower on the variable of stress appraisal had a tendency to score

higher on the perceived coping effectiveness. In sum, the child who

appraised the degree of stress during hospitalization as low was more

likely to perceive his or her coping behaviors as being effective than was

the child who appraised the degree of stress associated with hospitali

zation as high. However, the unique portion of variance attributable to

this variable was not statistically significant. Therefore, for this

sample, Hypothesis 8...d. was not supported.

Revision of Model

Consideration of the preceding results raised the question of the

relevance of the variable, stress appraisal, in the second portion of the

model. Because 1) the set of four variables, health status, gender, trait

anxiety, and stress appraisal, had a significant influence on the

perceived coping effectiveness, yet individually no one variable

contributed significantly to the model (Table 25), and because 2) the

correlation between stress appraisal and coping effectiveness (the

Hospital Stress Scale and the Hospital Coping Scale respectively) was - .26

(p< 0.05), yet when the effects of health status, gender, and trait

anxiety were partialed out, the unique variance contributed to coping

effectiveness by stress appraisal was only 0.02 (p = 0.146), and because

3) in the first portion of the model the influence of trait anxiety onstress appraisal was highly significant (Table 24), it appeared probable

that the influence of stress appraisal on perception of coping

181

effectiveness was highly dependent on the moderating characteristics of

the person. Therefore it was decided to revise the second portion of the

model, eliminating the path between stress and coping, and reexamine the

statistics.

As before, simultaneous regression analysis was used to test the

revised second portion of the model, with all three variables being

entered in one step. The results of this analysis are presented in Table

26 and illustrated graphically by Figure 7. The cumulative R* of . 12 due

to the set of three independent variables, indicated that together they

explain a significant (<.05) proportion of the variance in perceived

coping effectiveness. Examination of the unique contribution attributable

to each variable indicates that both health status and trait anxiety had

a significant influence on perceived coping effectiveness, but that the

relationship between gender and coping was not significant.

Table 26

Revised Effects of Independent Variables on Dependent Variable of Coping

Variable df Cumulative R* Unique R* F p-value

Characteristics 3 0.1197 3.536 <. 05

Health status 1 . 0466 4. 131 <. 05

Gender 1 . 0.066 0. 587 N. S.

Trait anxiety 1 . 0660 5. 847 <. 05.

Residual 78

182

Health Status

Anxiety -

Tº Coping_- behaviors

-.084Gender —

Figure 7: Theoretical model of factors influencing coping appraisal

It appears that in the original model, the redundancy between trait

anxiety and stress appraisal was sufficient to prevent the significance of

either factor. Because theoretically the personal characteristics are

antecedents of the appraisal process (Lazarus & Folkman, 1984a; Lazarus

& Launier, 1978) it appears logical to accept the revised model as a more

accurate portrayal of the relationships between the variables and to

reexamine the subhypotheses.

Subhypothesis 8. a. proposed that chronically ill children would

perceive their coping behaviors during hospitalization as more effective

than would acutely ill children. Recall that the coding for health status

was as follows: 1 - acute condition, 2 - chronic condition, and that the

higher score on the Hospital Coping Scale indicated a greater perceived

effectiveness of the coping. The standardized beta of - .221 indicated

that the relationship was inverse, implying that a child assigned a lower

score on the variable of health status (acute condition) had a tendency

to score higher on the variable of perception of coping effectiveness. In

sum, the acutely ill child was more likely to perceive his or her coping

183

as effective than was the chronically ill child. The unique portion of

variance attributable to this variable was statistically significant at

the .05 level. However, the relationship was not in the direction

predicted in the hypothesis, therefore, Hypothesis 8. a. was not supported.

Subhypothesis 8. b. proposed that girls would perceive their coping

behaviors during hospitalization as more effective than would boys.

Recall that the coding for gender was as follows: 1 - male, 2 - female,

and that the higher score on the Hospital Coping Scale indicated a greater

perceived effectiveness of coping. The standardized beta was - .084,

indicating that the relationship was inverse. Although slightly

increased, this result remains so close to zero that the previous

conclusion stands. No trend was evident due to gender, and the unique

portion of variance attributable to this variable was not statistically

significant. Therefore, Hypothesis 8. b. was not supported.

Subhypothesis 8... c. proposed that children with low levels of trait

anxiety would perceive their coping behaviors during hospitalization as

more effective than would children with high levels of trait anxiety.

Again recall that the trait anxiety scale of the State-Trait Anxiety

Inventory for Children is scored so that the higher score indicates a

greater degree of trait anxiety. The scoring of the Hospital Coping Scale

is similar, the higher score indicates a greater perceived effectiveness

of the coping. The standardized beta was - .269, indicating that the

relationship was inverse. This implies that the child who scored lower on

the variable of trait anxiety was more likely to score higher on the

perceived coping effectiveness. In sum, the child who has a low level of

trait anxiety was more likely to perceive his or her coping behaviors as

being effective than was the child who scored high in trait anxiety. The

184

unique portion of variance attributable to this variable was statistically

significant at the .05 level. Therefore, for this sample, Hypothesis 8. c.

was supported.

At this point is must be noted that elimination of the path between

stress appraisal and coping behavior in the model, eliminated

Subhypothesis 8...d. Therefore, analysis of this hypothesis was not

conducted for the revised model.

Summary of Word Graphic Scale Analyses

Figure 8 shows the entire revised theoretical model with

standardized beta weights illustrating the relationships between the

variables. For comparison, the beta weights from the original second

portion of the model are included in parentheses.

Health Status

... 104

-.221 (-.2O3)

Anxiety - -.269 (-,205)Nº.

.378 Stress (.-.167) T* Coping

*—- appraisal Tº behaviorsGender ~. -.O84 (-.081)

Figure 8. Theoretical model of relationships between variables

Note: Beta weights in () are from original model

Table 27 presents a decomposition of the relationships between the

independent and dependent variables in the original and in the revised

models. In examining the table, note that in the original model there are

both indirect and direct relationships necessitating a separate

185

Table 27

Summary of the Effects of Independent Variables on Dependent Variables

Original Model Revised Model

Bivariate Relationship Direct Indirect Total Direct/Total

Health status/Stress appraisal . 104 none . 104 ... 104

Anxiety/Stress appraisal . 378 none . 378 . 378

Gender/Stress appraisal . 013 none . 013 . 013

Health status/Coping effectiveness - .203 - . 017 - .220 - .221

Anxiety/Coping effectiveness - . 205 - . 063 - .268 - .269

Gender/Coping effectiveness - . 082 - . 002 - . 084 - .084

Stress appraisal/Coping effectiveness - . 167 none - . 167 none

calculation of the total relationship. In the revised model, however,

only direct relationships exist, so the direct relationship is also the

total relationship.

A comparison of the standardized beta weights in the decomposition

table (Table 26) provides further support for the revised theoretical

model. The first portion of the model was not effected by the revision,

so the relationship between the independent variables, health status,

anxiety and gender, and the dependent variable, stress appraisal, remained

the same. The revision of the second portion did increase the effect of

the independent variables of health status and anxiety on the dependentvariable of coping effectiveness through elimination of redundancy

resulting in a difference in the original and revised total effects of

186

only .001 for both variables. This small difference further demonstrates

the very limited contribution of stress appraisal to the original model.

The relationship between gender and coping effectiveness was not changed

by the revision. Because the path between stress appraisal and coping

effectiveness was not eliminated from the model, this relationship was not

examined in the revised calculations.

Summary of Findings

Eighty-two, children, ages 8 through 11 years, meeting the

inclusion-exclusion criteria, completed the protocol for this study. This

sample was comprised of 41 males and 41 females; 21 acutely ill children

and 61 chronically ill children; 20 eight year olds, 16 nine year olds, 19

ten year olds, and 27 eleven year olds; 52 Caucasian children, 13

Hispanic children, 10 African American children, 2 Asian children, and 4

of other ethnicity.

Analysis of potential confounding factors indicated no differences

in stress appraisal and perception of coping behavior effectiveness due to

site of data collection, age, prior out-patient experiences,

prehospitalization teaching programs, and parental rooming-in. Therefore

all analyses were conducted on the total sample.

Content analysis was used to examine the interview data. Six

categories of stressful events were derived from the data: intrusive

events, physical symptoms, therapeutic intervention, restricted activity,

separation, and environment. The individual events identified in the

interviews were assigned to one of these categories and quantified bycounting the responses in each category. These data then were used to

examine the first six hypotheses of the study, Chi square being used to

187

examine Hypotheses 1 through 4, and one-way analysis of variance being

used to examine Hypotheses 5 and 6. Of the first six hypotheses, only

Hypothesis 1 was significant indicating that there is a relationship

between health status and the type of event appraised as stressful by the

subjects. Specifically, chronically ill children were significantly more

likely to identify intrusive events as stressful than were acutely ill

children, and acutely ill children were significantly more likely to

identify physical symptoms as stressful than were chronically ill

children. No significant relationship was found between Hypothesis 2:

health status and coping behavior; Hypothesis 3: gender and the appraisal

of an event as stressful; Hypothesis 4: gender and coping behavior;

Hypothesis 5: trait anxiety and the appraisal of an event as stressful; or

Hypothesis 6: trait anxiety and coping behavior.

Multiple regression and path analysis, used in this study for the

purpose of description, was employed to examine the data obtained from the

Hospital Stress Scale and the Hospital Coping Scale. The theoretical

model was tested in two phases corresponding with Hypotheses 7 and 8.

First, the relation between the independent variables of health status,

gender, trait anxiety and the dependent variable of stress appraisal was

examined. Simultaneous regression analysis was used to test this portion

of the model, with the three independent variables being entered as a set

in the first step and the dependent variable of stress appraisal in the

second step. The overall significance of this portion of the model was <

.01. Further examination indicated that only trait anxiety contributed

significantly (<.001) to the model. Therefore, Hypothesis 7. c. , proposing

that a high level of trait anxiety would be related to a high level of

stress appraisal was supported. However, Hypothesis 7. a. , proposing that

188

acutely ill children would appraise hospitalization as more stressful than

would chronically ill children was not supported because the contribution

of health status to the model was not significant and because the trend of

the data indicated that chronically ill children appraise hospitalization

as more stressful than do acutely ill children. Similarly, Hypothesis

7.b., proposing that girls would appraise hospitalization as more

stressful than boys, was not supported because the contribution of gender

to the model was not significant, and because the standardized beta weight

was very near zero.

The second portion of the model was tested using the same procedure.

Simultaneous regression analysis again was used, with the four independent

variables, health status, gender, trait anxiety, and stress appraisal,

being entered as a set in the first step and the dependent variable of

coping entered in the second step. The overall significance of this step

was < .05. Further examination indicated that individually none of the

independent variables contributed significantly to the model. Therefore,

while Hypothesis 8 was supported, the subhypotheses were not supported.

Hypothesis 8...a., proposing that chronically ill children would perceive

their coping as more effective than would acutely ill children was not

supported because the contribution of health status to the model was not

significant and because the trend of the data indicated that acutely ill

children appeared to perceive their coping as more effective than did

chronically ill children. Hypothesis 8.b., proposing that girls would

perceive their coping behaviors as more effective than would boys, was not

supported because the contribution of gender to the model was not

significant, and because the standardized beta weight was very near zero.

Hypothesis 8. c. proposing that children with a low trait anxiety level

189

would perceive their coping as more effective than would children with a

high trait anxiety level, was not supported because the contribution of

trait anxiety to the model was not significant, although the trend of the

data did show this proposal to be accurate. Hypothesis 8. d. , proposing

that children who appraise hospitalization as lowly stressful perceive

their coping behaviors during hospitalization as more effective than

children who appraise the event of hospitalization as highly stressful,

was not supported because the contribution of stress appraisal to the

model was not significant, although again the trend of the data did show

this proposal to be accurate.

Consideration of the statistical results relating to Hypothesis 8

indicated that the variable of stress appraisal contributed little to the

model. Therefore the model was revised, eliminating the path between

stress appraisal and coping effectiveness, and the multiple regression

analysis recalculated entering the independent variables of health status,

gender, and trait anxiety as a set in the first step and the dependent

variable of coping in the second step. The overall significance of the

set was ‘ .05. Examination of the data pertaining to Subhypothesis 8. a.

indicated that health status contributed significantly to the model at 3

.05 level, however, the results were not in the direction of the

hypothesis. Therefore, the proposal that chronically ill children would

perceive their coping as more effective than would acutely ill children

was not supported as the results indicated that the reverse relationship

was true for this sample. The acutely ill children perceived their coping

as more effective than did chronically ill children. The findings

pertaining to Hypothesis 8.b. were not altered by the revision of the

model. As stated before, the proposal that girls would perceive their

*.

s

190

coping behaviors as more effective than would boys, was not supported

because the contribution of gender to the model was not significant.

Additionally, because the standardized beta weight was very near zero a

trend cannot be assumed from the data. Examination of Hypothesis 8. c.

indicated that the results were significant at the 3.05 level and that the

direct of the hypothesis was correct. The proposal that children with a

low trait anxiety level would perceive their coping as more effective than

would children with a high trait anxiety level, was supported for this

sample.

191

CHAPTER FIVE

DISCUSSION

In this chapter the results of the study will be discussed.

First, the theoretical rationale for revision of the model will be

detailed. Second, the meaning of the results will be examined in view of

the theoretical basis of the study and prior relevant research. Third,

limitations of the present research related to the sample and

instrumentation will be identified. Fourth, implications for nursing

practice and education will be presented. Last, suggestions for future

research in the area will be offered.

Revision of the Model

While examining the statistical results relevant to hypotheses 7 and

8, the portion of the data analyzed by multiple regression and path

analysis, it became evident that the discussion pertaining to the relation

between stress appraisal and coping effectiveness (8. d.) was a repetition

of the discussion pertaining to the relation between trait anxiety and

stress appraisal (8.c.). To try to understand this situation, the

theoretical basis of the study was reexamined. Briefly, coping may be

examined either in relation to the type of stress appraisal made, harmful,

threatening, or challenging, or according to the coping resources and

constraints relevant to the individual (Lazarus & Folkman, 1984a). If the

current research study had been examining the relationship between an

appraisal of harm, threat, or challenge and the type of coping behavior

192

appraisal of harm, threat, or challenge and the type of coping behavior

used, then inclusion of the path between stress appraisal and coping

behavior would have been appropriate. However, the purpose of the study

was to examine the relationship between personal characteristics of the

child and the appraisal process and between those same characteristics and

coping behaviors. Therefore, inclusion of the path between stress

appraisal and coping behaviors was unnecessary. Furthermore, because

there is some overlap between the person and situation factors influencing

appraisal and the resources and constraints that influence coping, such as

experience and beliefs (Lazarus & Folkman, 1984a), inclusion of the

pathway in question was redundant. For these reasons the theoretical

model for this study was modified by removing the path between stress

appraisal and coping behavior. As described in Chapter 4, the statistics

relevant to these variables supported this decision, as did the results of

the regression analysis based on the revised model. Revision of the model

did not affect the analysis of the interview data, hypotheses 1 through 6.

Relation of Results to Hypotheses

The results of the study will be discussed according to the two

primary concepts of the study, stress and coping. First, the findings

relating to the appraisal of stress will be discussed, followed by the

findings relating to coping.

Discussion of Results Relating to Stress Appraisal

There is no question that hospitalized school-age children are

capable of appraising events as stressful. As "stress is in the eye of

193

the beholder" (McGrath, 1977), whatever the child believes to have

personal implications for well-being involving harm, threat, or challenge

is stressful. When asked what were the upsetting things that happen in

the hospital, most of the children responded easily, without need for the

prompts provided with the interview. Only three children were unable to

identify any stressful events associated with hospitalization. One child,

who appeared tense and restrained while answering, denied the occurrence

of any stressful events. Interestingly, this child's score on the

Hospital Stress Scale was quite high, implying that hospitalization indeed

was appraised as stressful. The remaining two children seemed somewhat

surprised to think that anything associated with hospitalization would be

upsetting, possibly indicating use of defensive reappraisal (Lazarus &

Folkman, 1984a) as a coping mechanism. As would be expected if this

explanation was correct, the Hospital Stress Scale scores for these two

children were very low. In general, the other children easily identified

stressful events that had occurred while they were hospitalized.

Similarly, most of the children did not seem to have difficulty

switching from thinking about the specific stressful events to considering

the global stressfulness of the event when asked to respond to the

Hospital Stress Scale. Occasionally, a child would begin to mark the

scale for separate events, but when redirected to think about "everything

that had happened all together" would erase the first marks and place a

new line on the scale. This would indicate that the subjects for this

study had moved beyond the earlier thought processes of syncreatism and

juxtaposition typical of the pre-operational stage and were able to

consider the relationship of the parts to the whole (Ginsburg & Opper,

1988).

