Here are some factors that may be related to Ineffective Coping:

 Confusion in pattern of appraisal of threat or pattern of tension release

 Gender differences in coping strategies
 High degree of threat
 Inability to conserve adaptive energies
 Inadequate available resources
 Inadequate level of confidence in ability to cope
 Inadequate preparation for stressors
 Inadequate support system
 Maturational crises
 Situational crises
 Uncertainty

Defining Characteristics

Ineffective Coping is characterized by the following signs and symptoms:

 Abuse of chemical agents

 Change in usual communication patterns
 Destructive behavior toward self or others
 Fatigue
 High illness rate
 Inability to ask for help
 Inability to make decisions
 Inability to meet role expectations
 Inadequate problem-solving
 Inappropriate use of defense mechanisms
 Lack of goal-directed behavior
 Poor concentration
 Verbalization of inability to cope
 Sleep disturbances

Goals and Outcomes

The following are the common goals and expected outcomes for Ineffective Coping:

 Patient communicates needs and negotiates with others to meet needs.

 Patient describes and initiates effective coping strategies.
 Patient describes positive results from new behaviors.
 Patient focuses on the present.
 Patient identifies personal strengths and accepts support through the nursing
relationship.
 Patient makes decisions and follows through with appropriate actions to change
provocative situations in the personal environment.
 Patient uses available resources and support systems.
 Patient verbalizes feelings related to emotional state.

Nursing Assessment

Assessment is required in order to distinguish possible problems that may have lead
to Ineffective Coping as well as name any episode that may happen during nursing care.

Assessment Rationales

Behavioral and physiological responses to stress

Assess for the presence of
can be varied and provide clues to the level of
defining characteristics.
coping difficulty.

Assess for the influence of

The patient’s coping behavior may be based on
cultural beliefs, norms, and
cultural perceptions of normal and abnormal coping
values on the patient’s
behavior.
perceptions of effective coping.

Observe for causes of ineffective

coping such as poor self-concept, Situational factors must be identified to gain an
grief, lack of problem-solving understanding of the patient’s current situation and
skills, lack of support, or recent to aid patient with coping effectively.
change in life situation.

Assess for intergenerational

Intergenerational family problems put families at
family problems that can
risk of dysfunction.
overwhelm coping abilities.
 Accurate appraisal can facilitate development of
appropriate coping strategies. Because a patient
has an altered health status does not mean the
Identify specific stressors. coping difficulties he or she exhibits are only (if at
all) related to that. Persistent stressors may
exhaust the patient’s ability to maintain effective
coping.

Family members who are coping with critical

Observe for strengths such as
injuries often feel defeated, hopeless, and like a
the ability to relate the facts and
failure; therefore it is necessary to verbally praise
to acknowledge the source of
them for their strengths and use those strengths to
stressors.
aid functioning.

Patients may believe that the threat is greater than

their resources to handle it and feel a loss of control
over solving the threat or problem. The patient’s
Determine the patient’s
cultural heritage and previous experiences may
understanding of the stressful
affect the patient’s understanding of and response
situation.
to the present situation. This information provides a
foundation for planning care and choosing relevant
interventions.

Successful adjustment is influenced by previous

Analyze past use of coping coping success. patients with a history of
mechanisms including decision- maladaptive coping may need additional resources.
making and problem-solving. Likewise, previously successful coping skills may be
inadequate in the present situation.

Monitor risk of harming self or

A patient with hopelessness and an inability to
others and intervene
problem solve often runs the risk of suicide.
appropriately.

Patients may have support in a single setting, such

Evaluate resources and support
as during hospitalization, yet lack sufficient support
systems available to the patient.
in the home setting.

Identify an emergency plan should the patient

Assess for suicidal tendencies.
become suicidal. A suicidal patient is not safe in the
Refer for mental health care
home environment unless supported by professional
immediately if indicated.
help.

Nursing Interventions

The following are the therapeutic nursing interventions for Ineffective Coping:
 Interventions Rationales

An ongoing relationship establishes trust,

Set a working relationship with the
reduces the feeling of isolation, and may
patient through continuity of care.
facilitate coping.

Assist patient set realistic goals and Involving patients in decision making helps
identify personal skills and knowledge. them move toward independence.

Verbalization of actual or perceived threats

Provide chances to express concerns,
can help reduce anxiety and open doors for
fears, feeling, and expectations.
ongoing communication.

Acknowledging and empathizing creates a

Use empathetic communication. supportive environment that enhances
coping.

