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A STUDY TO ASSESS THE STRESS AND COPING
STRATEGIES AMONG ELDERLY WIDOWS IN
SELECTED RURAL AREAS, BANGALORE
WITH A VIEW TO DEVELOP AN INFORMATION
PAMPHLET.
PROFORMA FOR REGISTRATION OF SUBJECT
FOR
DISSERTATION
MISS.BEENA VARGHESE
1ST YEAR M.Sc. NURSING
PSYCHIATRIC NURSING
YEAR 2010-2012
HARSHA COLLEGE OF NURSING
HARSHA HOSPITAL CAMPUS
♯193/4, SONDEKOPPA CIRCLE
NH-4, NELAMANGALA,
BANGALORE-562123
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
NAME OF THE CANDIDATE AND
ADDRESS
MS.BEENA VARGHESE
1ST YEAR M.SC.NURSING
HARSHA COLLEGE OF NURSING
HARSHA HOSPITAL CAMPUS
♯193/4, SONDEKOPPA CIRCLE
NH-4, NELAMANGALA,
BANGALORE-562123
NAME OF THE
INSTITUTION
Harsha College of Nursing
Bangalore
COURSE OF THE STUDY
AND SUBJECT
1 year M.sc.Nursing
Psychiatric nursing.
DATE OF ADMISSION
05/05/2010
TITLE OF THE STUDY
To Assess The Stress and Coping Strategies
among Elderly Widows In Selected Rural areas
with a view to develop an information
pamphlet.
6. BRIEF RESUME OF INTENDED WORK:
6.1 INTRODUCTION
“Small minds are much distressed by little things.
Great minds see them all but are not upset by them.”
— Francois de La Rochefoucauld
Life being a continuous struggle from day to day, the hardships of life
brings a lot of stresses and strains. Stress has become endemic over recent
years. Stress is an ambiguous word that is used in different occasions to denote
positive or negative strain in a physical or emotional context.1
Stress in addition to being itself, and the result of itself, is also the cause
of itself. Adaptation as a healthy response to stress has been defined as
restoration of homeostasis to the internal environmental system. The reaction to
stress occurs at different levels, the alarm stage, stage of resistance and the
stage of exhaustion. Domains of adaptation may occur ex: headache, mental
disorders, coronary artery diseases ulcers, colitis and so forth. Without
intervention reversal, exhaustion and even death can ensue. 2
Stress is more likely to occur in situations where the demands are high,
the amount of control an individual has is low, and there is limited support or
help available for the individual. A rapidly changing work situation with
associated role conflict or ambiguity can also be a major cause of occupational
stress. Stress is a dynamic process that changes in quality and quantity in
response to internal and external factors. It has been suggested that the nature
of the profession facilitates an inflexible response to pressure due to the culture
of personal responsibility rather than delegation, and also, the need to provide
best care for each patient rather than making trade-offs in a resource
constrained environment. 3
Experience of stress does not necessarily result in pathological changes
or damages. Stress may be contained within the body’s normal homeostatic
limits. The adaptive coping strategies are awareness, relaxation, meditation,
problem solving, better communication with significant others, taming of pets. 4
A strong support network is your greatest protection against stress.
When you have trusted friends and family members you know you can count
on, life’s pressures don’t seem as overwhelming. So spend time with the people
you love and don’t let your responsibilities keep you from having a social life.