194 º

Of the six categories of stressful events identified through content

analysis of the interviews with the children, all were identified in the

literature, but with varying frequency. Four categories of stressful

events were well represented: intrusive events, physical symptoms,

restricted activity, and separation. The types of intrusive events

mentioned by the children and in the literature were similar, primarily

procedures involving needles (Eiser & Patterson, 1984; Erickson, 1958a,

1958b, 1972; Langford, 1961; Menke, 1972; Reissland, 1983; Timmerman,

1983). The physical symptom of pain was named frequently in the

literature (Eiser & Patterson, 1984; Gofman, Buckman, & Schade, 1957;

Langford, 1961; May & Sparks, 1983; Menke, 1972; Stevens, 1986; Timmerman,1983) and by the children, but the children also identified a number of

other symptoms, often side effects of medication, such as nausea, blurry

eyes, and dizziness. Regarding restricted activity, the literature

mentioned immobilization (Blom, 1968; Erickson, 1965, 1972; Freud, 1952)

and confinement (Kueffner, 1975; May & Sparks, 1983; McGuire, Shepherd, &

Greco, 1978; Menke, 1972; Powazek, Goff, Schyving, & Paulson, 1978), but

the children seemed to be more bothered by not being allowed to leave the

unit to go out to eat, shopping, or participate in sports. Separation was

mentioned by only a small number of the children, in contrast to frequent

identification in the literature (Bowlby, 1973; Erickson, 1965; May &

Sparks, 1983; Menke, 1972; Prugh, et al., 1953; Reissland, 1983;

Robertson, 1970; Timmerman, 1983), the probable explanation being that the

literature often did not distinguish between age groups. The two

categories infrequently mentioned in the literature were therapeutic

interventions and environment. Regarding therapeutic interventions, the

primary area of agreement was measurement of vital signs (Erickson, 1958a,

º

195

1958b; Menke, 1972), but the children also identified aspects of the

physical exam, dressing removal, and walking after surgery as stressful.

Stressful aspects of the environment were seldom mentioned in the

literature (Reissland, 1983), but frequently identified by the children,

ranging from nightmares caused by the equipment on the walls to

interpersonal problems with roommates and staff. In general, although

little research has been focused on what children perceive as stressful

during hospitalization, the major stresses have been accurately identified

in the literature. However, there are events that children appraise as

stressful that the adult health care provider may tend to overlook,

underscoring the importance of gaining input directly from the children

regarding events encountered during hospitalization that are likely to be

appraised as stressful.

Examination of the events identified by the total groups of children

as stressful has several interesting parallels with developmental

research. First, the most frequently named category of stressful

situations, intrusive events, was identified twice as often as the next

most frequent event. This finding is paralleled by Miller's (1979)

conclusion, following a review of eleven studies examining the fears of

school-age children, that fear of bodily injury increases in the 7 to 12

year old age group. The current study demonstrates that school-age

children continue to appraise bodily injury as a major source of concern

while in the hospital, just as they do when healthy.

Second, separation was identified as stressful less frequently than

any other category. Separation from parents is less difficult for the

child of school-age, than it was during the toddler or preschool years

(Prugh, 1965). Although hospitalized school-age children tend to want

196

parents to be present, the child does not appear to appraise separation as

a major source of stress. Factors contributing to the decreased appraisal

of separation as stressful would be acquisition of a sense of time and

knowledge that parents will return, familiarity with being separated from

parents during the school hours, and rooming-in by parents when possible.

Thus, the frequencies with which the children reported intrusive events

and separation as stressful during hospitalization is in accordance with

the developmental changes of this age group.

Beyond these initial observations, the question remains, given the

statistical results of the data analysis, what do the numbers mean? This

will be addressed by discussing the relationship of the three factors,

health status, gender, and trait anxiety, to stress appraisal, considering

the theoretical basis of the study and prior research.

Health Status and Stress Appraisal

The results of the data analysis indicated that health status does

have an affect on the type of event appraised as stressful by the child

during hospitalization with acutely ill children more likely to identify

physical symptoms as stressful and chronically ill children more likely to

identify intrusive procedures as stressful. A careful review of the

literature located only one prior study examining these same

relationships. Ritchie, Caty, and Ellerton (1984), studying preschool

children, also noted that chronically ill children demonstrated more

concern with intrusive events than did acutely ill children. Key elements

of the Lazarus theory that explain these findings are the process of

primary appraisal and the affect of novelty on the appraisal process.

Primary appraisal involves determining whether the situation is harmful or

º

*.197

helpful to personal well-being, a decision that is based partially on the

novelty or familiarity of the situation for the person (Lazarus & Folkman,

1984a). This premise is supported by McGrath (1977), in a review of

literature concerning the role of prior experience in stress appraisal,

concluding that the type of experience, as positive or negative, will

influence stress appraisal. For the chronically ill children in the

study, the intrusive events associated with hospitalization were not

novel, and prior experience likely had taught them that the procedures

were painful and unpleasant. Therefore, when asked what events were

stressful during hospitalization, the chronically ill children identified

intrusive events significantly more often than did the acutely ill

children. This did not appear to be due to a greater knowledge of

possible types of intrusive procedures. The majority of the items named

were common events experienced by both acutely and chronically ill,

hospitalized children, such as shots, intravenous needles, blood work, and

surgery. Only occasionally were more uncommon procedures such as lumbar

punctures or bone marrow taps mentioned. Similarly, it is not likely that

the result was due to differences in the extent of experience during the

current hospitalization, as all subjects were interviewed on the second or

third day of admission as stipulated in the inclusion criteria.

A reason that the acutely ill children did not appraise intrusive

events as stressful as frequently as did the chronically ill children may

be related to the influence of a sense of personal control on stress

appraisal (Lazarus & Folkman, 1984a). As was seen in the coping responses

of the children, the acutely ill group tended to report behaviors that

would provide a measure of personal control over the situation more than

did the chronically ill group. Lazarus has hypothesized that a sense of

3.

º

2

s

>

198

control of a situation may influence the process of stress appraisal

(Lazarus & Folkman, 1984a). If the acutely ill children thought that

relaxing or holding still would provide a measure of control over

harmfulness of the intrusive event, they would be less likely to appraise

it as stressful than would the chronically ill child who may have learned

that it will be uncomfortable, painful, or unpleasant regardless of what

behaviors are used to deal with the situation.

The element of novelty and the process of primary appraisal (Lazarus

& Folkman, 1984) may also explain the finding that acutely ill children

were significantly more likely to report physical symptoms as stressful

than were chronically ill children. Prior to admission to the hospital,

the acutely ill group were basically healthy children. The experience of

physical symptoms related to the illness, injury, or treatment was new.

But rather than being neutral, these symptoms were appraised as posing a

threat or harm to personal well-being of the child, emphasized by the

concern of parents and health care personnel. Simply, the child had not

experienced these exact physical symptoms before and had good cause to

believe that the symptoms would result in some type of personal jeopardy.

However, for the chronically ill children, the physical symptoms were not

novel. Having had the problem for a minimum of three months, or for some,

since birth, the children were apparently accustomed to the symptoms and

were not as likely to consider physical symptoms to be threatening as were

the acutely ill children.

In contrast to the above findings regarding the stressfulness of

specific events during hospitalization, health status was not

significantly related to the child's appraisal of the stressfulness of the

hospital experience as a whole, although there was a tendency for

199

chronically ill children to appraise the event as more stressful than

acutely ill children. There are several possible explanations for this

finding. First, it may be correct. It is possible that the emphasis on

creating a non-threatening environment (Mott, Fazekas, & James, 1985;

Petrillo & Sanger, 1980; Waechter, Phillips, & Holaday, 1985) that may be

individualized to meet the needs of a specific child has been successful,

resulting in similar appraisals of the global stressfulness of

hospitalization by acutely and chronically ill children. Another possible

reason for this finding may be the use of defensive reappraisal by the

children. Defensive reappraisal is the positive reinterpretation of the

past so that it is viewed in a less threatening or harmful light (Lazarus

& Folkman, 1984a). Ascertaining the child's appraisal of the

stressfulness of hospitalization requires a retrospective analysis of the

eVent. It is possible that in this process the child reframes the

hospital experience so that it does not seem so stressful, thereby

eliminating differences in the appraisal of the two groups.

It is also possible that this finding was not accurate, that a

difference actually exists in the appraisal of hospitalization as

stressful by acutely and chronically ill children. The rationale for this

possibility lies in the power analysis of the study. In planning the

investigation, it was decided to assign a medium effect size to the

variable of health status, as this would be the conservative approach when

beginning research in an unexplored area. However, the results of this

study indicate that relationship between health status and stress is of a

small magnitude. Therefore, with the current sample size, the probability

of finding an actual difference, if it existed, was greatly reduced. It

may be that the present finding of no difference between the two groups is

--

s

sº

º,) º

200

true, or it may be that the trend of chronically ill children to appraise

the event of hospitalization as more stressful than acutely ill children

is accurate. If the latter is true, the influence of novelty, event

uncertainty, and temporal uncertainty (Lazarus & Folkman, 1984a) on the

primary appraisal process may explain the difference. The chronically ill

hospitalized child knows from prior experience that specific events are

likely to occur during each hospitalization, such as insertion of an

intravenous needle and administration of chemotherapy for the child with

cancer. This child also knows that new procedures may occur unexpectedly.

Thus, due to uncertainty of when expected events will occur and if a new

and possibly threatening event will occur, the chronically ill child may

perceive hospitalization as more stressful than the acutely ill child who,

due to the relative novelty of the situation, does not have these

expectations. For these reasons, it does appear that health status is

likely to have an influence on the process of stress appraisal of

hospitalized school-age children.

Gender and Stress Appraisal

The results of the data analysis indicated that gender does not have

an affect on the type of event appraised as stressful by the child during

hospitalization or on the child's appraisal of the global event of

hospitalization as stressful. Lazarus and colleagues have identified

three characteristics of the person that will influence the appraisal

process: 1) intellectual resources and skills, 2) belief systems, and 3)

commitments or motivational characteristics (Cohen & Lazarus, 1983;

Lazarus & Folkman, 1984a). The question is whether or not these factors,

all dependent on cognitive functioning, may be influenced by the gender of

■

201

the child. Studies comparing the intellectual abilities of boys and girls

are mixed. Although, in a review of research, Maccoby and Jacklin (1974)

concluded that girls have better verbal skills and that boys perform

better in math and spatial skills, other research has demonstrated such

findings may be culturally specific (Lesser, Fifer, & Clark, 1965; Nash,

1979; Schratz, 1978), implying that the gender difference may be due to

environmental, rather than genetic, factors. Some motivational

characteristics of the child also appear to be gender specific due to

disparate treatment, such as the lower achievement expectations of girls

(Dweck & Elliot, 1983), the learned helplessness seen more commonly in

girls, and the mastery-orientation more common in boys (Dweck & Wortman,

1982). In contrast, children's beliefs about personal control do not

appear to be gender related, as indicated in a review by Nowicki (1986) of

35 studies of children's locus of control beliefs.

Regardless of whether such characteristics are inherent or learned,

the differences in the resources and motivations of girls and boys would

be expected to influence the appraisal process, particularly secondary

appraisal, the process of evaluating the resources available for coping

(Lazarus & Folkman, 1984a). However, this was not the finding in the

current study or in the study by Menke (1972). Other researchers (May &

Sparks, 1983; Reissland, 1983; Timmerman, 1983) examining children's

concerns or fears during hospitalization have not commented on the gender

stress relationship. It is difficult to explain the difference between

the expected results and the actual findings. One possible explanation

may be that the hospital environment tends to encourage passivity in

patients, negating any possible difference in motivation or achievement

due to gender. A second possibility is that the results of the two

g º

**

S. s

sº

W.

202

studies finding no difference are sample specific and not representative

of the actual relationship between gender and stress appraisal of

hospitalized children. Further research is needed to clarify this

relationship.

Anxiety and Stress Appraisal

The results of the data analysis indicated that trait anxiety does

not have an affect on the type of event appraised as stressful by the

child during hospitalization, but that it does have a significant affect

on the child's appraisal of the global event of hospitalization as

stressful. As a personality characteristic, trait anxiety is a factor

likely to influence the transaction between the person and environment,

resulting in an appraisal of stress (Lazarus, 1981; Lazarus & Launier,

1978). Unlike situational anxiety that occurs in response to a specific

event, trait anxiety is the child's "tendency to perceive a wide range of

situations as threatening..." (Spielberger, 1975, pp. 137). Trait anxiety

is the person's global tendency toward being anxious. However, as it

influences global, rather than specific, reactions, it is not surprising

that there was no relationship between a specific category of stressful

events and the level of trait anxiety. Rather, it would be expected that

a relationship would exist between the trait anxiety score and the global

appraisal of the stressfulness of hospitalization, which was found. It is

logical that the highly anxious child would have a greater tendency to

perceive the hospital environment as threatening than would the child with

a lower trait anxiety level, and would therefore appraise the event as

more stressful.

203

Surprisingly, a careful review of Spielberger's (1989) comprehensive

bibliography of over 3000 studies using either the adult or child form of

the State-Trait Anxiety Inventory and a computer search of the literature

since that publication failed to locate any other study assessing the

relationship between trait anxiety and either the specific or global

stress appraisal of hospitalized children. Rather, the emphasis in the

health related studies has seemed to be on the relationship between

physical illness and state-trait anxiety (e.g., Kellerman et al., 1980;

Sides, 1977), or between emotional illness and state-trait anxiety (e.g.,

Bedell & Roitzsch, 1976; Ollendick, Finch, & Nelson, 1976). Because no

prior reports are available to support or refute the result of the current

study, the findings that trait anxiety was not related to appraisal of

specific events as stressful, but that it did appear to be related to the

global appraisal of hospitalization as stressful, should be considered to

be possible, but not definite, evidence of the influence of the modifying

influence of trait anxiety on the stress appraisal process of hospitalized

children.

In summary, the results of the current study appear to indicate that

the appraisal of specific events as stressful during hospitalization may

be influenced by the health status of the child as acutely or chronically

ill, but that it is uncertain if either gender or trait anxiety influence

this process. It also appears possible that the stress appraisal of the

global event of hospitalization may be influenced by the child's trait

anxiety, but it is uncertain if either health status or gender have a

modifying influence on this relationship.

y ‘.*-

204

Discussion of Results Relating to Coping

Unlike the inquiry regarding stressful events, some of the subjects

seemed to have difficulty answering the interview question about coping

behaviors used in response to stressful events. This was not unexpected

as asking the child to relate how they coped with the stressful event (in

the language of the interview, what did you do or think about to help

yourself take care of the upsetting thing) required a form of thinking

beyond the basic concrete thought process. Rather than simply asking for

identification of things that upset them, as with the stress question, the

coping question asked them to think about and relate what they did or

thought. While thinking about what you did is still clearly concrete

thinking, thinking about your thinking moves toward the abstract thought

patterns of the formal operational stage (Siegler, 1986), although it does

not require hypothesis formulation or testing. Accordingly, the probes

for the coping question were used fairly often in the interviews to help

the children understand the question. With the use of the probes, the

children seemed to understand what was being asked and replied

appropriately.

Four children did not answer the coping question. Three of these

were the children who were unable to identify any stressful events, and

therefore could not be questioned regarding subsequent coping behaviors.

The fourth child did identify two stressful events, both intrusive, but

even with the probes was unable to identify any coping behaviors. Review

of the interview seemed to indicate that rather than being unable to

cognitively process the information needed to answer the question, the

child was overwhelmed by the illness and hospitalization, supported by the

205

fact that this was one of the few children unable to respond to the first

interview question regarding good things that happen during

hospitalization.

The frequency of the responses in each of the coping categories also

raises the question of children's use of cognitive coping behaviors. The

two categories requiring primarily cognitive coping, cognitive processing

and cognitive restructuring, occurred with low frequency in the current

study. In particular, cognitive processing behaviors were mentioned by

only 4.3% of the children, nearly one-half less frequently than the next

lowest category. It is possible that, as discussed above, relating

cognitive coping techniques is more difficult for concrete operational

children than is relating behavioral coping techniques. It is also

possible that the concrete thinker uses proportionately less cognitive

than behavioral coping as a function of the developmental level. This

latter proposition appears to be refuted by Savedra and Tesler's (1981)

findings that hospitalized school-age children used this type of behavior

frequently, particularly in the anticipatory phase of coping before a

procedure, as evidenced by the questions the children asked and their

looking at or taking in of the situation. The disparity in these results

may be partially due to the method of data collection, the current study

being based on interview and the Savedra and Tesler (1981) study based on

observation. It is possible that both propositions are correct, children

use less cognitive than behavioral coping and have difficulty recalling

this more abstract behavior. Further work is needed to clarify this

issue.

