A DESCRIPTIVE STUDY TO ASSESS THE STRESS LEVELS

AND COPING METHODS OF PARENTS OF CHILDREN

UNDERGOING CARDIO-THORACIC SURGERY AT
NARAYANA HRUDHAYALAYA,BANGALORE,
KARNATAKA.


by


RANI ELSA OOMMEN


Dissertation Submitted to the
Rajiv Gandhi University Of Health Sciences, Karnataka, Bangalore

In partial fulfillment
of the requirements for the degree of


Master of Science in Nursing

in


Child Health Nursing


Under the guidance of
Associate Professor. Cinobi John


Department of Child Health Nursing
The Oxford College of Nursing
Bangalore


June 2005




I




RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled A Descriptive study to assess
the stress levels and coping methods of parents of children undergoing cardio-
thoracic surgery at Narayana Hrudhayalaya,Bangalore,Karnataka is a bonafide
and genuine research work carried out by me under the guidance of Associate Prof.
Cinobi John (Department of Child Health Nursing).


Date: Signature of the candidate

Place: RANI ELSA OOMMEN














II







CERTIFICATE BY THE GUIDE

This is to certify that the dissertation/thesis entitled A descriptive study to assess
the stress levels and coping methods of parents of children undergoing cardio
thoracic surgery at Narayana Hrudhayalaya, Bangalore, Karnataka is a
bonafide research work done by RANI ELSA OOMMEN in partial fulfillment of the
requirement for the degree of Master of Science in Nursing in Child Health
Nursing.
Date: Signature of the Guide


Place: Mrs.Cinobi John
Associate Professor
Dept. of Child Health Nursing














III




ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE
INSTITUTION

This is to certify that the dissertation/thesis entitled A descriptive study to assess
the stress level and coping methods of parents of children undergoing cardio
thoracic surgery at Narayana Hrudhayalaya, Bangalore, Karnataka. is a
bonafide research work done by RANI ELSA OOMMEN under the guidance of
Asst.Prof. Cinobi John (Department of Child Health Nursing).


Seal & Signature of the HOD Seal & Signature of the Principal

Ms.Lakshmi Priya G.M Prof. M.C. Belliappa


Date: Date:

Place: Place:











IV


COPY RIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall
have the rights to preserve, use and disseminate this dissertation / thesis in print or
electronic format for academic / research purpose.

Date: Signature of the candidate


Place: RANI ELSA OOMMEN


Rajiv Gandhi University of Health Sciences, Karnataka.









V



Acknowledgement
An effort of this academic pursuit would not have been a reality for me but for the
constructive and purposeful support, guidance and encouragement rendered by a
number of persons whose help I specially recognize through this acknowledgement.
While my words are few, my appreciations are unmeasured, for the wisdom I realized
and learning I experienced is second to none.
First of all I sincerely thank GOD ALMIGHTY for showering his blessings,
and giving me the strength and courage to overcome difficulties for having helped me
to complete the study successfully.
The present study could never have been successfully completed without the
expert guidance of research supervisors. I acknowledge my deep sense of gratitude to
my research advisor Asst: Professor Cinobi J ohn, St.J ohns College of Nursing,
Bangalore for her patience, valuable guidance, direction and advice given for the
completion of this study and for making my dream come true.
I consider it a great privilege to work under Prof: M.C.Belliappa, Principal of
The Oxford College Of Nursing, Bangalore who spent his valuable time in giving
correction and suggestions for my work. I sincerely acknowledge my gratitude to, sir.
I express my sincere thanks to Dr: B.S.Shakuntala, Professor and HOD of
Community Health Nursing, for her intellectual enlightenment, valuable suggestions
and sustained patience for the successful completion of this study.
I owe a deepest sense of gratitude to Dr: Subbarao, HOD of Pediatrics
St.J ohns Medical College and Research Center,Bangalore,for his constant
encouragement ,support, loving wishes, concern and prayers for the success of this
study.
VI


I acknowledge and thank all my teachers for their support, guidance and
valuable suggestions throughout the study.
My grateful acknowledgement to all the experts who validated the tool, for
their judgement and constructive criticism to make this piece of work beautiful.
My sincere thanks to the administrators of J ayadeva Institute of Cardiology,
Bangalore, Narayana Hrudhayalaya, Bangalore for their administrative permission to
conduct the study.
My special thanks to all the participants who enthusiastically participated in
the study and for being very co-operative and also for adding light to my studies with
their heartfelt expressions.
I am forever indebted to Ms.LakshmiPriya, Lecturer, for her wonderful
inspiration and prayers for the success of this study.
I am grateful to Dr: Ramesh, Ph.d, Statistician, KIDWAI Memorial Institute of
Oncology for his generous help in the analysis of the study.
I express my heartfelt thanks to Mrs.Manju Sharma for her generous help in
editing to make it more presentable.
My sincere thanks to Mr: Mallikarjuna for his sincere efforts, amazing speed,
and fabulous touch in typing the manuscript meticulously.
I also thank the staff of our college library and Rajiv Gandhi University of
Health Sciences, Library staff for providing all the relevant information and books for
the study.
I thank all my friends for their prayers, support and encouragement and help
during my study.

VII


I am indebted to my family members for all that they are to me without whom
I could not have been what I am now.
There was somebody all the time wholeheartedly willing to help to sail
through, to give courage and to boost up in the ups and downs, it was none other than
Mr: Sogy George (My Husband). I extend a very sincere gratitude for always being
there.
We leave behind the past, never to be recaptured, but always to be
remembered, it is so applicable to my son, because he missed his childhood in my
absence. So I sincerely express my gratitude, love and affection, care to my loving
son.
Last but not least my thanks to all my classmates those who helped me for
completion of this project.
Thanks to one and all for the encouragement given.
Mrs. Rani Elsa Oommen










VIII


ABSTRACT
A descriptive study to assess the stress levels and coping methods of
parents of children undergoing cardio- thoracic surgery in Narayana Hrudhayalaya,
Bangalore was under taken as a partial fulfillment of requirement for the Degree of
Master of Science in Nursing at The Oxford College of Nursing, Rajiv Gandhi
University of Health Sciences, Bangalore during the year 2005.
Objectives of the Study:
To assess the stress levels of parents of children undergoing cardio-thoracic
surgery.
To assess the coping methods of parents of children undergoing cardio-
thoracic surgery.
To compare the stress levels and coping methods of parents of children
undergoing cardio-thoracic surgery.
To find an association between the stress levels of parents of children with
demographic variables like age, education, occupation, income, previous
hospitalization of the child, number of children and ordinal position of the
child.
Hypothesis:
There is no significant association between the stress levels and coping
methods used by parents of children undergoing cardio-thoracic surgery.
Research Approach:
A descriptive research approach was used.


IX


Setting:
The study was conducted in the ITU of Narayana Hrudhayalaya Bangalore.
Sample:
The sample of the study consisted of 50 parents of children undergoing cardio-
thoracic surgery.
Tool:
Structured interview schedule was used to collect the data. It consists of 2
sections.
Part I: Demoghraphic variables which include age, education, occupation, income,
number of children, ordinal position of the child and previous hospitalization of the
child.
Part II: Stress questionnaire consists of 48 items and coping questionnaire consists of
29 items. It is measured with the help of modified Likert type scale.
Pilot study:
Pilot study was conducted in J ayadeva Institute of Cardiology of 5 parents of
children undergoing cardio-thoracic surgery on 3/10/2004.Inorder to find out the
feasibility of conducting the study. Both descriptive and inferential statistics were
used to analyze the data. The following conclusions were made from the study
findings.









X


Major findings of the study
Section-1
Age:
Most of the subjects were in the age group of 26-30yrs and minimum number of
subjects (2%) was found in the age group of 41-45yrs.The mean age is 31yrs.
Education (Father):
Maximum numbers of fathers (56%) were Graduates.
Education (Mothers):
With regard of education of mothers 72% were studied above 10nth standard.
Occupation (Fathers):
Majority of the fathers (92%) were doing Non-professional work.
Occupation (Mothers):
Most of the mothers 88% were housewives.
Family income:
With regards to family income 26% were having an income between 5001-
10000.The ranges of income is 5001-25000 and mean of income is 13,988.
Religion (Father):
With regards to religion 48% were belongs to Hindu religion and 36% belongs to
Muslim.
Religion (Mother):
More than half (64%) of the mothers were belongs to Hindu religion and 24%
belongs to Muslim.
Number of Children:
Majority of the parents (46%) got only single child.
XI


Ordinal position of the Child:
Most of the parents (50%) first child is affected.
Previous Hospitalization:
Majority of the children (60%) had previous hospitalization.
Age of the Child:
Majority of the children belongs to the age group of 0-1yr.
Sex:
Most of the children (56%) were boys.
Section-2
Distribution of parents according to their Stress levels.
The present study found that more than half of fathers (64%) had moderate
stress and (24%) had severe stress.
Majority of the mothers (84%) had moderate stress and (12%) had severe
stress.
Area wise analysis of stress among fathers revealed that severe stress in
financial domain (65.5%), followed by environmental (65.1%) and social
stress (64.4%).
Area wise analysis of stress among mothers revealed that severe stress in
financial domain (68%), followed by environmental (67.73%) and social stress
(64.73%).



XII



Section-3
Distribution of parents according to their coping methods.
Majority of the fathers (68%) were used moderate coping and 20% had poor
coping.

More than half of the mothers (68%) were used moderate coping and 12% had
good coping.
Section-4
Relationship between stress and coping methods.
Study found that there is no correlation between stress levels and coping
methods(r =0.064, P >0.05) of fathers of children undergoing cardio-
thoracic surgery.
The present study revealed that there is no relationship between stress
levels and coping methods (r =0.24, P >0.05) of mothers of children
undergoing cardio-thoracic surgery.
Section-5
Association between stress levels and selected demographic variables.
The present study found that stress levels are independent of age, eduacation,
occupation, income, ordinal position of the child, number of children and
previous hospitalization.
Conclusion:
The following conclusions were drawn based on the following;
1. Both the parents are having moderate stress and are using moderate coping
methods. Mothers are coping well than fathers.

XIII


2. There is no significant relationship between stress levels and coping methods.
3. The study did not find any significant association between stress levels and
demographic variables.
4. While comparing the literacy level, it is heartening to note that all the females
were educated, which reveals that India is moving ahead towards
development.




































XIV


TABLE OF CONTENTS
Title Page No
1. Introduction:
2. Objectives
3. Review of literature
4. Methodology
5.Results
6.Discussion
7.Conclusion
8.Summary
9.Bibliography
10.Annexures


























XV


LIST OF TABLES

Sl. No Table Page No
1.


2


3

4

5

6

7

8

9

10

11


12

13

14


15


16

17

18


19



Description of children undergoing cardio thoracic surgery
by age.

Description of children undergoing cardio thoracic surgery
by sex.

Distribution of parents by age group

Distribution of parents by sex

Distribution of parents by family income

Distribution of parents by the number of children

Distribution of parents by ordinal position of the child

Distribution of parents by their educational qualification

Distribution of parents by religion

Distribution of parents by occupation

Distribution of parents by previous hospitalization of the
child

Distribution of Fathers according to their stress level

Distribution of mothers according to their stress level

Area wise categorization of stress level of fathers of
children undergoing cardio thoracic surgery

Area wise categorization of stress level of mothers of
children undergoing cardio thoracic surgery

Distribution of Fathers according to their coping methods

Distribution of mothers according to their coping methods

Relationship between stress level and coping methods of
fathers of children undergoing cardio thoracic surgery

Relationship between stress level and coping methods of
mothers of children undergoing cardio thoracic surgery





20



21



22



23
Association between stress level with selected
demographic variables of fathers of children undergoing
cardio thoracic surgery

Association between stress level with selected
demographic variables of mothers of children undergoing
cardio thoracic surgery

Association between coping methods with selected
demographic variables of fathers of children undergoing
cardio thoracic surgery

Association between coping methods with Demographic
variables of mothers of children undergoing cardio thoracic
surgery.


































XVII


LIST OF FIGURES

Sl. No Figures Page No
1
2
3

4

5

6

7

8


Conceptual framework

Schematic representation of research design

Bar diagram indicating the distribution of children by age

Pie diagram representing the distribution of children by sex

Bar diagram representing the distribution of parents by age

Bar diagram representing the distribution of parents by family
income

Cylinder diagram representing the distribution of parents by
their educational qualification

Cone diagram representing the distribution of parents by
religion

Pie diagram representing the distribution of parents by previous
hospitalization of the child







XVIII




1. INTRODUCTION





The concept of stress is as old as medical history. Hippocrates taught that disease is
not only suffer (pathos) but also toil (ponos), that is the fight of the person to regain
normality. Hanse selye is generally considered as the father of stress research who
introduced the concept of stress in 1936, and further did elaborate work on the
subject
1
.
Selye defined stress as the non-specific response of the body to any demand
regardless of its nature. This response included a series of physiologic reactions that
he labeled as general adaptation syndrome, which as 3 stages Alarm, Resistance and
exhaustion. During the alarm stage, physiological mechanisms in the body are
mobilized so that the person can deal with whatever is threatening homeostasis.
During the resistance stage, the person is adapting to the stressor and is trying to
return to a stage of equilibrium. The stage of exhaustion occurs when the body
stressor is overwhelming in intensity or duration and the person no longer has the
resources to handle the situation
1
.
Stress in human life includes tension, anxiety, worry and pressure. It is an
accepted fact that stress is necessary for life and it can be either beneficial or
detrimental. These effects can be physical, emotional, intellectual, spiritual and
2
Speak tenderly to them. Let there be kindness in your face, in your eyes, in
your smile, in the warmth of your greeting. Always have a cheerful smile.
Dont only give your care, but give your heart as well. Mother Teresa


social. Illness is an added stressful event for a person and a quick resolution of such
stressful situations is sometimes needed to test the possibility of an escalating stress
that could overwhelm a person experiencing it. Understanding the concept of stress is
therefore necessary as it provides a way of understanding a person as a unified being
who responds in totality to a variety of chaos that takes place in daily life
2
.
It is widely acknowledged that chronic illness such as cancer; chronic renal
failure, mental retardation etc can produce stress. One such stressful situation is
children being diagnosed with congenital heart disease. Parents of children
undergoing cardio thoracic surgery are at increased risk for psychological distress
2
.
Lazarus and Folkman defined coping as constantly changing cognitive and
behavioral efforts to manage specific external and internal demands that are appraised
as taxing or exceeding the resources of the person
3
.
Lazarus and Folkman identified 2 types of coping responses as problem
focused and emotion focused. Problem focused coping involves efforts to deal with
the sources of stress whether by changing ones own problem maintaining behaviour
by changing environmental conditions
3
.
Emotion focused coping is aimed at reducing emotional distress and
maintaining a satisfactory internal state for processing information and action
3
.
Any illness severe enough to necessitate admission to a critical care unit is life
threatening and can precipitate severe anxiety within a family system. Due to the
sudden onset of critical illness, anxiety experienced within the family system cannot
be prevented. Fear of death, uncertain outcome, emotional turmoil, financial
concerns, role changes, disruptions of routines and unfamiliar hospital environments
are a few sources of anxiety for the family members.
3