If you don’t have any close relationships, or your relationships are the source of
your stress, make it a priority to build stronger and more satisfying
connections. 5
The effects of stress are directly linked to coping. The study of coping
has evolved to encompass large variety of disciplines beginning with all areas
of psychology such as health psychology, environmental psychology, neuro
psychology and developmental psychology to areas of medicine spreading into
the area of anthropology and sociology. Dissecting coping strategies into three
broad components, (biological/physiological, cognitive, and learned) will
provide a better understanding of what the seemingly immense area is about. 6
The real problem of old age comes, if they are isolated. Old age is not an
accident of life. It is an unavoidable incident of life. You know that it is
coming. It has to come! So, why worry over the inevitable? But, if you don't
make proper plans for your retirement, you are to blame yourself for that. 7
Contrary to the general belief that old age is a stressful period of time,
studies have consistently shown that older adults experience fewer life events
than do younger adults. However, though the overall number of events that
individuals experience may decline with advancing aging, some specific types
of life events are more likely to be encountered in later life. Illness and injury,
hospitalization, and the death of a spouse or a friend are examples of
undesirable life events that are more prevalent in old age. Using a large sample
of community-dwelling older adults, Stanley Murrell and colleagues (1984)
showed that over half of their sample had experienced hospitalization, either
their own or that of significant others, in the past year. Of course, some other
types of life events, such as family conflict and problems with jobs, are less
prevalent in older adults. 8
Chronic strains can even change the context and outcomes of major life
events. Research suggests that highly strained caregivers show some recovery
of functioning after the death of a spouse, while non caregivers react with
increased depression. Since chronic strains and life events interact in a variety
of ways, examination of both life events and chronic strains is helpful in
understanding individuals' responses to life events. 9
6.2 NEED FOR THE STUDY:
"Stress resides neither in the situation nor in the person; does it depend
on a transaction between the two."
Stress is a common problem that affects almost all of us at some point in
our lives. Learning to identify when you are under stress, what is stressing you,
and different ways of coping with stress can greatly improve both your mental
and physical well being.
Modern life is full of hassles, deadlines, frustrations, and demands. For
many people, stress is so commonplace that it has become a way of life. Stress
isn’t always bad. In small doses, it can help you perform under pressure and
motivate you to do your best. But when you’re constantly running in
emergency mode, your mind and body pay the price.
Stress symptoms may be affecting the aged health, even though one
might not realize it. They may think illness is to blame for that nagging
headache, your frequent forgetfulness or your decreased productivity at work.
But sometimes stress is to blame. Indeed, stress symptoms can affect the body,
thoughts, feelings, and
behavior. When one recognize common stress
symptoms, can take steps to manage them. 10
Due to stress one will face potentially serious health problems also can
cause some of these symptoms. If you not sure if stress is the cause or if you've
taken steps to control your stress but symptoms continue, consult the doctor.
Also, if one have chest pain, especially if it occurs during physical activity or is
accompanied by shortness of breath, sweating, dizziness, nausea or pain
radiating into your shoulder and arm, get emergency help immediately. These
signs and symptoms may indicate a heart attack and not simply stress
symptoms it may have adverse effect on elders they should know about coping
strategies.
Social isolation and physical ageing can prove to be a destructive
combination, resulting in more stress hormones flowing through the body. A
recent study conducted by Louise Hawkley and John Cacioppo, psychologists
of the University of Chicago, has shown that the toll of loneliness may be
placid and unremarkable in early life, but may go up with time. The
researchers, who reported their findings in the August 2007 issue of Current
Directions in Psychological Science, a journal of the Association for
Psychological Science, studied college-age individuals and adults aged 50 to
68.11
When the psychologists looked at the lives of the middle-aged and old
people in their study, they found that though the lonely ones reported the same
number of stressful life events, they identified more sources of chronic stress
and recalled more childhood adversity. Moreover, they differed in how they
perceived their life experiences. The researchers report that, even when faced
with similar challenges, the lonelier people appeared more helpless and
threatened. They were also less likely to seek meaningful help when stressed.
Stress hormones are involved in fighting inflammation and infection, it
is apparent that loneliness contributes to the wear and tear of ageing through
this pathway as well. When people experience stress, the bodies normally rely
on restorative processes like sleep. But when the they monitored the older
volunteers sleep, they found that the nights of the lonely were broken by many
awakenings. 12
A longitudinal study was conducted on psychosocial factors affecting
adaptation to bereavement in the elderly A spouse's death requires more
readjustment on the part of the bereaved than any other stressful life event. This
finding holds across the many age groups and cultural backgrounds that have
been studied. Although it is unclear as to whether the stress of bereavement is
greater for women than for men, for the young than for the old, for one
socioeconomic level or for another, a critical review of the literatures suggests
the following: Negative changes in physical health, mortality rate and mental
health status usually accompany widowhood; Complex social-psychological
variables such as the individual's characteristic ways of coping with stress , the
adequacy of the social network - plus other factors such as income and
religious commitment - may attenuate widowhood's negative impact.