In contrast, the most frequently reported categories were those

requiring behavioral coping; countermeasure, control, and seeking support.

206

These involved recalling something that the child had done, not just

thought. Countermeasures were identified by 33.7% of the children, a

higher frequency than any of the other coping categories. Most of the

countermeasure behaviors involved avoiding the stressful situation by

ignoring it, such as watching television, playing video games, or

sleeping; or by refusing to participate, for example by not eating. These

same behaviors have been described by other researchers under the labels

of suspends, ignores, negates (Savedra & Tesler, 1981), avoidance (Neff,

1978; Ryan, 1989; Youssef, 1981), and distracting activities (Ryan, 1989).

Very seldom did the children describe trying to physically escape the

stressful event. Whether this did not happen or whether the child did not

recall or choose to report it is uncertain. Other researchers have

identified school-age children's attempts to physically escape a stressful

event as a coping behavior (Neff, 1978; Rose, 1972a, 1972b; Savedra &

Tesler, 1981; Siegel & Smith, 1989), but none have commented on the

frequency with which this occurs. Atshuler and Ruble (1989), presenting

a hypothetical negative (stressful) situation to healthy 5 to 12 year old

children, noted that use of escape strategies decreased significantly with

age. Given sufficiently threatening circumstances, the school-age child

may attempt to escape or resist, as would the adult under comparable

circumstances (Schuster & Ashburn, 1986), but it appears that at this age

the child has developed the self-control to attempt to cope with most

stressful events by using coping behaviors other than escape.

Developmentally, an interesting facet of this study is the use of

cognitive restructuring and countermeasures by the subjects. Cognitive

restructuring acts to mentally reverse the meaning of the situation and

countermeasures act to nullify or negate the stressful situation.

2O7

Acquisition of the operations of negation and reversibility are

characteristics of the concrete-operational child (Ginsburg & Opper,

1988). It is unlikely that the younger child would spontaneously use

these coping behaviors, a premise supported by the noticeable absence of

such behaviors in research describing the behaviors of the hospitalized

preoperational child (Ritchie, Caty, & Ellerton, 1988; Rose, 1972a,

1972b).

Concerning the utility of the six categories of coping behaviors

that were derived from the literature (see Chapter 2), each category was

represented by the coping behaviors described by the children, however the

frequency of use was quite uneven. To an extent this should be expected;

some behaviors may be more developmentally appropriate than other

behaviors. As discussed above, the categories of cognitive processing and

restructuring were mentioned infrequently. In contrast, coping responses

belonging to the more behaviorally oriented categories of countermeasures,

control, and seeking support were mentioned frequently. Interestingly,

the category of cooperation, a behavioral oriented response, was seldom

identified in the children's responses. A possible explanation for this

is the difficulty in determining the purpose of some coping behaviors due

to the highly contextual nature of coping, a phenomenon also noted by

Walker (1988). For example, if a restricted activity such as staying on

the unit is stressful to a child and the reported coping behavior is

watching television or playing a video game, is that an attempt to remove

the self mentally from the stressful situation, a countermeasure, or is it

an attempt to cooperate with the restriction? Because the interview was

not structured to clarify the purpose of the coping, a question that would

have been difficult for the concrete - operational child to answer, it was

208

at times difficult to determine the purpose of the coping behavior,

possibly resulting in underrepresentation of the cooperation category and

overrepresentation in other categories.

Although these insights are important, the primary issue remains the

interpretation of the statistical analysis. This will be addressed by

discussing the relationship of the four factors, health status, gender,

trait anxiety, and stress appraisal to coping behaviors, considering the

theoretical basis of the study and prior research.

Health Status and Coping Behaviors

The results of the data analysis indicated that health status does

not have a significant influence on the type of coping behavior used by

the child in response to an intrusive event during hospitalization. This

pattern was also noted by Ritchie, Caty, and Ellerton (1988), although it

must be noted that study focused on preschool rather than school-age

children and the findings may not be generalizable to a different age

group. If the results of the current study are accurate, the most

probable explanation would be the dynamic nature of the coping process.

During the transaction between person and environment, the appraisal and

reappraisal process are continuous, possibly resulting in changes in

coping behavior that may occur very quickly (Lazarus, 1981; Lazarus &

Folkman, 1984a). This dynamic nature of coping has been observed in

hospitalized children (Savedra & Tesler, 1981). Thus, the ongoing

appraisal process may result in use of a wide spectrum of coping behaviors

determined primarily by the immediate situation rather than in a narrow

range of behaviors the child is familiar with due to prior experience.

s

**

º

209

However, it is possible that the initial hypothesis may have been

correct, that a relationship between health status and coping behaviors

does exist. Examination of the frequency data (Table 16) indicated that

in three categories, cognitive restructuring, control, and seeking

support, there was a trend (greater than 10%) toward a difference between

the groups. The acutely ill children reported using cognitive

restructuring 10.5% more frequently and control 16.7% more frequently than

did the chronically ill group. The chronically ill children reported

using seeking support 12.5% more frequently than did the acutely ill

children.

It is possible that these trends may reflect the true relationship

between health status and coping, but that this was not evident due to the

low cell frequency for the less common coping behaviors. The possibility

that there is a relationship is supported by Lazarus' (Lazarus & Folkman,

1984a) proposal that problem solving skills, dependent on prior experience

and knowledge, influence coping behaviors. Acutely ill children are

relatively unfamiliar with the stressful events that occur during

hospitalization. They may be able to convince themselves that a shot does

feel like a mosquito bite. They also may believe that they have some

degree of control over the situation as they do at home, bargaining to

delay an event or trying to control how the event takes place, and so

attempt to use these behaviors in the hospital. Although chronically ill

children do use control and cognitive restructuring, it is not to the

extent of the acutely ill group, the chronically ill children know better.

Due to past experience they know the shot will hurt more than a mosquito

bite, and they know that they have very little actual control over the

procedures that are imposed upon them. They may have learned that the

—-

c

º&

*

* * *

210

benefit gained from these techniques is not sufficient to compensate for

the energy expended in using them. The chronically ill children, however,

do tend to use seeking support behaviors more than do the acutely ill

children. Perhaps this form of coping requires less expenditure of effort

by transferring some of the burden to someone else. Although this trend

to use different coping behaviors cannot be supported statistically at

this time, the information is of clinical interest and may be useful when

planning methods of supporting children's coping during hospitalization.

The position that different coping behaviors may be emphasized by

acutely ill and chronically ill children is not in conflict with the

preceding argument regarding the dynamic nature of coping. Both groups

did report a wide range of behaviors. However, it is possible, that due

to differences in prior experience, the repertoire of behaviors used by

the two groups is somewhat different, yet remains dynamic, responsive to

a change in the appraisal of the situation.

The hypothesis that health status affects the perception of

effectiveness of coping behavior was supported in the revised model,

although not in the direction predicted. The analysis indicated that

acutely ill children perceive their coping behaviors to be more effective

than do chronically ill children. It seems strange that the group with

less experience in coping with the stresses of hospitalization should

perceive their coping to be more effective. Logically, it would seem that

through experience the chronically ill group would learn which behaviors

are more helpful, would use those behaviors, and would therefore be more

likely to rate their coping as effective. A possible explanation for this

unexpected finding may be the concept of learned helplessness.

211

Learned helplessness occurs when an organism learns that its

responses do not influence the outcome of a situation (Seligman, 1975).

Applied to humans, the model proposes that the greater the belief that

control is possible, the longer the period needed to realize the outcome

is independent of control efforts, but that when this belief is destroyed,

repeated exposure to uncontrollable situations is likely to result in

lowered motivation and passivity (Dweck & Wortman, 1982). This perception

of noncontingency is probably influenced by prior experience (Fincham &

Cain, 1986). Applying this concept to the findings of this study, the

acutely ill child may believe that he or she will be able to control the

occurrence of negative events in the hospital by his or her behavior in

much the same manner as negative events are avoided at home or school. In

contrast, the chronically ill child, due to prior experience, will likely

have learned that in the hospital negative events cannot always be

controlled, regardless of personal efforts to cooperate or to find

alternate solutions. If this premise is true, the chronically ill child

may exhibit characteristics of learned helplessness, such as passivity,

low motivation, and depression (Dweck & Wortman, 1982), resulting in

decreased effort and less effective coping (Compas, 1987). Thus, the

phenomenon of learned helplessness may explain the finding that

chronically ill children perceive their coping to be less effective than

do acutely ill children. Further examination of this possibility by

including learned helplessness in the stress and coping model is

warranted.

212

Gender and Coping Behavior

The results of the data analysis indicated that gender does not have

an affect on the type of coping behavior used in response to an intrusive

procedure or on the child's perception of the effectiveness of the coping

behavior. In the Lazarus theory (Lazarus & Folkman, 1984a) it is proposed

that coping behavior is dependent on available coping resources, such as

health and energy, positive beliefs, problem solving, social skills,

social support, and material resources; and on constraints against using

these resources, such as personal or cultural beliefs, the environment,

and the level of threat. Most of these resources and constraints are

unlikely to have an influence during childhood. For example, for the

hospitalized child, health and energy is dependent on the acuity of the

illness, not on gender; children's belief system is not likely to differ

due to gender as discussed earlier regarding locus of control and gender

(Nowicki, 1986); and the material status of the family is not dependent of

the gender of the child. However, it is possible that the social support

given to children and behavioral expectations of children may differ

according to gender. In the classic examination of sexual differences by

Maccoby and Jacklin (1974) it was note that there were many differences in

parental treatment of boys and girls, such as encouraging more physical

activity in boys and perceiving girls as more fragile, yet it was

concluded that young children are treated quite similarly by parents

regardless of gender. In a more recent review, Huston (1983) concluded

that there is more support for differences in treatment according to

gender than was originally thought, such as permitting school-age boys

more independence than same age girls (Newson & Newson, 1976), and

assigning failure of boys to lack of motivation and failure of girls to

* ** ~ *

213 *--

lack of ability (Dweck, Davidson, Nelson & Enna, 1978). Accordingly, it

could be expected that if coping behavior is dependent in part on social

support, the coping used by boys and girls during hospitalization would

differ. This premise is supported by the work of Savedra and Tesler

(1981), who found that hospitalized boys are more likely to use control

and girls are more likely to use pre-coping (cognitive processing). In

the current study, however, gender did not influence the coping behavior,

a finding supported by other research of children in health care

situations (Curry & Russ, 1985; Hamner & Miles, 1988; LaMontagne, 1984,

1987). It is difficult to explain this discrepancy. Perhaps further

refinement of instruments and methodology will provide additional insights

in this area.

Trait Anxiety and Coping Behavior

The results of the data analysis indicated that trait anxiety does

not have a significant influence on the type of coping behaviors used by

the child during hospitalization. Examination of the relationship between

trait anxiety and the types of coping behaviors used by hospitalized

children was exploratory, no prior research had been reported in this

area. As shown in Table 22, there was only a four point difference in the

means of the trait anxiety score between the coping categories and the Chi

square statistic was not significant. Regardless of the category of

coping behavior used in response to an intrusive event, there was very

little difference in the trait anxiety scores of the children. Although

personal characteristics influence the coping process (Lazarus & Folkman,

1984b), it does not appear that the characteristic of trait anxiety

influences the type of coping behavior used by a hospitalized child.

214

In contrast, data analysis of the revised model indicated that trait

anxiety does have a significant influence on the child's perception of the

effectiveness of the coping behaviors used during hospitalization.

Theoretical support for this relationship comes from the coping

constraints detailed above (Lazarus & Folkman, 1984a), specifically the

level of threat. A child with a higher level of trait anxiety approaches

a situation with increased apprehension and fear. This increases the

perceived level of threat regarding the situation, in turn interfering

with problem solving, resulting in decreased effectiveness of coping

(Lazarus & Folkman, 1984a). Although no other research examining this

relationship was found, the finding is logical, providing one more piece

of information that will help health care professionals understand

children's reactions during hospitalization.

In summary, the results of the current study appear to indicate that

the coping behaviors used during hospitalization in response to an

intrusive event may possibly be related to health status, although this

relationship is tenuous, but that it is less likely that either gender or

trait anxiety influence the coping process. It also appears possible that

the perceived effectiveness of coping may be influenced by the child's

health status and trait anxiety, but it is uncertain if gender has a

modifying influence on this relationship.

Limitations

All research is limited in generalizability due to decisions that

must be made in the development and implementation of the research

.

215

protocol. The limitations of this study will be discussed according to

those pertaining to the sample and those relevant to data collection.

Limitations Related to the Sample

The primary limitation due to sampling was the decision to use a

convenience, rather than random, sample. While use of a probability

sample would have increased the generalizability of the findings, for the

purposes of this study, a convenience sample was necessary due to

limitation of time and resources. An advantage of the convenience sample

was the ability to specify inclusion-exclusion criteria that resulted in

a fairly homogenous group of children in respect to cognitive functioning

and extraneous factors. These same criteria define the population to

which the results may be generalized: English speaking children between

the ages of 8 through 11 years of normal cognitive and sensory

functioning, who have been hospitalized for two to three days, but have

not been in the intensive care unit during the current admission, were not

admitted due to child abuse, and were not in the terminal phase of

illness.

An additional limitation was the underrepresentation of acutely ill

children in the sample. Had a quota sample been obtained, resulting in

equal numbers in the acute and chronic groups, it is possible that the

results of the data analysis may have been different, particularly the Chi

square analysis due to a probably increased frequency of cell size.

Several, factors may have contributed to the low number of acutely ill

children in the study. First, during the school-age years, acute

illnesses of sufficient severity to require hospitalization appear to be

216

less common than chronic illness resulting in admission. The most common

diagnoses of the acutely ill children were appendectomy and fracture.

Other acute illnesses such as pneumonia, croup, meningitis, and

gastroenteritis occur more commonly in younger children. In contrast,

many chronic illnesses persist throughout childhood, resulting in

hospitalization during the school-age years, although diagnosis may have

been made quite early in life. Therefore, it seemed that the number of

potential subjects that were acutely ill was less than that of chronically

ill children. Second, two of the six facilities used for data collection

were tertiary hospitals likely to draw a population of chronically ill

children and one of the six facilities specialized in orthopedic problems

primarily of a chronic nature. While the remaining three facilities

accepted both chronic and acute illnesses, it is possible that, as a total

group, chronically ill children comprised a greater percentage of the

potential subjects than did acutely ill children. Third, as noted in

description of the sample (see Chapter 4) of the potential subjects who

were approached about the study but declined to participate, 39% were

acutely ill children, a number considerably higher than the 25.6% of

acutely ill children that participated in the study. This further

contributed to the low number of acutely ill subjects. Finally, at each

facility there were periods of time when no data collection was attempted

due to the unavailability of the data collector. Due to the difficulty of

gathering post hoc data to determine if children admitted during these

periods met the eligibility criteria, it is not known whether the

proportion of acutely ill to chronically ill children during these periods

was the same or different from that of the sample.

217

Limitations Related to Instrumentation

The results of a study, and thereby the generalization of the

findings, are always affected by the instruments used to collect the data.

In this study, a major portion of the findings were dependent on

assumptions related to the stress and coping interview. First, it was

assumed that the interview would provide an accurate sampling of the

stressful events and coping behaviors used by the children. Consideration

of the data implies, however, that the coping behaviors identified in this

study are representative only of those the children are aware of using,

and may not adequately represent the behaviors that are actually used, as

evident by the difference in frequency of cognitive processing in this

study and orienting behaviors in the study by Savedra and Tesler (1981)

that used observation rather than interview. Second, as addressed above

in the section, Discussion of Results Relating to Coping, thinking about

cognitive coping behaviors was difficult for the some of the children.

Although it is necessary to ask the child about these behaviors as

cognitive coping cannot be observed, the results must be interpreted

recognizing that such an inquiry is pushing the child toward a higher

level of thinking than he or she may use on a routine basis, possibly

influencing the types of responses given by the subjects.