Critical illness is a potential crisis situation for both the patient and his or her
family members. The unexpected hospitalization has a significant impact on family
members. During the admission period families must deal with many stressors
including role changes, financial concerns, uncertain prognosis, isolation from other
family members, dramatic disruption in daily routines and unknown critical care
environments.
Stress is a big problem in our society. In recent years stress and its possible
effect on mental health have become increasingly important in nursing. Moreover
public has become more aware of the potential effects of stress on their lives.
Need for the study:
Overall management of the childs serious illness or disability can place
psychologic and social burdens on the family. Most of the literature on the impact of
chronic childhood illness on families has found on the mother and on the relationship
with the ill child
4
.
Hospitalization involves that parents are in an unfamiliar environment and
their parental role changes. Parents of children with complex or terminal heart
conditions often face agonizing decisions about cardiac transplantation. Nurses and
physicians can best support families in this situation, showing sensitivity to the steps
that parents use to make their decisions
5
.
From the parents perspective, intensive care units are busy and intimidating
places, dominated of sick children, worried staff and family members, advanced
medical technology, bright lights and shrill monitors. Most intensive care units offer
little privacy for families who may be in the midst of a medical crisis, with only their
curtains separating families from each other. Parents are introduced to many
4



unfamiliar staff members where they perceive as holding the childs fate in their
hands. The technical language that staff members use may be confusing and parents
often search the faces of physicians and nurses for clues about how their child is
really doing. Although PICU may be a traumatic environment, it also offers hope to
families, sometimes the last hope. Some parents hold fast to the belief that the
intensive care unit is a place where miracles can happen.
5

Anxiety, sadness, and anger are the predominant emotions that parents
experience, particularly when their child is unstable or has a disease with an
unpredictable course. The severity of illness, uncertainty of prognosis, range of
outcomes, ethical dilemmas and societal expectations for childrens health and well
being converge to make this setting especially stressful
5
.
The experience of being a family member of a patient in CICU is an
experience of uncertainty emotional turmoil and distress. Admission of a child to a
PICU frequently described by parents of children as among the most stressful of all
parenting experiences. The complexity of care given in ICU could provoke additional
stress and new needs its family members
6
.
Gottesfeld identified issues parents faced with the diagnosis of congenital
heart disease: Guilt, fear of loss and fear of the unknown
7
.
Lynda L identified that parental anxiety decreased significantly from pre-
operative to post operative levels but remained high indicating that parents continue to
be emotionally distressed during their childs recovery
8
.


5


Coffman and Levitt identified that hospitalization itself often resulted in
relationship changes, with less contact with friends and relatives who could provide
social and emotional support in coping with the stress.
9

Whyte identified that the diagnosis of a childs chronic illness is a stressful
event for parents
10
.
Cohen said that uncertainty regarding the childs condition and his/her
potential outcomes is a major stress at the time of diagnosis.
11

Mu & Tomlinson identified that parents identify the potential separation from
their child, altered parenting roles and role strain are more stressful
11
.
Hughes and Mc Collum said that being unable to carefor, protect and parent
their child is stressful
12
.
Many chronic illnesses are fraught with exacerbations and deterioration in the
childs functioning or quality of life, which tax parents coping resources. These
exacerbations frequently require hospitalization, increased services and changes in
family life styles. Hospitalizations create stress as they interrupt normal routines and
place increased demands on parents who have to further divide their time between
their normal responsibilities and their hospitalized child. The lack of control and
sense of powerlessness many parents feel when their child is hospitalized
12
.
Uncertainty and fear about the future is a constant worry for parents of
children who are chronically ill. Many parents and their children have to anticipate
major procedures, which offer both hope and doubt for continued survival and come
with great cost and a new set of uncertainties
12
.
The progressive integration and gradual acceptance are needed to facilitate
adaptation. The need for assistance in caring for the affected child is important. The
6


need for more services aimed at psychological problems, peer support, professional
counseling and wishing for more communication with other families merit
attention
13
.
Satisfying parents on going need for information plays a critical role in their
ability to cope with the stressors related to their childs hospitalization. Research
findings indicate that providing information resources confirms and assists parental
coping
13
There is a paucity of literature both in the Western setting as well as in Indian
setting regarding stressors and their coping of parents in the event of hospitalization
of a critically ill child. Most of the research in this area has been done in U.S.A or
Canada. This does not negate the findings, but it is important to acknowledge that
there are some fundamental differences between cultures and health care system of
these countries and those of other countries. In the scenario there is a need to identify
the stressors and coping methods of parents of children undergoing cardio thoracic
surgery in the Indian setting to add to available literature.
The purpose of this study is to identify and compare the stress and coping
methods of the parents with children undergoing cardio thoracic surgery. Identifying
the experiences perceived as most stressful and coping methods used by parents can
help the nurse in anticipating parental needs and formulation of policies and
interventions.
Family centered cares, parental participation in care in children are trends in
Pediatric Nursing, which have been receiving increasing focus. The cardio thoracic
Intensive thoracic Unit of Narayana Hrudhayalaya has started with the aim of
providing holistic quality care to critically ill child. For this, family centered care is
7


the need of the era. If one want to facilitate family centered care the stressors must be
accurately identified and they must be helped to cope-up and this has to be
incorporated in the plan of care for the family and the child. To date, there were no
studies conducted in Narayana Hrudhayalaya, Bangalore that relates to stressors and
coping methods used by parents of children undergoing cardio thoracic surgery. This
endeavour could help the nurses in the development of effective nursing interventions
for parents and children.






























8


2. OBJECTIVES OF THE STUDY
This chapter deals with the statement of the problem, objectives of the study,
operational definitions, assumptions of the study and conceptual framework.
Statement of the Problem:
A descriptive study to assess the stress levels and coping methods of parents
of children undergoing cardio thoracic surgery.
Objectives of the Study:
1. To assess the stress levels of parents of children undergoing cardio thoracic
surgery.
2. To assess the coping method of parents of children undergoing cardio thoracic
surgery.
3. To compare the stress level and coping methods of parents of children
undergoing cardio-thoracic surgery.
4. To find an association between the stress levels of parents of children with
demographic variables like age, sex, education, occupation, Income, previous
hospitalization of the child and ordinal position of the child.
Hypothesis:
Ho: There is no significant association between the stress level and coping
methods used by parents of children undergoing cardio thoracic surgery.
Operational Definitions:
Parents:
Referred to father and mother who stays with the child for more than 3 days.


10


Children:
Referred to children less than 12 years who are admitted in cardiac ICU for
not less than 24 hours and not more than 84 hours.
Stress:
In this study stress is the tension producing factor that have the potential of
weakening the normal lines of defense, which is divided into physical, psychological
and economical.
Coping methods:
In this study coping method means parents ability to deal with the stress
successfully and realistically and willing to choose one of the options towards
problem solving.
Assumptions:
The parents of children admitted in cardiac intensive care unit may undergo
high levels of stress.
Family members may go through a crisis when their children are critically ill
or hospitalized and they try to adapt the situation by using various coping
methods.
Parents perceive that their children are critically ill when the child is
hospitalized in cardio thoracic intensive care unit.
Parents perception of stress may differ according to their age, sex,
educational status, income, previous hospitalization of the child and ordinal
position of the child.


11


Delimitations:
The study is limited only to parents who will be with the critically ill children
during the first 84 hours of admission in cardiac Intensive thoracic unit of Narayana
Hrudhayalaya Hospital in Bangalore.
Conceptual Framework of the Study.
A conceptual framework is a group of concepts and a set of propositions that
spells out the relationships between them. The overall purpose of this conceptual
framework is to make scientific findings meaningful and generalizable
14
.
Polit and Hungler state that a conceptual framework is an interrelation of
concepts or abstractions that are assembled together in some rational scheme by
virtue of their relevance to a common theme. It is a device that helps to stimulate
research and the extension of knowledge by providing both direction and impetus. A
framework may serve as a springboard for scientific advancements
14
.
The conceptual framework of this study was based on Sister Callista Roys
Adaptation Model
14
.
The changing environment stimulates the person to make adaptive responses.
For human beings life is never the same. It is constantly changing and presenting new
challenges. The person has the ability to make new responses to these changing
conditions. As the environment changes, the person has the opportunity to continue to
grow, to develop and to enhance the meaning of life for everyone
15

Each person is a unified biopsychosocial system. Roys Adaptation model
views a person as an adaptive system in constant interaction with an internal and
external environment. The environment is the source of a variety of stimuli that either
threaten or promote the persons unique wholeness. A stimulus is any entity that
12


provokes a response. The persons major task is to maintain integrity in face of these
environmental stimuli
16
.
Roy drawing on the work of Helson categorizes these stimuli as being either
focal, contextual or residual. A focal stimulus is defined as the internal or external
stimuli most immediately challenging the persons adaptation. The focal stimulus is
the phenomenon that attracts ones attention.
16

In the present study, parents of children undergoing cardio thoracic surgery is
conceptualized as an adaptive system has input coming from internal environment
such as age & sex. The external environment such as family income, education,
occupation, religion, ordinal position of the child, previous hospitalization of the child
and childs cardio thoracic surgery.
Along with stimuli the adaptation level of the person acts as input, which is the
range of stimuli to which a person adaptively responds with ordinary effort. The range
of responses is unique to the individual. Each persons adaptation level is constantly
changing aspect, which is modulated by coping mechanisms of that person.
16

Roy categorizes these coping mechanisms into either regulator or cognator
subsystem. Regulator is a subsystem coping mechanism, which responds
automatically through neural, chemical, endocrine processes. Cognator is a subsystem
coping mechanism, which responds through complex process of perception,
information processing, learning & judgement
16

In this study control process i.e., coping mechanisms are oriented to behaviors
which were primarily aimed at solving a problem in handling a stressful situation and
strategies used to manage emotions in stressful situations
16

13


Roy proposes that the behavioral responses of these two subsystems can be
observed in any of the adaptive modes physiological, self concept, role function and
interdependence adaptive modes
16

Where as in present study, parents are presumed to use coping mechanisms in
response to various stressors. The stressors were divided into physiological such as
fatigue, breathing difficulty, nausea, vomiting etc, psychological stressors such as
getting nervous, role reversal with spouse, losing temper over small things, getting
irritated, social stressors such as uncertainty about the treatment, decreased
communication and economic stressors such as decreased income, length of
treatment, cost of treatment etc.
According to Roy output includes adaptive or ineffective responses. Adaptive
responses promote integrity of the person where as ineffective responses to stimuli
leads to disruption of the integrity of the person
16.

Output behaviors demonstrated in the present study are inferred by use of
positive coping mechanisms such as accept situation as it is, talks with the parents
with the same condition, seeks comfort and help from others. And negative coping
mechanisms such as blaming others, started taking alcohol, started smoking, hits on
walls or others etc. However its direct relation to stressor has not been determined in
this study.
Nursing plays a vital role in assisting individuals, sick or well to respond to a
variety of new stressors, move toward optimal well being and improve quality of their
lives through adaptation.


14


3. REVIEW OF LITERATURE

Review of literature refers to an extensive, exhaustive and systematic
examination of publications relevant to the study. It is an essential part of every
research, which helps to support the hypothesis under the study and to critically
analyze the structure and content of the research report
14
.
Review of literature makes the researcher familiar with the existing studies
and provides information, which helps to focus on a particular problem and lays a
foundation upon which the new knowledge can be based
14
.
The scope of review of literature includes obtaining different types of
information available on a particular topic. The literature was reviewed from
published journals, textbooks and MEDLINE to widen the understanding of research
problem and methodology for the study. The reviewed literature is classified under
the following headings.
Review of Literature:
The review of literature in this study is organized as follows:
I. Cardio-thoracic post-operative environment
II. Stress factors of parents
III. Coping methods of parents
I. Cardio-Thoracic Post Operative Environment:-
Children are usually admitted in an intensive care unit when they require
intensive therapy to maintain their physiological homeostatic equilibrium. The
intensive care unit is often a perplexing and frightening environment for critically ill
children and their parents. Major reasons for hospitalization to the cardiac intensive
care unit are Patent ductus Arteriosus, Ventricular septal defect, Atrial septal defect,
17


Tetralogy of fallot. The child is often bombarded with a massive array of sensory
stimuli, the focus of which is primarily to maintain the physiological equilibrium.
Emphasis is on tasks rather than on the person who is critically ill. In such an
environment it is sometimes difficult for staff to provide intensive care and also, to
maintain parent-child relationships
17
.
Field had conducted a study about potentially stressful features of the
intensive care unit environment and found that factors such as continuous high
intensity noise and bright light have generated concern
18
.
Meyer Ellaine had conducted a study about pediatric intensive care:The
parents experience, and found the factors from the parents perspective, intensive care
units are busy and intimidating places, dominated by sick children, worried staff and
family members, advanced medical technology, bright lights and shrill monitors. The
technical language used by the staffs are confusing to the parents
5
.
II. Studies related to stress factors of parents:
Several research articles have described parental stress and needs of family
members or parents of children hospitalized in intensive care unit. Three potential
sources of stress that affect parents of children in intensive care unit as found by
Myles and Carter were personal or family background factor, situational conditions
and environment stimuli
17
.
The stressors in the peadiatric intensive care unit as perceived by 155 mother-
father couples were examined by Riddle et; al. It was found that neither fathers, nor
mothers were highly prone to stress reactions although, the mothers stress levels was
significantly higher than that of the fathers. Altered parent and child relationships