Suggestions for further research include studies exploring differential
adaptation to widowhood across age groups and in elderly men and women,
and longitudinal studies tracing the process of recovery from acute grief. 13
A telephone survey was conducted on Coping strategies and care giving
outcomes among rural caregivers, they studied the coping styles by which
family caregivers living in rural areas of Alabama deal with the demands of
caring for an older relative. Data were obtained from a sample of 141
caregivers through the random-digit dialing telephone survey. Two coping
styles were identified: deliberate coping and avoidance coping. Deliberate
coping was related to higher life satisfaction scores and, avoidance coping was
related to lower life satisfaction scores and higher caregiver burden scores.
Avoidance coping appeared to moderate the effects of caregiver health on
caregiver burden. Social workers should pay greater attention to caregivers
with dysfunctional coping styles. 14
A study was conducted on Phenomenology and treatment of
bereavement-related distress in the elderly While brief periods of bereavementrelated distress should be neither pathologized nor treated, periods of distress
lasting several months that meet criteria for major depressive episode and, in
particular, for what we now refer to as traumatic grief reactions, are strongly
associated with considerable psychiatric and physical morbidity and deserve
careful clinical attention. As yet, they have no objective data on the outcome of
this procedure in traumatic grievers, but clinical outcomes have been consistent
with Foa's theory that re-experiencing the trauma and exposure to avoided
situations under controlled conditions ultimately leads to reductions in
subjective distress. We are currently planning an open treatment development
trial of this form of traumatic grief therapy. 15
Hence the investigator felt that these studies help the elderly women to enhance
their knowledge regarding stress and coping strategies, if they receive advance
and adequate information to lead a better life, cope up with the stress.
6.2. REVIEW OF LITERATURE
A review of literature refers to activities involved in identifying and
searching for information on a topic, developing and understanding the state of
knowledge on a topic. It is an extensive, systematic selection of potential
sources of previous work, which acquaints the investigator with fact finding
work after scrutinization. Polit& Hungle state that review of literature provides
readers with a background for understanding the significant of the study. 16
The review of literature is divided in to following headings
Section A: review of literature related to stress among elderly widows
Section B: Review of literature related to coping strategies among elderly
widows
Section A: review of literature related to stress among elderly widows
The survey was conducted on Health outcomes of bereavement In this
Review, they look at the relation between bereavement and physical and mental
health. Although grief is not a disease and most people adjust without
professional psychological intervention, bereavement is associated with excess
risk of mortality, particularly in the early weeks and months after loss. It is
related to decrements in physical health, indicated by presence of symptoms
and illnesses, and use of medical services. Furthermore, bereaved individuals
report diverse psychological reactions such as extreme stress. For a few people,
mental disorders or complications in the grieving process ensue. they
summarized research on risk factors that increase vulnerability of some
bereaved individuals. Diverse factors are likely to co-determine excesses in illhealth. They also assess the effectiveness of psychological intervention
programmes. Intervention should be targeted at high-risk people and those with
complicated grief or bereavement-related depression and stress disorders. 17
A cohort study was conducted on Traumatic grief as a risk factor for
mental and physical morbidity. The aim of this study was to confirm and
extend the authors' previous work indicating that symptoms of traumatic grief
are predictors of future physical and mental health outcomes. The study group
consisted of 150 widows and widowers interviewed Survival and regression
analyses indicated that the presence of traumatic grief symptoms approximately
6 months after the death of the spouse predicted such negative health outcomes
as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in
eating habits at 13- or 25-month follow-up. : The results suggest that it may not
be the stress of bereavement, per se, that puts individuals at risk for long-term
mental and physical health impairments and adverse health behaviors. Rather,
it appears that psychiatric sequelae such as traumatic grief are of critical
importance in determining which bereaved individuals will be at risk for longterm dysfunction. 18
A prospective study was conducted on complicated grief and
bereavement-related depression as distinct disorders: preliminary empirical
validation in elderly bereaved spouses. This study sought to determine whether
a set of symptoms interpreted as complicated grief could be identified and
distinguished from bereavement-related depression and whether the presence of
complicated grief would predict enduring functional impairments. Data were
derived from a study group of 82 recently widowed elderly individuals
recruited for an investigation of physiological changes in bereaved persons.