Another limitation of the study, relating to the interview data,

centers on the categories of stress and coping developed for use in this

study. This was the first study to use these stress and coping

categories. Although the validity of the categories is likely to have

be en good, due to the method of developing the categories (see chapters 2

and 4), it is possible the categories did not fully represent the range of

218

stressful events and coping behaviors characteristic of hospitalized

school-age children. For example, the researchers who participated in the

interrater reliability estimate suggested adding a coping category of

emotional behaviors. The reliability of the categories was also a

limitation. As detailed in chapter 4, the mean rate of interrater

reliability for assignment of stressful events to categories ranged

between 62.5 % to 70.8%, and for coping categories the mean rate ranged

between 56.25% and 70.8%. Although the moderate rate of agreement is

partially due to the process of the rating (the items were first

identified by the raters, and then categorized, causing the accuracy of

the Cohen's kappa to be dependent on the accuracy of the recognition of

items), it may also be due to the structure and definition of the

categories. Comments by the raters indicated that some categories

appeared to overlap, such as intrusive events and therapeutic

interventions, and control and cooperation. Further refinement of the

definitions of the categories may be helpful in increasing the reliability

of the coding scheme.

An additional limitation of the study is the low correlation between

the word graphic scales and the instruments used to determine concurrent

validity. As discussed in chapter 4, this finding may be acceptable as

the validity of the Child Medical Fear Scale and the Coping Response

Inventory are still being determined as both are fairly new instruments.

However, further psychometric testing of the Hospital Stress Scale and the

H ospital Coping Scale is needed to establish the reliability and validity

of the instruments.

219

Implications for Nursing

The fundamental concepts of the discipline of nursing have been

identified as person, environment, health, and nursing (Chinn & Jacobs,

1987; Flaskerud & Halloran, 1980; Fawcett, 1978; Fawcett, 1984; Yura &

Torres, 1975), although some nurse theoreticians have proposed a condensed

(Kim, 1983) or expanded (Meleis, 1985) version of the concepts. These

four basic concepts will be used to discuss the implications for nursing

derived from the current study.

Person

The concept of person has been defined for the nursing paradigm as

"the individual, family, community, society, or any other entity that is

the identified recipient of nursing" (Fawcett, 1984). For the purpose of

this study, the focus was placed on the individual, specifically, the 8 to

11 year old child receiving nursing care while hospitalized.

Three aspects related to the concept of person were examined in this

study. The first was the child's psychological reaction to

hospitalization with a particular focus on the appraisal of stress and

coping, the primary concepts of Lazarus' theory (Lazarus & Folkman,

1984 a). Analysis of the data indicated that children within the generally

accepted age range of concrete operational development (Brainerd, 1978;

Crain, 1985; Siegler, 1986) did have definite opinions on what events were

stressful during hospitalization, and were able to describe the things

they did to deal with the stressful events, more often describingbe havioral than cognitive coping activities. The second aspect of the

Person examined in the study was gender. With this sample, gender was not

220

found to be related to the stress and coping process in relation to

specific events occurring during hospitalization or the global event of

hospitalization. The third aspect of the person examined in this study

was trait anxiety. This relatively stable aspect of the personality of

was not found to be related to the appraisal of specific events as

stressful or the resulting coping behaviors, but it was related to the

child's perception of the stressfulness of the global event of

hospitalization and the effectiveness of the coping behaviors.

Several implications for nursing practice are evident in these

findings. First, children between the ages of 8 to 11 years are not

merely passive recipients of care and treatment while hospitalized.

Rather, they are actively engaged in an ongoing appraisal of the meaning

of the environment for their well-being. Second, when an appraisal of

stress is made, the child uses coping behaviors to reduce the

stressfulness of the situation. Thus, as Piaget (1983) noted children are

active participants in structuring and modifying their world, even when in

the hospital. Third, expectations regarding the behavior of hospitalized

children should not be based on gender. There is insufficient evidence to

support the common assumption that boys and girls appraise different

events as stressful or use different forms of coping. Finally, because of

the possible relationship between trait anxiety and the child's reaction

to the global event of hospitalization, the nurse should be aware that the

highly anxious child may need more preparation and support to deal with a

stressful event than will the child with a low level of anxiety.

221

Health

The concept of health has been defined for the nursing paradigm as

"wellness and/or illness" (Fawcett, 1984). All of the children in this

study were experiencing sufficient physical problems to warrant

hospitalization, and therefore would be considered to be ill. However,

the severity of the illness was limited to children not considered to have

a critical or terminal condition.

The concept of health also determined two key aspects of the study

design. First, the noncategorical approach to illness (Stein & Jessop,

1982, 1989), focusing on the commonalities of experience and needs rather

than on disease specific treatment, was used as this approach is more

congruent with a nursing, rather than medical, model. Second, health

status as acutely or chronically ill was selected for examination as a

moderating variable. Study of the Lazarus theory (Lazarus & Folkman,

1984a) indicated the extent of a child's prior experience with

hospitalization is likely to be a strong determinate of the stress and

coping process. The factor most likely to result in a difference in

experience would be the health status of the child as acutely or

chronically ill. In addition to the potential theoretical importance of

this factor, understanding the relationship between health status and the

stress and coping process also was thought to be of practical important as

chronically ill children are hospitalized more frequently and/or for long

periods than are acutely ill children (Butler et al., 1985; Perrin, 1985).

As discussed above, the findings of this study did support the inclusion

of the health status variable as a contributing factor in model of stress

and coping.

222

Several implications for nursing practice are evident relating to

the concept of health as used in this study. First, use of the

noncategorical approach promotes transference of nursing knowledge to new

situations by emphasizing the commonalities of children's experiences,

rather than the diagnostic and treatment related differences. Second, it

should not be assumed that chronically ill children eventually get used to

the stressful events occurring during hospitalization and develop methods

of coping effectively. Rather, dealing with stressful events,

particularly intrusive procedures, is an ongoing challenge for chronically

ill children. Nurses need to place a high priority on avoiding or

minimizing intrusive events and on supporting the child when the events

are inevitable. Additionally, because chronically ill children seem to

perceive their coping as less effective, possibly due to learned

helplessness (Fincham & Cain, 1986), effort needs to be made to provide

appropriate opportunities for control, adequate explanation of essential

events that are uncontrollable, support for the child's coping behaviors

with supplementation as needed by teaching additional coping techniques,

and confirmation that the effort to cope was helpful.

Environment

The concept of environment has been defined for the nursing paradigm

as encompassing "relevant animate and inanimate surroundings" (Fawcett,

1984). For the purposes of this study the environment was considered to

be the structural and interpersonal aspects of the hospital encountered by

the child while a patient.

223

Although the environment was not one of the independent variables of

the study, it was a primary determinant of the dependent variable of

stress appraisal. By definition, stress is the result of a transaction

between the person and environment (Lazarus & Folkman, 1984a, pp. 19).

Therefore, when the children were asked to identify upsetting things that

happen in the hospital, the answers were reflective of the immediate

environment. Inanimate aspects of the environment that resulted in an

appraisal of stress ranged from medical equipment mounted on the walls

causing nightmares to a variety of intrusive events and therapeutic

interventions. Interpersonal aspects of the environment resulting in

stress included separation from family, incompatibility of roommates, and

impatient nurses and doctors.

The primary implication for nursing practice related to the concept

of environment, as used in this study, is the modification of the hospital

environment to reduce elements that are likely to be stressful to the

child, whenever this is possible. Ask the children to tell you what is

upsetting to them about being in the hospital. If the child's concern

centers on the physical environment, redecorate the room with personal art

work or posters from the child, cover or remove unnecessary equipment, or

avoid unnecessary noise, such as flushing the toilet at night. If the

child's concern centers on aspects of the health care regimen, reduce the

frequency of the stressful event if possible, such as limiting the number

of persons conducting a physical assessment during a shift, or if the

event is necessary, provide information and support. If the source of the

child's stress is interpersonal, attempt to find compatible roommates,

follow hospital regulations reasonably rather than rigidly, and do not

allow irritation or frustration due to work related problems to spill over

224

into interaction with the child. Obviously in a hospital situation not

all sources of stress can be eliminated. However, those that can be

removed or modified should be .

Nursing

The concept of nursing has been defined for the nursing paradigm as

"the totality of activities of members of the discipline" (Fawcett, 1984).

For the clinician caring for hospitalized children, one facet of these

nursing activities involves caring for the psychological needs of the

child, of which stress and coping is a part.

This study was a descriptive examination of selected factors

influencing the stress and coping process of hospitalized children,

therefore nursing actions were not directly assessed. Rather, the purpose

was to further develop the foundation of nursing knowledge relating to

children's reactions during hospitalization, enabling the nurse working

with children to provide care based on scientific knowledge.

The specific implications of the study for nursing care have been

discussed under the headings of person, health, and environment. A more

general implication for nursing would be the inclusion of the knowledge

relating to the stress and coping of hospitalized children in the nursing

process. Pediatric nurses are generally quite aware that children find

intrusive events and separation to be stressful. It may be less well

recognized, however, that therapeutic interventions, restricted activity,

physical symptoms, and environmental factors may also be stressful for the

child. Knowledge of these potential sources of stress and the unique

reactions of chronically ill and acutely ill children will guide the nurse

225

in the assessment process. Similarly, knowledge of the types of coping

behaviors used by children in response to stressful hospital events may

provide an additional tool for the pediatric nurse to use in assessment of

the psychosocial status of the hospitalized child. Awareness of the

categories of coping behaviors typically used by hospitalized school-age

children and the possible differences in coping behaviors related to

health status and anxiety, will guide the assessment process as the nurse

talks with and observes the child.

In the current taxonomy of nursing diagnoses, the category most

closely related to stress appraisal is that of Fear, defined as, "a state

in which the individual experiences a feeling of physiological or

emotional disruption related to an identifiable source which the person

perceives as dangerous" (Carpenito, 1987, pp. 242). Although this

diagnosis places more emphasis on the emotional reaction to the event than

does Lazarus' definition of stress cited in chapter 2 (Lazarus & Folkman,

1984a, pp. 19), the focus on perception of personal danger is closely

aligned to the appraisal of harm and threat in the stress concept.

Therefore, this diagnosis could be used appropriately to represent actual

or potential appraisals of stress that may occur.

The diagnosis most closely pertaining to the child's coping process

is Ineffective Individual Coping, defined as "a state in which the

individual experiences or is at risk of experiencing an inability to

manage internal or environmental stressors adequately due to inadequate

resources (physical, psychological, or behavioral)" (Carpenito, 1987, pp.

202). Because this diagnosis assumes that the person is having or will

have ineffective coping, careful assessment of the individual child's

coping behaviors must occur before listing this diagnosis as a nursing

226

problem. The child's repertoire of coping behaviors may be sufficient to

deal with the stresses encountered during hospitalization, removing the

need for this diagnosis.

If the child has successfully coped with the stress previously, the

most effective nursing plan and intervention may be to support the child

in that coping behavior. For example, if separation from parents at night

is difficult, but manageable, as long as the child has a favorite security

object and is allowed to call home at bedtime, then incorporate these

elements into the plan of care. Be aware, however, that the appraisal of

stress may change due to changes in the the person and environment.

Therefore, due to excessive fatigue or additional stresses, the situation

may be appraised differently and the usual coping behaviors may be

insufficient. In this case, the nurse may need to help the child find

alternative methods of dealing with the situation, such as distraction by

reading a bedtime story or social support in the form of a hug or holding

the child's hand until sleep occurs.

If the diagnosis of Ineffective Individual Coping is appropriate, a

more structured approach may be needed to help the child cope with the

event. In recent years a number of methods of helping children cope with

stressful health care situations have been developed and studied, such as

preprocedural teaching (Ferguson, 1979; Peterson & Shigetomi, 1981;

Visintainer, 1977), relaxation (LaMontagne, Mason, & Hepworth, 1985;

Zastowny, Kirschenbaum, & Meng, 1986; Peterson & Shigetomi, 1981),

modeling (Ferguson, 1979; Melamed & Siegel, 1975; Peterson & Shigetomi,

1981), mental imagery (Johnson, Whitt, & Martin, 1987; Kuttner, Bowman, &

Teasdale, 1988; Peterson & Shigetomi, 1981), and self-talk (Peterson &

Shigetomi, 1981; Ross, 1984). Selection of a particular approach will be

227

dependent on the child's personality, needs, and the characteristics of

the stressful event. Implementation requires careful planning and

possibly specialized training of the clinical nurse specialist or other

health care professional who will guide the child in the use of these

coping techniques.

Finally, it should be remembered that the appraisal of stress is an

ongoing process, constantly changing and shifting in response to changes

in the person or environment (Lazarus & Folkman, 1984a). Because of this,

the plan of care must be frequently reevaluated to ensure that the child's

ever changing needs are being met.

In sum, the nursing process may be used to apply the knowledge

gained through this study to the clinical practice of nursing. Through

this approach the fundamental goal of this research, the promotion of the

psychological well-being of the hospitalized child by the professional

nurse, will be met.

Implications for Future Research

Pediatric nurse researchers responsible for the basic foundation of

knowledge pertaining to the coping behaviors of hospitalized children have

made a valuable contribution to nursing knowledge (Caty, Ellerton, &

Ritchie, 1984; LaMontagne, 1984, 1987; Ritchie, Caty, & Ellerton, 1988;

Rose, 1972a, 1972b; Savedra & Tesler, 1981; Stevens, 1984, 1989). This

study has added to the building of this base of knowledge. Clinical

interaction with sick children demonstrates that not all children appraise

the same events as stressful or use the same coping behaviors, yet very

little is known about the factors contributing to these differences.

228

While this study has contributed much needed information about three

fundamental characteristics of the child to the knowledge base, the

factors studied account for only 14% of the variance in children's

appraisal of the stressfulness of hospitalization and only 12% of the

variance in children's perception of coping effectiveness. More research

is needed before a clear understanding of hospitalized children's stress

and coping will emerge.

In order to proceed with research in this area, the first step

needed is a reexamination of the representativeness of the categories of

stress and coping used in this study, further refinement of the

operational definitions, and testing of the taxonomy. Based on the

taxonomy, an instrument then could be developed that will facilitate

assessment of children's stress and coping during hospitalization. Given

a standardized method of assessing these concepts, examination of factors

influencing stress and coping will be facilitated. More information is

needed regarding the personal and environmental factors that influence the

child's stress and coping process. Factors needing examination include

temperament, ethnicity, self-concept, and locus of control. It may also

be beneficial to further examine the concept of health status and tease

out possible differences in the reactions of children with a chronic

condition versus those with a chronic illness. Research is also needed

that will examine the nature of a child's stress appraisal and coping

behavior over time to determine if the processes are a relatively stable

characteristic of the person or if the behaviors change as the child

develops cognitively.

A second line of needed research is the development of intervention

studies that will assess the efficacy of teaching coping strategies to

229

children experiencing specific stressful events during hospitalization.

We need to know if teaching specific techniques such as relaxation or

imagery are helpful to hospitalized children and if so, is promotion of

these techniques more effective than support of the child's own coping

behaviors. We also need to understand the relationship between various

personality styles and the use of coping techniques. Such information

will enhance the nurse's ability to plan psychosocial interventions that

will best meet the needs of the child. In this manner, nursing research

will contribute directly to the nursing practice of those working with

children.

Conclusion

The two-fold purpose of this study was to examine the influence of

health status, gender, and trait anxiety, on 1) the specific events

school-age children perceive as stressful during hospitalization and the

coping behaviors used in response to the events, and on 2) school-age

children's appraisal of stressfulness of the global event of

hospitalization and their perception of the effectiveness of their coping

behaviors. Conceptualization of the problem and development of the

protocol were guided by Lazarus' cognitive theory of stress and coping and

Piaget's theory of the cognitive development of children.

Eighty-two children meeting the inclusion-exclusion criteria

comprised the sample. Data were collected on the second or third day of

the child's hospitalization. All instruments required self-report from

the children and included an interview, two word graphic scales, and three

inventories using Likert-type responses.

230

Analysis of the interview data indicated that of the six possible

relationships between the independent variables of health status, gender,

and trait anxiety and the dependent variables of stress appraisal and

coping behaviors, only the relationship between health status and stress

appraisal was statistically significant. Analysis of the data pertaining

to the global stressfulness of the hospital experience and the perceived

effectiveness of coping indicated that the health status, gender, and

trait anxiety, as a set, accounted for 14% of the variance in the

children's stress appraisal, with trait anxiety alone contributing

significantly to the model; and that health status, gender, trait anxiety,

and stress appraisal, as a set, accounted for 14% of the variance in the

children's perception of coping effectiveness, with none of the variables

contributing significantly to the model. Due to redundancy, stress

appraisal was eliminated from the second portion of the model, and the

relationship reexamined. In the revised model, health status, gender, and

trait anxiety, as a set, accounted for 12% of the variance in perception

of coping effectiveness, with both health status and trait anxiety

contributing significantly to the model.

These findings indicate that both health status and trait anxiety

are important variables to take into consideration when trying to

understand the stress and coping process of hospitalized school-age

children, but that gender does not appear to have any affect on the

process. Although the contribution of these factors is small, the

knowledge generated through this study provides needed information

concerning the stress and coping of hospitalized children that will

enhance the understanding of the professional nurse and other health care

providers. Additional research that will identify other personal and

231

environmental variables affecting the model is needed to further advance

the development of knowledge concerning the stress and coping process of

hospitalized school-age children. r_< *

a

232

BIBLIOGRAPHY

Adams, M. L., & Bergman, D. C. (1965). The hospital through a child's

eyes. Children, 12, 102-104.

Aisenberg, R. B., Wolff, P., H., Rosenthal, A., & Nadas, A. S. (1973).

Psychological impact of cardiac catheterization. Pediatrics, 51,

1051 - 1059.

Altshuler, J. L., & Ruble, D. N. (1989). Developmental changes in

children's awareness of strategies for coping with uncontrollable

stress. Child Development, 60, 1337-1349.

Amato, P. R., & Ochiltree, G. (1987). Interviewing children about their

families: A note on data quality. Journal of Marriage and the

Family, 49, 669-675.

Asher, N. B. (1983). Causal Modeling. Newbury Park: Sage.

Astin, E. W. (1977). Self reported fears of hospitalized and non

hospitalized children aged ten to twelve. Maternal-Child Nursing

Journal, 6, 17-24.

Barowsky, E. I. (1978). Young children's perceptions and reactions to

hospitalization. In E. Gellert (Ed.), Psychosocial issues of

pediatric care (pp. 37-49). New York: Grune & Stratton.

Bedell, J. R. , & Roitzsch, J. (1976). The effects of stress on state and

trait anxiety in emotionally disturbed, normal, and delinquent

children. Journal of Abnormal Child Psychology, 4(2), 173-177.

Beilin, H. (1989). Piagetian theory. In R. Vasta (Ed.), Annals of Child

Development: Vol. 6. Six theories of child development: Revised

formulations and current issues (PP. 85-131). Greenwich,

Connecticut: Jai Press.

4

T

º

233

Belmont, H. S. (1970). Hospitalization and its effects upon the total

child. Clinical Pediatrics, 2, 472-483.

Bishop, M. (1976). Coping behaviors of children born with a cleft lip and

palate. Unpublished master's thesis, Arizona State University,

Tempe, Arizona.

Blom, G. E. (1958). The reactions of hospitalized children to illness.

Pediatrics, 22, 590-600.

Bowlby, J. (1973). Attachment and loss; Separation, anxiety and anger.

Vol. 2. New York: Basic Books.

Boyd, H. F., & Johnson, G. O. (1981). Analysis of Coping Style. Charles

E. Merrill Publishing Company.

Brainerd, C. J. (1978). Piaget's theory of intelligence. New Jersey:

Prentice Hall.

Broome, M. E., Hellier, A., Wilson, T., Dale, S., & Glanville, C. (1988).

Measuring children's fears of medical experiences. In C. F. Waltz,

& O. L. Strickland (Eds.), Measurement of nursing outcomes: Vol. 1.

Measuring client outcomes (pp. 201-214). New York: Springer.

Brown, J. M., O'Keefe, J., Sander, S. H., Baker, B. (1986). Developmental

changes in children's cognition to stressful and painful situations.

Journal of Pediatric Psychology, 3, 343-357).

Burstein, S., & Meichenbaum, D. (1979). The work of worrying in children

undergoing surgery. Journal of Abnormal Child Psychology, 7, 121

132.

Butler, J. A., Budetti, P., McManus, M. A., Stenmark, S., & Newacheck, P.

W. (1985). Health care expenditures for children with chronic

illness. In Hobbs, N., & Perrin, J. M. (Eds.), Issues in the care

234

of children with chronic illness (pp. 827-863). San Francisco:

Jossey-Bass.

Carpenito, L. J. (1987). Nursing diagnosis: Application to clinical

practice (2nd ed.). Philadelphia: J. B. Lippincott.

Castaneda, A., McCandless, B. R. , & Palermo, D. S. (1956). The children's

form of the manifest anxiety scale. Child Development, 27, 317-326.

Caty, S., Ellerton, M. L., Ritchie, J. A. (1984). Coping in hospitalized

children: An analysis of published case studies. Nursing Research,

33, 277-282.

Chinn, P. L., & Jacobs, M. K. (1987). Theory and nursing: A systematic

approach. S. Louis: C. V. Mosby.

Cohen, F., & Lazarus, R. S. (1979). Coping with the stresses of illness.

In G. C. Stone, F. Cohen, N. E. Adler & associates (Eds.), Health

Psychology--A Handbook (pp. 217-254). San Francisco: Jossey-Bass.

Cohen, F., & Lazarus, R. S. (1983). Coping and adaptation in health and

illness. In D. Mechanic (Ed.), Handbook of health, health care, and

the health professions (pp. 608-635). New York: Free Press.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences.

(2nd ed.). Hillsdale, NJ: Lawrence Erlbaum.

Cohen, J., & Cohen, P. (1983). Applied multiple regression/correlation

analysis for the behavioral sciences. New Jersey: Lawrence Erlbaum.

Compas, B. E. (1987). Coping with stress during childhood and

adolescence. Psychological Bulletin, 101, 393-403.

Cook, T. D. & Campbell, D. T., (1979). Quasi- Experimentation: Design &

analysis issues for field settings. Boston: Houghton Mifflin.

Crain, W. C. (1985). Theories of development: Concepts and applications.

2nd ed. New Jersey, Prentice-Hall.

235

Curry, S. L., & Russ, S. W. (1985). Identifying coping strategies in

children. Journal of Clinical Child Psychology, 14., 61-69.

Curry, S. L., Fuss, S. W., Johnsen, D. C., DiSantis, T. A., (1988). The

role of coping in children's adjustment to the dental visit.

Journal of Dentistry for Children, 55, 231-236.

Deatrick, J. A., & Faux, S. A. (1989). Conducting qualitative studies

with children and adolescents. In J. M. Morse (Ed.), Qualitative

nursing research: A contemporary dialogue (pp. 185-203). Rockville,

MA: Aspen.

Dweck, C. S. Davidson, W., Nelson, S., & Enna, B. (1978). Sex differences

in learned helplessness: II. The contingencies of evaluative

feedback in the classroom; and III. An experimental analysis.

Developmental Psychology, 14, 268-276.

Dweck, C. S. & Elliot, E. S. (1983). Achievement motivation. In P. H.

Mussen (Ed.), Handbook of child psychology. Vol. IV. Socialization.

personality, and social development. (pp. 644-691). New York: John

Wiley & Sons.

Dweck, C. S. & Wortman, C. B. (1982). Learned helplessness, anxiety, and

achievement motivation. In H. W. Krohne & L. Laux (Eds),

Achievement, stress, and anxiety (93-125), Washington: Hemisphere.

Eiser, C., and Patterson, D. (1984). Children's perceptions of hospital:

a preliminary study. International Journal of Nursing Studies, 21,

45-50.

Elkins, P. D., & Roberts, M. C. (1984). A preliminary evaluation of

hospital preparation for nonpatient children: Primary prevention in

a "Let's pretend hospital". Children's Health Care, 13(1), 31-36.

236

Elkins, P. D. , & Roberts, . M. C. (1985). Reducing medical fears in a

general population of children: A comparison of three audiovisual

modeling procedures. Journal of Pediatric Psychology, 10, 65-75.

Elwood, S. W. (1987). Stressor and coping response inventories for

children. Psychological Reports, 60, 931-947.

Ellerton, M. L., Caty, S., Ritchie, J. A. (1985). Helping young children

master intrusive procedures through play. Children's Health Care,

13, 167-173.

Endler, N. S., & Edwards, J. (1982). Stress and personality. In L.

Goldberger & S. Breznitz (Eds.), Handbook of stress: Theoretical and

clinical aspects (pp. 36-48). NY: Free Press.

Erickson, F. H. (1958a). Play interviews for four-year-old hospitalized

children. Monographs of the Society for Research in Child

Development, 23 (3, Serial No. 69), 1-77.

Erickson, F. (1958b). Reactions of children to hospital experience.

Nursing Outlook, 6, 501-504.

Erickson, F. (1963). Viewpoints on children in hospitals. Hospitals, 37,

47-48.

Erickson, F. (1965). When 6- to 12-year olds are ill. Nursing Outlook,

13 (7), 48-50.

Erickson, F. (1972). Stress in the pediatric ward. Maternal - Child

Nursing Journal, 1, 113-116.

Faux, S. A., Walsh, M., Deatrick, J. A. (1988). Intensive interviewing

with children and adolescents. Western Journal of Nursing Research,

10, 180-194.

237

Fawcett, J. (1978). The "what" of theory development. In Theory

development: What, why, how? (pp. 17-33). New York: National League

for Nursing.

Fawcett, J. (1984). Analysis and evaluation of conceptual models of

nursing. Philadelphia: F. A. Davis.

Ferguson, B. F. (1979). Preparing young children for hospitalization: A

comparison of two methods. Pediatrics, 64, 656-664.

Field, T., Alpert, B., Vega-Lahr, N., Goldstein, S., Perry, S. (1988).

Hospitalization stress in children: Sensitizer and repressor coping

styles. Health Psychology, 6, 433-445.

Fincham, F. D., & Cain, K. M. (1986). Learned helplessness in humans: A

developmental analysis. Developmental Review, 6, 301-333.

Fischman, S. E., & Friedland, G. W. (1986). Psychologic aspects of

dealing with children in uroradiology. Urology, 27, 478-481.

Flaskerud, J. H. & Halloran, E. J. (1980). Areas of agreement in nursing

theory development. Advances in Nursing Science, 3, 1-7.

Folkman, S. (1984). Personal control and stress and coping processes: A

theoretical analysis. Journal of Personality and Social Psychology,

46, 839-852.

Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle

aged community sample. Journal of Health and Social Behavior, 21,

219 - 239.

Folkman, S., & Lazarus, R. S. (1985). If it changes it must be a process:

Study of emotion and coping during three stages of a college

examination. Journal of Personality and Social Psychology, 48, 150

170.

238

Folkman, S., & Lazarus, R. S. (1988). Coping as a mediator of emotion.

Journal of personality and social psychology, 54, 466-475.

Folkman, S., Lazarus, R. S., Dunkel-Schetter, C., DeLongis, A., Gruen, R.

J. (1986). Dynamics of a stressful encounter: Cognitive appraisal,

coping, and encounter outcomes. Journal of Personality and Social

Psychology, 50, 992-1003.

Freud, A. (1952). The role of bodily illness in the mental life of

children. The Psychoanalytic Study of the Child, 7, 69-81.

Gelman, R. & Baillargeon, R. (1983). A review of some Piagetian concepts.

In P. H. Mussen (Ed.), Handbook of child psychology: Volume III:

Cognitive Development (pp. 167-230). 4th ed. New York: John Wiley.

Ginsburg, H. P., & Opper, S. (1988). Piaget's theory of intellectual

development (3rd ed.). New Jersey: Prentice Hall.

Gofman, H., Buckman, W., Schade, G. H. (1957). The child's emotional

response to hospitalization. American Medical Association Journal

of Disease of Children, 93, 157-163.

Gorman, G. (1980). The school-age child as historian. Pediatric Nursing,

5 (1), 39-40.

Goslin, E. R. (1978). Hospitalization as a life crisis for the preschool

child: A critical review. Journal of Community Health, 3, 321-346.

Hamner, S. B., & Miles, M. S., (1988). Coping strategies in children with

cancer undergoing bone marrow aspirations. Journal of the

Association of Pediatric Oncology Nurses, 5 (3), 11-15.

Heavenrich, R. M. (1963). Viewpoints on children in hospitals.

Hospitals, 37, 40-46.

Hobbs, N., Perrin, J. M., & Ireys, H. T. (1975). Chronically ill

children and their families. San Francisco: Jossey-Bass.

239

Holaday, B., & Turner-Henson, A. (1989). Response effects in surveys with

school-age children. Nursing Research, 38, 248-250.

Holt, J. L. (1968). Discussion of the method and the clinical

implications from the study "children's recall of a preschool age

hospital experience after an interval of five years". In M. V. Batey

(Ed.), Communicating nursing research (PP. 56-84). Boulder,

Colorado: Western Interstate Commission for Higher Eduction.

Hughes, M. C. (1982). Chronically ill children in groups: Recurrent

issues and adaptations. American Journal of Orthopsychiatry, 52,

704 - 711.

Hughes, R. B. (1967). Children's fears of surgery. Hospital Topics,

45 (9), 116-117.

Huston, A. C. (1983). Sex- typing. In P. H. Mussen (Ed.), Handbook of

child psychology. Vol. IV. Socialization, personality, and social

development. (pp. 387-467). New York: John Wiley & Sons.

Illingworth, R. S (1958). Children in hospital. The Lancet, 2, 165-171.

Inhelder, B. & Piaget, J. (1958). The growth of logical thinking from

childhood to adolescence. New York: Basic Books.

Inhelder, B. & Piaget, J. (1964). The early growth of logic in the child:

Classification and seriation. New York: Harper & Row.

Janis, I. (1958). Psychological stress. New York: Wiley.

Janis, I. (1965). Psychodynamic aspects of stress tolerance. In S. F.

Klausner (Ed.), The quest for self-control (pp. 213-246). New York:

Free Press.

Jessner, L., Blom, G. E., & Waldfogel, S. (1952). Emotional implications

of tonsillectomy and adenoidectomy on children. The Psychoanalytic

Study of the Child, 7, 126-169.

240

Johnson, J. E., Kirchhoff, K. T., & Endress, M. P. (1975). Altering

children's distress behavior during orthopedic cast removal.

Nursing Research, 24, 404-410.

Johnson, M. R., Whitt, J. K., & Martin, B. (1987). The effect of fantasy

facilitation of anxiety in chronically ill and healthy children.

Journal of Pediatric Psychology, 12, 273-283.

Johnson, R. T. (1976). Tests and measurements in child development:

Handbook II. San Francisco: Jossey Bass.

Joshi, R. T. (1974). Field-dependence, anxiety and personality.

Perceptual and Motor Skills, 38, 1328.

Kellerman, J., Zeltzer, L., Ellenberg, L., Dash, J., & Rigler, D. (1980).

Psychological effects of illness in adolescence. I. Anxiety, self

esteem, and perception of control. The Journal of Pediatrics, 97,

126-131.

Kerlinger, F. N. (1986). Foundations of behavioral research. New York:

Holt, Rinehart, & Winston.

Kim, H. S. (1983). The nature of theoretical thinking in nursing.

Norwalk, CN: Appleton-Century-Crofts.

Klein, R. G. (1988). Childhood anxiety disorders. In C. J. Kestenbaum &

D. T. Williams (Eds.), Handbook of clinical assessment of children

and adolescents (pp. 722-742). NY: New York University.

Knight, R. B., Atkins, A., Eagle, C. J., Evans, N., Finkelstein, J. W.,

Fukushima, D., Katz, J., & Weiner, H. (1979). Physiological

stress, ego defenses, and cortisol production in children

hospitalized for elective surgery. Psychosomatic Medicine, 41, 40

49.

-7 ■ º*-I7, º

º

-

241

Kueffner, M. (1975). Passage through hospitalization of severely burned,

isolated school-age children. Communicating Nursing Research, 7,

181-197.

Kuttner, L., Bowman, M., Teasdale, M. (1988). Psychological treatment of

distress, pain, and anxiety for young children with cancer.

Developmental and Behavioral Pediatrics, 2, 374-381.

Lambert, S. A. (1984). Variable that affect the school-age child's

reaction to hospitalization and surgery: A review of the literature.

Maternal-Child Nursing Journal, 13, 1-18.

LaMontagne, L. L. (1984). Children's locus of control beliefs as

predictors of preoperative coping behavior. Nursing Research, 33,

76 - 85.

LaMontagne, L. L. (1987). Children's preoperative coping: Replication and

extension. Nursing Research, 36, 163-167.

LaMontagne, L. L., Mason, K. R., & Hepworth, J. T. (1985). Effects of

relaxation on anxiety in children: Implications for coping with

stress. Nursing Research, 34, 289-292.

Langford, W. S. (1961). The child in the pediatric hospital: Adaptation

to illness and hospitalization. American Journal of

Orthopsychiatry, 31, 667-684.

Lapouse, R., & Monk, M. A. (1959). Fears and worries in a representative

sample of children. American Journal of Orthopsychiatry, 29, 223

248.

Lazarus, R. S. (1981). The stress and coping paradigm. In E. Eisdorfer,

E. Cohen, A. Kleinman, & P. Maxim (Eds.), Models for clinical

psychopathology (pp. 175-214). New York: SP Medical & Scientific

Books.

- |

242

Lazarus, R. S., DeLongis, A., Folkman, S., & Gruen, R. (1985). Stress

and adaptational outcomes: The problem of confounded measures.

American Psychologist, 40, 770-779.

Lazarus, R. S., & Folkman, S. (1984a). Stress, appraisal, and coping.

New York: Springer.

Lazarus, R. S., & Folkman, S. (1984b). Coping and adaptation. In W. P.

Gentry (Ed.), The handbook of behavioral medicine (pp. 282-325).

New York: Guilford.

Lazarus, R. S. , & Launier, R. (1978). In L. A. Pervin & M. Lewis, (Eds.),

Perspectives in interactional psychology (pp. 287-327). New York:

Plenum Press.

Lesser, G. S., Fifer, G. , & Clark, D. H., (1965). Mental abilities of

children from different social-class and cultural groups. Monograph

of the Society for Research in Child Development, 30 (4, Serial No.

102).

Levy, D. M. (1960). The infant's earliest memory of inoculation: A

contribution to public health procedures. Journal of Genetic

Psychology, 96, 3-46.

Maccoby, E. E., & Jacklin, C. N. (1974). The psychology of sex

differences. Stanford, CA: Stanford University Press.

Mason, J. W. (1975a). A historical view of the stress field, part I.

Journal of Human Stress, 1, (1), 6-12.

Mason, J. W. (1975b). A historical view of the stress field, part II.

Journal of Human Stress, 1, (2), 22-36.

Maxwell, S. (1985). Review of Child Anxiety Scale. In J. V. Mitchell

(Ed.), The ninth mental measurements yearbook: Vol. 1. (pp. 297

298). Lincoln, NE: University of Nebraska Press.

243

May, B. K., & Sparks, M. (1983). School age children: Are their needs

recognized and met in the hospital setting? Children's Health Care,

11, 118-121.

McGrath, J. E. (1977). Settings, measures, and themes: An integrative

review of some research on social-psychology factors in stress. In

A. Monat and R. S. Lazarus, (Eds.), Stress and coping : An anthology.

(pp. 67-76). New York: Columbia University.

McGuire, M., Shepherd, R., & Greco, A. (1978). Hospitalized children in

confinement. Pediatric Nursing, 4 (6), 31-35.

Meeks, J. E. (1970). Dispelling fears of the hospitalized child.

Hospital Medicine, 6 (10), 77-81.

Melamed, B. G., Dearborn, M., & Hermecz, D. A. (1983). Necessary

considerations for surgery preparation: Age and experience.

Psychosomatic Medicine, 45, 5117-525.

Melamed, B. G., & Lumley, M. A. (1988). Observer rating scale of anxiety.

In M. Hersen, & A. S. Bellack (Eds.), Dictionary of behavioral

assessment techniques (pp. 319-320). New York: Pergamon.

Melamed, B. G., & Siegel, L. J. (1975). Reduction of anxiety in children

facing hospitalization and surgery by use of filmed modeling.

Journal of Consulting and Clinical Psychology, 43, 511-521.

Melamed, B. G., Siegel, L. J., Ridley-Johnson, R. (1988). Coping

behaviors in children facing medical stress. In T. Field, P. M.

McCabe, & Schneiderman, N. (Eds.), Stress and coping across

development (pp. 109-137). New Jersey: Lawrence Erlbaum

Meleis, A. I. (1985). Theoretical nursing: Development and progress.

Philadelphia: J. B. Lippincott.

244

Menke, E. M. (1972). Factors related to children's perception of stress

in the hospital. Unpublished doctoral dissertation, Ohio State

University.

Menke, E. M. (1981). School-aged children's perception of stress in the

hospital. Journal of the Association for the Care of Children's

Health, 9, 80-86.

Miller, S. R. (1979). Children's fears: A review of the literature with

implications for nursing research and practice. Nursing Research,

28, 217-223.

Mott, S. R., Fazekas, N., R., & James, S. R. (1985). Nursing Care of

Children and Families: A holistic approach. Menlo Park, CA:

Addison-Wesley.

Munro, B. H., Visintainer, M. A., Page, E. B. (1986). Statistical methods

for health care research. Philadelphia: J. B. Lippincott.

Murphy, L. B. (1962). The widening world of childhood. New York: Basic

Books.

Murphy, L. B., & Moriarty, A. E. (1976). Vulnerability, coping, and

growth from infancy to adolescence. New Haven: Yale Press.

Nash, S. C. (1979). Sex role as a mediator of intellectual functioning.

In M. A. Wittig & A. C. Petersen (Eds.), Sex related differences in

cognitive functioning (pp. 263-302). New York: Academic Press.

Neff, E. J. A. (1978). Orienting, resistive and adaptive responses of

children undergoing hemodialysis for kidney failure. Maternal-Child

Nursing Journal, 7, 195-254.

Newson, J. & Newson, E. (1976) Seven years old in the home environment.

London: Allen & Unwin.

245

Nowicki, S. (1986). A manual for the children's Nowicki-Strickland

internal - external control scale. Emery University: Atlanta,

Georgia.

Ollendick, T. H. (1983). Reliability and validity of the revised fear

survey schedule for children (FSSC-R). Behaviour Research Therapy,

21, 685 - 692.

Ollendick, T. H., Finch, A. J., Nelson, W. M. (1976). Correlates of

question- asking by emotionally disturbed and normal children.

Psychological reports, 38, 923-929.

Oremland, E. K., & Oremland, J. D. (1973). The effects of hospitalization

on children. Springfield: Charles C. Thomas.

Pearlin, L. I., Lieberman, M. A., Menaghan, E. G., & Mullan, J. T.,

(1981). The stress process. Journal of Health and Social Behavior,

22, 337-356.

Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal

of Health and Social Behavior, 19, 2-21.

Perrin, J. M. (1985). Introduction. In N. Hobbs & J. M. Perrin (Eds.),

Issues in the care of children with chronic illness (pp. 1-10). San

Francisco: Jossey-Bass.

Peterson, L., & Shigetomi, C. (1981). The use of coping techniques to

minimize anxiety in hospitalized children. Behavior Therapy, 12, 1

14.

Peterson, L., & Toler, S. M. (1986). An information seeking disposition

in child surgery patients. Health Psychology, 5 (4), 343-358.

Petrillo, M. & Sanger, S. (1980). Emotional care of hospitalized

children: An environmental approach (2nd ed.). Philadelphia: J. B.

Lippincott.

*

*. º

246

Phillips, L. R. F. (1986). A clinician's guide to the critique and

utilization of nursing research. Norwalk, CT: Appleton-Century

Crofts.

Piaget, J. (1952). The origins of intelligence in children. New York: W.

W. Norton.

Piaget, J. (1954). The construction of reality in the child. New York:

Ballantine Books.

Piaget, J. (1957). Logic and psychology. New York: Basic Books.

Piaget, J. (1959). The language and thought of the child. New York:

Meridian.

Piaget, J. (1983). Piaget's Theory. In P. H. Mussen (Ed.), Handbook of

child psychology: Vol. I. History, theory, and methods (PP. 103

128). New York: John Wiley & Sons.

Piaget, J., & Inhelder, B. (1969). The psychology of the child. New

York: Basic Books.

Pless, I. B., & Perrin, J. M. (1985). Issues common to a variety of

illnesses. In Hobbs, N., & Perrin, J. M. (Eds.), Issues in the care

of children with chronic illness (PP. 41-60). San Francisco :

Jossey-Bass.

Pless, I. B., and Pinkerton, P. (1975). Chronic childhood disorder:

Promoting patterns of adiustment. Chicago: Year Book Medical

Publishers.

Powazek, M., Goff, J. R., Schyving, J., & Paulson, M. A. (1978).

Emotional reactions of children to isolation in a cancer hospital.

The Journal of Pediatrics, 92, 834 - 837.

aw

\ º, sº a

247

Prugh, D. G. (1965). Emotional aspects of the hospitalization of

children. In M. F. Shore (Ed.), "Red is the color of hurting" (pp.

17-34). Bethesda, Maryland: National Institutes of Health.

Prugh, D. G., Staub, E. M., Sands, H. H., Kirschbaum, R. M., & Lenihan, E.

A. (1953). A study of the emotional reactions of children and

families to hospitalization and illness. American Journal of

Orthopsychiatry, 23, 70-106.

Rankin, W. W. (1988). Fear and courage. Journal of Pediatric Nursing, 3,

46-47.

Reissland, N. (1983). Cognitive maturity and the experience of fear and

pain in hospital. Social Science Medicine, 17, 1389–1395.

Reynolds, C. R. (1981). Long-term stability of scores on the revised

children's manifest anxiety scale. Perceptual and Motor Skills, 53,

702.

Reynolds, C. R., & Richmond, B. O. (1978). What I think and feel: A

revised measure of children's manifest anxiety. Journal of Abnormal

Child Psychology, 6, 271-280.

Rich, J. (1968). Interviewing children and adolescents. London:

Macmillan.

Ritchie, J. A., Caty, S. & Ellerton, M. L. (1984). Concerns of acutely

ill, chronically ill, and healthy preschool children. Research in

Nursing and Health, 7, 265-274.

Ritchie, J. A., Caty, S., Ellerton, M. L., (1987). Coping in preschool

hospitalized children: Are there differences between chronically ill

and acutely ill children? 1987 International Nursing Research

Conference abstract (pp. 374), American Nurses' Association.

º

* * *'i ( , ,

248

Ritchie, J. A., Caty, S., Ellerton, M. L. (1988). Coping behaviors of

hospitalized preschool children. Maternal-Child Nursing Journal,

17, 153-171.

Ritchie, J. A., Ellerton, M., Caty, S. (1986, May). Children’s coping:

Innovative methods in research design. Paper presented at

International Nursing Research Conference, Edmonton, Alberta.

Roberts, M. C., Wurtele, S. K. , Boone, R. R. (1981). Reduction of

medical fears by use of modeling: A preventive application in a

general population of children. Journal of Pediatric Psychology, 6.

293-300.

Robertson, J. (1970). Young children in hospital. 2nd ed. London:

Tavistock.

Rose, M. H. (1972a) The effects of hospitalization on the coping

behaviors of children. Unpublished doctoral dissertation, The

University of Chicago, Chicago, Illinois.

Rose, M. H., (1972b). The effects of hospitalization on the coping

behaviors of children. In M. V. Batey (Ed.), Communicating nursing

research: The many sources of nursing knowledge: Vol. 5 (Pp. 115

126). Boulder, Colorado : WICHE.

Ross, D. M. (1984). Thought-stopping: A coping strategy for impending

feared events. Issues in Comprehensive Pediatric Nursing, 7, 83-89.

Ross, D. M., & Ross, S. A. (1988). Childhood pain: Current issues,

research, and management. Baltimore : Urban & Schwarzenberg.

Rothbaum, R., Wolfer, J., Visintainer, M., (1979). Coping behavior and

locus of control in children. Journal of Personality, 47, 118-135.* --- ?

249

Ryan, N. M., (1989). Stress-coping strategies identified from school age

children's perspective. Research in Nursing and Health, 12, 111

122.

Sarason, S. B., Davidson, K. S., Lighthall, F. F. Waite, R. R. & Ruebush,

B. K., (1960). Anxiety in elementary school children. New York:

Wiley.

Sattler, J. M. (1988). Assessment of children (3rd ed.). San Diego:

Jerome M. Sattler, Pub.

Savedra, M., & Tesler, M. (1981). Coping strategies of hospitalized

school-age children. Western Journal of Nursing Research, 3(4),

371-384.

Scherer, M. W., & Nakamura, C. Y. (1968). A fear survey schedule for

children (FSS-FC): A factor analytic comparison with manifest

anxiety (CMAS). Behaviour Research and Therapy, 6, 173-182.

Schuster, C. S., & Ashburn, S. S. (1986). The process of human

development: A holistic life-span approach. Boston: Little, Brown,

and Company.

Schratz, M. (1978). A developmental investigation of sex differences in

spatial (visual-analytic) and mathematical skills in three ethnic

groups. Developmental Psychology, 14, 263-267.

Seligman, M. E. P. (1975). Helplessness. San Francisco: Freeman.

Selye, H. (1980). The stress concept today. In I. L. Kutash, & L. B.

Schlesinger (Eds.), Handbook on stress and anxiety (pp. 127-143).

San Francisco: Jossey-Bass.

Sherer, M. W., & Nakamura, C. Y. (1968). A fear survey schedule for

children (FSS-FC): A factor analytic comparison with manifest

anxiety (CMAS). Behaviour Research and Therapy, 6, 173-182.

º

250

Shore, M. F. (Ed.). (1965). "Red is the color of hurting". Bethesda,

Maryland: National Institutes of Health.

Sides, J. P. (1977). Emotional responses of children to physical illness

and hospitalization. Dissertation Abstract International, 38, 917

B.

Siegel, L. J. (1983). Hospitalization and medical care of children. In

C. E. Walker & M. C. Roberts (Eds.) Handbook of child psychology

(1089-1108). New York: John Wiley.

Siegel, L. J., & Smith, K. E. (1989). Children's strategies for coping

with pain. Pediatrician, 16, 110-118.

Siegler, R. S. (1986). Children's thinking. New Jersey: Prentice-Hall.

Sipowicz, R. R., & Vernon, D. T. A. (1965). Psychological responses of

children to hospitalization. American Journal of Diseases of

Children, 109, 228-231.

Sorensen, E. S. (1990). Children's coping responses. Journal of

Pediatric Nursing, 5, 259-267.

Spielberger, C. D. (1973). State-Trait Anxiety Inventory for Children.

Palo Alto, CA: Consulting Psychologists Press.

Spielberger, C. D. (1975). Anxiety: State-trait process. In C. D.

Spielberger & I. G. Sarason (Eds.), Stress and anxiety, Vol. 1, New

York: Wiley.

Spielberger, C. D. (1989). State- trait anxiety inventory: A comprehensive

bibliography (2nd ed. ). Palo Alto, CA: Consulting Psychologists

Press.

Stein, R. (1983). Growing up with a physical difference. Children's

Health Care, 12, 53-61.

-z&

s

º

251

Stein, R. E. K., & Jessop, D. J. (1982). A noncategorical approach to

chronic childhood illness. Public Health Reports, 97, 354-362.

Stein, R. E. K., & Jessop, D. J. (1984) General issues in the care of

children with chronic physical conditions. Pediatric Clinics of

North America, 31, 189-198.

Stein, R. E. K., & Jessop, D. J. (1989). What diagnosis does not tell:

The case for a noncategorical approach to chronic illness in

childhood. Social Science Medicine, 29, 769-778.

Sterling, F. E. (1985). Review of Child Anxiety Scale. In J. V. Mitchell

(Ed.), The ninth mental measurements yearbook: Vol. 1. (PP. 298

300). Lincoln, NE: University of Nebraska Press.

Stewart, C. (1978). A study of coping behaviors of hospitalized children

as affected by environmental factors. Unpublished master's thesis,

University of Washington, Seattle, Washington.

Stevens, M. (1984). Adolescents coping with hospitalization for surgery.

Unpublished doctoral dissertation, University of California, San

Francisco, San Francisco, CA.

Stevens, M. (1986). Adolescents' perception of stressful events during

hospitalization. Journal of Pediatric Nursing, 1, 303-313.

Stevens, M. (1989). Coping strategies of hospitalized adolescents.

Children's Health Care, 18, 163-169.

Stone, G. L. (1985). Review of Assessment of Coping Style. In J. V.

Mitchell (Ed.) The ninth mental measurements yearbook: Vol I (pp.

95-96). Lincoln, NE: The University of Nebraska Press.

Tesler, M., & Savedra, M. (1981). Coping with hospitalization: A study of

school-age children. Pediatric Nursing, 7(2), 35-38.

252

Tesler, M. D., Savedra, M. C., Wilkie, D. J., Holzemer, W. L., Ward, J.

A., & Paul, S. (1989). The word- graphic rating scale as a measure

of children's and adolescents' pain intensity. Manuscript submitted

for publication.

Tesler, M. D., Wegner, C., Savedra, M., Gibbons, P. T., Ward, J. A.

(1981). Coping strategies of children in pain. Issues in

Comprehensive Pediatric Nursing, 5, 351-359.

Thompson, R. H. (1985). Psychosocial research on pediatric

hospitalization and health care. Springfield: Charles C. Thomas.

Thompson, R. H., & Stanford, Gene . (1981). Child life in hospitals.

Springfield: Charles C. Thomas.

Timmerman, R. R. (1983). Preoperative fears of older children. AORN

Journal, 38, 827-834.