18


was perceived as more stressful than other dimensions of the pediatric intensive care
unit environment
17
.
Guler C conducted a exploratory study on stress factors and coping strategies
of parents with children treated by haemodialysis. The study was conducted in
Istanbul-Turkey by focus group interviews. The sample consists 31 parents. The
results of the study concluded about the common stress factors of parents included
financial and bureaucratic problems, growth and development of ill children, fluid
diet restriction and educational problems of the children, lack of social support and
anxiety about losing their children at any moment
19
.
Chen.Y etal, did an experimental study on comparison of the stress and coping
strategies between the parents of children with Duchenne Muscular Dystrophy and
children with fever. The study was conducted in Southern Taiwan. In this study they
included 31 parents with a Duchenne Muscular Dystrophy children and 30 parents
(Control Group) of a child with fever. The results shown the control group had higher
stress as compared with Duchenne Muscular dystrophy. Health care professionals
need to manage the parents conflict, by providing information and resources and
should support the parents emotional reactions to caring for a child with acute and
chronic illness.
4
Margaret S. et;al did a study about perception of stress, worry and support in
black and white mothers of hospitalized, medically fragile infants. The study was
conducted in a tertiary hospital in U.S.A. They have taken samples of 31 black and 38
white mothers of infants who were hospitalized for a serious life threatening illness.
Data collected by self-report questionnaires. All mothers reported high levels of
stress associated with the appearance of their infants and moderately high stress
19


associated with their altered parental role, moderately high levels of worry about their
infants health problems. Mothers with less education expressed more worry about
their infants than did mothers with more education. There is an increased need to help
mothers during the hospitalization of a critically ill infant.
20
Lynda L. et; al did a study among 60 parents on optimism, anxiety and coping
in parents of children hospitalized for spinal surgery. They administered Life
Orientation Test to assess optimism, Speilbergers State Anxiety Scale and The Ways
of Coping Questionnaire. The findings of the study were parental anxiety decreased
significantly from pre-operative to post-operative levels but remained high indicating
that parents continue to be emotionally distressed during their childs recovery.
Continual assessment of the parents need is necessary for providing reassurance and
support throughout the surgical experience
8
.
Lydia B. et;al did a study on perceived stress factors and coping mechanisms
among 200 mothers of children with sickle cell disease in western Nigeria. The
setting of study was in both public and private hospitals in lbadan-1barapa Health
Zone of Oyo state, Nigeria. They collected data by interview method using an
instrument comprised of stressors. The findings of the study was higher levels of
stress were associated with less educated and older women, as well as non-married
and more than one child with Sickle Cell Disease in the family. The health workers
should pay more attention to the needs of less educated and older mothers in order to
reduce their stress
21
.
Suddaby E.C. et;al did a study on stress and coping among parents of children
awaiting cardiac transplantation. Study was conducted in childrens National Medical
Centre, Washington, DC, U.S.A. The findings of the study were 26 parents of 18
20


children demonstrated a range of stress, 77% scoring at a moderate stress level.
Parents of girls viewed transplant negatively than did boys parents. This study
provides a beginning for assisting families during waiting period
22
.
Uzark K. and J ones K did a study on parenting stress and children with heart
disease. Study was conducted in childrens hospital medical center, U.S.A. This
study was done to find out the parenting stress reported by parents of children older
than 2 years with heart disease. They have used Abidins parenting stress index in
order to find out the stress. Approximately 1 in 5 parents expressed clinically
significant levels of stress. Parenting stress was not related to the severity of the
childs heart disease, family socio-economic status, or time since most recent surgery.
They expressed difficulty with setting limits or discipline of the child with heart
disease. Health care providers should assess parenting stress at each health care visit
to provide appropriate support and anticipatory guidance to families of children with
heart disease
23
.
Yeh CH done a study on Gender differences of parental distress in children
with cancer. The study was conducted in graduate Institute of Nursing Science, Chang
Gung University, Taiwan they have selected 164 couples (Taiwanese fathers and
mothers) whose children were undergoing treatment for cancer were investigated. It
was a comparative study to find out parenting stress, psychological distress,
somatization as well as marital satisfaction between fathers and mothers whose
children had cancer. Result was mothers had higher levels of distress than fathers.
Both fathers and mothers whose children had been diagnosed within the past 2
months reported greater marital dissatisfaction than parents whose children were in
the other treatment groups. The findings of this study indicate the need for a thorough
21


psychiatric consultation for the families at the time of diagnosis of children with
cancer
24
.
Adams RA etal studied about maternal stress in caring for children with
feeding disabilities in Ball state university U.S.A. It was a comparative study to
compare the stress experienced by mothers of children with feeding disorders to the
stress experienced by mothers of children with other childhood disabilities. They
have used open-ended questionnaire and results were analyzed by using analysis of
variance. Results indicate that mothers of children requiring tube feeding experienced
significantly greater stress than mothers of children with disabilities who do not
require tube feedings
25
.
Hallstorm studied about the parents experience of hospitalization in 20 parents
of boys hospitalized for hypospadias repair in pediatric surgery department in
Sweden. In the descriptive study most of the parents felt hospitalization required
great deal of adaptation on their part, which was demanding both physically and
mentally. One of the important anxiety, they felt was encountering of wide variety of
the staff during the hospitalization
26
.
A study conducted by Martison on the experience of the family of children
with chronic illness at home in China by a descriptive survey with both quantitative
and qualitative question interview of 75 families and the children. In the study factors
such as severity of illness, the amount of assistance the child need for daily living, the
impacts of emotional and social need were assessed. In the psychological impact
children addressed issues of childs emotional problems, fears and social problem.
The reported fears included the fear of death, treatment, reoccurrence of illness,
hospitalization, and symptoms of disease
27
.
22


Tideman did a study on anxiety responses of parents during and after the
hospitalization of their 5 to 11 year old in 52 children. Parents anxiety were assessed
by speilbergers State Anxiety inventory. Data was analyzed using correlation and
percentage. Parents showed a decrease in anxiety from the admission to discharge,
where as their anxiety remained fairly constant after the discharge of the child. There
was a positive relationship found between parental anxiety and childrens anxiety.
There was also no relationship found between previous hospitalization of the child,
age and gender of their child
28
.
Youngblut and shiao SY did a study in USA to describe child behaviors and
level of family functioning after discharge from the pediatric intensive care unit. The
study further explored the relationship of family reactions and the childs severity of
illness to child and family outcomes after discharge. An exploratory, repeated
measures design was used. The subjects included were 9 mothers and fathers of
children admitted in pediatric intensive care unit. Result is that pediatric intensive
care unit admission of a child is a stressful event for parents, independent of the
review of the childs illness
29
.
Haines, Perger and Nagy in their study on 71 parents of children in a
technologically intense pediatric intensive care unit, identified the major sources of
stress for parents. They also compared the sources of stress for parents whose
children were intubated with those whose children were not intubated. The findings
showed that parents were most distressed by a) the painful procedures with their
children were subjected to b) by the sights and sounds of the pediatric intensive care
unit and c) by their children reactions to intensive care. Parents of intubated children
were compared with parents of non-intubated children. It showed that painful
23


procedures were a source of greater stress to parents of intubated children whereas the
behaviors of staff and the childrens reactions to the intensive care experiences caused
greater stress to the parents of non-intubated children. Health professionals need to
help parents to adjust to the pediatric intensive care environment by ensuring that
continual discussions and explanations take place throughout the childs stay.
30
Seideman,et al in their study identified and compared the parental perceptions
of children admitted in Neonatal intensive care unit and pediatric intensive care unit
in a South Central State ,USA. The sample consisted of 51 parents whose children had
been in the neonatal intensive care unit or pediatric intensive care unit for at least 3
days. Results indicated that parents in both units experienced the greatest stress from
alteration in their parenting role and in their infants behavior and appearance. When
parents were asked to indicate how stressful staff behavior was, parents of children in
pediatric intensive care unit found assistance with parenting role more helpful than
parents of children in neonatal intensive care unit. Be sensitive to individual needs of
parents when their child is sick.
31
Marcia S did a survey study on parents coping with infants requiring
home cardio respiratory monitoring in Mankato state University, Mankato, MN. The
sample consisted of 20 families whose children had been released from hospital to
home for not less than 1 month. A 19-item semi structured interview schedule was
conducted and the interviews were tape-recorded. The findings of the study is the
greatest percentage (85%) of the parents reported the persistent gravity of the situation
was the most stressful part of caring for their infant at home, (85%) indicated that it
was stressful to try to relax while their infant was in the care of incompetent and non
nurturing home care nurses, 70% said that their own feelings of inadequacy and lack
24


of confidence were a source of stress for them, 55% described social isolation as
stressful and inadequate financial assistance for the infants care was reported by
(20%)
32
.
Heaman conducted a comparative study on perceived stressors and
coping strategies of parents who have children with developmental disabilities. He
has selected 203 parents who were the primary care takers from south central and
south Eastern United States. Results showed that the greatest stressor of mothers
(88.8%) and fathers (85.2%) was the childs future. Other major stressors reported by
mothers were a) having enough money to meet family needs b) feeling worn out,
(78.9%) c) extra demands on their time (76.1%) and d) having money for extra
pleasures (73.3%). Stressors reported by fathers were a) getting out of the house with
spouse without child 78.2% b) the childs health (76.8%) c) having enough time alone
with spouse/partner (75.5%) and d) having enough money to meet family needs
(75.3%)
33
.
III. Studies related to Coping Methods:
Culer C did a exploratory study on 31 parents regarding stress factors and
coping strategies with children undergoing haemodialysis. The study was conducted
in Istanbul -Turkey. Data were collected through semi structured interview guides.
Results of the study were the parents used cry, prayer, self-inspiration, see the good
side of events and share their feelings with their spouse or other parents in order to
cope up with the stresses
19
.
J ih Y did a comparative study of the stress and coping strategies between the
parents of children with Duchenne Muscular Dystrophy and children with fever. The
study was conducted in southern Taiwan by using closed ended questionnaires.
25


Among the 61 subjects only 30 (49.2%) often used coping strategies. Thirty-nine of
subjects (63.9%) used rough information; 38 (62.3%) used emotional expression, 37
(60.7%) often used self-blame, 33 (54.1%) had a high wish fulfilling fantasy and 31
(50.8%) minimized threats
4
.
Rima and Ruth C have done a study on coping strategies of parents facing
child diabetes mellitus in 60 parents. They have conducted a home interview and
administered coping questionnaire. Results showed that both parents used planful
problem solving, exercised positive reappraisal and sought social support. Mothers
used more planful problem solving strategies than fathers
34
.
Lobionda et;al conducted a longitudinal descriptive study to examine the
relationship of family stress, severity of the stressor uncertainty, coping and family
adaptation from pre transplantation to post transplantation of liver. They have
selected 15 mothers whose children were at least 5 years post transplantation. The
findings of the study is, coping demonstrated significant changes over time. Long-
term interventions are required like reinforcement of teaching, as well as assessment
and provision of parental support
35
.
Lee and Chen conducted a longitudinal study on stressors and coping
behaviors of mothers with child receiving open-heart surgery. They have used field
method to collect the data. They have selected 10 subjects by purposive sampling.
The coping behaviors consisted of cognitive behavior, emotional response and
management. The result of the study was there was a significant difference in the
contribution of the stressors and coping at different stages of the treatment process
36
.
Lobiondo done a exploratory study on family adaptation to a childs transplant
pretransplant phase. Study was conducted in university of Texas Houston health
26


science center USA on 29 mothers whose children were being evaluated for a liver
transplant. Result of the study was mothers used very fewer coping skills related to
more unhealthy family adaptation during the pre transplant phase
37
.
Seppanen etal, conducted a study on coping and social support of parents with
a diabetic child. Study was conducted in Mikkeli Institute of vocational education,
Finland. The parental coping process was followed for a 4-week period after the
diagnosis of diabetes. The parents of two girls were selected and the data were
collected by interviewing and observing the parents over four separate periods. They
have used different phases of parental coping such as disbelief, lack of information
and guilt, learning to care, normalization, uncertainty and reorganization. In the
different phases of parental coping, the parents experience of stress, coping strategies
and sense of control varied .The parents should be introduced to the people who had
experienced the same problem
38
.
Lowes and Lyne conducted a study on A normal life style: Parental stress and
coping in childhood diabetes in university hospital of Wales. The parents used the
process of coping in different ways by a variety of interpersonal and environmental
factors. The most commonly used coping strategy is normalization. The parents
should be assisted to cope with the demands of the child with diabetes
39
.
Lynda L et;al conducted a study on optimism, anxiety and coping in parents of
children hospitalized for spinal surgery in Vanderbilt university school of nursing,
Nashville, USA. They have selected 60 parents and administered the Life Orientation
Test to assess Optimism and the Ways of coping questionnaire. The findings of the
study revealed that the positive reappraisal was the most often used emotion focused

27


coping strategy and seeking social support was the most often used problem focused
coping strategy
8
.
Lydia B Olley conducted a survey on perceived stress factors and coping
mechanisms among mothers of children with sickle cell disease in Western Nigeria.
They have selected 200 mothers by non-probability sampling. Acceptance (80%) was
the pre dominant mode of coping, (38%) tried to avoid the problem, 19.5% would
complain and 10% confront it
21
.
It was Lewandowski who first described the coping strategies of parents of
children undergoing open-heart surgery. She described several coping strategies such
as immobilization (delay in parental approach to bed side), visual survey (visually
scanning the environment and orienting self before attending to verbal explanations),
withdrawal (non responsive passive behaviors or actual physical withdrawal from the
bed space), restructuring (focusing on one physical detail or on the care provided),
and intellectualization (dealing with the childs illness on an intellectual level.)
31

Miles and Carter identified five coping strategies perceived as most helpful to
parents of critically ill children. These 5 categories included 1) seeking help or
comfort from others, 2) behaving that the child is getting the best possible care 3)
seeking as much information as possible 4) having hope, 5) being near the child as
much as possible. The use of prayers, asking questions to the staff and talking with
other parents was also mentioned as helpful
40
.
La Montagne and Pawlak in a semi-structured interview with parents of
children admitted in a pediatric intensive care unit identified the pre-dominant
stressor. Using ways of coping questionnaire parents identified coping strategies they
used to cope with that predominant stressor. All parents of children in pediatric
28


intensive care unit used a combination of both problem and emotion focused form of
coping. Seeking social support and positive reappraisal were the two most often used
strategies used by all parents. No significant associations were found between stress
and coping and any of the demographic variables
41
.
Heaman identified coping strategies used by parents having children with
developmental disabilities. The convenience sample of 203 parents/guardians of 103
children receiving services in a variety of settings which included five state area of the
south central and south eastern USA. Majority of mothers reported the following
coping strategies, trying to keep feelings about the problem from interfering with
other things, letting feelings out some how, trying to analyze the problem to
understand it better, concentrating on what to do next and talking to someone about
feelings. Important coping strategies were grouped as seeking social support,
problem solving and positive reappraisal. Problem solving coping strategies were
associated with the educational level and age of parents
33
.
Marcia S did a survey study on parents coping with infants requiring home
cardio respiratory monitoring in Mankato state university, Mankato, MN. The sample
consisted of 20 families whose children had been released from hospital to home for
not less than 1 month. Data collected by a semi structured interview schedule and it
was recorded. The largest percentage of the sample (75%) reported using a problem
focused strategy of vigilance or continual concentration on the infants status to
manage the constant threat of danger. 40% of the sample used a problem solving
approach to manage their infants care. 35% maintained control of their infants care,
45% used emotion-focused coping
32
.