An honest relationship facilitates problem-

solving and successful coping. False
Convey feelings of acceptance and
reassurances are never helpful to the
understanding. Avoid false reassurances.
patient and only may serve to relieve the
discomfort of the care provider.

Encourage patient to make choices and

Participation gives a feeling of control and
participate in planning of care and
increases self-esteem.
scheduled activities.

During crises, patients may not be able to

Encourage the patient to recognize his recognize their strengths. Fostering
or her own strengths and abilities. awareness can expedite use of these
strengths.

Consider mental and physical activities

Interventions that improve body awareness
within the patient’s ability (e.g., reading,
such as exercise, proper nutrition, and
television, outings, movies, radio, crafts,
muscular relaxation may be helpful for
exercise, sports, games, dinners out,
treating anxiety and depression.
and social gatherings).

It can be helpful for the patient to recognize

Assist patients with accurately that he or she has the skills and reserves of
evaluating the situation and their own strength to effectively manage the situation.
accomplishments. The patient may need help coming to a
realistic perspective of the situation.

If the patient is physically capable, Aerobic exercise improves one’s ability to

encourage moderate aerobic exercise. cope with acute stress.

Provide information the patient wants Patients who are coping ineffectively have
and needs. Do not give more than the reduced ability to absorb information and
patient can handle. may need more guidance initially.

Provide touch therapy with permission. A soothing touch can reveal acceptance and
Give patient a back massage using slow, empathy. Slow stroke back massage
rhythmic stroking with hands. Use a rate decreased heart rate, decreased systolic and
of 60 strokes a minute for 3 minutes on diastolic blood pressure, and increased skin
2-inch wide areas on both sides of the temperature at significant levels. The
spinous process from the crown to the conclusion is that relaxation is induced by
sacral area. slow stroke back massage.

Assist the patient with problem-solving Constructive problem solving can promote
in a constructive manner. independence and sense of autonomy.

In traumatic situations, families have a need

for information and explanations. Providing
Provide information and explanation
information prepares the patient and family
regarding care before care is given.
for understanding the situation and possible
outcomes.

The presence of noise associated with

Eliminate stimuli in an environment that
medical equipment can increase anxiety and
could be misinterpreted as threatening.
make coping more challenging.

Communication with the medical staff

Discuss changes with patient before
provides patients and families with
making them.
understanding of the medical condition.

Opportunities to role-play or rehearse

Provide outlets that foster feelings of
appropriate actions can increase confidence
personal achievement and self-esteem.
for behavior in actual situations.

Patients who are coping ineffectively may

Point out signs of positive progress or
not be able to assess their progress toward
change.
effective coping.

Relaxation techniques, desensitization, and

Encourage use of cognitive behavioral
guided imagery can help patients cope,
relaxation (e.g., music therapy, guided
increase their sense of control, and allay
imagery).
anxiety.

Be supportive of coping behaviors; give A supportive presence creates a supportive

patient time to relax. environment to enhance coping.
 Discuss with patient about his or her Describing previous experiences strengthens
previous stressors and the coping effective coping and helps eliminate
mechanisms used. ineffective coping mechanisms.

Use distraction techniques during Distraction is used to direct attention toward

procedures that cause patient to be a pleasurable experience and block the
fearful. attention of the feared procedure.

Apply systematic desensitization when

introducing new people, places, or Fear of new things diminishes with repeated
procedures that may cause fear and exposure.
altered coping.

Arranging for referral assists the patient in

working with the system, and resource use
Refer for counseling as necessary.
helps to develop problem-solving and coping
skills.

Refer to medical social services for This will promote adequate coping as part of
evaluation and counseling. the medical plan of care.

Based on knowledge of the home and

If the patient is associated with the family, home care nurses can often
mental health system, actively engage advocate for patients. These nurses are
in mental health team planning. often requested to monitor medications and
therefore need to know the plan of care.

Fear
Fear Definition

Response to perceived threat that is consciously recognized as a danger

Defining Characteristics:

Report of:

 apprehension;
 increased tension;
 decreased self-assurance;
 excitement;
 being scared;
 jitteriness;
 dread;
 alarm;
 terror;
 panic
Cognitive
 Identifies object of fear;
 stimulus believed to be a threat;
 diminished productivity, learning ability, problem-solving ability
Behaviors
 Increased alertness;
 avoidance or attack behaviors;
 impulsiveness;
 narrowed focus on "it" (i.e., the focus of the fear)
Physiological
 Increased pulse;
 anorexia;
 nausea;
 vomiting;
 diarrhea;
 muscle tightness;
 fatigue;
 increased respiratory rate and shortness of breath;
 pallor;
 increased perspiration;
 increased systolic blood pressure;
 pupil dilation;
 dry mouth

Related Factors:
 Natural/innate origin (e.g., sudden noise, height, pain, loss of physical support);
 learned response (e.g., conditioning, modeling from or identification with others);
 separation from support system in potentially stressful situation (e.g., hospitalization, hospital procedures);
 unfamiliarity with environmental experience(s);
 language barrier;
 sensory impairment;
 innate releasers (neurotransmitters);
 phobic stimulus
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

 Fear Control
Client Outcomes
 Verbalizes known fears
 States accurate information about the situation
 Identifies, verbalizes, and demonstrates those coping behaviors that reduce own fear
 Reports and demonstrates reduced fear
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

 Coping Enhancement

Nursing Interventions and Rationales

1. Assess source of fear with client.
Fear is a normal response to actual or perceived danger and helps mobilize protective defenses.

2. Have the client draw the object of their fear. This is a reliable assessment tool for children.
Because human figure drawings are reliable tools for assessing anxiety and fears in children, practitioners should
incorporate these drawings as part of their routine assessments of fearful children (Carroll, Ryan-Wenger, 1999).

3. Discuss situation with client and help distinguish between real and imagined threats to well-being.
The first step in helping the client deal with fear is to collect information about the situation and its effect on the client and
significant others (Bailey, Bailey, 1993).

4. If irrational fears based on incorrect information are present, provide accurate information.
Correcting mistaken beliefs reduces anxiety (Beck, Emery, 1985).

5. If client's fear is a reasonable response, empathize with client. Avoid false reassurances and be truthful.
Reassure clients that seeking help is both a sign of strength and a step toward resolution of the problem (Bailey, Bailey,
1993).

6. If possible, remove the source of the client's fear with accurate and appropriate amounts of information.
Clients' uncertainty regarding the outcomes can lead to feelings of distress. In one study, the major strategy used to
reduce distress was information management, in which the amount and type of incoming information was controlled
(Shaw, Wilson, O'Brien, 1994). Fear is a normal response to actual or perceived danger; if the threat is removed, the
response will stop.

7. If possible, help the client confront the fear.

Self-discovery enhances feelings of control.

8. Stay with clients when they express fear; provide verbal and nonverbal (touch and hug with permission) reassurances
of safety if safety is within control.
The nurse's presence and touch demonstrate caring and diminish the intensity of feelings such as fear (Olson, Sneed,
1995). Of 376 patients surveyed in 20 family practices throughout Ontario, Canada, 66% believe touch is comforting and
healing and view distal touches (on the hand and shoulder) as comforting (Osmun et al, 2000).

9. Explain all activities, procedures (in advance when possible), and issues that involve the client; use nonmedical terms;
calm, slow speech; and verify client's understanding.
Deficient knowledge or unfamiliarity is one factor associated with fear (Johnson, 1972; Garvin, Huston, Baker, 1992;
Whitney, 1992).

10. Explore coping skills used previously by client to deal with fear; reinforce these skills and explore other outlets.
Methods of coping with anxiety that have previously been successful are likely to be helpful again (Clunn, Payne, 1982).

11. Provide backrubs for clients to decrease anxiety.

The dependent variable, anxiety, was measured before back massage, immediately following, and 10 minutes later on
four consecutive evenings. There was a statistically significant difference in the mean anxiety (STAI) score between the
back massage group and the no-intervention group (Fraser, Kerr, 1993).

12. Provide massage before procedures to decrease anxiety.

Massage was done by parents before venous puncture of hospitalized preschoolers and school-age children. The results
obtained indicated that massage had significant effect on nonverbal reactions, especially those related to muscular
relaxation. (Garcia, Horta, Farias, 1997).

13. Use therapeutic touch (TT) and healing touch techniques.

Various techniques that involve intention to heal, laying on of hands, clearing the energy field surrounding the body, and
transfer of healing energy from the environment through the healer to the subject can reduce anxiety (Fishel, 1998).
Anxiety was reduced significantly in a TT group but was unchanged in a TT placebo group. Healing touch may be one of
the most useful nursing interventions available to reduce anxiety (Fishel, 1998).

14. Refer for cognitive behavioral group therapy.

In this study of 253 persons with neck or back pain, the experimental group who received the standardized six-session
cognitive behavioral group sessions had significantly better results with regard to fear avoidance beliefs than the
comparison group (Linton, Ryberg, 2001).
15. Animal-assisted therapy (AAT) can be incorporated into the care of perioperative patients.
In a study done on perioperative clients, interacting with animals was shown to reduce blood pressure and cholesterol,
decrease anxiety, and improve a person's sense of well-being (Miller, Ingram, 2000).
Refer to care plans for Anxiety and Death Anxiety.

Geriatric

1. Establish a trusting relationship so that all fears can be identified.

An elderly client's response to a real fear may be immobilizing.

2. Monitor for dementia and use appropriate interventions.

Fear may be an early indicator of disorientation or impaired reality testing in elderly clients.

3. Note if the client is irritable and is blaming others.

Recent findings in nursing research support the presence of these other behaviors as symptoms of depression (Proffitt,
Augspurger, Byrne, 1996).

4. Provide a protective and safe environment, use consistent caregivers, and maintain the accustomed environmental
structure.
Elderly clients tend to have more perceptual impairments and adapt to changes with more difficulty than younger clients,
especially during an illness.

5. Observe for untoward changes if antianxiety drugs are taken.

Advancing age renders clients more sensitive to both the clinical and toxic effects of many agents.

Multicultural

1. Assess for the presence of culture-bound anxiety/fear states.

The context in which anxiety/fear is experienced, its meaning, and responses to it are culturally mediated (Kavanagh,
1999; Charron, 1998).

2. Assess for the influence of cultural beliefs, norms, and values on the client's perspective of a stressful situation.
What the client considers stressful may be based on cultural perceptions (Leininger, 1996).

3. Identify what triggers fear response.

Arab Muslim clients may express a high correlation between fear and pain (Sheets, El-Azhary, 1998).

4. Identify how the client expresses fear.

Research indicates that the expression of fear may be culturally mediated (Shore, Rapport, 1998).

5. Validate the client's feelings regarding fear.

Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client
relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

1. During initial assessment, determine whether current or previous episodes of fear relate to the home environment (e.g.,
perception of danger in home or neighborhood or of relationships that have a history in the home).
Investigating the source of the fear allows the client to verbalize feelings and determine appropriate interventions.

2. Identify with client what steps may be taken to make the home a "safe" place to be.
Identifying a given area as a safe place reduces fear and anxiety when the client is in that area.

3. Encourage the client to seek or continue appropriate counseling to reduce fear associated with stress or to resolve
alterations in thought processes.
Correcting mistaken beliefs reduces anxiety.

4. Encourage the client to have a trusted companion, family member, or caregiver present in the home for periods when
fear is most prominent. Pending other medical diagnoses, a referral to homemaker/home health aide services may meet
this need.
Creating periods when fear and anxiety can be reduced allows the client periods of rest and supports positive coping.
5. Offer to sit with a terminally ill client quietly as needed by the client or family, or provide hospice volunteers to do the
same.
Terminally ill clients and their families often fear the dying process. The presence of a nurse or volunteer lets clients know
they are not alone. Fears are reduced, and the dying process becomes more easily tolerated.

Client/Family Teaching

1. Teach client the difference between warranted and excessive fear.

Different interventions are indicted for rational and irrational fears.

2. Teach stress management interventions to clients who experience emotions of fear.

Acute stress caused by strong emotions such as fear can sometimes cause sudden death in people with underlying
coronary artery disease (Pashkow, 1999).

3. Teach families to share personal stories about an illness using the computer-based psychoeducational application
experience journal.
The educational journal was reported to be useful for increasing understanding of familial feelings for families facing
pediatric illness (Demaso et al, 2000).

4. Teach client to visualize or fantasize absence of the fear or threat and successful resolution of the conflict or outcome
of the procedure.

5. Teach client to identify and use distraction or diversion tactics when possible.
Early interruption of the anxious response prevents escalation (Pope, 1995).

6. Teach clients to use guided imagery when they are fearful: have them use all senses to visualize a place that is
"comfortable and safe" for them.
Results from this study showed that the psychological intervention of guided imagery significantly improved subjects'
perceived quality of life and decreased fears (Moody, Fraser, Yarandi, 1993).

7. Teach client to allow fearful thoughts and feelings to be present until they dissipate.
Purposefully and repetitively allowing and even devoting time and energy to a thought reduces associated anxiety (Beck,
Emery, 1985).

8. Teach use of appropriate community resources in emergency situations (e.g., hotlines, emergency rooms, law
enforcement, judicial systems).
Serious emergencies need immediate assistance to ensure the client's safety.

9. Encourage use of appropriate community resources in nonemergency situations (e.g., family, friends, neighbors, self-
help and support groups, volunteer agencies, churches, recreation clubs and centers, seniors, youths, others with similar
interests).

10. Teach client appropriate use of ordered medications.