Baseline data were collected 3-6 months after the deaths of the subjects'
spouses, and follow-up data were collected from 56 of the subjects 18 months
after the baseline assessments. A principal-components analysis conducted on
intake data (N = 82) revealed a complicated grief factor and a bereavementdepression factor. Seven symptoms constituted complicated grief: searching,
yearning, preoccupation with thoughts of the deceased, crying, disbelief
regarding the death, feeling stunned by the death, and lack of acceptance of the
death. Baseline complicated grief scores were significantly associated with
impairments in global functioning, mood, sleep, and self-esteem in the 56
subjects available for follow-up. 19
A study was conducted on bereavement and late-life depression: grief
and its complications in the elderly. Spousal bereavement is a common event in
later life and, not infrequently, an important cause of psychiatric and medical
morbidity.
Depression,
anxiety,
substance
abuse,
and
symptoms
of
"complicated" grief are among the more important psychiatric sequelae of
spousal bereavement. They may represent, in part, forms of abnormal reaction
to the stress of loss and the challenges of adaption to becoming widowed. This
paper summarizes current knowledge about the clinical phenomenology of the
psychiatric sequelae to late-life attachment bereavement, some of the
hypothesized antecedents of abnormal stress response to bereavement,
psychobiologic correlates of bereavement-related depression, and the long-term
course. 20
A study was conducted on Anxiety among widowed elders: is it distinct
from depression and grief The purpose of this study was to test the validity and
utility of distinguishing symptoms of anxiety from those of depression and
grief in recently spousal bereaved elders. They also examined pathways from
baseline (six months or less post-spousal death) to follow-up (12 and 18
months post-death) levels of anxiety, depression and grief-related symptoms.
Baseline and follow-up data were available from 56 recently widowed elderly
subjects recruited for an investigation of physiological changes in bereavement.
Confirmatory factor analyses indicated that a model in which anxiety was
specified as a third factor, apart from depression and grief factors, fit the data
well and significantly better than either the one or two factor models. Path
analyses revealed that both baseline severity of grief and anxiety had
significant lagged effects and predicted follow-up severity of depression.
Symptoms of anxiety appeared distinct from those of depression and grief, and
the anxiety, depression and grief factors differentially predicted subsequent
symptomatology. These findings suggest a need for more specific identification
and treatment of stress, depression and grief symptoms within the context of
late-life spousal bereavement. 21
Section B: Review of literature related to coping strategies among elderly
widows
An analytical study was conducted on Appraisals of bereavement,
coping, resources, and psychosocial health dysfunction in widows and
widowers. The purpose of the study was to test a model, based on Lazarus and
Folkman's (1984) stress-coping framework, on widowed persons' psychosocial
health dysfunction after conjugal bereavement. Older widows (n = 100) and
widowers (n = 59) were identified through church burial records and
interviewed using the Ways of Coping Checklist, Sickness Impact Profile, and
questionnaires to assess appraisal of bereavement and resources. Path analysis
indicated that lower threat appraisal, more problem-focused and less emotionfocused coping, greater resource strength, and younger age had direct effects
on reducing psychosocial health dysfunction, explaining 30% of the variance.
Higher threat appraisal influenced the use of more problem- and emotionfocused coping strategies. 22
A descriptive study was conducted on the health of conjugally bereaved
older widows: the role of appraisal, coping and resources Relationships
between bereavement, coping, resources, and health dysfunction were
investigated in 100 older women (M age = 71.3 years) widowed from 1 to 12
months prior to the interview. Differences in coping for those who appraised
their bereavement as either (a) harmful loss, but without major accompanying
losses, (b) harmful loss with other anticipated threats, or (c) a challenge were
hypothesized. Data collection included use of the Ways of Coping Checklist,
Sickness Impact Profile, and appraisal of bereavement and resources. The
appraisal groups differed significantly in overall problem-focused coping,
wishful thinking, help seeking/avoidance, self blame, and growth-oriented
coping. There was no difference in use of emotion-focused coping and ways to
minimize threat and seek social support. Social support, strong religious
beliefs, practice of rituals, belief in control over bereavement, and good prior
mental health were related to less psychosocial and/or physical dysfunction.
Greater numbers of resources, but not greater numbers of coping strategies,
also were related to less psychosocial and/or physical dysfunction.