29


Svavarsdotti and McCubbin B conducted a descriptive co relational study to
examine the relationship between care giving demands, family system demands, and
parental coping behavior in 71 families who had an infant diagnosed with a congenital
heart defect. A setting of the study was pediatric cardiology clinics. They reported
that mothers spent the most care giving time attending to their infants physical needs,
and fathers spent the most time attending to infants emotional and developmental
needs. Fathers of younger infants reported higher infant care giving demands and
more helpful coping strategies related to the family, self, and the health care
situation
42
.
Swallow and J acoby did a qualitative study to assess the mothers coping in
chronic childhood illness, the effect of presymptomatic diagnosis of vesico ureteric
reflux. They have selected mothers of 15 children with vesico ureteric reflux
diagnosed pre symptomatically and post symptomatically and did a semi structured in
depth interviews. Findings for both groups fall into 3 discrete phases: the
prediagnostic diagnostic and post diagnostic. The mothers in the post symptomatic
diagnosis group experienced most problems in coping and mothers in the pre
symptomatic group coped well apart from those who themselves had vesico ureteric
reflux. Both the group required improved information provision and support to assist
coping with the sustained uncertainty of the condition
43
.
Seideman,et al in their study identified and compared the parental perceptions
of children admitted in Neonatal intensive care unit and pediatric intensive care unit
in a South Central State ,USA. The sample consisted of 51 parents whose children had
been in the neonatal intensive care unit or pediatric intensive care unit for at least 3
days. The result of the study revealed that the parents of children in pediatric intensive
30


care unit perceived problem-focused coping more helpful than parents of children in
the neonatal intensive care unit. Parents of children in the neonatal intensive care unit
felt emotion-focused coping more helpful than parents of children in the pediatric
intensive care unit. Both groups of parents considered problem-focused coping more
helpful than appraisal or emotion-focused coping
31
.
Kumar, S conducted an exploratory study of stress experience and coping
strategies adopted by the mothers of leukemic children in selected hospitals of
Karnataka. Findings of the study showed that one of the most frequently used coping
behavior was praying to God (94.6%) by the mother and go on pilgrimage worship
and offer offerings (86.5%)
44
.
Conclusion:
The above studies revealed that the children should get the quality care. Tell
parents and show that the child is in the safer hands of the experts. Provide parents
clear, continuos, consistent and honest communication about their childs condition,
plan of care and current status. The parents need to have an explanation for the
changes they see in their childs appearance and behaviours. Encourage parents to do
things that they have done in the past that effectively helped them to cope with
difficult situations.






31


4. RESEARCH METHODOLOGY
This chapter deals with the methodology to assess the stress levels and coping
methods of parents of children undergoing cardio thoracic surgery. It includes
research design, research approach, study setting and sampling technique, data
collection method, development of the tool, description of the tool and data analysis.
Methodology of research organizes all the component of the study in a way
that is most likely to lead to valid answer to the sub problems that have been posed
45
.
In this study it refers to the various logical steps that care generally adopted by the
investigator in studying the research problem.
The present study is aimed at assessing the stress levels and coping methods of
parents of children undergoing cardio thoracic surgery.
Research Approach:
Research approach indicates the procedure for conducting the study. In order
to accomplish the objectives of the study, a descriptive survey approach was adopted.
Descriptive approach described situations as they exist in the world and
provides an accurate account of characteristics of particular individuals, situations or
groups. The outcome of descriptive research provides a basis for future quantitative
research
45
.
Research Design:
Research design is an investigators overall plan for obtaining answers to the
research questions
14

For the present study non experimental research design was adopted as it is a
virtue of a situation that naturally happens. In many aspects of nursing there is a need
for a clearer picture or description of the phenomenon before causality can be
examine.
45
The schematic representation of study design is presented in the fig:2.
33


Setting of the Study:
The setting is the location where a study is conducted50. For the present study
the setting was in Narayana Hrudhayalaya Hospital, Bangalore.
This setting selected because availability of the sample, feasibility of
conducting study and ethical clearance.
Population:
The population referred to as the target population, which represents the entire
group or all the elements like individuals or objects that meet certain criteria for
inclusion in the study
45
. In this present study the population consisted of parents of
children undergoing cardio thoracic surgery.
Sample:
Sample refers to subset of a population that is selected to participate in a
particular study
45
. It is a portion of the population, which represents the entire
population. In this study sample consists of 50 parents of children undergoing cardio
thoracic surgery in Narayana Hrudhayalaya, Bangalore.
Sampling Technique:
Sampling defines the process of selecting a group of people or other elements
with which to conduct a study
45
. In this study non-probability purposive sampling
technique was adopted.
Purposive sampling, sometimes referred to as judgemental or theoretical
sampling, which involves the conscious selection by the investigator of certain
subjects or elements to include in the study
45
.


35


Sampling Criteria:
a) Inclusion Criteria:
Parents of children undergoing cardio thoracic surgery in Narayana
Hrudhalaya, Bangalore.
Who can communicate in English and Kannada.
b) Exclusion Criteria:
Parents who are visitors for the child.
Who are not willing to participate for the study.
Selection and Development of Tool:
Based on research problem and objectives of the study the following steps
were undertaken to select and develop the data collection tool.
Selection of the Tool:
A structured interview schedule selected on the basis of the objectives of the
study, as it was considered to be the most appropriate instrument to elicit responses
from the participants.
Development of Tool:
A structured interview schedule was prepared to assess the stress level and
coping methods of parents of children undergoing cardio thoracic surgery (5 point
likert scale).
The tool was developed:
After reviewing the related literature
Based on the experience of the investigator and
Based on the contact and consultation of the subject experts.

36


Description of the tool:
The researcher developed a structured interview schedule, which contains
items on the following aspects.
A. Demographic variables
Age of the child - Sex
Age of the parents - Sex
Education - occupation
Income - Number of children
Ordinal position of the child
Religion - Previous hospitalization
B. Five point likert scale for stress and coping methods:
Stress questionnaire consists of 48 items. It is measured with the help of
modified likert type scale. Each item has 5 alternatives never, rarely, sometimes, often
and always. It includes physical stress, physiological, psychological, social, financial
and environmental.
Coping questionnaire consists of 29 items. It is measured with the help of
modified likert type scale. Responses are scored in such a way that the endorsement
of positively worded statements and negatively worded statements assigned a higher
score. Each item has 5 alternatives never, seldom, sometimes, often and always.
Content Validity:
Content validity refers to the degree to which an instrument measures what it
is intended to measure
14
.
The prepared instrument along with the objectives and criteria checklist was
submitted to five experts in the field of Child Health Nursing and Mental Health
37


Nursing for establishing content validity. The first draft of the tool consisted of 56
questionnaire on stress levels and 28 questionnaire on coping methods and then based
on the suggestions given by the experts, modifications, deletion (14,15,19,20,27,37,
38, 39, 43, 46), added 2 questions and rearrangements were made. Thus the second
draft of the tool consisted on 48 questions on stress levels and 29 questions on coping
methods.
Translation of the Tool:
The tool was translated by the language expert into Kannada and English.
Pretesting of the Tool:
Tryout of the modified version of tool was carried out in J ayadeva Institute of
Cardiology in Bangalore, among 5 parents who fulfill the sample inclusion criteria.
The structured interview schedule was conducted for 50 minutes. The subjects found
the language of the tool simple and understandable.
Reliability of the Tool:
The reliability of the measuring instrument is a major criterion for assessing
the quality and adequacy. According to Polit and Hungler the reliability of
instruments is the degree of consistency with which it measures the attribute it is
supposed to be measuring
14
.
The reliability of the tool is computed by using split half technique with raw
score method - Spearman Brown Prophecy Formula
Spearman Brown Prophecy Formula for reliability
2 r
r
1
= Where
1 +r
r
1
=is the estimated reliability of the item
r =is the correlation co-efficient computed on split halves.
38


For computing coefficient the formula used is


Deviation method

xy
r=
[ x
2
X y
2
]


The reliability obtained by using Spearman Brown Prophecy formula
is 0.9 so the questionnaire found to be reliable.
Pilot Study:
Pilot study is a small-scale version or trial run of the major study. To assess the
feasibility in conducting main study and to obtain information for improving the
project, pilot study was under taken.
After obtaining a formal permission from the Medical Superintendent of
J ayadeva Institute of cardiology in Bangalore. Study was conducted on 10 parents on
13.10.2004-20.10.2004. A purposive sampling and the inclusion criteria was taken
into consideration during sample selection. The consent was taken by explaining the
purpose of the study. Structured interview schedule consisting of 11 items on
demographic variables, 48 questions on stress and 29 items on coping. Data
collected for 50 minutes. A concise data analysis was done using descriptive
statistics. Inferential statistics was not done because of limited number of samples.
The following were the findings of the pilot study, the maximum age the
parents of children undergoing cardio thoracic surgery is 31-40 yrs. All of them were
Hindus 60%, 40% were females majority of the participants 80% were literate. About
80% of participants were employed. Majority of participants have a family income

39


below 1500/-. The majority of the parents are experiencing moderate (60%) stress
and majority of parents (80%) were using moderate coping methods.
Reliability of the Tool:
The reliability of the measuring instrument is a major criterion for assessing
the quality and adequacy. According to Polit and Hungler the reliability of
instruments is the degree of consistency with which it measures the attribute it is
supposed to be measuring
14
.
The reliability of the tool is computed by using split half technique with raw
score method - Spearman Brown Prophecy Formula
Spearman Brown Prophecy Formula for reliability
2 r
r
1
= Where
1 +r
r
1
=is the estimated reliability of the item
r =is the correlation co-efficient computed on split halves.
For computing coefficient the formula used is

Deviation method

xy
r=
[x
2
X y
2
]


The reliability obtained by using Spearman Brown Prophecy formula
is 0.9 so the questionnaire found to be reliable.
Data Collection Method:
A formal written permission was obtained from the Nursing Superintendent of
Narayana Hrudhayalaya Bangalore. The data collected from 19
th
Nov. 2004 to 19
th


40


Dec. 2004, from parents who fulfilled sample inclusion criteria. The structured
interview schedule was conducted for 50 min. Before conducting the study, consent
was taken from them by explaining the purpose of the study.
Plan for Data Analysis: The data was planned to be analyzed on the basis of
objective and hypothesis of the study.
The collected data was coded and transformed to master sheet for statistical
analysis.
Demographic data was planned to represent in terms of frequency and
percentage.
Mean, median and standard deviation for total scores of the parents was
computed.
Chi-square test was computed for finding out the association between level of
stress and demographic variables.
Karl Pearsons Coefficient of Correlation was calculated to find the relationship
between stress and coping.
SUMMARY:
This chapter on methodology has dealt with research approach and design, the
setting, population, sample and sampling technique, development of the tool and its
description, the pilot study, procedure for data collection and the plan for data
analysis.




41


5. RESULTS
This chapter deals with the analysis and interpretation of the data gathered to
assess the stress level and coping methods of parents of children undergoing cardio
thoracic surgery.
Analysis is a process of organizing and synthesizing the data in such a way
that research questions may be answered and hypothesis tested
14
.
The analysis and interpretation of the data of this study are based on the data
collected through structured interview schedule on the stress levels and coping
methods of parents of children undergoing cardio-thoracic surgery. The results were
computed using descriptive and inferential statistics based on the following objectives
of the study.
Objectives:
To assess the stress levels of parents of children undergoing cardio-thoracic
Surgery.
To assess the coping methods of parents of children undergoing cardio-thoracic
Surgery.
To compare the stress levels and coping methods of parents of children
undergoing cardio-thoracic surgery.
To find an association between the stress levels of parents of children with
demographic variables like age, education, occupation, income, previous
hospitalization of child, number of children and ordinal position of the child.
Hypothesis:
Ho: There is no significant association between the stress level and coping methods
used by parents of children undergoing cardio-thoracic surgery.
43


Organization and Presentation of Data:
The obtained data were entered in to the master sheet for tabulation and
statistical processing. The analysis of data was organized and presented under the
following section.
Section I:
Description of sample characteristics.
Section II:
Distribution of parents according to their stress level.
Section III:
Distribution of parents according to their coping levels.
Section IV:
Relationship between stress and coping methods of parents of children
undergoing cardio-thoracic surgery.
Section V:
a) Association between stress level with selected demographic variables.
b) Association between coping methods with selected demographic variables.








44


Section I
Description of sample characteristics
A sample of 50 parents of Children undergoing cardio thoracic surgery was
drawn from the selected hospital, based on specific criteria. The data on sample
characteristics were analyzed using descriptive statistics and presented in terms of
frequency, percentage and diagrams.
The data obtained from sample are presented in terms of Age, Sex, Religion,
Educational Status, Occupation, Income, Number of Children, Age of the Child, Sex
and Birth order of the child.
Table :1.1
Description of children undergoing cardio thoracic surgery by Age.
N=50
Sl. No Variables Numbers %
I
1
2
3
4
Age of the child
0 1 year
1 3 years
4 6 years
7 12 years

37
9
1
3

74
18
2
6
TOTAL 50 100









Fig: 3 Age of the Child
Data presented in the table and figure show the following findings. More than 90% of
children included in this study was below 3 years among this 74% were below 1 year.
45
74%
18%
2%
6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
0-1 year 1-3 year 4-6 year 7-12 years



Table 1.2
Description of children undergoing cardio thoracic surgery by sex
N=50
Sl.No Variables Numbers %
II
1
2
Sex of the child
Male
Female

28
22

56
44

TOTAL 50 100













Fig: 4 Sex of the Child

Data presented in the Table-1 and fig: 3 & 4 show the following findings. Majority of
the children (56%) were boys. Only 44% were girls.

