Ostomy surgery has been performed since the 170Os and an estimated 70,000 to 100,000 ostomy operations are performed annually in the United States (United Ostomy Association, 1996). Cancer and ulcerative colitis are the most common reasons for surgery resulting in a permanent ostomy (American Cancer Society, 19,98; Manworren, 1996; Shipes, 1987). Regardless of the reason, the individual with an ostomy faces many challenges. Major lifestyle changes include both physical and psychological adjustments (e.g., changes in body image, changes in serf-concept, and the Stressors associated with colostomy functioning and care) (Trunnell, G996).
Psychological Stressors refer to those dealing with the illness itself, the hospital expenence, and reactions of others (Shipes, 1987). Some individuals feel less sexually attractive because of the ostomy (Bell, 1989; MacArthur, 19%; Roberts, 1997; Salter, 1992). Selfrespect and interpersonal relationships are affected as the individual tries to regain t control of bowel function (Roberts, 1997). Also, the-ostomy'site and equipment have been a concern for individuals with ostomies. Therefore, they seek ways to cope in their own personal manner (Klopp, 1990 Walsh, Grunert, Telford, &*Ottefson, 1995).
Despite varjous improvements in medical and surgical management of an ostomy (Ball, 2T?f), a deficit still remains in meeting the psychosocial needs of those individuals and their families related to the particular stressor» involved with coping with an ostomy (Roberts, 1997; Stupes', 1987). This "can be especially important in older ,adults because the stress of living with an ostomy may lead to additional psychological problems, such as anxiety, depression, loss of control, and uncertainty (Northouse, Schafer, Tipton, & Mrtivier, 1999; Righter, 1995). Also, the oider adult may be already coping with other existing medical problems, such as diabetes or hypertension (Kühn & Flaherty,.199Q).
Many individuals with an ostomy copç well when they have been given the appropriate information about medical care (Pieper & Mikols, 1996). However, certain problems, such as stoma management, sexual dysfunction, and social isolation, may be avoided by early intervention and prevention of psychological distress (Hurny & Holland, 1985; Pieper & Mikols, 1996). Therefore, through the identification of an individual's coping style and implementation of nursing interventions, nurses · can assist with stress reduction and promote use of effective coping mechanisms (Novell, 1991; Ramer, 1992).
If individuals use their own coping styles, then they will be able to more effectively handle any Stressors encountered. This can be conducted pre- ' and postoperatively through counseling regarding the surgical procedure, acute care, diet, and other long-term follow-up care needs. Nurses with specialty training, such as an enterstomal therapist (ET),. can provide education and promote stress management techniques to emphasize effective coping skills and help to identify ineffective, coping mechanisms (Pieper, Mikols, & Dawson-Grant, 1996). Also, the ET nurse can assist other nurses in caring for ostorny patients by sharing their expertise in the field.
Lazarus andFolkman's (1984) theory on stress and coping served as the framework to guide this study. In this model, stress is described as a relationship between trie characteristics of the individual and the nature of the environment in which one interacts. The individual's response to a Stressor, such as an ostomy,* is mediated by an appraisal of the Stressor and the ability to cope with it. ??e individual attempts to overcome* any situaficn perceived as a threat, challenge or frustration, such as dealing with the psyhological aspects of having an ostomy
Furthermore, this theory states that the way an individual copes is somewhat determined by resources (e.g., hcalth status, personal beliefs, social and family support, various health care providers). In this study the researchers were particularly interested in how older individuals coped with the stress of living witji an ostomy. Stress reduction as a result of coping affects the individual's quality of life because coping assists in managing emotions, maintaining self-esteem, and enhancing a positive attitude:
Throughout the years, various information related to the physiological and psychological adjustments of individuals with an ostomy across a life ' span has been reported in the literature (Dyk & Sutherland, 1956; Klopp, 1990; Manworren, 1 996; Piwonka & Merino, 1999; Shipes, 1987). However,., flo recent studies are provided specifically targeting older adults' styles of coping with having an ostomy. Most studies reported a range of ages. Therefore, the researchers identified a need to explore coping styles of adults age 50 and older to get their perspective of living with an ostomy for at least 6 months.
Klopp (1990) explored the perceptions of body image in patients with a conventional stoma, compared with those who had a conventional stoma followed by a continent pouch. The outcome of this study reflected the problems faced by patients undergoing stoma surgery; that is, patients with a stoma, on the whole, expressed difficulties in dealing with an ostomy with perceived negative feelings of body image.