A study was conducted on Mood and stress disorders in widowhood: a
systematic review, the association between widowhood and mental health
problems, such as depressive symptomatology and stress, has been examined
extensively. Eleven studies were identified, exploring the prevalence and
incidence of mood and anxiety disorders in 3,481 widowed individuals and
4,685 non-widowed controls. As expected, the prevalence of Major Depressive
Disorder (MDD) and anxiety disorders were considerably elevated in widowed
individuals, especially in the first year after the loss of a spouse. During the
first year of bereavement, almost 22% of the widowed were diagnosed as
having MDD; almost 12% met diagnostic criteria for Post Traumatic Stress
Disorder; and there were higher risks of Panic Disorder and Generalized
Anxiety Disorder. The incidence rate of MDD and several anxiety disorders
ranged from 0.08-0.50. The relative risk of developing a mood or anxiety
disorder ranged from 3.49-9.76, in the widowed, compared to control subjects.
23
6.3 STATEMENT OF THE PROBLEM
A Study to Assess the Stress and Coping Strategies Among Elderly Widows in
Selected Rural Areas, Bangalore, With a View to Develop an Information
Pamphlet.
6.4 OBJECTIVES
1. To assess the level of stress among elderly widows.
2. To assess the coping knowledge among elderly widows.
3. To associate the level stress and coping strategies of elderly widows
with selected demographic variables.
4. To develop information pamphlet regarding stress management.
6.5 OPERATIONAL DEFINITIONS
1. Assess: Statistical measurements of responses to the checklist stated in
the tool regarding stress and coping stratergies.
2. Stress: A mentally or emotionally upsetting condition occurring in
response to adverse external influences and capable of affecting physical
health,
3. Coping strategies: It is the process of making an effort to solve
personal and interpersonal problems, and seeking to minimize, reduce or
tolerate stress.
4. Elderly widows: The women who lost her husband and within the age
group of 45 to 60.
5. Information Guide Sheet: It is the guide sheet which contains more
information regarding stress management among elderly widows.
6.6 ASSUMPTIONS.
1. Elderly widows may have insufficient knowledge regarding stress and
coping strategies.
2. Information booklet may enhance the coping strategies of elderly
widows.
6.7. HYPOTHESIS
H1- There is a significant association between the level of stress and coping
strategies among elderly widows with selected demographic variables.
7. MATERIALS AND METHODS
7.1 SOURCE OF DATA
The data will be collected from elderly widows from selected rural areas,
Bangalore.
7.2 METHODS OF DATA COLLECTION
i. Research Design:
Non experimental, descriptive approach
ii .Research Variables
1. Research variables: stress and coping strategies among elderly
widows.
2. Demographic variables: Age, no years after the death of
spouse, religion,
family income, no of children, source of
information.
iii. Setting
The study will be conducted at selected rural areas, Bangalore.
iv. Population
The elderly widows living in a selected rural areas.
v. Sample
The elderly widows at selected rural areas who fulfills the inclusion
criteria. Sample size is 60.
vi. Criteria for sample selection
 Inclusion Criteria
 The widows between the age group of 45 to 60.
 Who are willing to give consent.
 Who are willing to participate.
 Exclusion Criteria
 Who are not available at the time of data collection
 Who are not willing to participate.
vii. Sampling technique
Non Probability sampling, purposive sampling.
viii. Tool for data collection
The tool consists of following sections
Section A: Consists of Demographic Performa of elderly widows like age,
no of years after the death of spouse, religion, family income, no of
children, source of information.
Selection B: Consists of checklist to assess the level of stress and coping
strategies among elderly widows.
ix. Method of data collection
The researcher will collect the data from subjects after informed consent
and Obtaining the permission from concerned authorities .
Duration of the study: Four weeks
x. Plan for data analysis
The data collected will be analyzed by using descriptive & inferential
statistics.
Descriptive Statistics
Frequency, percentage distribution, mean, median & standard deviation will
be used to assess the level stress among elderly widows.
Inferential Statistics
Un paired’ test, Chi-square will be used to associate the level of stress and
coping strategies of elderly widows with selected demographic variable.
xi. Projected outcome
The investigator will be able to give appropriate instructions to the elderly
widows regarding the aspects of stress and coping strategies based on results of
the study. It will help to reduce the stress in future.