46
56%
44%
Male Female


Table: 2.1
Distribution of parents by age group
N = 50
Sl. No Variables Numbers %

1
2
3
4
5
Age of the parents
21 25 years
26 30 years
31 35 years
36 40 years
41 45 years

9
16
10
14
1

18
32
20
28
2
Total 50 100











Fig: 5 Age of Parents

The data presented in the table2: 1 and fig: 5 reveals that as high as 32% of parents
were belonging to 26-30yrs and 50% of parents belonging to above 30 yrs followed
by 18% of parents was falling below 25yrs.



47
18%
32%
20%
28%
2%
0%
5%
10%
15%
20%
25%
30%
35%
21-25 yrs 26-30 yrs 31-35 yrs 36-40 yrs 41-45 yrs








Table: 2.2
Distribution of parents by sex
N = 50
Sl. No Variables Numbers %

1
2
Sex
Male
Female

25
25

50
50
Total 50 100



The above table and figure showed that equal number of fathers and mothers had
selected for the study.



















48




Table: 2.3
Distribution of parents by Family income.
N = 50
Sl. No Variables Numbers %

1
2
3
4
5
6
7
Family Income
1001 5000
5001 10000
10001 15000
15001 20000
20001 25000
25001 30000
30001 35000

4
13
9
9
10
3
2

8
26
18
18
20
6
4
Total 50 100









Fig: 6 Family Income

The table and figure represents the family income of the parents of children cardio
thoracic surgery. It is observed that a majority (26%) of parents belonged to the
income group of 5001-10000.
49
8
26
18 18
20
6
4
0
5
10
15
20
25
30
1001-
5000
5001-
10000
10001-
15000
15001-
20000
20001-
25000
25001-
30000
30001-
35000



Table :2.4
Distribution of Parents by the Number of Children
N = 50
Sl. No Variables Numbers %
IV

1
2
3
4
Number of children in the
family
1
2
3
4 and above


23
16
8
3


46
32
16
6
Total 50 100

The above table explained the number of children and ordinal position of the child. As
per present day norm the number of children in the family is single or two. It can be
seen that majority of the parents had only one child (46%). Maximum of children
(50%) were first born.
Table :2.5
Distribution of Parents by the Ordinal Position of the Child.
N = 50
Sl. No Variables Numbers %
1
2
3
4
1
st
child
2
nd
child
3
rd
child
4
th
child and above
25
14
9
2
50
28
18
4
Total 50 100

The above table explained the ordinal position of the child. Maximum of
children (50%) were first born followed by 28% of children were 2
nd
born.

50


Table: 2.6
Distribution of parents by their educational qualification
N = 50

Sl.no
Variable Fathers Mothers
Educational
qualification
Numbers % Numbers %
1.
2.
3.
4.
Primary (1-5)
High School (6-10)
Degree (11-15)
Post graduation and
above
1
7
14
3
4
28
56
12
2
5
18
--
8
20
72
--

Total 25 100 25 100
0
10
20
30
40
50
60
70
80
Primary ( 1-5) High School (
6-10)
Degree (11-15) Post graduation
and above
Father
Mother

Fig: 7 Educational Qualification of the Father and Mother
The above table and figure represents the educational status of the father and mother.
It is evident that majority (56% and 72%) of parents are educated upto degree, 28%
and 20% were educated upto high school, and 4% and 8% had only primary school
education.

51


Table: 2.7
Distribution of parents by Religion

N=50
Sl.no
Variable Fathers Mothers
Religion Numbers % Numbers %
1.
2.
3.

Hindu
Muslim
Christian
12
9
4
48
36
16
16
6
3
64
24
12

Total 25 100 25 100


0
10
20
30
40
50
60
70
Hindu Muslim Christian
Father
Mother

Fig: 8 Religion of Father and Mother

The above table and figure showed that a vast majority in fathers and mothers (48%
and 64%) were Hindus followed by Muslims and Christians.




52


Table: 2.8
Distribution of parents by Occupation.
N = 50
Sl.no
Variable Fathers Mothers
Occupation Numbers % Numbers %
1.
2.
3.

Professional
Non-professional
Housewife
2
23
-
8
92
-
1
2
22

4
8
88


Total 25 100 25 100


As regarding the occupation of parents it is observed that majority (92%) of the
fathers were doing non-professional work; while 88% of mothers were housewives
and 8% were non-professionals. Remaining 8% and 4% were professionals.














53



Table: 2.9
Distribution of parents by Previous Hospitalization of the Child
N = 50
Sl. No Variables Numbers %
XII

1
2
Previous hospitalization of
the child
Yes
No


30
20


60
40











Fig: 9 Previous Hospitalization of the Child


The above table and figure explains that majority (60%) of the children had history of
previous hospitalization. Remaining (40%) of children did not have any previous
hospitalization.






54
60%
40%
Yes No


SECTION II

Distribution of Parents according to their Stress level
This section deals with the analysis and interpretation of data with regard to
the stress level of parents of children undergoing cardio-thoracic surgery obtained
through the stress rating scale.
The scores obtained by each sample were tabulated in a master data sheet.
Data regarding the stress scores was analyzed using descriptive and inferential
statistics. The data were presented in the form of tables & diagram.
Table: 3.
Distribution of Fathers according to their Stress Level
n = 25
Sl. No Stress scores No % Category
1
2
3
114 & less
115 158
>158
3
16
6
12
64
24
Low stress
Moderate stress
Severe stress















Fig: 10.Stress level of Fathers

The data presented in the Table-3 and fig: 10 show that (24%) of fathers had
severe stress and more than half of the fathers (64%) had moderate stress and
remaining fathers (12%) had low stress.
55
12%
64%
24%
114 & less 115-158 >158




Table: 4.
Distribution of mothers according to their Stress level
n= 25
Sl. No Stress scores No % Category
1
2
3
116 and less
117 158
>158
1
21
3
4%
84%
12%
Low stress
Moderate stress
Severe stress









Fig: 11.Stress level of mothers.

The data presented in the table 4 and fig: 11 shows that (12%) of mothers
had severe stress and 84% of mothers had moderate stress and remaining 4% of
mothers had low stress.











56
4%
84%
12%
116 and less 117-158 >158





Table: 5
Area wise categorization of Stress level of Fathers of Children undergoing cardio
thoracic surgery
n=25
Sl.
No.
Domains Number
Maximum
Score
Mean
Mean
%
S.D
1. Physiological 13 65 37.84 58.5% 6.55
2. Social 13 65 42.32 64.6% 7.03
3. Psychological 12 60 28.20 46.7% 6.76
4. Physical 4 20 8.40 42.5% 2.42
5. Environmental 3 15 9.76 65.1% 2.00
6. Financial 3 15 9.84 65.6% 3.20

The data depicted in table V and fig: 12 show that the fathers of children
undergoing cardio-thoracic surgery had severe stress in financial domain (mean %
score 65.6%) and it is followed by environmental (65%) stress and social stress
(64.6%).











57


Table: 6.
Area wise Categorization of Stress level of Mothers of Children undergoing
Cardio Thoracic Surgery
n=25
Sl.
No.
Domains Number
Maximum
Score
Mean
Mean
%
S.D
1. Physiological 13 65 37.20 57.23% 7.68
2. Social 13 65 42.08 64.73% 5.34
3. Psychological 12 60 28.80 48% 6.38
4. Physical 4 20 8.16 40.8% 1.67
5. Environmental 3 15 10.16 67.73% 2.30
6. Financial 3 15 10.20 68% 3.04

The data depicted in table VI and fig: 12 show that the mothers of children
undergoing cardio-thoracic surgery had severe stress in financial domain (mean %
score 68%) and it is followed by environmental (67.73%) stress and social stress
(64.73%).
0
10
20
30
40
50
60
70
80
P
h
y
s
i
o
l
o
g
i
c
a
l

S
o
c
i
a
l

P
s
y
c
h
o
l
o
g
i
c
a
l

P
h
y
s
i
c
a
l

E
n
v
i
r
o
n
m
e
n
t
a
l

F
i
n
a
n
c
i
a
l

Father
Mother

Fig: 12 Area wise Categorization of Stress level of Father & Mother
58


SECTION III

Distribution of Parents According to their Coping Methods

This section deals with the analysis and interpretation of data obtained through
a coping scale with regard to coping methods adopted by the parents of children
undergoing cardio-thoracic surgery. Data regarding the coping methods was analyzed
using descriptive and inferential statistics. This data is also represented in the form of
tables and diagrams.
Table: 7
Distribution of fathers according to their coping methods
N - 25
Sl. No Coping scores No % Category
1
2
3
76 or less
77 100
>100
5
17
3
20
68
12
Poor coping
Moderate coping
Good coping









Fig: 13 Coping scores of fathers.

The data in the table-7 and fig: 13 show that more fathers (68%) used
moderate coping and 20% had poor coping methods.


59
20%
68%
12%
76 or less 77 - 100 >100


Table: 8.
Distribution of Mothers According to their Coping Methods
N - 25
Sl. No Coping scores No % Category
1
2
3
77 and less
78 100
>100
5
17
3
20
68
12
Poor coping
Moderate coping
Good coping










Fig: 14 Coping scores of mothers

The data presented in the Table-8 and Fig: 14 show that more mothers (68%)
had moderate coping and 12% of mothers had good coping and 20% of mothers had
poor coping.











60
20%
68%
12%
77 and less 78-100 >100


SECTION: IV
Relationship between Stress Level and Coping Methods of Parents of Children
undergoing Cardio-thoracic Surgery:

This section presents the relationship between stress level and coping methods
of parents of children undergoing cardio-thoracic surgery. In order to test the
relationship, a null hypothesis has been formulated.
Ho : There is no significant relationship between the stress and coping
methods of parents of children undergoing cardio-thoracic surgery.
The hypothesis was tested by using Karl Pearson s Coefficient of correlation.
Table: 9
Relationship between Stress level and Coping Methods of Fathers of Children
undergoing Cardio-thoracic Surgery.
Variable Mean + SD Correlation Coefficient Inference
Stress 136.36 +21.47
Coping Methods 88.8 +12.31
0.064 NS

Data in the table-9 show that there is no significant relationship between
coping and stress scores (r =0.064 P >0.05). Hence the null hypothesis is accepted.






61






Table: 10
Relationship between Stress level and Coping Methods of Mothers of Children
undergoing Cardio-thoracic Surgery.
Variable Mean + SD Correlation Coefficient Inference
Stress 136.36 +21.47
Coping Methods 89.4 +11.61
0.24 NS

Data in the table-9 show that there is no significant relationship between coping and
stress scores (r =0.24, P >0.05). Hence the null hypothesis is accepted.











62


SECTION V

a) Association between Stress levels with selected Demographic Variables.
This section deals with the analysis and interpretation of the association
between the stress of parents of children undergoing cardio-thoracic surgery with
selected demographic variables such as age of the parents, education, family income,
occupation, previous hospitalization, ordinal position of the child and number of
children.
This was tested by using Chi-square (x
2
) test by preparing contingency table.
The stress scores were put in the master data sheet. The scores above the mean and
below mean were identified and grouped according to the demographic variables.
The findings are given in the Table-11 & 12
Table: 11
Association between stress level with selected demographic variables of fathers
of children undergoing cardio-thoracic surgery.
Median=132
Variables Stress scores
Median & below
Median
Stress scores
above median

2

Age
36 and less
> 36

8
6

5
6

1.031**
Educational
Status
11
th
standard and
below
11
th
standard



5

9


3

8


0.205**
63


Occupation of
fathers
Professional
Non-professional


1
13


1
10


0.165**
Income
<Rs.15,000
> Rs.15,000

6
8

7
4

1.065**
No. of children
2 & Less
>2

10
4

10
1

1.461**
Ordinal position
of the child
2
nd
and Less
>2
nd


10
4

10
1

1.461**
Previous
hospitalization
Yes
No


9
5


7
4


0.011**

2
(1,0.05) =3.84: P<0.05 Level
* =Significant
** =Non-significant
The obtained chi-square value is less than the table value indicating that there
is no significant association between the stress of the fathers and the demographic
variables such as age of the father, education, occupation, income , number of
children ,ordinal position of the child and previous hospitalization.





64


Table: 12
Association between Stress level with selected Demographic variables of
Mothers of Children undergoing Cardio-thoracic Surgery.
Median:133
Variables Stress scores
Median & below
Median
Stress scores
above median

2

Age
28 & Less
>28 years

7
6

6
6

0.27**
Educational status
<10
th
standard
>10
th
standard

5
8

2
10

1.470**
Occupation
Employed
Unemployed

2
11

1
11

0.293**
Income
<Rs.15,000
>Rs.15,000

7
6

6
6

0.279**
No. of children
1
> 1

7
6

6
6

0.279**
Ordinal position of
the child
<2
nd
child
>2
nd
child


9
4


10
2


0.268**
Previous
hospitalization
Yes
No


7
6


6
6


0.085**

65

2
(1,0.05) =3.84: P<0.05 Level
* =Significant
** =Non-significant
The obtained chi-square value is less than the table value indicating that there
is no significant association between the stress levels of mothers and demographic
variables such as age of the mother, education, occupation, income, number of
children and previous hospitalization.
b) Association between Coping methods with selected Demographic
Variables
This section deals with the analysis and interpretation of the association
between the coping of parents of children undergoing cardio-thoracic surgery with
selected demographic variables such as age of the parents , education, occupation,
family income, no. of children, previous hospitalization and ordinal position of the
child.
This was tested by using chi-square (x
2
) test by preparing the contingency
table. The scores above the mean and below the mean were identified and grouped
according to the demographic variables.
The findings are given in the table 13 & 14.