Jones (1987) explored social support and coping related to adaptation among 26 people who belonged to selfhelp ostomy groups for several years. The study suggested that support was at least partly responsible for a person's adjustment of an ostomy. Participants with good support had significantly higher quality of life scores than participants with poor support. The results supported the usefulness of assessing social networks and identifying coping styles. Additionally, results revealed no significant correlations between the type of ostomy and coping.
Previous research consistently identifies body image and self -concept as important concepts when impacting ostomy surgery (Trunnell, 1996; Walsh et al., 1995). An individual's ability to cope with an altered physical appearance seems to be related to levels of social support and coping styles (Jones, 1987; Piwonka & Merino, 1999; Righter, 1995). Although it has been speculated that an individual's coping style may influence body image, no studies directly addressing this concept have been found.
Kinash, Fischer, Lukíe, and Carr (1993) used an ex post facto design to study body image and self-concept among 152 individuals with stomas. The relationship between variables and length of time since surgery were studied. Results indicated that length of time since surgery did not relate to body image or self-concept, but the relationship between body image and self -concept was consistently positively correlated. Individuals with ileostomies were found to have better self-concepts than those with colostomies. Jenks, Morin, and Tomaselli (1997) investigated changes in body image prospectively after ostomy surgery and found that body image changes were statistically significant during time.
Various case studies have been performed to explore and identify selfperceptions and coping mechanisms of having an ostomy (Jones, 1987; Walsh et al., 1995; Manworren, 1996). Results revealed these participants relied heavily on social and family support to cope with the Stressors of having an ostomy.
Kinash et al. (1993) examined the coping styles, personality, and mood characteristics of 150 nonhospitalízed older adults with inflammatory bowel disease using a descriptive study design. The Jalowiec Coping Scale QCS) Qalowiec, 1991) was used to address classes of coping styles used by the participants. Results showed that problem-oriented styles were used more frequently than affective-oriented styles. Implications for nurses included assessment of coping capacity and coping patterns when planning care. This assessment data would enable nurses to build on identified strengths that patients already possess.
Halstead and Fernsler (1994) conducted a descriptive study of coping styles of long-term cancer survivors using the revised JCS (Jalowiec, 1987). This allowed the investigator to list the stressful situation with which the investigator is interested. The convenience sample consisted of 59 participants, mostly older adults, who completed the revised JCS (Jalowiec, 1987). Participants chose coping styles that were optimistic and confrontive in nature and used support systems to modify the stress of cancer survival. Effective coping was viewed by the participants as methods that increased hope, did something to alleviate the problem, restored equilibrium, and used available support systems. The findings indicated that chosen coping styles were often highly effective in reducing the stress of cancer survival.
Because coping is a changing process, an individual may cope differently at various times and with changing situation, such as with time (Rheaume & Gooding, 1991). The researchers specifically wanted to explore differences in coping styles of older adults and, therefore, two research questions were posed:
* What are the differences in coping styles among older adults with ostomies?
* Is there a difference between gender and ostomy type in older adults with ostomies?
Design and Sample
An exploratory descriptive design was used for this study to identify the coping styles used by older adults with an ostomy and their perception of helpfulness of these styles for dealing with the ostomy. In addition, differences in gender and type of ostomy were explored.
The researchers obtained a list of 65 potential participants registered through a local ostomy association to recruit and locate eligible participants. A convenience sample of 30 participants was used for this study. Criteria for individuals eligible to participate included age 50 or older; able to read and speak English; and having had a colostomy, ileostomy, or urostomy for a period of at least 6 months.
A demographic data form developed by the researchers collected data regarding gender, age, race, marital status, years of education, reason for ostomy surgery, type of ostomy, and length of time since surgery. The revised JCS (Jalowiec, 1987) is used to either assess general coping behavior or situation-specific coping. The questionnaire consists of 60 coping methods, which were selected on the basis of review of the literature on stress, coping, and adaptation. Degree of use of the coping methods is rated from "O" (never used), to "3" (often used). Helpfulness of the coping method used is rated from "O" (not helpful), to "3" (very helpful). Each Ítem is classified into one of eight coping styles: confrontive, evasive, optimistic, fatalistic, emotive, palliative, supportant, and self-reliant. These classification categories were designed by Jalowiec (1987) as she developed the instrument and were derived from literature on coping, stress, and adaptation.
Two main types of scores can be derived from the revised JCS (Jalowiec, 1987): the Use score and Effectiveness score. These scores can be obtained for each of the eight coping styles and also for the overall scale. Jalowiec (1991) summarizes psychometrics from 12 studies and found Cronbach alphas ranging from 0.64 to 0.97 for total Use (M = 0.86), and from 0.84 to 0.96 for total Effectiveness (M = 0.90). An empirical construct validity study was performed on the revised JCS QaIowiec, 1987). It found that the mean percent agreement between the author and an expert was highest for classifying the supportant (94%), confrontive (86%), and evasive (85%) items. The lowest percents of agreement were found on the fatalistic (67%), self-reliant (66%), and emotive items (54%).
Internal consistency reliability for the revised JCS (Jalowiec, 1987) using Cronbach's alpha coefficient was .88 for the total scale, .94 for total Use and .93 for total Effectiveness. Test-retest reliability was conducted by correlating results at study entry and 3 months later. All correlations were significant at p < 0.002, thereby supporting stability of the tool.
Eligible members of the association who met the criteria were given a packet including a cover letter, consent form, demographic data form, and the JCS questionnaire. Participants were asked to complete the questionnaires in their homes. It required approximately 20 minutes. A self-addressed, stamped envelope was provided for the participant to return the completed consent form and questionnaires. Packets were numbered for the purpose of matching the demographic data with the questionnaire. Human rights protocols, including confidentiality, were adhered to throughout the study. Thirty questionnaires were returned and three were eliminated because of incomplete information, resulting in data analysis on 27 older aduhs (14 men and 13 women).
DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS*
Descriptive and inferential statistics were used to report the results of the study. Frequencies, percentages, mean, and standard deviation of selected demographic characteristics were calculated to describe the participants. The use of specific coping styles and their helpfulness were identified by determination of the mean and mode responses on the revised JCS (Jalowiec, 1987). The authors used t tests to identify if a statistically significant difference existed for gender among participants with ostomies. An analysis of variance (ANOVA) was conducted to determine if there were differences in coping in participants with different types of ostomies.
Demographic characteristics are shown in Table 1. Frequencies and percentages were used to calculate differences in gender, marital status, race, education level, reason for surgery, time since surgery, and ostomy type. Mean and standard deviation were used to measure differences in ages of the participants. Ages ranged from 50 to 84 years and most participants had a colostomy for at least 1 year.
* TABLE 2
DIFFERENCES IN COPING STYLES IN MEN (n = 14) AND WOMEN (n = 13)
Mean, standard deviation, and t tests were used to measure the differences in coping among men and women as illustrated in Table 2. Data analysis revealed that there were no statistically significant differences in coping styles reported by men and women (p < .05).
An ANOVA was used to determine if a relationship existed between the type of ostomy and the reported coping. Because of the small sample size of urostomy participants, the ANOVA was conducted with ostomy and ileostomy participants. Table 3 demonstrates there were no statistically significant differences in coping styles used based on the type of ostomy for either the coping Use (f - 0.360, p <.555) or the Effectiveness (f = 0.014, p <.907) groups. Results revealed that participants with a colostomy used the same coping styles as those with an ileostomy.
This study used a relatively small convenience sample. The researchers' inability to generalize to participants who did not fit into a similar demographic profile, such as individuals younger than age 50, different ethnic backgrounds, and those who were not married, may have limited the findings. Also, the aging process does not seem to be a variable when it comes to coping with an ostomy.
A demographic profile of the participants revealed the typical respondent in this study was age 64, White, married, and had a colostomy for treatment of cancer for at least 6 months. Gender of the participants was almost split at 50%. The results of this study could be generalized to individuals with similar demographics. However, it would be speculative to assume these results would be similar in participants who do not fit this demographic profile.
Previous studies of ostomy patients (Follick, Smith, & Turk, 1984; Jenks et al., 1997; Klopp, 1990; Northouse et al., 1999; Ramer, 1992; Rheaume & Gooding, 1991) included participants who were typically older than age 60, men, married, and had a colostomy for treatment of cancer. Thus, the demographic profile of participants in the current study is similar to previous study profiles.
Participants chose coping styles that were optimistic and self-reliant in nature and reported they were effective. Evasive and emotive strategies, such as "wished that the problem would go away" and "getting mad and letting off steam," were not perceived as effective means of coping with the problems associated with an ostomy. This finding may be because evasive and emotive styles do nothing to alter the problem.
Effective coping was viewed by the participants as a strategy that "increased hope," "did something about the problem," and "improved the person's ability to handle the problem." These findings suggest individuals with ostomies and similar demographic profiles might use coping styles that are optimistic and self-reliant and perceive these styles as effective for dealing with ostomy Stressors.
Halstead and Fernsler (1994) investigated coping styles of long-term cancer survivors and reported that the optimistic style was used most frequently by the respondents and was effective in dealing with cancer. Rheaume and Gooding (1991) studied coping styles among patients with ostomies and reported that optimistic strategies, such as "try [ing] to maintain some control over the situation" and "thinkfing] through different ways of solving the problem" were used most frequently by participants. Thus, the perceived coping styles of participants in the current study are consistent with reported coping styles of patients with ostomies and cancer in previous studies.
In this sample, a supportive strategy of faith was identified as often useful and very helpful by 74.1% of the participants. Spiritual coping was used frequently and identified as very helpful by the study participants. Halstead and Fernsler (1994) reported that cancer survivors used this same style often and reported it was very helpful. Therefore, it could be generalized that use of this support style would be helpful to individuals with an ostomy who have spiritual beliefs.
The findings in this study support Lazarus and Folfcman's Theory of Stress and Coping (1984). The theory postulates that either a problemfocused or an emotion-focused coping style is used by an individual after appraisal of a situation. Through the process of coping, the individual attempts to overcome perceived threats, challenges, or frustration. The results of this study indicated that chosen coping strategies were often highly effective in reducing the stress of having an ostomy. The way an individual coped (in this case, in an optimistic and self-reliant manner) resulted in stress reduction of living with an ostomy. As a result, the individual seemed to perceive a positive outlook about the situation.
This study found no difference in gender and coping styles used by older adults with an ostomy. This is consistent with findings reported by Rheaume and Gooding (1991) who found no significant correlation between gender and type of coping in older adults. Lazarus and Folkman's (1984) theory makes no theoretical assertions regarding gender specific coping. It could be generalized that men and women use similar coping styles when dealing with the Stressors of having an ostomy.
Abo, results showed no difference in coping styles used by older adults with different types of ostomies. Participants with colostomy and ileostomy used similar coping strategies. These findings are consistent with those of Rheaume and Gooding (1991) who found no significant correlation between type of ostomy and use of coping. Thus, it could be generalized that individuals with different types of ostomies use similar styles of coping.
ANALYSIS OF VARIANCE (ANOVA)OF TYPE OF OSTOMY AND COPING STYLE USE AND EFFECTIVENESS (M = 24)
Based on the results of this study, recommendations for future research indicate a need to use multiple sites to obtain a larger sample size, varied ages, and more diverse ethnic backgrounds. This would enhance the statistical results related to demographic data.
Further investigation into specific feelings and moods (e.g., depression) may result in valuable findings related to coping behaviors, especially in the older adult. Although the questionnaire in the current study did not request this information, five participants commented that they experienced depression after their ostomy surgery.
Studies examining the use of spirituality to assist with coping in individuals with ostomies are recommended. In this study, 74% of the participants reported that the supportant strategy of spirituality was very helpful. A study addressing spiritual needs could yield useful results for nursing education and practice.
The results of this study have implications for all nurses who care for older adults with ostomies on a regular basis. Nursing assessment of the individual preoperatively should include identification of fears, concerns, and Stressors involved with having an ostomy. Nurses should assess and identify any existing problems of the older adult, such as chronic illness or sensory deficits, before teaching and counseling. Additionally, an assessment of the individual's usual coping style would assist the nurse in encouraging the use of these styles after surgery.
Nurses can also teach and reinforce the use of coping styles that are useful for others, such as positive thinking, maintaining a normal routine, and not allowing the problem interfere with routines. Nurses can provide education on disease .management, assist with identification of ineffective coping mechanisms, and promote effective coping skills and stress management techniques. Also, nurses can provide follow-up related to community resources for the individual and significant others.
Participants in this study included in their written comments that the ET nurse played an important role in their recovery of ostomy surgery. Because of specialty training, ET nurses can provide long-term support through teaching, counseling, and problemsolving. These nurses serve as a resource after a patient's discharge from the hospital and can enhance the patient's recovery and reassure them that support is available. The ET nurses can communicate their observations of ostomy patient needs to administrators, legislators, and others who control allocation of resources.
Every day, people encounter Stressors that challenge them to use some type of coping. Individuals who undergo ostomy surgery are faced with Stressors that will most likely remain with them for the rest of their lives. Overall, nurses can assist these individuals with their physical healing and are in an ideal position to assist with their psychological healing, as well. By using effective coping, the individual will return to some level of normalcy and be able to encourage others who are in similar situations.
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DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS*
* TABLE 2
DIFFERENCES IN COPING STYLES IN MEN (n = 14) AND WOMEN (n = 13)
ANALYSIS OF VARIANCE (ANOVA)OF TYPE OF OSTOMY AND COPING STYLE USE AND EFFECTIVENESS (M = 24)