Vernon, D. T. A., Foley, J. M., Sipowicz, R. R., & Schulman, J. L. (1965).

The psychological responses of children to hospitalization and

illness : A review of the literature. Springfield: Charles C.

Thomas.

Visintainer, M. (1977). The effects of pre-admission psychological

preparation on children's stress responses and adjustment during and

following hospitalization for minor surgery. Nursing Research

Report, 12(2), 3-5.

Visintainer, M. A., & Wolfer, J. A. (1975). Psychological preparation for

surgical pediatric patient: The effect on children's and parents'

stress responses and adjustment. Pediatrics, 56, 187-202.

Walker, C. L. (1988). Stress and coping in siblings of childhood cancer

patients. Nursing Research, 37, 208-212.

253

Waechter, E. H., Phillips, J., & Holaday, B. (1985). Nursing Care of

Children. Philadelphia: J. B. Lippincott.

Webb, E. T., Campbell, D. T., Schwartz, R. D., Sechrest, L., & Grove, J.

B. (1981). Nonreactive measures in the social sciences, 2nd ed.

Boston: Houghton Mifflin.

Weber, R. P. (1985). Basic content analysis. Beverly Hills: Sage

Publications.

Wertlieb, D., Weigel, C., Feldstein, M. (1987). Measuring children's

coping. American Journal of Orthopsychiatry, 56, 548-560.

Wolfer, J. A. & Visintainer, M. A. (1975). Pediatric surgical patients'

and parents' stress responses and adjustment. Nursing Research, 24.

244-255.

Woods, N. F., & Catanzaro, M. (1988). Nursing research: Theory and

practice. St. Louis: C. V. Mosby.

Wise, F. F. (1986). Development of self-discipline. In C. S. Schuster,

& S.S. Ashburn (Eds.), The process of human development: A holistic

life - span approach (357-379). Boston: Little, Brown.

Yarrow, L. J. (1960). Interviewing children. In P. H. Mussen (Ed.),

Handbook of research methods in child development (561-602). New

York: John Wiley.

Yamamoto, K, & Felsenthal, H. M. (1982). Stressful experiences of

children: Professional judgments. Psychological Reports, 50, 1087

1093.

Youssef, M. M. S. (1981). Self control behaviors of school-age children

who are hospitalized for cardiac diagnostic procedures. Maternal

Child Nursing Journal, 10, 219-284.

254

Yura, H., & Torres, G. (1975). Today's conceptual frameworks within

baccalaureate nursing programs. In Faculty-curriculum development.

Part III. Conceptual framework-- its meaning and function (PP. 17

25). New York: National League for Nursing.

Zarske, J. A. (1985). Review of Assessment of Coping Style. In J. V.

Mitchell (Ed.) The ninth mental measurements yearbook: Vol I (pp.

96-97). Lincoln, NE: The University of Nebraska Press.

Zastowny, T. R., Kirschenbaum, D. S., & Meng. A. L. (1986). Coping skills

training for children: Effects on distress before, during, and after

hospitalization for surgery. Health Psychology, 5, 231-247.

Zeitlin, S. (1980). Assessing coping behavior. American Journal of

Orthopsychiatry, 50, 139-144.

Zeitlin, S. (1985). Coping Inventory: A measure of adaptive behavior.

Bensenville, IL: Scholastic Testing Service.

-*tº~º*

>

AT:

0 ºl

255

APPENDIX A

Human Subjects Committee Approval

University of California, San Francisco

º

CCMMITTEE ON HUMAN RESEARCH 2560. FICE OF RESEARCH AFFAIRS, Box O616UNIVERSITY OF CALIFORNLA, SAN FRANCISCO

TO: Bonnie Holaday, RN, DNS Elizabeth Bossert, RN, MSBox 0606 480 Warren Dr., &430

San Francisco, CA 94131

RE: The Influence of Health Status, Gender, and Anxiety on the Stress and CopingProcess of Hospitalized School Age Children

The UCSF Committee on Human Research (an Institutional Review Board holdingDepartment of Health and Human Services assurance #M-1169) has approved the aboverequest to involve humans as research subjects, with the following

CONDITION: First, because Bonnie Holaday is the Principal Investigator, her name andphone number should be included in the Questions section of the consent form. Second, themembers wished to compliment you on the excellent Child Assent Form. Once these havebeen received, the status of this protocol will automatically be changed from ConditionalApproval to Approval.

.*PPROVAL NUMBER: H1777-05091-01. This number is a UCSF CHR number whichshould be used on all consent forms, correspondence and patient charts.

APPROVAL DATE: November 30, 1989. Expedited Review

LXPIRATION DATE: November 15, 1990. If the project is to continue, it must be renewedby the expiration date. See reverse side for details.

ADVERSE REACTIONS/COMPLICATIONS: All problems having to do with subjectsafety must be reported to the CHR within ten working days.

MODIFICATIONS: All protocol changes involving subjects must have prior CHRapproval.LEGAL NOTICE: The University will defend and indemnify a principal investigator inlegal actions arising from research activities involving humans only if the activities hadcurrent CHR approval.

QUESTIONS: Please contact the office of the Committee on Human Research at(415) 476-1814 or campus mail stop, Box 0616.

\}ood luck on your project.

ChairmanCommittee of Human Research

HEPC Project ºf 89005091

-** * * *

257 º

APPENDIX B

The State-Trait Anxiety Inventory for Children

by C. D. Spielberger

is a copyrighted instrument

for information regarding this tool contact:

Consulting Psychologists Press

3803 East Bayshore Road S.Palo Alto, CA 94.303 *-*

258 º,

APPENDIX C

Hospital Stress Scale

C

259

Code #:

Hospital Stress Scale

Everybody in the hospital has things happen that are upsettingor that bother them. Some children in the hospital get alittle upset and some get very upset.

When you think about everything that has happened to you sinceyou have been in the hospital, how upset has it made you?

On the line below put a mark at the place that shows how upsetyou have been. You may put your mark any place on the line.

| |not little medium large Worst

upset upset upset upset possibleupset

260

APPENDIX D

Hospital Coping Scale

261

Code #:

ospital C cal

When you think about everything you have done to take care ofor manage the upsetting things that happen in the hospital, howmuch has it really helped with the upset?

On the line below put a mark at the place that shows how muchwhat you did or thought really helped you with the upsettingthings.

You may put your mark any place on the line.

l |no little medium large best

help help help help possiblehelp

yº,*~

L; ;

262 º

APPENDIX E

Practice Scale

263

Code #:

actice ale

Everybody likes some classes in school more than other classes.

The scale below is a way of showing how much you like, or don'tlike, some of your classes.

What class do you like best of all?Put a straight mark on the line near the right end of the line toshow how much you like the class.

What class don't you like at all?Put a straight mark on the line near the left end of the line toshow how much you don't like the class.

What is another class you have in school?How much do you like that class? Put a mark on the line to showhow much you like that class. You may put your mark any place onthe line.

|don't like the like the like the like thelike class a class a class class

class little medium a lot best ofat all amount all

264 º

APPENDIX F

Child Medical Fear Scale

265

Listed below are things that children are sometimes afraid of when they aresick or need to go to the hospital. Beside each item please circle whetheryou are: not at all afraid, a little afraid, a lot afraid

1.

2.

10.

11.

12.

13.

14.

15.

16.

17.

I am afraid

I am afraidoffice

I am afraid

I am afraidout of me

I am afraid

I am afraidstuck

I am afraidnot tell meto me

I am afraid

I am afraidI'm sick

I am afraidhurt

I am afraidI'd have to

I am afraid

Child Medical Fear Scale

of hurting myself

of going to the doctor's

of getting a shot

of seeing blood come

of going to the hospital

of having my finger

the doctor and nurse willwhat they are going to do

to throw up

of missing school if

I will cry when I get

if I went to the hospitalstay a long time

my friends/family willcatch something I have if I'm sickand play with them

I am afraid I might die if I goto the hospital

I am afraid of having the doctoror nurse look down my throat

I am afraid the nurse or doctor will

tell me something is wrong with me

I am afraidfamily if I

I am afraid

of being away from mygo to the hospital

of the doctor puttinga tongue blade in my mouth

not

not

not

not

In Ot

not

not

In Ot

not

not

not

not

not

not

not

not

not

at

at

at

at

at

at

at

at

at

at

at

at

at

at

at

at

at

all

all

all

all

all

all

all

all

all

all

all

all

all

all

all

all

all

Code #:

little

little

little

little

little

little

little

little

little

little

little

little

little

little

little

little

little

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

lot

266

APPENDIX G

Coping Response Inventory

267

Code #:O esdo VentO

Listed below are different ways other children your age behave when they are in asituation that they find upsetting or stressful. Read through all the behaviors listedbelow.

Now think about the situation of being in the hospital. What have you done to takecare of the upsetting things that have happened? Beside each of the behaviors below,circle the answer that tells how much that way helped you. If you didn't use that way atall, skip that line.

made it worse no change helpful very helpful

1. I talked to someone else about l 2 3 4

what happened.

2. I tried to ignore it. 1 2 3 4

3. I went away and did something l 2 3 4else with a friend.

4. I went away and did something 1 2 3 4else by myself.

5. I went off by myself but did l 2 3 4did nothing.

6. I was mean to the person that l 2 3 4was bothering me.

7. I hit or messed up something l 2 3 4else. (punch pillow, kick bed)

8. I misbehaved or acted "weird". l 2 3 4

9. I asked for help. 1 2 3 4

10. I tried to do the thing or to l 2 3 4do something about the thing thatwas bothering me.

ll. I worried or got mad but kept l 2 3 4it inside.

12. I cried or yelled. 1 2 3 4

13. I planned what I should do 1 2 3 4the next time.

14. I kept on doing what I was 1 2 3 4already doing.

268

APPENDIX H

Hospital Stress/Coping Interview

º*

:

269

O tal Stress/Copi Inte w Code #

First, I want to talk with you about what it is like to be in the hospital.Remember, there are no right or wrong answers, anything you say is O.K.Would you like to turn the tape recorder on for me?

Code Number

l. (Name), lots of different kinds of things happen in the hospital.What are some of the good things that have happened while you have been in

the hospital?(Anything else?)Those are good answers :

Besides all the good things, everybody in the hospital has somethinghappen that is upsetting or that bothers them.

What kind of upsetting things have happened to you here in the hospital?(Anything else?)

(Suggested probes if needed:Have you had to do something you don't want to do?Have the nurses done anything to help you get well that is upsetting?Have the doctors done anything to help you get well that is upsetting?Is there something that you usually do at home that might not be

allowed in the hospital?)

Those do sound like really upsetting things.

When the upsetting things happen, different kids try to take care of ordeal with them in different ways.

Think real hard and try to remember what it was like whenhappened.

What things did you do or say to yourself to help you deal with7

(Repeat for each upsetting event identified in # 2)

(Suggested probe if needed:When some kids are upset they will try to think about something else, or

ask questions about it, or try to stop it from happening, or asksomeone to help them, or just try to get it over fast. Sometimessomething else might help.

What did you do or say to yourself to help you deal with 2)

Those sound like good ways of trying to deal with the upsetting things.

Is there anything you wish the nurses or doctors would do to help you whenthe upsetting things happen?

Those are good ideas. Thank-you!

Would you like to turn the tape recorder off?

270

APPENDIX I

University of California, San Francisco

Permission for Child to Be a Research Subject

271

Code Number :

UNIVERSITY OF CALIFORNIA, SAN FRANCISCOPERMISSION FOR CHILD TO BE A RESEARCH SUBJECT

A. PURPOSE AND BACKGROUND

Bonnie Holaday, R.N., D. N. S., Associate Professor, and Elizabeth Bossert,R.N., M. S., doctoral candidate, School of Nursing, University of California,San Francisco, are conducting a study of the school age child's stress andcoping during hospitalization. My child is being asked to participate in thisstudy.

B. PROCEDURES

If I agree that my child may be in this study, the following will happen:

1. I will be asked to provide some general information about my child, suchas age, grade, number of previous hospital admissions, and health status.

2. My child will receive a simplified version of this consent form and willbe asked if he/she is willing to be a part of the study. If so,

3. My child will be interviewed about what is stressful duringhospitalization and how he/she copes with the stress. The interview will beaudio tape recorded, and the tape destroyed after the study is completed.

4. My child will also be given three short questionnaires on anxiety,hospital fears, and coping, and two scales on stress and coping.

5. Because children sometimes expect their parents to answer questions forthem, I will be asked to step out of the room while my child answers thequestions. If I want to know what my child said, the answers will be sharedwith me at the end of the session.

These procedures will be done in my child's hospital room or another nearbyquiet room in the hospital. The time needed for the session will be aboutthirty to forty-five minutes.

C. RISKS/DISCOMFORTS

1. During the interview or while filling out the questionnaires, my child maybe reminded of unpleasant events during hospitalization. He/she will be freeto stop answering questions at any time if it becomes too upsetting. If mychild becomes upset, the nurse research will attempt to comfort him/her andwill call me or my child's nurse to further reassure my child.

2. While responding to the interview and questionnaires, it is possible thatmy child may become tired, if so he/she may stop participating at any time.

272

3. All study records will be kept as confidential as is possible. No namesor information that would permit identification of my child by the public willbe given in any report or publications resulting from the study. Studyinformation will be coded by number, not name, and kept in a locked locationat all times. Only study personnel will have access to the files and theaudiotapes. After the study has been completed and all data has beentranscribed from the tapes, the tapes will be permanently erased.

D. BENEFITS

There will be no direct benefit for my child from participation in this study.The anticipated benefit is a better understanding of school age children'sreactions to hospitalization, which may lead to better understanding of how toprovide emotional support for children during hospitalization.

E. ALTERNATIVES

I am free to choose not to allow my child to participate in this study.

F. COSTS

There will be no costs to me as a result of my child taking part in this study

G. REIMBURSEMENT

There will be no financial reimbursement for my child participating in thisstudy. However, with my approval, if my child participates partially or fullyin the study he/she will be offered a small token of appreciation, such as astrip of colorful stickers, costing less than $1.00. I will not tell my childof the possibility of receiving the stickers so that his/her decision toparticipate in the study will not be influenced.

H. QUESTIONS

I have talked to Bonnie Holaday, (415) 476-4663, Elizabeth Bossert, (415) 753 -6215, or , phone number , about this study,and have had my questions answered. If I have any further questions aboutthis study, I may call either person at the numbers provided above.

If I have any questions or comments about my child participating in thisstudy, I should first talk with the investigator. If for some reason, I donot wish to do this, I may contact the Committee on Human Research, which isconcerned with protection of volunteers in research projects. I may reach theCommittee office between 8:00 AM and 5:00 PM, Monday to Friday, by calling(415) 476-1814, or by writing to the Committee on Human Research, Suite 11,Laurel Heights Campus, Box 0616, University of California, San Francisco, CA94143.

273

I. CONSENT

I have been given a copy of this consent form to keep.

PARTICIPATION IN RESEARCH IS VOLUNTARY. I am free to decline permission formy child to be in this study and may withdraw my child from the study at anypoint. My decision as to whether or not to permit my child to participate inthis study will have no influence on the present or future status of myself ormy child as a patient, student, or employee at the University of California,San Francisco, or as a patient or employee of the hospital where my child is apatient.

If I wish for my child to participate, I should sign below.

Date Legally Authorized Representative

Person Obtaining Consent

H1777 - 05091 - 01 11 - 30 - 89

274

APPENDIX J

Experimental Subjects Bill of Rights

UNIVERSITY OF CALIFORNIA, SAN FRANCISCO 275

EXPERIMENTAL SUBJECT'SBILL OF RIGHTS

The rights below are the rights of every person who is asked to be in a researchstudy. As an experimental subject I have the following rights:

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

To be told what the study is trying to find out,

To be told what will happen to me and whether any of the proce.dures, drugs, or devices is different from what would be used instandard practice,

To be told about the frequent and/or important risks, side effectsor discomforts of the things that will happen to me for researchpurposes,

To be told if I can expect any benefit from participating, and, if so,what the benefit might be,

To be told the other choices I have and how they may be better orworse than being in the study,

To be allowed to ask any questions concerning the study both be.fore agreeing to be involved and during the course of the study,

To be told what sort of medical treatment is available if any compli.cations arise,

To refuse to participate at all or to change my mind about partici.pation after the study is started. This decision will not affect myright to receive the care I would receive if I were not in the study.

To receive a copy of the signed and dated consent form,

To be free of pressure when considering whether I wish to agree tobe in the study.

—%—

If I have other questions I should ask the researcher or the research assistant. Inaddition, I may contact the Committee on Human Research, which is concernedwith protection of volunteers in research projects. I may reach the committeeoffice by calling; (415) 476-1814 from 8:00 AM to 5:00 PM, Monday to Friday,or by writing to the Committee on Human Research, University of California, SanFrancisco, CA 94143.

Call X1814 for information on translations.

276

APPENDIX K

General Data Form

277

Code #

GENERAL DATA FORM

Child's gender:

1) Male2) Female

Birth date : Month Day Year

Age:1) 8 years2) 9 years3) 10 years4) 11 years

Child's ethnic group:

1) African American2) Asian3) Hispanic4) White5) Other

Grade in school:

1) First grade2) Second grade3) Third grade4) Fourth grade5) Fifth grade6) Sixth grade7) Seventh grade8) Not enrolled in school

Is your child in a special education classroom?

1) Yes2) No

If yes, has this placement been made because of your child's :

1) physical problems2) learning difficulties3) other

278

10.

11.

12.

Does your child have any chronic health problems?

1) Yes2) No

If yes, what is the condition and when it was first diagnosed?

How many times before this admission has your child been a patient in ahospital?

If your child has been in the hospital before, when was the most recentadmission?

In the last year, about how many times has your child been seen as apatient in a clinic or doctor's office?

Has your child ever attended a program at a hospital designed to helpthem understand the hospital and be less afraid of being a patient?

1) Yes2) No3) Uncertain

While your child has been in the hospital, how many hours a day have youstayed with him/her?

Does your family live in:

1) a rural area (country)2) an urban area (city)?

Approximately, how much was the total income for your family last year,before taxes?

1) less than $ 5,000 6) $ 25,000 to $ 29,9992) $ 5,000 to $ 9,999 7) $ 30,000 to $ 34,9993) $ 10,000 to $ 14,999 8) $ 35,000 to $ 39,9994) $ 15,000 to $ 19,999 9) $ 40,000 and higher5) $ 20,000 to $ 24,999

279

APPENDIX L

Summary of Research Results

280

SUMMARY OF RESEARCH RESULTS

When this research study is completed, do you want a brief summary of theresults sent to you?

1) Yes--please complete the rest of this form2) No -- leave this form blank

If yes, please print your name and address below:

Name

Street Address or P.O. Box

City State Zip Code

281

APPENDIX M

Consent to be a Research Subject

Child Assent Form

282

Code Number:

UNIVERSITY OF CALIFORNIA, SAN FRANCISCO

CONSENT TO BE A RESEARCH SUBJECT

CHILD ASSENT FORM

I have been asked to be part of a project that will find out

what children my age think are the upsetting parts of being in

the hospital and what they do when the upsetting things happen.

This project is being done by Elizabeth Bossert, a nurse at the

School of Nursing, University of California, San Francisco.

All I will need to do is to talk with someone who will ask

me questions about what it is like to be in the hospital and to

answer some written questions. There are no right or wrong

answers to any of the questions. The questions and answers will

be tape recorded. While I am answering the questions my parents

will leave the room for a little while. When they come back, if

they want to know how I answered the questions they will be told.

It will take about thirty to forty-five minutes for me to do

everything in the project.

If I get tired or upset and want to quit answering

questions, I can stop any time I want.

No one except the people doing the study and my parents will

know what I say or write.

Answering these questions will not help me right now while I

am in the hospital, but it may someday help other kids my age.

283

I have had a chance to ask questions and Elizabeth Bossert

Or has answered them for me.

By signing my name below, I am giving my permission to be a

part of the study. I don't have to be in the study if I don't

want to do it. If I decide to be in the study and later change

my mind and want to quit, that is O.K., I can stop anytime I

want. If I do stop, no one will be unhappy with me.

I give my permission to be a part of this study. I will be

given a copy of this form to keep.

(put today's date here) (sign your name here)

(nurses name)

H1777-05091-01 11-3 0-89

-— º ■ ºlº Li B RARY sº L- º Z/~ º ■ º LIBRARY sº----

º,- º --- º, - r- º O- ■ º º –– *o --- º L. º- -

| * *-

^, - + | |& ºvº º 17 º sº a- ■ / º *… " -- " --> ºf vº; G | T ºr s cº- / /*J.- º

- -

--" º, sº * | *- %, sº º, º ºf C.- º - » fºr * -º º, ºr **** * **** 2-1 : ~ º º

-

dº?!/? º/?-

Q.º --- - - - *.N. dº/*. '4, \

- - - : - -º sº cº■ º º

ºº sº, cºyºcº*. º - -- - -->

- * -

º 0) º º º º -- - º ))) º º) ''', *** - sº ■ - º, Li º RARY | || º t * Sº ■ º º, L■ B R A R Y-

(). º — -- º º) c ---º, y r º - º > *-

º r- ºº C,º – sº ~ : * > * - | º - º º, —l & ~1 v. N. ■ ºº L. s

* º'-' ºuti º Tº .." -- s ºvº. 9 in º. º--" º, * 1. s t C

- - º, ~ * º, º... -- , - - -- - - -" -- -

º º gº.) º/º © V, , 7......, * - Cºolº■ MºC 2.5 .- * * * * * ***** - ------ - --- - -- - - -ºf tºº -S ºr-- 4- ... *. * * * º/7º º ºs A- .Nº º, *-

* > º - -- * , *- wº- *.*, * - -º- "…

- º _O)

-- • *. .* ** y) -º- ‘’’,* R Y sº [-r-, *, J/1 sº- lip RARY ºr -º L// -5. Nº ■ º-º-, *º---

sº /- t ■ - *** - f º - )*- r o .* - -- - - -- ~ – - *

- -ºf º, *—

- - : S. 0. - -

_l ~ * *T/C º T. * M ºf J 17 º-

tº- º - C º T s Aºvº; J in- * *

- * *

º_s * …" - º - - º, sº

~. _ * > nº . . . º, sº ~ **, * - **, ºr º º º __

-- º - ----- 1. Cºyº / º \- - -- - ???, ºf ■ º, ". *.* (7.7).

- - -

2 Sººn, ■ º sº %- - -

º º *. º 7 .” (75. º s & º→

º- * - ~ * ,

- - *- L■ B RARY ". O).- º º n L■ tº RARY sº- ”, O■ lº

Q- To |* --Co

** - -

- º-

- *sº

-

->

- o [-r] … r-º-, -º-

* L. ~º | || § i. T º Cº. v. M■ J 17 º º- C - - - C* Q 17 4,-º, º º

-- º

º ~ ! . . . * * * , - - - - - - ->- ! -" -A■ ºº ºs S. -*.*.*, *- * > (1.7% º/ºº *.s .." ºf #1-7/7, -º- º i.

-

º sº % C 17//, .*. ºt () º º- - *- º * <- º / .7/7 ºt () º º

-- - *- * * */ --º- º º º

7 * º º º * - ) jº wº- º º *- - - * "-- n - * -– * ,

~ is T- º, L■ 6 RARY º |-* º, a '' –" sº ■ º º, L■ ■ º RARY sº | º,

-

º —l %) --- sº * - - * º - * - so -r- º |**- & ~ : * > * º L. º - º t º, ■ º º - N. *… L. ** c- y

& A Nºv. M G | T º - Sº - // º' sº A-Tºv M. J . T º -> (■º º, - * ! - - -- **, *

--> * --> *Y.-

...º º 1, Nº

-tº ■ /º (C. z - -\ * * * *- : * ~ * * > tº yº/º *.* º --- ºr ~, --

• *,- *- _º º, º º } it?'t ■ º Al º º, 4- & º, º & 7 *** * * * * *

º * º º *-- * * * O- -S ºr* * Y --- - !” º ( * *

--

º, ...) n 2 º ■ º ”, L. B R A R Y sº -- º, " - sº ■ º º, LIBRARYº sº - * – - ( –

z * , -* - º-

*. […] -> sº - ºr-- ºtº- |- -

f ~ * * r | | ~y - - ºz. L l º r º ~ -- º **/ * - / Sº ºvºi g ■ º, º –– º º■■ % ----' sº ºf a 1-1 %, ºº -- -

º º º º º -->- † - sº- - ~ ". sº -

; , ºr ■ º Q ■ º vº-

12. - º -- w - - - - ^4 º tº 71/11/ º// - º º,gº - * * ~ *- 7 º º tº 7/11/ 7/?' - º .."

". .”: º 1) Q & -" 4– .Nº * * * * º 7.7/7. ■ º t º &-

º º º, *-- - ** - ** &- --

-n sº C.Ole sºº º O) n º º In 15 ºvº Lºº º-' s ■ ºlº tºº Lº […] …

c -----' --C º 0. &

~ º | | ~-s — (C * -- ºg in

- -º ^ º ~ º ºr--ºc º Tº sººn tº L ºy ** º

- *-

º º- * * * - *- º, S. º *** { º ~, º º

- - * -- º, sº dº / º* , CYº! / i■■ i■■ ºt * 2 --~ :-

-

Sº sº 17//, 7.1//cºld sº % -º-, *-* * -- * - \!.- gº !, º º

-º *- º º * *~/

º*z.

*A.

-º* } º ** º o C * +

º L■ ■ º & – ’ o - -> S. º O º- ºl. ! {} RA R_Y º L- º tº ' --> sº T º, L■ ■ º RA R_* º º, / —"* - º —- - so o

º - A- -

º, —r-- º º º ■ º ~ *-

f | ] sº "c T- wººglu º TAC * - sº ºvºgº º * - (C *… 1–1 &~, 1. Sº -* '?... -- º

2- . 12 º' !, N* -s tº ^. Sº■ º ºf Sº, Zºº, º cºlº/” 2s 20-–4 º, Cº■ º sº, ^ "lº “Yº sº. CY.7/7-i■ ºciº- - -

*- - º- -º - .** º - -

º

* – is […] tº B RARY _º [...] *. 2. le s º L■ B RARY sº -- "º-

& º º º * •o ---- sº

ºuri º Lºlº - C º■ lºs ºvºgri º Lºlº - C-> * - -*

-- ~, ■ º º º sº--" - -- º - - -

º º }//?! / º º º- - -

º, º º , ºf º -N" -y -

- . -- *-* - * * * º 1. ("Yº, ■ º ºn-

~ *-* - ºf 'V' ºr - - ºr fºr--, -, ---º: § 2, * Jº'■ tº i■ ºut .Nº º A- º 'º, O.7'■ ■ º--- *-

- A- ~ -

*Oyn *, ) -* -

O º * ,*.. º º :- Tº ■ º. A nº- * * ** / .* -| º, º' ' --" sº ■ º * L ■ º ºv : R^. º L_ º, * * º * sº ■ º º Li ■ º R_* Qº■ º [ ] sº º _º - - - - - - -- * : ~ * º ...Sº -* - - -7 * - º º-

º, L l º* / Q. vºj J in º. º “Tº ■ º º' -- sº ºvºi gin º. º

- - ~

*** * * * ºgº ºf '''''', e.

// º I º, w

* * -- º, º-

º tº /■ º o os -\

*_*

_y sº […]” Li B RA R_Y sº L_ º , V/ 4– º […] ”, L! B RA R_Y s' L– º, º

º-

*o sº C. •o ~ *-

|ºv’■ gº º, L– sº ~/C *-s ºvºgº º LC s - C -

ºf, ºr º º, sº-ºut■ º 5 * *

*º, sº º/* 5 °2's Sººncº

- - , Sº, 17//, nºnci■ co * 64*

sº *, 77/7-incºro-

sº "… º () cº, Ole sº tierº sº. On sº tie Rºss' s

º, * - _º […] 4- L. °o. 4. * T- J -|*

ºx C c ~&w so , -

[…] sº ºvº gº * -- cº

*

º

.** *

sº […] –-

~ * * rº

% CT s ºvº an º-'º [[C *, 's (º - ~ --- * º 72 S

12 Nº º 42, sº º, Nº nº 91 º' ■ ■ º 12 S-" ºf ~ 71/?? / / / /* º

º * -- ºf . Cºl/?'—■ ■ (2/??(J- -

tº sº, anyºl, º/?Sº is *. & frºncºco sº ºº

sº º º** cº º

- º º * * *-

c O º, º ** -tº sº I jº, Ole s -- tº Luº O■ lº st- tº*- -C - * *

_2 º […] & T o, | __ -> º, […] sº º |s - (C %2 -a- sº Jºvºi g in º, º “I■ C ”, –– º Aºvº g : T *,º,

z º º, S.-

-> '4. se 4./... .º. º * ~,º º ºr a * ºff 2 * 7. - * º 0.0 putº■ º

*cºncººr &, cºin '■ º º & cº ºf Cºco sº &

~

\*~ cº º n ºlº tºº sº º 0/] sºº < º, º, º - & ºº, tº Lº 07 s Tºº, "ºº" […]” . s’ ■,” I sº * [Tº sº. […] sº º, [T] sº,

1-1 % º sº % - sº ºvºi gin º. º (C * -- s ºr* - *... sº * >º

* a *. º dº? !/?? Z/º Q 2.S. C■ .- -: *- º dº 1/

! C ºnciº -S º* *- sº (7//7.1/■ ci■■ o SS º

* **, sº º * * º & a'

- sº º, L16 RARY sº —r- º, O/ le .* T- º, L■ B RARY sº [T º, * ,º L. CA --- *o L.

7, ºf -> 74, sº-

12 N. 2. Nº 2 -º *

* , º/” O % . - - - - - *S ºut■ º cºncº* !S 3 * C■ º it/?c■ . To sº °, sº º, & 777/7c, ■ co*

! *-

-~ º * 1. 0) º, O *

º º, () *- ar +, º Sº

º, 0) sº º, L. BRARY is ■ ºlº, , /2 s ■ ºlº tºc → - w

L. C * 2.*

•º r- &&Lºl * -

() —r- sº […] cº º Qºvariº, Lºls * I■ c º'-'º ºvº an *. L. Jºs - C *-

!sº

O. ■ º-* º --- º 2. [T]

~ -- ~ -f ~, o sº- -

º,* !--- sº ºvº gº º, -- - C - ºgº º2 º º, &

*s ºr ”, sº * ºnº ”, sºº

* - ..)- f * º - * - - - - * : * * * * - /?” * -

C■ .^{(0 is 2, cºyotº º is *. Sºft. 1//c■ . To § 4,

-

Sº sº º, *- º/S 4. p ~ *k, º “º <- {) º

Y sº | º, 4. / le sº […] º, L■ B RARY sº L. J º, O) le º […] ”, L; Gsº Oe T- sº – 29 L. J sº 9. ■ º- sº –– º, |º o

- ºf sº * _j &- -

ºIIC *-- ºgº ºs - C º'-'º ºvugin º.º º, sº ºn ■ ººn ºs' º, sº ºut ■ ºro

C º/rºne (VC)-

3. *: ony, !/?-

7// \- sº cºnciº s % *- º // S.*~ -- %. <-A- º *. A- º

* - C-

sº º c º,-

º"º tº 2- tº tºº ■ º. Oley cy- ---- --- º o c

-

º L., - C | | º o, | sº º | | o”* - -11 * is cº-º/* *2 L_1 | Sº cºvº, c. - %. & * L__j & Cº.

J. ~ L * ,-

r º sºº, º cºC

() c’7, º A º, S- * ~º º, sº FO R REF ERENCE º, sº* * * % º dº

*sº, •)º, * * 17///7-incºco sº º

* **, T ~ & 4, ºf "º5 s ■ º L■ B s […] °, L18 RARY sº —r-

º,* .

&--

a OM THE ROOM-

Vo --- S- - º -z ■º

- -º | NOT TO BE TAKEN FR ****o *z, L. J sº º

*ºuri º º ºgº º- ºC º,º % car. Ma. as ovº

-~7. sº º - - -

* ºf 77.1 / / /* - a º, S 757.01/11/ / ///#! 2 - C■ . --~~~~~■ º jº 1/?? / º s' * c).7/■ . 7-incºco º & () nº !/?º sº * 11/7, 11/7( ■ º º*S* * f. * -

%. º 9. -*

o / º º º ■ º Dyn * -- ", Lip RARY sº º º, Li P RARY S –– º cº'' 4–2 Nº […] º ~~~ 1 º' ■A- ** […] o Cº 'o. º ~ • X * l>

-Vo rº- &

* (C * [I] ºvº G 11 %. | || º c-

* º-- T - -

"e […] sº –– 'o -- r-

&-Yº- -

º *

% -- sº ºvº■ q ■ º * -- ~ *y A. -º, s-- -

!-- ~~- -

* → ºf ■ ºvo 2.S. -C.º, 2

º, º ~- -… ** dº ■ ºno ºs C.