66


Table: 13
Association between Coping methods with selected Demographic variables of
Fathers of Children undergoing Cardio-thoracic Surgery.
Median:92
Variables
Coping scores
Median & below
Median
Coping scores
above median

2

Age
<36
>36

7
5

6
7

0.370**
Educational status
<11
th
standard
>11
th
standard

3
10

5
7

1.216**
Occupation
Professional
Non-professional

0
13

2
10

2.355**
Income
<Rs.15,000
>Rs.15,000

8
5

5
7

0.987**
Number of
children
< 2
> 2

12
1

8
4

2.564**
Ordinal position
of the child
< 2
> 2


12
1


8
4


2.564**
Previous
hospitalization
Yes
No


8
5


8
4


0.071**

2
(1,0.05) =3.84: P<0.05 Level
* =Significant ** =Non-significant
67


The obtained chi-square value is less than the table value indicating that there
is no significant association between the coping methods of fathers and demographic
variables such as age of the mother, education, occupation, income, number of
children, ordinal position of the child and previous hospitalization.



























68






Table: 14
Association between Coping methods with selected Demographic Variables of
Mothers of Children undergoing Cardio-thoracic Surgery.
Median:93
Variables Coping scores
Median & below
Median
Coping scores
above median

2

Age
< 28
> 28

7
7

6
5

0.057**


Educational status
<10
th
standard
>10
th
standard

3
11

4
7

0.681**
Occupation
Employed
Unemployed

1
13

2
9

1.048**
Income
<Rs.15,000
>Rs.15,000

8
6

5
6

0.337**









69





Number of
children
<2 children
>2 children

11
3

8
3

0.115**
Ordinal position
of the child
< 2
> 2


11
3


8
3


0.115**
Previous
hospitalization
Yes
No


9
5


4
7


1.924**

2
(1,0.05) =3.84: P<0.05 Level
* =Significant
** =Non-significant
The obtained chi-square value is less than the table value indicating that there
is no significant association between the coping methods of mothers and demographic
variables such as age of the mother, education, occupation, income, number of
children, ordinal position of the child and previous hospitalization.











70


6. DISCUSSION
The present study was intended to find out the relationship between stress and
coping methods of parents of children undergoing cardio-thoracic surgery. The
findings of the study have been discussed based on the objectives of the study and
findings of other similar studies.
1.Stress level of fathers of children undergoing cardio thoracic surgery.
In the present study it was found that more than half of the fathers (64%) had
moderate stress, and remaining (24%) had severe stress and (12%) had low stress.
The area wise categorization of stress scores among the fathers showed severe stress
in financial domain (65.6%) and moderate stress in environmental domain (65.1%)
and social domain (64.6%).
2. Stress level of mothers of children undergoing cardiothoracic surgery.
In the present study it was found that more than half of mothers (84%) had
moderate stress and remaining (12%) had severe stress and (4%) had low stress. The
area wise categorization of stress scores among the mothers showed, severe stress in
financial domain (68%) and moderate stress in environmental domain (67.73%) and
social domain (64.73%). This was consistent with the findings of Mendoca. Indicated
that area wise analysis of the level of stress indicated that highest percentage
(43.55%) of mothers had severe stress related to financial factor and 32.26% of the
mothers experience stress related to environmental factors. It also indicated that
majority of (74.20%)mothers had moderate stress and 22.58% had severe stress and
only 3.23% had mild stress
46
.


72


3.Coping Methods of fathers of children undergoing cardio-thoracic surgery
In the present study more fathers (68%) were using moderate coping and
remaining (12%) were using good coping and (20%) were using poor coping
methods.
4. Coping Methods of Mothers of Children under going cardio-thoracic surgery
In the present study more of mothers (68%) were using moderate coping and
(12%) were using good coping and remaining (20%) were using poor coping
methods.
5.Relationship between stress level and coping methods of fathers
The present study found that there was no correlation between stress and
coping (r =0.064, P >0.05). The findings was consistent with the report of
Shyamala Kumari, who also found no significant relationship between stress level and
coping of mothers of children with leukemia
44
.
6.Relationship between stress level and coping methods of mothers
Present study found that there is no correlation between stress and coping (r =
0.24, P >0.05). The finding was consistent with the report of Shyamala Kumari, who
found no significant relationship between stress level and coping of mothers of
children with leukemia
44
.
7.Association between stress level with selected demographic variables.
The study did not establish any significant association between the stress and
age of the mother. This was supported by the study conducted by Celinamma Thomas
who assessed the stress and coping strategies of mothers of children with cardio-
thoracic surgical treatment and found there is non-significant association with the age
of the mother and stress
47
. The findings are also consistent with the findings of the
73


Usha Vargheese who described the stress and coping behaviour of mothers of children
in PICU and the study found a non-significant relationship between the age and
stress
48
. The findings of the study are compatible with the findings of Shyamala
Kumari who assessed the stress levels of mothers with Leukemic Children and found
there is no significant association
44
.
With regard to education, the chi-square test did not establish any significant
relationship between stress and education of mothers at 0.05 level. This was
supported by the findings of Usha Vargheese who described the stress and coping
behavior of mothers of children in PICU
48
.
There was no significant relationship between occupation and stress.
The chi-square test did not establish any significant relationship between
income and stress. The findings are consistent with the findings of Shyamala Kumari
who assessed the stress levels of mothers with Leukemic Children. The study found a
non-significant relation ship between income and stress
44
.
With regard to number of children, there is no association between number of
children and stress. The study was supported by Celinamma Thomaswho assessed
the stress and coping strategies of mothers of children with cardio-thoracic surgical
treatment
47
. The findings are also consistent with the findings of Shyamala Kumari

who assessed the stress levels of mothers with Leukemic children
44
.
There was no significant association between the stress and ordinal position of
the child.
The study did not establish any significant association between the stress and
previous hospitalization. This was supported by the study done by Susan, Robert,

74


Newman, Campbell and Fowler who found that previous hospitalization does not
have any association with stress
49
.
Association between coping methods with demographic variables.
The present study findings showed that there is no significant association with
age of the mother, education, occupation, income, number of children, ordinal
position of the child and previous hospitalization. It is supported by the study of
Celinamma Thomas who reported negative association between coping with age of
the mother, education & number of children
47
.
The findings of the present study indicate that one of the most frequently used
coping behaviour is pray more than usual (72%). Also another coping behaviour used
in this context by the mothers is making special offering (62.7%). This shows that
mothers had belief in the spiritual systems as it would give peace and reduce their
stress level and better coping. This is supported by the study done by Shyamala
Kumari who found in her study that the mothers of children with leukemia used the
coping behaviour pray to God and reported as being the most helpful coping
behaviour
44
.








75


7. CONCLUSION
The study was undertaken to assess the Stress levels and Coping methods of
parents of children undergoing cardio thoracic surgery in Narayana Hrudhayalaya,
Bangalore
The following conclusions were based on the findings. The results were
described by using descriptive and inferential statistics.
Major findings of the study:
1. Majority of the fathers (64%) revealed moderate stress related to their children
cardio-thoracic surgery.
2. Majority of the mothers (84%) revealed moderate stress related to their childrens
cardio thoracic surgery.
3. Fathers had severe stress in related financial domain (65.6%) and moderate stress in
environmental (65.1%)and social domains (64.6%).
4. Mothers had severe stress in related financial domain (68%) and moderate stress in
environmental (67.73%) and social domains (64.73%).
5. The most commonly used coping methods by fathers are hope for the best (79%),
and pray more than usual (74%).
6. The most commonly used coping method by mothers are pray more than usual, and
make special offerings.
7. There was no significant relationship between stress level and their coping methods
of fathers of parents of children undergoing cardio thoracic surgery
(r =0.06, P >0.05)
8. There was no significant relationship between stress and their coping methods of
mothers of children undergoing cardio thoracic surgery( r =0.24, P>0.05).
77


9. There was no significant association between stress and the demographic variables.
These facts draw attention to planning, education and counseling services to
the parents of children undergoing cardio-thoracic surgery.
Implications:
The findings of the study have implication for nursing practice, nursing
education, nursing administration and nursing research.
Nursing Practice:
Any parents of children who are being diagnosed to be congenital heart
disease will experience stress. It is the nurse who is the core member spending most
of her time with the patient hence it is the responsibility of the nurses to bring the
family in the caring process. For this the nurses need to have adequate knowledge
regarding how much stress situation it is to accept the childs diagnosis, how to assess
their psychological problems and how to respond them accordingly and encourage the
parents to interact with other parents who have similar problems. Health care
professionals need to assess their coping levels.
Nurses need to help parents to adjust to hospital environment by giving
information and proper explanations through out the childs stay. Such information
should include orientation, and also prepare parents for the behaviour and emotional
responses of the child. Parents need to understand what is happening to their child.
To provide this information, nursing staffs need to be educated on stress and coping
of parents of children in the hospital and on the factors to be considered while
providing information and explanation.


78


Nursing Education:
Nursing curriculum is mainly theory based, and little is focused on the
practice, there is always a gap exist in between the theory and practice. A person is
considered to be healthy only when his / her physical, psychological, social and
spiritual status is at normal level. Most of the time the nursing education focuses on
the physical health in terms of treating the signs and symptoms and neglects the
psychological aspects of a patient, which is very important. Hence more emphasis
should be given to conduct in service education programme to upgrade the knowledge
of the nurses about factors causing stress and its relationship with coping, which may
help to plan effective care.
Nursing Education prepare the nurses to function as educators. In the present
nursing curriculum, physical aspect of the care is more emphasized than any other
aspects such as psychological and social. Psychological dimension is an important
dimension of care. Findings of this study suggest that non pharmacological measures
for stress reduction such as relaxation training should by included in the curriculum.
Client education services provide opportunity for nurses to train children and
families on relaxation techniques, which will help them to function at their optimum
level. An awareness of parental stressors should be emphasized to student nurses
during their pediatric rotations. Stress and coping of parents in the surgical unit need
to be incorporated in the education of pediatric nursing in undergraduate and graduate
programmes.
Nursing Administration
Nurses as administrators should take great interest in formulating the policies
and procedures for caring a patient.
79


The administrator should plan and organize educational programme for
nursing personnel, in order to prepare them to provide quality care. Client education
services are an integral part of nursing care. The nursing administrators should see
that the aspect of health promotion is included while providing nursing care.
Nurses being the key members of the health team are subject to many
stressors, which are caused by the work situation and interaction with various groups
of people. She is responsible for the duties assigned to her and the clients she care
for. Nursing administrators should see that stress reduction programmes are included
in staff welfare programmes and relaxation techniques are taught to the nursing
personnel as a part of their orientation programme, which helps them to cope with the
stressors they face in the work setting and to reduce their stress, which eventually
would improve the quality and quantity of work done.
Nursing Research:
Research in nursing field helps in the growth of the professional and personal
life. Professional organizations in nursing are convinced of the importance of nursing
research as a major contribution of meeting the health on welfare of patients.
Research can also be done in the area of stress and coping to identify unique
stressors for parents in particular settings. Findings can be used to determine action
plans.
Future research studies can build on this database and involve comparisons of
these variables in families at various stages of development with other chronic
childhood conditions (E.g. diabetes epilepsy, and cancer). The purpose of subsequent
research will be to develop family Health Nursing Intervention Strategies.

80


Limitations:
The limitations of the present study were: -
1.The study was conducted using purposive sample, which restricted the
generalization that could be made.
2. The study is limited to specific dimensions of stress and coping of parents of
children undergoing cardio-thoracic surgery.
3.The tools used were not standardized tools.
Recommendations:
In the view of the findings reported, the following recommendations are made
for further research.
1. The study can be replicated on a large sample.
2. An evaluative study to determine the effectiveness of counseling in reducing the
stress levels may be conducted.
3. An evaluative study can be done to determine the effectiveness of relaxation
therapy in reducing stress.
4. A comparative study to assess the stress and coping methods of parents of children
undergoing cardio-thoracic surgery and parents of children with other chronic
illness can be done.
5. An evaluative study on the effectiveness of the stress management techniques
among parents of children undergoing cardio-thoracic surgery.
6. Developmental studies are recommended for constructing standardized tool on
stress in Indian setting.


81


8. SUMMARY
Waiting in an emergency department during a childs admission for acute
illness or trauma can be frightening for parents. Even under the best circumstances
the uncertain nature of the situation represents a stressful period that places emotional
burdens on the parents. Once the child is stabilized he or she is admitted to a critical
care unit for further monitoring and care. For the parents, the initial crisis may be
over but the stressors generated by the situation continue to evolve.
A person cannot stay in a state of disruption for very long a stress is thought to
be short lived but some solution must be found. It can achieve only by mastering
adaptive tasks paramount to a persons adjustment to the situation. These adaptive
tasks include establishing meaning and understanding the personal significance of the
event, confronting reality by responding in the demands of the external situation
sustaining relationships with significant others and maintaining a sense of
competence.
A major stress that some parents have had to face is their childs
hospitalization. There is strong research evidence that such an event is stressful for
parents. Stressor identified by parents in these studies include parental concerns
about the adequacy of the information provided by the staff about their childs illness,
uncertainty over the childs medical status and recovery, and disruption of their usual
parental role. Other studies have found that specific environmental stimuli such as
noise, lights, and the fast pace of the setting, are stress producing for parents
50
.
83
Although there is ample empirical support regarding what aspects of the sit-
uation produce parental stress, very little is known about the ways parents cope during


the experience. Parents use a variety of coping strategies that focus on problem
solving a well as their emotional responses to the situation
8
.
Parents of chronically ill infants consistently reported more stress than parents
of healthy children. Parents of infants with congenital heart problems generally
reported the highest amount of stress because of the threat to life and uncertainties
about outcome
42
.
Nurses must use communication skills which include listening to and valuing
parents concerns using a caring, friendly, empathetic and honest attitude and avoiding
questions or comments that may lead parents to feeling of guilty or responsible for
their childs illness. Nurse becomes a part of health team and facilitates this care
towards the needy parents to help them in coping and anxiety reduction.
The present study was undertaken by the investigator to assess the stress levels
and coping methods of parents of children undergoing cardio thoracic surgery with a
aim to find out relationship between these two.
Objectives of the Study were:
1.To assess the stress levels of parents of children undergoing cardio-thoracic surgery.
2. To assess the coping method of parents of children undergoing cardio-thoracic
surgery.
3. To compare the stress level and coping methods of parents of children undergoing
cardio-thoracic surgery.
4. To find an association between the stress levels of parents of children with
demographic variables like age, sex, education, occupation, income, previous
84
hospitalization of the child and ordinal position of the child.
Assumptions of the Study:


1.The parents of children admitted in cardiac intensive care unit may undergo high
levels of stress.
2. Family members may go through a crisis when their children are critically ill or
hospitalized and they try to adapt the situation by using various coping methods.
3. Parents perceive that their children are critically ill when the child is hospitalized in
cardio-thoracic ICU.
4. Parents perception of stressors may differ according to their age, sex, educational
status, income, previous hospitalization of the child and ordinal position of the
child.
The study attempted to examine the following Hypothesis:
Ho: There is no significant association between the stress and coping methods used by
parents of children undergoing cardio-thoracic surgery.
The conceptual framework of the study was based on Roys Adaptation
Model. The study was conducted in intensive thoracic unit of Narayana
Hrudhayalaya Hospital, Bangalore.
The research approach used in this study was descriptive correlational
approach. Population consisted of parents of children undergoing cardio-thoracic
surgery admitted in the intensive thoracic unit of the selected hospital. The sample
comprised of 50 parents who were selected using a purposive sampling technique.
The tools used in the study were :
Demographic Performa.
Stress rating scale.
85
Coping scale.