7.3. Does the study require any investigation to the patients or other
human beings of animals?
No.
7.4. Has ethical clearance been obtained from your college?
YES, informed consent will be obtained from the institution, authorities,
privacy; confidentiality and anonymity will be guarded. Scientific objectivity of
the study will be maintained with honesty and impartiality.
8. BIBLIOGRAPHY
1. Aldwin, C.M., ed. (2003). Stress, Coping and Development: An
integrative perspective. New York: Guildford.
2. Bernard, L. C., & Krupat, E. (2004). Health Psychology:
Biopsychosocial Factors in Health and Illness. New York: Harcourt
Brace College Publishers.
3. Cannon, W.B. (2008). The Wisdom of the Body. New York:
Norton.
4. Dienstbier, R. A. (2009). Arousal and physiological toughness:
Implications for mental and physical health. Psychological Review,
96:84-100.
5. Emmons, R.A., & King, L.A. (2008). Conflict among personal
strivings: Immediate and long-term implications for psychological
and physical well-being. Journal of Personality and Social
Psychology, 54:1040-1048.
6. Franken, R.E. (2004). Human Motivation, 3rd ed. Belmont, CA:
Brooks/Cole Publishing Company.
7. Frankenhaeuser, M. (2006). A psychobiological framework for
research on human stress and coping. In M.H. Appley and R.
Trumbll, eds. Dynamics of stress: Physiological, psychological,
and social perspectives. New York: Plenum.
8. Frijda, N.H. (2008). The laws of emotions. American Psychologist,
43:349-353.
9. Holroyd, K.A., & Lazarus, R.S. (2002). Stress, coping, and somatic
adaptation . In L. Goldberger and S. Breznitz, eds. Handbook of
Stress: Theoretical and Clinical Aspects. New York: The Free
Press.
10. Lazarus, R.S., & Folkman, S. (2004). Stress, Appraisal and Coping.
New York: Guilford.
11. Lazarus, R.S., & Launier, R. (2008). Stress-related transactions
between person and environment. In L. A. Pervin & M. Lewis, eds.
Perspectives in Interactional Psychology. New York: Plenum.
12. Mandler, G. (2002). Stress and Though Processes. In L. Goldberger
and S. Breznitz, eds. Handbook of Stress: Theoretical and Clinical
Aspects. New York: The Free Press.
13. Merton, R.K. (2007). Social structure and anomie. In R. K. Merton,
ed. Social Theory and Social Structure, 2nd ed. New York: Free
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14. Pearlin, L. I. (2002). The social contexts of stress. In L. Goldberger
and S. Breznitz, eds. Handbook of Stress: Theoretical and Clinical
Aspects. New York: The Free Press.
15. Selye, H. (2006). The Stress of Life. New York: McGraw-Hill.
16. Polit DF,Beck CT, Nursing research principles and methods. 7th
edition.New delhi; wotters kluwer health india;2007:88-89
17. Selye, H. (2006). Stress in health and disease. Reading, MA:
Butterworth.
18. Selye, H. (2002). History and present status of the stress concept.
In L. Goldberger and S. Breznitz, eds. Handbook of Stress:
Theoretical and Clinical Aspects. New York: The Free Press.
19. Selye, H. (2005). History and present status of the stress concept.
In A. Monat & R.S. Lazarus, eds. Stress and Coping, 2nd ed. New
York: Columbia University.
20. Zakowski, S., Hall, M.H. & Baum, A. (2002). Stress, stress
management, and the immune system. Applied and Preventative
Psychology, 1:1-13.
21. Murray Beckman. Psychiatric mental health nursing. 1st ed. New
Jersey: Prentice Hall; 1983. p. 371-431.
22. Cooper CL. Introduction In: Cooper CL, Theories of organizational
stress. Oxford: Oxford University Press; 1998. p. 1-5,
23. Lovall William. Stress and healing. 1st ed. New Delhi: Sage
Publications; 2007. p. 146-149.
9. Signature of the candidate
10. Remarks of the guide
:
:
11. Name and designation of
11.1 Guide
:
11.2 Signature
:
11.3 Co- guide (if any)
:
11.4 Signature
:
11.5 Head of the department
:
12.1 Remarks of the principal
:
12.2 Signature
: