Coping and adaptation in adults living with spinal cord injury.
Article Type: Report
Subject: Adults (Health aspects)
Spinal cord injuries (Research)
Spinal cord injuries (Complications and side effects)
Adjustment (Psychology) in adolescence (Research)
Quality of life (Research)
Rehabilitation (Risk factors)
Rehabilitation (Research)
Authors: Barone, Stacey Hoffman
Waters, Katherine
Pub Date: 10/01/2012
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2012 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: Oct, 2012 Source Volume: 44 Source Issue: 5
Topic: Event Code: 310 Science & research
Product: Product Code: E121940 Adults
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 303641395
Full Text: ABSTRACT

Biopsychosocial adaptation remains a multifaceted challenge for individuals with spinal cord injury, their families, and healthcare providers alike. The development of frequent medical complications necessitating healthcare interventions is an ongoing, debilitating, and costly problem for those living with spinal cord injuries. Although several demographic variables have been correlated with positive adaptation in individuals with spinal cord injury, the research outcome data present limitations in understanding and facilitating which coping techniques work best to augment biopsychosocial adaptation in this population. Coping facilitates adaptation and adjustment to stress and can help to increase quality of life in people living with spinal cord injury and reduce common complications. The purpose of this study was to determine the extent to which sociodemographic characteristics and hardiness explain coping in 243 adults living with a spinal cord injury. In addition, this study examined which predictors of coping explain biopsychosocial adaptation. A descriptive explanatory design was utilized. Standardized instruments were administered nationally to assess hardiness, coping, and physiological and psychosocial adaptation. Canonical correlation and multiple regression analyses indicated that less educated, less hardy, and recently injured participants were more likely to use escape-avoidance coping and less likely to use social support, problem solving, and positive reappraisal coping behaviors (p < .05). Individuals with paraplegia had a higher level of functional ability, spent less time in rehabilitation, had a greater sense of control, and experienced less frequent complications. The control dimension of hardiness was the only dimension that significantly related to biopsychosocial adaptation within this sample.

Keywords: biopsychosocial adaptation, coping, hardiness, Roy Adaptation Model, spinal cord injury

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Promoting positive biopsychosocial adaptation remains a complex challenge for individuals with spinal cord injury, their families, and healthcare providers. Multiple physiological, psychological, and environmental stressors are associated with spinal cord injury, resulting in the difficult process of coping with the effects of the disability. These stressors have the potential for interfering with adaptation and increasing an individual's vulnerability to physiological, psychological, and social sequelae. Consequently, these complications cause a rise in healthcare utilization and overall healthcare costs. Although several demographic and outcome variables have been correlated with positive adaptation within this population, limitations and controversial results remain in understanding and facilitating biopsychosocial adaptation after spinal cord injuries. Variables associated with positive adaptation include higher level of education (Paker et al., 2006), younger age at injury, and high Functional Independence Measure (FIM) scores (Middleton, Tran & Craig, 2007). Variables such as lower FIM scores, specified payer source, and race have been correlated with negative adaptation (Cardenas, Hoffman, Kirshblum, & McKinley, 2004).

Several researchers have suggested that personality factors such as hardiness and self-efficacy are positively related to adaptation outcomes in individuals with chronic illness (Middleton et al., 2007; Pollock, 1989). Hardiness, as defined by Kobasa, Maddi, and Kahn (1982), measures three attributes of an individual. These are the belief that one can influence or control life's events, the ability to feel commitment to life's activities, and the motivation to challenge oneself to make changes for further development. Thompson, Coker, Krause, and Henry (2003) found that purpose in life has more of a direct influence on adjustment than personality variables or internal health locus of control. Therefore, the relationship between personality factors such as hardiness and adaptation remains unclear and warrants further investigation.

The three aims of this study were (a) to determine the extent to which the stimuli, sociodemographic characteristics and hardiness, explain coping; (b) to determine the extent to which the significant sociodemographic characteristics and hardiness that predict coping also explain physiological adaptation; and (c) to determine the extent to which the significant sociodemographic characteristics and hardiness that predict coping also explain psychosocial adaptation.

Conceptual Framework

The conceptual framework utilized to guide this study, the Roy Adaptation Model, was first published in 1970 and has continuously evolved and been updated by the theorist (Roy, 2009). The person or group is described by Roy as an adaptive system with processes for coping with change. Roy describes people in terms of holistic adaptive systems.

Components of the model include the coping processes of the regulator and cognator for the individual and the stabilizer and innovator for groups (Barone, Roy, & Frederickson, 2008). The adaptive modes are physiological-physical, self-concept, role function, and interdependence. The environment is defined as all conditions, situations, and influences surrounding and affecting the development and behavior of persons and groups with particular consideration of mutuality of person and early resources. The environment can be classified as focal, contextual, and residual stimuli. Finally, health can be seen as a state and process of being and becoming integrated and whole that reflects person and environmental mutuality and depends on adaptation (Barone et al., 2008).

The process of adaptation occurs when thinking and feeling persons as individuals and groups apply both conscious awareness and choice to enhance human and environmental integration. Roy, (2009) describes three levels of the life processes: integrated, compensatory, and compromised. The science of nursing expands adaptive abilities and promotes person and environment transformation with the goal of promoting adaption for individuals and groups in the four adaptive modes, thereby supporting health, quality of life, and dying with dignity (Barone et al., 2008). The schematic representation of the application of the components of the Roy Adaptation Model to the current study variable is diagrammed in Table 1. The immediate threat or the focal stimulus is the sustained spinal cord injury as experienced by the individual. Although the mean time post spinal cord injury was almost 13 years for this study's sample, the widespread and permanent effects of the injury maintain its impact as a focal stimulus. Contextual stimuli are those supported by the literature, which include the following relevant demographic data: age, gender, marital status, education level, time postinjury, level and severity of injury, and time spent in rehabilitation. The residual stimulus is the hardiness personality characteristic, a multidimensional construct composed of control, challenge, and commitment. The coping mechanisms accessed by the individual and operationalized by Folkman and Lazarus (1988), through the Revised Ways of Coping Checklist, were evaluated. The outcomes of the individual are divided into physiological and psychosocial adaptations. Roy and Andrews (1991) refer to two major categories of assessment factors for the activity portion of the physiological mode: the type and amount of physical activity and the person's motor function status. The activity level was assessed using the modified FIM (Smith, Hamilton, & Granger, 1990), and medical complications resulting from management of the condition was assessed using Cyr's (1989) Sequelae of Spinal Cord Injury Instrument.

Psychosocial adaptation includes the three psychosocial modes of the individual as defined by Roy (self-concept, role function, and independence) and was operationalized by Derogatis (1983), with the Psychosocial Adjustment to Illness Survey--Self-Report (PAIS-SR).

Background

A spinal cord injury is often a permanent disabling chronic condition resulting in permanent changes in an individual's entire being requiring comprehensive physical and psychosocial rehabilitation. Currently approximately 250,000-400,000 people are living with a spinal cord injury in the United States, and 14,000 new injuries occur each year (Gibson, 2003; Ignativicius & Workman, 2006). More traumatic spinal injuries occur among persons in the 16- to 30-year-old age group than all other groups combined at 52% (National Spinal Cord Injury Statistical Center, 2006), suggesting that such individuals face a lifetime of coping with the often ravaging and life changing effects of spinal cord injury. Individuals with spinal cord injuries continue to experience medically related issues that can result in death. These medical complications include pneumonia, heart disease, primarily unexplained heart attacks, ischemia and hypertension, infective and parasitic diseases associated with decubitus ulcers, and urinary tract and respiratory infections causing septicemia.

Nontraumatic spinal cord injury occurs because of medical illness such as spinal cord compressions, spinal hemorrhage, arthritis, intevertebral disk herniation, vascular impairment, inflammation, infection, or spinal cord tumors. The fifth leading cause of death was neoplasms including locations in the lung, colon, bladder, prostate, brain, and other organ systems (National Spinal Cord Injury Statistical Center, 2006). This patient population tends to be older, and these types of conditions are more common that the traumatically injured group. Permanent functional impairment is a common outcome, leaving this population also vulnerable to the same medical complications as patients who have sustained spinal cord injuries because of trauma. These patients must learn to adapt to major lifestyle changes and are at risk for developing medical sequelae requiring frequent rehospitalization.

Cost

Ignativicius and Workman (2006) state that the cost of care for an individual living with C1-4 quadriplegia is $626,588 for the first year and $112,237 for each subsequent year. The development of medical complications after spinal cord injury is a concern not only because hospital readmissions and/or frequent outpatient healthcare visits are extremely costly but also because they compromise quality of life (Hawkins & Heinemann, 1998). Costs of care estimates do not include loss of income, fringe benefits, and productivity. Estimated lifetime cost for a C1-4 quadriplegic injury at age 25 is $2,393,507 (Ignativicius & Workman, 2006). Cardenas et al. (2004) found that neurological level and extent of spinal cord injury, decreased functional abilities at discharge from rehabilitation, and payer source have been shown to influence rehospitalization rates. With an increased understanding of such issues, clinicians work toward reducing medical complications and decreasing hospitalizations and their associated costs.

Psychosocial Adaptation

Research findings addressing psychosocial adaptation after spinal cord injury have been inconsistent. For example, only weak empirical evidence exists supporting the notion that longer duration of disability results in more positive adaptation to spinal cord injury (Martz, Livneh, Priebe, Wuermser, & Ottomanelli, 2005). There are conflicting findings among the relationship between chronological age, negative affectivity, and psychosocial adaptation in the population with spinal cord injury. A comprehensive review of the literature indicates that there are only weak, if any, relationships found among the level of injury, the severity of injury, and the functional impairment as predictors of psychosocial adaptation to spinal cord injury (Martz et al., 2005).

Psychological complications such as depression, decreased quality of life, and life satisfaction have been reported by individuals with spinal cord injury more frequently when compared with the general population (Krause & Sternberg, 1997; Martz et al., 2005; Middleton et al., 2007; Thompson et al., 2003). Martz et al. concluded that depression, anxiety, and other negative emotional responses to spinal cord injury were related to lower levels of psychosocial adaptation (Martz et al., 2005). Other negative emotional responses causing lower levels of adaptation reported by Martz are disengagement-type coping such as coping using denial and avoidance (Martz et al., 2005). In addition, Anderson and Andberg (1979) and Davidoff, Roth, and Thomas (1988) reported that psychosocial factors such as depression, the inability to utilize coping skills and support networks effectively, and decreased cognitive performance resulted in preventable hospital readmissions precipitated by the development of medical complications.

Health-impairing habits or behaviors often occur when persons engage in lifestyles that are detrimental to health (Krantz, Grunberg, & Baum, 1985). Longterm use of denial and avoidance coping strategies may promote self-defeating behaviors such as smoking and substance abuse, delay in seeking medical care, or noncompliance with treatment and rehabilitation regimes (Tate, Forchheimer, Krause, Meade, & Bombardier, 2004). In an attempt to identify common risk factors with this population, consequences of maladaptive behavior such as frequent costly rehospitalizations and follow-up care have been investigated (Anderson & Andberg, 1979; Cull & Smith, 1973; Meyers, Feltin & Master, 1985). Davidoff et al. (1990) studied the incidence and risk factors of rehospitalizations post acute spinal cord injury and concluded that 34% of all readmissions were considered preventable by modification of patient behaviors. Such behavioral modifications included increasing compliance with the medical regimen and utilization of basic problem-solving skills. Common preventable complications causing readmission included urinary tract infections, general decrement in function, pressure ulcers, bums, and respiratory infections (Davidoff et al., 1990). Cardenas et al. (2004) examined the frequency and reasons for rehospitalization in persons with acute traumatic spinal cord injury, and reported that the leading causes of rehospitalization were diseases of the genitourinary system, including urinary tract infections, respiratory complications, and diseases of the skin. Cardenas et al. (2004) also showed that, between 1995 and 2002, nearly one in every three or four persons (28%-37%) with spinal cord injury was rehospitalized, averaging a length of stay of approximately 14 days.

In the long term, secondary medical complications play an important role in the continuum of care for people with spinal cord injury. They are a frequent cause of morbidity and mortality and lead to increased rates of rehospitalization, increased cost of care, loss of employability, and decreased quality of life (Cardenas et al., 2004). Cardenas et al. also found that people discharged with lower motor FIM scores had a higher likelihood of rehospitalization. Clients whose financial means limit their length of stay in acute rehabilitation may be particularly at risk for rehospitalization; those funded by state and federal programs had a greater likelihood of rehospitalization (Cardenas et al., 2004). As stated above, certain medical complications are risk factors for rehospitalization, thereby increasing length of stay, healthcare utilization, and cost.

Hardiness

Numerous studies evaluating coping indicate that personality traits such as hardiness are related to health and illness outcomes (Folkman & Lazarus, 1980; Holahan & Moos, 1985; Kobasa et al., 1982). Kobasa (1979) conducted a study over a period of 8 years on the impact of stress on executives who were losing their jobs or being reassigned. Kobasa describes two behavioral patterns in response to stress. The first group includes those who became increasingly symptomatic with medical and psychological problems, resulting in an increase in doctor visits. The second group showed no difference in symptoms during the stressful period, essentially rising to meet the challenge. Kobasa describes the second group as having stress hardy personality. On the basis of this classic work, Kobasa et al. proposed that individuals who experienced high levels of stress, yet remained healthy, had a different personality structure than individuals who experienced high levels of stress and became ill. Kobasa et al. identified the qualities of stress hardy personalities or hardiness as control, or the belief that one can control or influence events in an experience; commitment or the ability to sustain curiosity to feel deeply involved in the activities of life; and challenge or the anticipation of change as a positive step towards further development (Kobasa et al., 1982; Kobasa & Puccetti, 1983).

Kinder (2005) expanded on this work and conducted a secondary qualitative analysis of eight women with paraplegia, revealing three themes and a revised model of psychological hardiness. Her model indicates that transformational coping, positive health behaviors, and activistic social support may be qualitative indicators of hardiness, and their presence represents an expression of hardiness as its three inherent synergistic components: control, commitment, and challenge.

In summary, patients living with spinal cord injuries report life-changing experiences related to the catastrophic nature of the injury, and the development of costly and chronic medical and psychosocial complications. Coping with these life-long changes requires effective coping techniques to facilitate adaptation and adjustment to stress, thereby promoting positive health behaviors and patient outcomes. The literature remains limited and conflicted in understanding which coping techniques best augment biopsychosocial adaptation in this population, thus supporting the purpose of the study. Therefore, our focus is to determine the extent to which sociodemographic characteristics and hardiness explain coping in 243 adults living with a spinal cord injury. In addition, this study will evaluate which predictors of coping explain adaptation in this population and, consequently, which predictor's impact healthcare utilization related to rehospitalization.

Methods

A descriptive explanatory design was used, and the sample was a nonprobability purposive sample. Human subject approval was obtained from the institutional review board at the New England Rehabilitation Hospital and the National Spinal Cord Injury Association. This sample was composed of 243 participants who were current members of the U.S. National Spinal Cord Injury Association and were accessed through their national mailing list. The sample included adults, 18 years or older, who had sustained a spinal cord injury resulting in partial or complete quadriplegic or paraplegia, were at a minimum of 4 weeks postinjury, and were unable to functionally ambulate independently more than 150 feet. Participants were mailed an information packet that included a consent form, a demographic sheet, and five questionnaires, which are described below. Participants were offered assistance in filling out the surveys by calling a toll-free number to schedule an appointment for assistance. This was done to ensure that participants filled out the questionnaire without bias and without family or other helpers assisting them. Requested return time was 2 weeks.

In total, 1,000 questionnaires were mailed out, 290 were returned, and 243 met the inclusion criteria. Therefore, the response rate was 29%. Four percent of the returned questionnaires could not be utilized for the following reasons: The subjects did not meet the study criteria in terms of minimum age and ambulation status; a family member responded for the individual with spinal cord injury; there were sufficient missing data on multiple instruments to warrant it unusable; the individual was deceased or not living at the current address, and it was returned uncompleted. The participants who completed the study were not provided a gratuity.

The country was divided into the following five regions to obtain proportional geographic representation: North East, South East, North Central, South Central, and Pacific Mountain. The percentage of questionnaires that were mailed out to potential participants was determined by the percentage represented on the mailing list. For example, approximately 45% of the National Spinal Cord Injury Association's mailing list was composed of individuals living in the North East region; therefore, 45% of the questionnaires that were mailed went to individuals living in this region. Proportional representation by region was obtained in the returned surveys.

In determining sufficient sample size with canonical correlation analyses, the number of cases needed for analysis is dependent on the reliability of the variables (Tabachnick & Fidell, 2001). When reliability is approximately .80 for most variables, a case to variable ratio of 10:1 is sufficient. The study had 19 predictors: eight demographic variables, three hardiness dimensions, and eight coping subscales. Reliabilities for these variables fell in the range of .63-.90 with four subscales of the ways of coping checklist (confrontive, distancing, accepting responsibility, and self-controlling), one subscale of the Health-Related Hardiness Scale (HRHS; commitment), and one subscale of the PAIS (healthcare orientation) falling between .63 and .70. Of the 18 subscales, 12 of the subscales fall between .70 and .90. Most variables therefore were in the .80 range; thus, a study sample of 190 participants was judged to be sufficiently large for the purpose of this study (Tabachnick & Fidell, 2001).

A pilot study (n = 5) was implemented to test a combined 90-minute structured qualitative interview as well as an extensive quantitative analysis. Through the pilot study process, it was determined that including both qualitative and quantitative interview components in the study was too exhausting for subjects. Thus, the study became solely quantitative. The qualitative data therefore were not analyzed and are subsequently not included. The quantitative questionnaires took subjects an average of 60 minutes to complete. The variables involved in the study included hardiness, coping, and physiological and psychosocial adaptation. These were measured using the HRHS, the Revised Ways of Coping Checklist, Derogatis's Psychosocial Adjustment to Medical Illness Scale, and the Modified FIM.

Instruments

The HRHS contains 34 items on a 6-point likert-type scale. Although Pollock and Duffy (1990) describe the concept of health-related hardiness as consisting of these discrete but related dimensions, results of a principal components analysis with chronically ill subjects (389) supported two dimensions. The commitment and challenge components of hardiness appear to be closely related and not discrete dimensions in a health-specific context, and consequently, Pollock combined these. The first factor (20 items) encompassed the dimensions of commitment and challenge, whereas the second factor (14 items) accounted for the control dimension. Cronbach's alpha for the HRHS are .91 and .87 for the 20-item commitment/ challenge subscale and the 14-item control scale. Test-retest reliability (n = 150) for 6 months was .76 for the total HRHS and .74 and .78 for the commitment/ challenge and control scales, respectively.

The modified FONE FIM is a 15-item instrument measured on a seven-level scale. The FONE FIM version was modified by the researcher to allow for subjects to respond in a written, self-report fashion as compared with a telephone follow-up. The content of the questions and responses remained the same; however, the tool was rewritten with the permission of the authors to facilitate written comprehension and response. This modified version includes the motor components of the scale, assessing self-care, sphincter management, mobility, and locomotion. The cognitive section measuring comprehension, expression, and memory are not frequently a problem with this patient population and, therefore, are not included. The range of scores for the FONE FIM is 13-91. Pilot, trial, and implementation phase studies were conducted testing the original FIM for validity and reliability in more than 50 facilities nationally with good results (Hamilton, Laughlin, Granger, & Kayton, 1991; Smith et al., 1990).

The medical sequelae instrument partially represented physiological adaptation and measured the frequency and incidence of the development of medical sequelae post spinal cord (Cyr, 1989). The 74-item instrument evaluates chronicity and management of the medical complications most frequently identified in the literature as being associated with spinal cord injury. These include spasticity, bowel and bladder problems, skin problems, respiratory problems, and general decrement in function. The frequency value of those subjects who reported the complications as being a problem was utilized as a partial measure of physiological adaptation. Although this instrument was limited in terms of its psychometrics, its detailed level of specificity, given the unique and specialized needs of the patient population, discerned it the most appropriate instrument available. Content validity was established using a panel of experts.

The PAIS-SR is a multidimensional, 46-item instrument designed to assess the psychological and social adjustment of medical patients, many with chronic medical disorders (Derogatis, 1983, 1990). The PAIS was developed to reflect adjustment in seven principal psychosocial areas, all of which have been supported in the literature as having significant relevance to adjustment to medical illness. The seven scales, which have responses rated on a 4-point Likert scale, were used to measure psychosocial adaptation to spinal cord injury: healthcare orientation, vocational environment, domestic environment, sexual relationships, extended family relationships, social environment, and psychological distress.

Previous studies indicate the internal consistency reliability alpha coefficients for the PAIS-SR range from .47 (health orientation domain) to .85 (psychological distress domain) in patients with cardiac illness; .63 (health orientation domain) to .81 (vocational environment domain) with patients requiring renal dialysis; and .72 (extended family domain) to .93 (social environment domain) in patients with lung cancer (Derogatis, 1990; Zyanski, Stanton, Jenkins, & Klein, 1981). Each domain of the PAIS was correlated with an appropriate Roy Adaptation Model mode to measure psychosocial adaptation as indicated in Table 2.

The Revised Ways of Coping Checklist, composed of eight Likert-type scales, reflects different types of coping and is used to assess the way in which individuals cope in a stressful encounter (Lazarus & Folkman, 1984). Each participant was asked to have in mind a problem dealt with during the past week relating to their spinal cord injury. The 66 items included in the Ways of Coping Checklist are categorized into the following eight coping subscales: confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal. The eight subscales' scores were used in the data analysis process in order to capture the pattern of various coping types.

Reliability can be evaluated by examining the internal consistency of the coping measures, estimated with the Cronbach's coefficient alpha, which ranged from a low of .63 to a high of .80 (Folkman & Lazarus, 1988). Five of eight coping measures had an alpha coefficient of greater than .70. Face validity was established because the strategies described are those that individuals have reported to be using to cope with the demands of stressful situations. Study results are consistent with theoretical predictions: (a) coping consists of both problem-focused and emotion-focused strategies and (b) coping is a stress process, establishing construct validity (Folkman & Lazarus, 1988).

Statistical Analysis

Statistical analysis was done using SPSS. As part of the data analysis procedures, descriptive statistics were used to give a sample profile and to examine for systematic missing data, marked skewness, and the presence of outliers. Internal consistency reliabilities (Cronbach's alpha) was computed on all subscale and total scores of the study instruments. A Pearson's product moment intercorrelational matrix was generated and examined for multicollinearity and the presence of confounding variables. The research questions were answered using canonical correlational analyses as the primary statistical analysis technique and hierarchical multiple regression as the secondary statistical analysis technique.

Methodological Limitations of the Study

The PAIS was originally developed for the assessment of any medical condition that has an identifiable psychosocial component and which is of sufficient severity to impact measurably on the psychological and interpersonal integrity of the patient (Derogatis, 1990). Sustaining a spinal cord injury certainly meets these criteria. However, this instrument was not sensitive to the often extreme physical limitations experienced by many individuals with spinal cord injury. Although the researcher did make minor modifications to the PAIS (with permission) to better address the experience of the individual with spinal cord injury, it still lacked sensitivity to the homogeneity of this population. This instrument had the most missing data, indicating the lack of specificity of the responses in some cases. The missing data were a problem when attempting to run the canonical correlation analysis.

The cost of hospitalizations was not measured. The medical sequelae instrument measured the incidence of the following sequelae post spinal cord injury: spasticity, bowel and bladder problems, and skin and respiratory problems. Attempting to construct a weighted score for the physiological adaptation variable as represented by the number of complications requiring hospitalization was problematic. The wording of the questions did not elicit the response hoped for. Instead the frequency value of subjects reporting complications was used as a partial measure of physiological adaptation and addressed in study aim II.

Results

The sample consisted of 243 predominately Caucasian males (66.3%) and female (33.7%) adults with spinal cord injury (see Tables 3 and 4). The mean age of the sample was 42 years (SD = 15 years). Forty-seven percent of subjects reported completing a bachelor's degree. Mean length of time since injury was almost 13 years (SD = 11.5 years). Mean length of rehabilitation hospitalization was 25 weeks. The mean combined annual income per household was $46, 650. The mean number of persons living in a household was 2.6. Fifty-three percent of subjects reported being paraplegic, and 47% reported being quadriplegic. Eighty-six and a half percent of subjects indicated that they had sustained their spinal cord injury because of a trauma of some sort, and 11.9% indicated that their disability was because of a nontraumatic event.

Study aim I evaluated the extent to which age, gender, marital status, educational level, time post-injury, level and grade of injury, and time in rehabilitation and hardiness explain cognator coping processes. The first canonical correlation was .60, and the second was .43. The first two clusters of canonical variates accounted for the significant relationships between the two sets of variables, explaining a total of 73% of the variance. The first canonical variate, explaining 51% of the variance, indicated that subjects with less education and with more recent injuries who were less hardy in all three dimensions were more likely to use escape-avoidance coping strategies and less likely to use seeking of social support, planful problem solving, and positive reappraisal coping behaviors. The second variate, explaining 22% of the variance, suggested that recently injured, younger, never married males used confrontive, self-controlling, accepting responsibility and planful problem solving and coping behaviors.

Study aim II evaluated the extent to which age, gender, marital status, education, years postinjury, level and grade of injury, and weeks in rehabilitation explain coping and physiological adaptation. The predictor variables were demographics, hardiness, and coping (set 1) and the dependent variables were the total FONE FIM scores and frequency of complications (set 2). Fifty-four cases were rejected because of missing data, leaving a sample size of 189. The first canonical correlation of .71, accounting for 90% of the variance, indicated that subjects who had a lower level of spinal cord injury spent less time in rehabilitation, had a greater sense of control, had a higher FIM score, and experienced less frequent complications.

Study aim III evaluated the extent to which demographics and hardiness, which explain coping, also explain psychosocial adaptation. Canonical correlation analysis was initially attempted to address this aim, but 123 cases were rejected because of missing data, leaving a sample size of 120. Caution would have had to be taken in interpreting the finding generated from this analysis because the average case-to-variable ratio had not been met. Hierarchical multiple-regression analysis with means substitution for missing data was then used. The literature supported demographics to be listed first as a block, followed by the hardiness subscales and the coping subscales (Polit & Tatano, 2004). The dependent variable was the total PAIS mean score.

As indicated in Table 3, the demographic variables accounted for 6% of explained variance, but only age variable was statistically significant. Of the hardiness subscales, which accounted for an additional 6% of variance, only the control scale was statistically significant (<.05). Entrance of the coping scales added an additional 13% of explained variance, with the escape--avoidance, confrontive, self-controlling, and positive reappraisal strategies being the significant predictors. These results indicate that younger individuals who were more likely to have higher overall psychosocial adjustment than their counterparts had an increased sense of control and used less escape-avoidance, confrontive, and self-controlling coping behaviors but utilized more positive reappraisal coping behaviors.

Discussion

Clusters in the first canonical correlation support two significant sets of relationship between variables. The first set clustered less educated, nonhardy, more recently injured individuals who used many escape--avoidance coping behaviors and did not use strategies to seek social support, problem solve, or engage in personal growth. The utilization of escape--avoidance coping strategies by individuals recently injured is supported by Drew-Cates (1989), who reported the use of emotive-moderator coping strategies, including escape--avoidance as common with those recently injured. The frequent utilization of escape--avoidance coping behaviors may be appropriate and adaptive in a time-limited manner. Denial is typically ranked low in the hierarchy of effective coping strategies, but it has been shown to be adaptive under certain circumstances, particularly immediately after a trauma (Lazarus, 1983). More recently, Martz et al. (2005) stated that disengagement coping was linked to greater depression, emotional distress, decreased life satisfaction, and decreased participation in rehabilitation activities. Empirical research does demonstrate a positive relationship between escape--avoidance and poorer adaptation to spinal cord injury (Martz et al., 2005). The effectiveness of a given coping strategy must be evaluated within the context it used.

The emergence of a lower educational level as a sign of decreased problem-solving ability or direct action coping strategies is supported by Paker et al. (2006), who found a strong relationship between decreased education and increased hospital readmissions and length of time spent initially in rehabilitation. The association of lower educational level with readmission suggests that learning capacity or the inability to take direct action to manage the condition may be related to risk for readmission (Paker et al., 2006). Although it is unclear if lower educational level is a sign of decreased problem solving or if it puts a person at risk for having trouble problem solving, participants with lower educational level experience increased length and frequency of rehospitalization.

Seeking social support may provide emotive-reducing qualities. However, such an effort requires an action and problem-oriented approach (Schult & Decker, 1985). This group of individuals avoided using action and problem-oriented approaches and may explain why seeking social support was not used as a coping strategy.

The second canonical variate cluster indicated that younger, more recently injured, and never married male subjects used confrontive, self-controlling, accepting responsibility, and problem-solving coping strategies. Because marital status is likely to influence the nature of social support available to the individual (Kutner, 1987), one might speculate that the emphasis on action-oriented coping behaviors is related to the difference in the nature of social support available in this group. Kutner (1987), in a study that investigated social ties, perceived support, received support, and perceived healthy status in a sample of 332 persons with disabilities, found that women with disabilities were more likely to be single and were less likely to have the received and perceived social support associated with being married than men. Without this support, these individuals must accept more responsibility for themselves and take a more aggressive, problem-focused approach to survive the experience.

In addition, taking an action-oriented approach may divert attention away from the losses associated with the injury (providing a "buffering" effect) and require concentration on the issues that can lead to adaptation and improvement of the patient's situation. The processes and experiences associated with being involved through direction action often facilitates an empowerment or lessening of powerlessness experienced by the individual. This was also a younger group of individuals, and as the literature strongly supports, age is inversely related to adjustment to spinal cord injury (Krause & Steinberg, 1997).

The second canonical correlation analysis clustered subjects with a lower level of injury and increased functional independence, spent less time in rehabilitation, had a greater sense of control, and experienced less frequent medical complications. In a study assessing positive outcomes after a spinal cord injury, McMillen and Cook (2003) found that those patients with a higher FIM level tended to report increased self-efficacy or a perceived sense of control. In addition, Cardenas et al. (2004) found that decreased functional level is a risk factor for the most common medical complications that result in more frequent rehospitalizations.

The clustering of a lower level of injury, with less time spent in rehabilitation as partial predictors of physiological adaptation, was expected. The less severe the spinal cord injury, the less impairment the individual experiences and, consequently, the less time required for rehabilitation. In addition, the greater the functional independence of the individual, the greater the physical abilities and the less complications predicted to occur.

Hierarchal multiple regression results suggest that younger subjects had an increased sense of control and used less escape-avoidance, confrontive, and self-controlling coping mechanisms. This same group utilized more positive reappraisal coping and showed a high overall psychosocial adjustment. These findings support the conclusions of Krause and Sternberg (1997) that there is a significant inverse relationship between acceptance of disability (psychosocial adjustment) and age, despite the duration of the disability. Martz et al. (2005) concluded that there was a negative correlation between age at onset of injury and level of psychosocial adaptation, as measured in terms of quality of life, self-concept, perceived well-being, and life satisfaction. Older individuals have a more difficult time adapting to their injury and to the changes in their self-image (Martz et al., 2005). The use of positive reappraisal coping strategies indicate efforts by the subjects to create positive meaning by focusing on personal growth, an important part of enhancing one's self-concept.

The finding regarding the control dimension of hardiness as a partial predictor of psychosocial adaptation is well supported in the literature. Kinder (2005) supports the idea of a significant correlation between perceived control and reports of high levels of well-being and life satisfaction. This relationship is not a surprise, because individuals who feel their lives are more under their own control generally derive a greater sense of satisfaction from life (Kinder, 2005).

In this study participants were less likely to use confrontive and self-controlling coping behaviors. Confrontive coping behaviors are defined by Lazarus and Folkman (1984) as aggressive efforts to alter the situation and suggest that it involves some degrees of hostility and risk taking. Confrontive coping can manifest as an attempt to change a relatively unchangeable health situation, resulting in a destructive waste of energy. If the aggression and hostility associated with confrontive coping is directed toward others, it can also negatively impact social support. Self-controlling coping behaviors are defined as efforts to regulate one's feelings and actions (Folkman & Lazarus, 1988). It is especially important to understand the decrease in use of the confrontive and self-controlling coping behaviors that we found in our study. The participants who avoided the use of these coping strategies had healthy adaptive responses and better coping. This group of subjects expressed having a perceived sense of control or a belief that they can make lasting personal choices and influence events around them.

Hardiness was less strongly supported as a predictor of coping behaviors or outcome measures than anticipated. The composite score of hardiness did not have a significant relationship with any of the study's variables. Pollock (1989) recommended that, to facilitate greater understanding of adaptation to chronic illness, larger samples of patients with specific illness need to be studied as independent entities. Therefore, this study used patients living with spinal cord injuries as a specific illness population and looked for statistical significance related to hardiness and adaptation. Unfortunately, the results did not prove to be statistically significant for the presence of hardiness impacting adaptation in this population.

The individual score of the control dimension of hardiness did significantly relate to physiological and psychosocial adaptation within this sample. The commitment/challenge dimensions never significantly correlated with other study variables. Although the impairments incurred from spinal cord injury are permanent, there is no evidence to suggest that the condition is progressive. Consequently, this group of subjects may be able to feel in control of the condition, without the uncertainty that accompanies progressive conditions. The fact that those individuals with lower levels of injury and less functional impairment showed more control is evidence of the relationship between functional ability and perception of control. The relationship between perceived control and adaptation to spinal cord injury is well supported in the literature and deserves further attention. Rehabilitation nurses should continue to facilitate patients' perception of control over their lives through the promotion of functional and psychosocial independence as it clearly impacts life satisfaction.

The strengths of the study include the proportional geographic representation of the sample, adequate sample size, the conceptual framework applied to guide the study design and its comprehensiveness, the implementation of a pilot study to fine tune the study's procedures, the utilization of study instruments with good psychometric data when available, and the application of a sound study design. Limitations to the study include the occasional lack of available instruments sensitive enough to measure specifics in this highly specialized population of patients. For example, the utilization of an instrument to measure the frequency and incidence of medical complications post spinal cord injury had limited psychometric data available but offered a detailed level of specificity necessary for this population. The study response rate of 29% was lower than anticipated, but certainly understandable given the physical limitations of living with a spinal cord injury and the extra effort often necessary to complete lengthy questionnaires, even with offered phone support. In the future, e-mailing the surveys rather than mailing them may increase the response rate and ease the efforts required to complete the instruments by study participants. Missing data were a problem with one of the study's instruments (the PAIS), and even the instrument modifications (with the author's permission) aimed to increase sensitivity of the instrument to the patient population and its needs still left gaps, which resulted in incomplete responses and large amounts of missing data.

Practice and Research Implications

The results of this study support an inverse relationship between age and psychosocial adaptation to spinal cord injury, which is consistent with the literature (Martz et al., 2005). Implications of this finding for nursing practice include recognizing that the older individual with spinal cord injury will require more time and intervention throughout the rehabilitation process, particularly those interventions addressing psychosocial adaptation to the injury. Given the shortened length of stay in rehabilitation mandated by the medical care climate, expanding the role of the nurse into the community, even via phone and telecommunication contact postdischarge to provide palliative and instrumental support for problem solving and facilitating other effective coping responses, may be a method to meet the needs of this population. Logic dictates that the reduction in frequency of acquired medical and psychological sequelae will reduce healthcare costs.

The use of denial or escape-avoidance coping strategies immediately after injury has many implications for nursing practice. Nurses often hold the expectation that the individual with the spinal cord injury will process the severe implications of their new disability during their rehabilitation. Drew-Cates (1989) suggests that the mind alone requires full knowledge of the injury to be incorporated. Furthermore, a necessary component in this process seems to be holding on to the hope that the person will return to what they once were. This gives one time to awaken to reality to cautiously confront the implications of the spinal cord injury and to choose how to live one's life. Conversely, the use of denial and escape-avoidance strategies on a long-term basis rather than other more positive coping strategies may promote risk-taking behaviors and thus negative adaptation, increasing the patient's risk of acquired medical and psychological sequelae and the frequency of hospitalization and healthcare costs. The focus of future research within this population should involve training to promote the development of coping skills, which facilitate long-term adjustment. In addition, hospital-based research utilization programs should continue to update nurses regarding evidence-based practice outcomes to meet the needs of this population.

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Questions or comments about this article may be directed to Stacey Hoffman Barone, PhD RN CRRN, at baronest@bc.edu. She is an associate clinical professor, Boston College, William F. Connell School of Nursing, Chestnut Hill, MA.

Katherine Waters, RN BSN, is a staff nurse at Massachusetts General Hospital, Heme/Oncology, Bone Marrow Transplant Unit, and a Master of Science in Nursing Candidate at Boston College, William F. Connell School of Nursing, Chestnut Hill, MA.

The authors declare no conflicts of interest.

DOI: 10.1097/JNN.0b013e3182666203
TABLE 1. Representation of the Study Variables Within the Roy
Adaptation Model

Stimuli                 Coping Mechanisms      Responses

Focal

  Spinal cord injury

Contextual              Cognator               Physiological
                                               adaptation

  Gender and marital      Ways of coping         Functional
  status                  checklist              independence
                                                 measure

  Educational level,      Distancing, self-      Development of
  time postinjury,        controlling,           medical sequelae
  level and grade of      social support,
  injury, and time        accepting
  in rehabilitation       responsibility,
                          escape-avoidance,
                          planful problem
                          solving, and
                          positive
                          reappraisal

Residual                Regulator              Psychosocial
                                               adaptation

  Health-related          Not evaluated in       Psychosocial
  hardiness scale         this study             adjustment to
                                                 illness survey

TABLE 2. Typology of Indicators of Positive Adaptation (Roy & Andrews,
1991) and Domains of Psychosocial Adjustment to Illness Survey
(Derogatis, 1983) Used to Measure Adaptive Psychosocial Modes

                                               Psychosocial Adjustment
Self-Concept Mode                              to Illness Survey

* Positive body image                          * Healthcare orientation
* Effective sexual function                    * Sexual relationships
* Psychic integrity                            * Psychological distress
* Compensation for bodily changes
* Stable pattern of self-consistency/esteem
* Effective integration of self-ideal
* Effective processes of moral-ethical-
  spiritual growth

                                               Psychosocial Adjustment
Role Function Mode                             to Illness Survey

* Role transition                              * Domestic environment
* Instrumental and expressive role behaviors   * Vocational environment
* Primary, secondary, and tertiary roles
* Stable pattern of role mastery
                                               Psychosocial Adjustment
Interdependence Mode                           to Illness Survey

* Stable pattern of giving and receiving       * Social environment
* Affectional adequacy                         * Extended family
* Effective pattern of aloneness and             relationships
  relating

TABLE 3. Multiple Regression Summary Table Between Total Psychosocial
Adjustment to Illness Scale Scores, Demographics, Health-Related
Hardiness Scale, and Ways of Coping Checklist (n = 243)

Step  MultR  Rsq   F(Egn)  SigF   Variable      Betaln  F(Egn)  SigF

1                                 Rehab           -.07    1.50  .22

2                                 Frankel         -.09     .01  .94

3                                 Age             -.11     .01  .00 (a)

4                                 Gender          -.03    9.50  .90

5                                 Educ             .11     .33  .57

6                                 LOI              .12    2.25  .13

7                                 Marital          .03     .06  .81

8      .24   .06    1.8      .08  Yearinj          .10     .20  .66

9                                 Challenge        .17     .36  .55

10                                Control          .17    3.78  .05 (a)

11     .35   .12    3.0     .001  Commitment       .22    1.68  .20

12                                Distance        -.03    2.19  .14

13                                Social          -.11     .00  .98
                                  support

14                                Planful          .05     .12  .74
                                  problem
                                  solving

15                                Escape          -.30    6.77  .01 (a)

16                                Accepting       -.13    2.34  .01 (a)
                                  responsi-
                                  bility

17                                Confront        -.19    5.84  .02 (a)

18                                Self-control    -.14    3.97  .05 (a)

19     .50   .25    4.0    .000   Positive         .09    1.26  .00 (a)
                                  reapp

Note. Adjusted [R.sup.2] = 18.9%. Dependent variable: Total
Psychosocial Adjustment to Illness Scale mean score. MultR = multiple
regression; Rsq = R squared; F(Egn) = eigenvalue of f; SigF =
statistical significance of f; Betaln = regression coefficient for
predictor; rehab = weeks in rehabilitation; Frankel = Frankel grade of
spinal cord injury; Educ = highest completed level of education up to
graduate/professional school; LOI = level of spinal cord injury;
Yearinj = number of years since injury.

(a) Mean substitution used for missing data.

TABLE 4. Demographic Characteristics
of Sample (n = 243)

Variables                                 Frequency   Percent

Gender

  Female                                         82      33.7

  Male                                          161      66.3

Educational level

  junior high to high school                     40      16.4
  graduate

  Partial college                                61      25.1

  Associate degree                               28      11.5

  Bachelor's degree                              66      27.2

  Graduate professional training                 48      19.8

Marital status

  Single, never married                          92      37.9

  Divorced, separated                            32      13.2

  Widowed                                         8       3.3

  Not married, living with                       10       2.4
  significant other

  Married                                       101      41.6

Source(s) of income

  Salary of self                                 60      24.7

  Salary of Spouse/significant                   26      10.8
  other/parents

  Social security                                42      17.3

  Medicare/Medicaid, State                       13       5.3
  Rehabilitation Commission

  Disability

  Investments                                    38      15.6

  Combination of above                           62      25.5

  Missing                                         2       0.8

Race/ethic origin

  American Indian or Alaskan                      1       0.4
  Native

  Asian or Pacific Islander                       1       0.4

  Black, not of Hispanic origin                   8       3.3

  Hispanic                                        6       2.5

  White, not of Hispanic origin                 226        93

Levels of spinal cord injury

  C1-2                                            4       1.6

  C3-4                                           20       8.2

  C5                                             58      23.9

  C6                                             27      11.1

  C7                                             10       4.1

  T1-9                                           66      27.2

  T10-12                                         38      15.6

  Ll-2                                            7       2.9

  L3-4                                            5       2.1

  Missing                                         8       3.3

Frankel grade of spinal cord injury

  Complete                                      110      45.3

  Incomplete with sensation                      53      21.8

  Incomplete with motor                          30      12.3
  function

  Incomplete with useful motor                   42      17.3
  function

  Complete recovery                               0         0

  Missing                                         8       3.3

  Quadriplegic or paraplegic
  (self-report)

  Quadriplegic                                  113      46.5

  Paraplegic                                    128      52.7

  Missing                                         2       0.8

  Traumatic vs. nontraumatic injury

  Traumatic                                     210      86.5

  Nontraumatic                                   29      11.9

  Missing                                         4       1.6

  Completing packet alone or
  with assistance

  Alone                                         203      85.5

  With assistance                                40      16.5

  Number of hours/week
  assistance with activities of
  daily living

  No assistance                                 109      44.8

  1-10 hours of assistance                       41      16.9

  11-20 hours of assistance                      26      10.7

  21-30 hours of assistance                      19       7.8

  31-40 hours of assistance                      12      4.91

  More than 40 hours of                          35      14.4
  assistance

  Provider assistance with
  activities of daily living

  No home health aide                           211      86.8

  Home health aide                               31      12.8

  No personal care attendant                    201      82.7

  Personal care attendant                        42      17.3

  No spouse/significant other                   183      75.3

  Spouse/significant other                       60      24.7

  No other family member                        199      81.9

  Other family member                            44      18.1

  No friends                                    230      94.7

  Friends                                        13       5.3

  No other                                      232      95.5

  Other                                          11       4.5
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