Demographic Performa was listed to obtain the baseline information regarding
the sample characteristics. Stress rating scale consists of 48 items from physical
physiological, Psychological, Social, Economics & Environmental domains. Coping
scale consists of 29 items.
Discussion with experts and reviewing the literature guided to the construction
of the tools. The validity, pretesting and reliability of the tools were established. The
reliability of stress rating scale and coping scale were 0.9.
Pilot study was conducted to confirm the feasibility in conducting the main
study. Data for the main study was collected 19 November 2004 to 19 December
2004.
Data obtained was analyzed by descriptive and inferential statistics.
Frequency and percentage were used to analyze the demographic characteristics.
Frequency, Percentage, Mean, standard deviation, mean % score, range and
coefficient of co-relation of stress and coping scores were calculated. The
relationship between coping methods and stress levels were found by Karl Pearsons
Correlation coefficient formula.
Association between the stress and selected demographic variables were
calculated using Chi-square test.
Findings of the Study:
Description of the sample characteristics.
Most of the parents (32%) were in the age group of 26-30 years.
Most of the mothers (64%) belong to Hinduism.
Many of the fathers (48%) were Hindu believers




86
Maximum of the fathers (56%) had attended college.
Many of the mothers (72%) were educated up to degree.
Most of the fathers (92%) were non-professionals.
More than half of the mothers (88%) were housewives.
Most of the families (26%) had a monthly income of 5001-10000.
More than half of the children (74%) were in the age group of 0-1 year.
Maximum children (56%) were males.
Majority of children (50%) were first born.
Many of the parents (46%) had only one child.
Most of the children (60%) had previous hospitalization.
Major Findings of the Study:
The severe stress was expressed among fathers 24% and moderate stress in 64%
of fathers.
The mothers 12% had severe stress and 84% of mothers had moderate stress.
Area wise distribution of stress scores among the fathers showed severe stress in
financial domain (65.6%), it is followed by environmental domain (65.1%) and
social stress (64.6%) .
Area wise distribution of stress scores among the mothers showed severe stress in
financial domain (68%) it is followed by environmental domain (67.73%) and
social stress (64.73%).
Maximum fathers (68%) used moderate coping methods and (20%) had poor
coping.
Maximum mothers (68%) were used moderate coping and (12%) used good
coping.


87
The present study found that there is no significant correlation between stress and
coping. It has got inverse relationship indicating that as stress increases, coping
decreases.
Other Findings:
There was no significant association between the stress of the fathers with
demographic variables.
The fathers stress was independent of the age, education, occupation, income,
number of children, ordinal position of the child and previous hospitalization.
There was no significant association between the stress of the mothers with
demographic variables.
The mothers stress was independent of the age, education, occupation, income,
number of children ,ordinal position of the child and previous hospitalization of
the child.
There was no significant association between the coping of the fathers with the
demographic variables.
Fathers utilization of coping methods were independent of their age, education,
occupation, number of children, ordinal position of the child, income, number of
children and previous hospitalization of the child.
There was no significant association between the copings of the mothers with the
demographic variables.
Mothers utilization of coping methods was independent of their age, education,
occupation, number of children, ordinal position of the child and previous
hospitalization.



BIBLIOGRAPHY

1. Seyle H. The stress of life. Newyork: Mc. Graw-Hill Book Agency; 1988.


2. Kozier Barbara, Erb Glenora, Blais Kathleen. Fundamentals of Nursing
concepts, process and practice. 5
th
ed.Philadelphia: Addison Wesley
Publishing Company; 1995.


3. Lazarus R.S, Folkman. Stress appraisal and coping. New-york: Springer
publishing Inc; 1982.


4. Chen J ih- Yuan, Chen Shun-Sheng, J ong Yuh-J yn, Yang Fi-Hsin, Chang
Yong-Yuan. A comparison of the stress and coping strategies between the
parents of children with duchenne muscular dystrophy and children with a
fever. J ournal of pediatric nursing. (2002);17(5):369-379.


5. Elaine Meyer C, Linda K Snelling, Lori k Myren-Manbeck. Pediatric
intensive care: The parents experience. 1998 ;9(1): 64-74.


6. J . Noyes. A critique of studies exploring the experiences and needs of parents
of children admitted to paediatric ICU. J ournal of advanced nursing.(1998);
2(1): 134-141.

7. I.B. Gottesfeld. The family of the child with congenital heart disease.
American journal of maternal child nursing. (1979); 4: 101-104.

8. La Montagne Lynda L, Hepworth J oseph T, Salisbury Michele H, Riley
Linda P. Optimism, anxiety and coping in parents of children hospitalized for
spinal surgery. Applied nursing research. (2003); 16(4): 228-235.



90




9. Coffman S, Mary J L, Nathalic Gauli I. Mothers stress and close relationship
correlates with infant health status. J ournal of pediatric nursing. (1993);19:130


10. Whyte DA. A family nursing to the care of a child with chronic illness.
J ournal of advanced nursing. 1992;17(3):317-327.


11. Melnyk Mazurek Bernadette, Feinstein Nancy fisch beck, Moldenhouer
Zendi, Small Leigh. Coping in parents of children who are chronically ill:
strategies for assessment and intervention. Pediatric nursing. 2001; 27(6):
547-555.


12. M.A. Hughes, J McCollum. Neonatal intensive care: mothers and fathers
perceptions of what is stressful. J ournal of Early interventions. 1994; 18:258-
268.

13. Snowdon WA, Kane J D . Parental needs following the discharge of a
hospitalized child. Pediatric nursing. 1995; 21(5).425-428.


14. Polit Denise F, Hungler Bernadette P. Nursing Research. 6
th
ed. Philadelphia:
Lippincott ;1999.


15. Alligood MR, Tomey AM. Nursing theory utilization and
application.St.Louis: Mosby; 1997.

16. Tomey Ann Marrinner. Nursing theorists and their work.3
rd
ed.
St.Louis:Mosby; 1994.
91


17. D.M Fisher. Identified needs of parents in a pediatric intensive care unit.
Critical care nurse.1994; 6:82-90.

18. Rei Rita Marie, Fong Carolyn. The Spanish version of the parental stressor
scale: pediatric intensive care unit. J ournal of pediatric nursing. 1996; 11(1);
3-9.

19. Cimete Guler. Stress factors and coping strategies of parents with children
treated by hemodialysis: A qualitative study. J ournal of pediatric nursing.
2002; 17(4):297-306.
20. Miles Shandor Margaret, Burchinal peg, Davis-Holditch Diane, Brussen
Susan, Wilson Sonja M. Perceptions of stress, worry and support in black
and white mothers of hospitalized medically fragile infants. J ournal of
pediatric nursing . 2002;17(2):82-88.

21. Olley Lydia B, Brieger Willian R, Olley BO. Perceived stress factors and
coping mechanisms among mothers of children with sickle cell disease in
Western Nigeria. Health education Research. 1997;12(2): 161-170.

22. EC Suddaby, MP Flattery, M Luna. Stress and coping among parents of
children awaiting cardiac transplantation. J ournal of transplant coordination.
1997 ;7(1):36-40.

23. K Uzark, K J ones. Parenting stress and children with heart disease. J ournal of
pediatric health care.2003; 17(4):163-168.

24. Yeh CH. Gender differences of parental distress in children with cancer.
J ournal of advanced nursing. 2002; 38(6): 598-606.
92



25. RA Adams, C Gordon, AA Spangler. Maternal stress in caring for children
with feeding disabilities: implications for health care providers. J ournal of
american diet association.1999; 99(8): 962-966.

26. IK Hallstorm. Parents experience of hospitalization: Different strategies for
feeling secure. J ournal of pediatric nursing.1997; 22(5):61-64.

27. Martinson IM, Armstrong V, Qiao J , Davis A, Yi-Hua L, Gan M. The
experience of the family of children with chronic illness at home in china.
Pediatric Nursing. 2002 ;23(8):371-375.

28. Tiedeman E. Anxiety Responses of parents during and after the hospitalization
of their 5 to 11 year old children. J ournal of paediatric nursing.
1997;12(2):110-118.

29. Younghblut J M and Shiao SY. Characteristics of childs critical illness and
parents reaction. American journal of critical care. 1993; 1(3): 80-84.

30. Haines C, Perger C, Nagy S. A comparison of the stressors experienced by
parents of intubated children. J ournal of Advanced Nursing. 1995; 21:350-
355.

31. Seideman RY, Watson MA, Corff KE, Odle P, Hasse J , Bowerman J L.
Parent stress and coping NICU and PICU. J ournal of pediatric nursing.
1997;12(3):169-176.

32. Steven Marcia S. Parents coping with infants requiring home cardio
respiratory monitoring. J ournal of pediatric nursing. 1994;9(1):2-12.

33. Heaman DJ . Perceived stressors and coping strategies of parents who have
children with developmental disabilities: a comparison of mothers with
fathers. J ournal of pediatric nursing. 1995; 10(5):311-319.

34. Azar Rima, Solomon Ruth C. Coping strategies of parents facing child
diabetes mellitus. J ournal of pediatric Nursing. 2001;16(6):418-428.
93


35. Wood-Lobiondo G, L Williams, C McGhee. Liver transplantation in children:
maternal and family stress, coping and adaptation. J ournal of special pediatric
nursing. 2004; 9(2):59-66.

36. Lee SL , Chen YC. Stressors and coping behaviors of mothers with child
receiving open heart surgery.Medline. 2001; 9(2):172-182.

37. Wood-Lobiondo G, L Williams, K Kouzekanani , C Mcghee. Family
adaptation to a childs transplant: pretransplant phase.Medline.2000;10(2):81-
87.

38. SM Seppanen, MA Kyngas, MJ Nikkonen. Coping and social support of
parents with a diabetic child. Nursing health science. 1999; 1(1):63-70.

39. L Lowes, P Lyne. A normal life style: parental stress and coping in child hood
diabetes. British journal nursing. 1999;8(3):133-139.

40. Miles MS, Carter MC. Parental stressor scale:Pediatric intensive care unit.
Medline.1985.

41. La Montagne LL, Pawlak R. Stress and coping of parents of children in a
PICU. Heart Lung .1990; (4):416-421.

42. Svavarsdottir EK, Mc Cubbin M. Parenthood transition for parents of an
infant diagnosed with a congenital heart condition. J ournal of paediatric
Nursing.1996; 11(4):207-215.


43. Swallow VM, J acoby A. Mothers coping in chronic childhood illness: The
effect of presymptomatic diagnosis of vesico ureteric reflux. J ournal of
advanced nursing. 2001; 33(1): 69-78.

94


44. Shyamalakumari. Stress experiences and coping strategies adopted by the
mothers of leukemic children in a selected hospital in Karnataka. Unpublished
Masters thesis. Manipal. 1996.

45. Burns Nancy, Grove Susan K. Understanding nursing research. U.S.A.:W.B.
Saunders company ;1995.


46. Mendonca Theresa Leonilda. A study to assess the stress among the mothers
of children admitted to paediatric ward in a selected hospital Mangalore.
Unpublished masters thesis. 1998.

47. Thomas Celinamma. Stress and coping strategies adopted by the mothers of
children with cardio thoracic surgical treatment during the post-operative
period in a selected cardiac hospital. Unpublished masters thesis. 2003.

48. Vargheese U. Stress,coping and effectiveness of communication participation
model of care among mothers of children in pediatric ICU at Calicut.
Unpublished masters thesis. Manipal Academy of higher Education, Manipal,
Karnataka. (2000)


49. Goldberg Susan, Simonons Robert T, Newman J an, Campbell Kathy, Fowler
Rodney S. Congenital heart disease, parental stress and infant mother
relationships. J ournal of pediatrics. 1991;119:661-666.


50. La Montagne Lynda, J ohnson Barbara D, Hepworth J oseph T. Evolution of
parental stress and coping processes: A framework for critical care practice.
J ournal of pediatric nursing. 1995; 10(4):212-218.



95





TABLE OF ANNEXURE
Sl. No Title Page No
1
2
3

4
5
6
7
8




Letter requesting permission to conduct study
Letter seeking permission for validation of tool
Criteria rating scale for validating the questionnaire of stress
scale and coping methods
Content validity certificate
Letter requesting conducting pilot study
Questionnaire on stress level and coping methods(English).
Questionnaire on stress level and coping methods(kannada).
List of content validators



















97


ANNEXURE - 1
LETTER REQUESTING PERMISSION TO CONDUCT STUDY

From
Mrs. Rani Elsa Oommen
2
nd
Year M.Sc. Nursing
The Oxford College of Nursing
Bangalore 78.

To
The Director
Narayana Hrudhayalaya
Bangalore.

Through:
The Principal
The Oxford College of Nursing
Bangalore 78.

Respected Sir,
Sub: Request for permission to conduct study in the Hospital

I Mrs. Rani Elsa Oommen a Post Graduate Nursing student (Paediatric
Nursing) of The Oxford College of Nursing, have selected the below mentioned topic
for Dissertation to be submitted to Rajiv Gandhi University of Health Sciences,
Bangalore, as a partial fulfillment of Master Degree in Nursing.

Title of the study:

Stress level and coping methods of parents of children undergoing cardio
thoracic surgery.

Regarding this, I am in need of your help and co-operation to conduct study in
your hospital in the month of November 2004. Kindly consider and do the needful.

Thanking you in anticipation


Prof. M.C. Belliappa Yours faithfully

(Rani Elsa Oommen)
(Principal)



98


ANNEXURE - 2
LETTER SEEKING PERMISSION FOR VALIDATION

To




Through

The Principal
The Oxford College of Nursing
J .P. Nagar, 1
st
Phase
Bangalore 560 078.

Sub: Seeking permission for validation of the Research Tool

Respected Madam/Sir,

I, Mrs. Rani Elsa Oommen 1
st
Year M.Sc. Nursing (Child Health Nursing)
student at The Oxford College of Nursing, request your good self, if you would kindly
accept to validate my research tool on the topic.
Stress level and coping methods of parents of children undergoing cardio
thoracic surgery.
I would be obliged if you would kindly affirm your acceptance to endorse
your valuable suggestions on this topic. I shall send the details of my study along
with the research tool.
Thanking you in anticipation
Yours Sincerely
(RANI ELSA OOMMEN)
From
Mrs. Rani Elsa Oommen
1
st
Year M.Sc. Nursing
The Oxford College of Nursing
J .P. Nagar, 1
st
Phase
Bangalore 560 078.

Enclosed:
1. Reply letter
2. Self addressed envelope
99


REPLY LETTER

Topic: Stress level and coping methods of parents of children undergoing
cardio thoracic surgery

I,
Agree / disagree to validate the research tool.
Name:
Designation:

Signature:
Date:














100


ANNEXURE - 3
CRITERIA RATING SCALE FOR VALIDATING THE STRESS SCALE AND
COPING QUESTIONNAIRE
Respected Madam/Sir.
Kindly go through the content and place right mark ( ) against questionnaire
in the following columns. When found to be not relevant and needs modification
kindly give your opinion, in the remarks column.

Part: 1 Demographic data
Includes all the relevant variables of the parent and child.
Part: 2 Questionnaire on stress level and coping method
STRESS SCALE

S
No
STATEMEN
TS
Ne
ve
r

R
ar
el
y
So
met
ime
s
Al
wa
ys
Relevant

Appropriat
e
Measurin
g
Rema
rks
1 2 3 4
Agre
e

Dis
agr
ee
Ag
ree
Dis -
agree
Ag
ree
Dis
agr
ee

1 I feel
difficulty in
breathing

2 I feel
nauseated

3 I vomit
4 I have
headache

5 I have loss
of appetite

6 My bowel
movements
are
increased





7

I have
frequency of
passing
urine

8 My heart is
beating fast

9 I have dark
circles
around the
eyes

10. I am
excessively
sweating

11. I have
tremors of
the hand

12. I feel
fatigue

13. I am
confused

14. My blood
pressure is
altered

15. I am
uncertain
about the
outcome of
the
treatment


16. I am
separated



from my
friends
17. I am
separated
from my
friends

18. I have lack
of family
support

19. I have fear
of the
unfamiliar
environment

20. I am afraid
of childs
condition

21. I have fear
about
surgical
intervention
s

22. I am
irritated

23. I get angry
24. I lose my
temper over
small things

25. I get
nervous

26. There is role
reversal
with my
spouse.





27.

I am
blaming
others

28. I lost
interest in
social life

29. My
grooming is
changed

30. My daily
routine
changed

31. I consume
alcohol
more than
usual

32. I smoke
more than
usual

33. I am not
informed
adequately
about my
childs
illness and
treatment.

34. I lost
decision
making
capacity

35. I have
difficulty in



communicat
ion
36. My
communicat
ion with my
spouse is
decreased

37. I cannot
express my
feelings

38. Im not
crying

39. Im
speechless

40. I imagine
that my
childs
condition
become
worse

41. I pray
42. I lost trust in
God

43. I attend
religious
meetings as
many as
possible

44. I am
abusing

45. I am
screaming

46. I am


holding and
touching
others for
relief and
comfort.
47. I am hitting
on the walls
/ others /
self

48. My income
is reduced

49. Treatment
and surgery
are costly

50. Stay in the
hospital is
costly
























106


COPING SCALE

Sl.
No
STATEMENTS Sel
do
m

So
me
tim
es
Oft
en
Al
wa
ys
Relevant Appropri
ate
Measuring Re
ma
rks
1 2 3 4 Ag
ree
Dis
agr
ee
Ag
ree
Dis
agr
ee
Agre
e
Dis
agr
ee

1. I accept the
situation as it
is.


2. I think about
the problem
again and
again to
understand it.


3. I tryout
different ways
of solving the
problem.


4. I try to find
more about
the problem
so that it can
be handled
better.


5. I talk about
the problem
with family
members.


6. I talk about
the problem
with friends


7. I talk with the
parents whose
children have




been in the
same situation
8. I talk with the
professional
person (s)


9. I analyze the
situation to
solve it.


10. I set specific
goals to solve
it.

11. I tell to
myself not to
worry because
everything
would
workout fine.

12. I tell to
myself, this
surgery will
improve my
childs health.

13. I tell to
myself, let
time take care
of the
problem

14. I tell to
myself that all
the health
members will
work together
for the
progress of



my childs
health.
15. I tell to
myself, not to
worry about
the problem.

16. I try to forget
about the
stressful
situation

17. I compare
myself with
others
feelings

18. I try to keep
up a sense of
humor

19. I talk about
childs
problem as
little as
possible.

20. I seek comfort
and help from
the family

21. I seek comfort
and help from
the friends

22. I get prepared
to expect the
worse

23. I hope for the
best

24. I eat
adequately



25. I pray more
than usual

26. I visit places
for worship

27. I consult the
religious
leaders

28. I make special
offerings




































110


ANNEXURE - 4
CONTENT VALIDITY CERTIFICATE


I hereby certify that I have validated the tool of Mrs. Rani Elsa Oommen,
M.Sc. Nursing Student, who is undertaking a study.
Stress level and coping methods of parents of children undergoing cardio
thoracic surgery.






Place: Signature of the expert




Date: Name and Designation


























111


ANNEXURE - 5
LETTER REQUESTING PERMISSION TO CONDUCT A PILOT
STUDY

From
The Principal
The Oxford College of Nursing
1
st
phase, J .P. Nagar
Bangalore 78.

To
The Director,
J ayadeva Institute of Cardiology,
Bangalore.

Respected Sir,
Sub: Letter requesting permission for conducting pilot study

Mrs. Rani Elsa Oommen is a post graduate nursing student of our institution.
She has selected the below mentioned topic for her research project to be submitted to
Rajiv Gandhi University of Health Sciences as a partial fulfillment of Master Nursing
Degree.

Title of the Topic:
A descriptive study to assess the stress levels and coping methods of
parents of children undergoing cardio thoracic surgery.

Regarding this project, she is in need of your esteemed help and co-operation
as she is interested in conducting a study of her project, in your institution. I request
you to kindly permit her to conduct the proposed study and provide her the necessary
facilities.

The student will furnish further details of the study, if required personally.
Please do the needful and oblige.

Thanking you,
Yours faithfully,

(Prof. M.C. BELLIAPPA)
PRIINCIPAL
Place:
Date:






112


ANNEXURE 6
QUESTIONNAIRE ON STRESS LEVEL AND COPING METHODS
ENGLISH VERSION
Consent Form
Dear respondent,
I am a post graduate Nursing student (Paediatric Nursing) from the Oxford
College of Nursing, Bangalore. Conducting a study on to Assess the Stress levels and
Coping Methods of parents of children undergoing Cardio Thoracic Surgery. Hope
you will cooperate with me for the same.
I request you all to answer the given stress and coping Scale with the most
appropriate responses. Kindly do not leave any question unattended. The information
given by you will be kept confidential and used only for the study purpose. Kindly
sign the consent form given below.
Thanking you,
Yours Faithfully,

( Rani Elsa Oommen)
CONSENT FORM
I ---------------------------------------------- here with consent for the above said
study knowing that all the information provided by me will be treated with utmost
confidentiality by the investigator.

Date : Signature of the Participant
Place: Name and Address

113


INSTRUCTION TO THE RESPONDENT
Dear respondents! Here are few statements, which reflects your opinions.
Listen to each statement and kindly check your position on the scale as to whether
you never, rarely, sometimes, often and always as the statements first impress you.
There are no right and wrong answers. So answer according to your own conviction.
The respondents are request to put a tick mark () for any one if the option is given.
Questionnaire contains items on the following aspects.

Part : I It deals with Demographic data of the child and parents.

Part : II Stress Scale and Coping Methods.





























114


BASELINE PERFORMA OF THE CHILD

Hospital number of the child :

Age :

Sex :


BASELINE PERFORMA OF PARENTS

Name :

Age :

Sex :

Religion :

Language :

Relationship to the sick child:

Number of children in the family:

Ordinal position of the child in the family:

Educational qualification :

Occupation :

Previous hospitalization of child:

Family income :













115


STRESS SCALE

Sl.
No
STATEMENTS Never

Rarely Someti
mes
Often Always
Physiological 1 2 3 4 5
1. I feel difficulty in
breathing

2. I feel nauseated
3. I vomit
4. I have headache
5. I have loss of appetite
6. My bowel movements
are increased

7. I have frequency of
passing urine

8. My heart is beating fast
9. I have dark circles
around the eyes

10. I am excessively
sweating

11. I have tremors of the
hand

12. I feel fatigue
13. I am confused
Social
14. I am separated from my
family because of my
childs frequent
hospitalization.

15. I am separated from my
friends because of my
childs frequent
hospitalization.

16. I have difficulty in


communication
17. My communication
with my spouse is
decreased

18. I am not able to
manage home and other
activities

19. Not getting adequate
visiting time to spent
with my child.

20 I can concentrate
during prayer

21. I trust in God
22 I have lack of family
support

23. I lost interest in social
life

24. I feel distressed
regarding lack of
information.

25. I got adequate
information regarding
my childs illness and
treatment.

26. Lack of social support.
Psychological
27. I am irritated
28. I get angry
29. I lose my temper over
small things

30. I get nervous
31. There is role reversal
with my spouse.

32. I have fear about
surgical interventions



33. I imagine that my
childs condition
become worse

34. I am abusing
35. I am screaming
36. I am hitting on the
walls / others / self

37. I feel uneasy when the
doctors and nurses are
unapproachable.

38. I lost decision making
capacity

Physical
39. My grooming is
changed

40. My daily routine
changed

41. I started consuming
alcohol

42. I started smoking
Environmental
43. Sounds and scenes of
ICU makes me scared.

44. I dont have adequate
place for sleeping

45 Observing child
suffering with pain is
painful.

Financial
46. My income is reduced
47. Cost of surgery and
treatment is burden
upon me.



48. Stay in the hospital for
longer duration is
costly.













































119


COPING SCALE

Sl.
No
STATEMENTS Seldom

Some
times
Often Always
0 1 2 3 4
1. I accept the
situation as it is.

2. I think about the
problem again
and again to
understand it.

3. I tryout different
ways of solving
the problem.

4. I try to find more
about the problem
so that it can be
handled better.

5. I talk about the
problem with
family members.

6. I talk about the
problem with
friends

7. I talk with the
parents whose
children have
been in the same
situation.



8. I talk with the
professional
person (s)

9. I analyze the
situation to solve
it.

10. I am holding and
touching others
for relief and
comfort

11. I tell to myself
not to worry
because
everything would
workout fine.

12. I tell to myself,
this surgery will
improve my
childs health.

13. I tell to myself,
let time take care
of the problem

14. I tell to myself
that all the health
members will
work together for
the progress of
my childs health.

15. I tell to myself,
not to worry
about the
problem.



16. I try to forget
about the stressful
situation.

17. I compare myself
with others
feelings

18. I try to keep up a
sense of humor

19. I talk about
childs problem
as little as
possible.


20. I seek comfort
and help from the
family

21. I seek comfort
and help from the
friends

22. I get prepared to
expect the worse

23. I hope for the best
24. I eat adequately
25. I pray more than
usual

26. I visit places for
worship

27. I consult the
religious leaders

28. I make special
offerings

29. I am blaming
others

122


ANNEXUXRE - 8
LIST OF EXPERTS

1. Dr. Assuma Beevi T.M
Associate Professor,
Govt. College of Nursing,
Calicut, Kerala.
2. Mrs. Preethi D Souza
Associate Professor,
St.J ohns College of Nursing
Bangalore.
3. Mrs. Mary Anbarasi J ohnson,
Professor in Nursing,
College of Nursing,
C M C, Velloor, Tamilnadu.
4. Mrs. Veena G. Tauro,
Associate Professor,
M.V. Shetty College of Nursing
Mangalore.
5. Dr. Nagarajaiah,
Asst. Professor,
NIMHANS,
Bangalore.



132

Sample Subjects Variables Instruments Plan of analysis
























Stress level
Copingmethods
-Age of the parents
-Education
-Occupation
-Income
-No of children
Ordinal position of
the child
-Previous
hospitalization
Stress Scale
Low
Stress levels Moderate
High
Parents of
children
undergoing
cardio thoracic
surgery
Coping Scale
Poor
Coping Moderate
methods Good
Demographic
Performa
Stress Vs coping
Stress Vs Selected
variables




INPUT PROCESSES EFFECTORS OUTPUT




















FEED BACK Not included
In the study

CONCEPTUAL FRAMEWORK BASED ON ROYS ADAPTATION MODEL

PARENTS
Internal
environment
* Age
* Sex
External
environment
* Family
* Education
* Occupation
* Family income
* Ordinal
position
of the child
* Previous
hospitalization
* Childs cardio
thoracic surgery
Regulator
& cognator
responses of
parents
* Accept the
situation as it is
* Try to handle
things
* Trust in God
* Pray
* Hope things will
get better.
Physiological effect
*Fatigue
*Breathing difficulty
*Nausea
*Vomiting
*Headache
Psychosocial effect
*Uncertainty about the
treatment
*Decreased
communication
*Low self esteem
*Change in role
*Lack of family &
social support
Economic effect
*Decreased Income
*Cost of treatment
*Length of treatment
Use of
positive
coping
mechanisms
Use of
negative
coping
mechanisms