Chapter 1: Stress, Coping, and Health: A Conceptual Overview - SAGE

CHAPTER 1. Stress, Coping, and Health 7is characterized by (a) comprehensibility—thedegree to which a situation is predictable andexplicable, (b) manageability—the availabilityof sufficient resources (internal and external)to meet the demands of the situation, and(c) meaningfulness—the degree to which life’sdemands are worthy of the investment of energy.Persons with a high SOC have a tendency to viewthe world as ordered, predictable, and manageable.Importantly, Antonovsky (1987) arguedthat we often ask the wrong question—that is,“Why do some people become ill?”—when, perhapswe should be asking, “Why do people stayhealthy despite life stress?”Notwithstanding the dominance of the stimulusapproach to studying the relationship betweenlife event stress and illness (disease) in the 1970sand early 1980s, the value of this paradigm inexplaining the relationship between stress andillness was not confirmed. In an attempt to cometo grips with the issues regarding the a prioriweighted measures of major life events, Kanner,Coyne, Schaefer, and Lazarus (1981) proposed ameasure of chronic daily hassles and uplifts—the Hassles Scale consisting of 117 items and theUplifts Scale containing 135 items. Hassles weredefined as “relatively minor” daily experiencesand demands that are appraised as threatening orharmful, and uplifts are favorable experiencesand events. On the Hassles Scale, respondentsindicated whether or not an occurrence of any ofthe experiences “hassled or bothered” themwithin the past week or month and, if so,whether the hassle was “somewhat,” “moderately,”or “extremely” severe. Similarly, on theUplifts Scale, respondents indicated if they experiencedan event as an uplift, a positive event,and, if so, to what extent was it positive (“somewhat,”“moderate,” or “extremely”). Using theHassles Scale and a life events questionnaire,Delongis, Coyne, Dakof, Folkman, and Lazarus(1982) were able to demonstrate, through a multipleregression analysis, that the hassle scoreswere more strongly associated with somatichealth than were life event scores. Interestingly,the uplift scores made very little contribution tohealth that was independent of hassles. Despitethe stronger performance of hassles in predictingillness, the authors concluded that the experiencesof daily hassles or uplifts were insufficientin predicting health outcomes.In 1987, Lyon and Werner noted that approximately30% of the nursing research on stressfrom 1974 to 1984 used a stimulus-based or lifeevent approach. In fact, Volicer and Bohannon(1975) adapted the SRRS to stressful events ofhospitalization and developed the Hospital StressRating Scale (HSRS). Consistent with findingsfrom other disciplines, the correlations betweenlife event as HSRS scores and physical and mentaldisruptions were small in magnitude (r = .20–.28).By the late 1980s, the stimulus-based approach todefining and measuring stress without appraisalhad fallen out of favor in nursing.A recent search of the OVID Nursing DataBase for research literature from 2000 to 2010using the key words “stress and life events,” “copingand life events,” and “stress, illness, and lifeevents” generated 628 funded research reports.In all of these studies the focus was on discretelife events such as divorce, environmental disasters,or traumatic experiences such as rape,incest, and unexpected hospitalization in anintensive care unit. None of the studies usedtools developed to measure life events consistentwith the assumptions underlying the“stress as a stimulus” conceptualization posedby Holmes and Rahe (1967).In 1993, Werner significantly modified andextended the notion that stress and healthrelatedresponses were triggered from events. Sheproposed a framework to examine trigger eventsor stimuli that resulted in the experience of stressor significant physical or psychosocial reaction.Werner labeled the trigger event a stressor andproposed that there are four types of stressors:event, situation, conditions, and cues. An event issomething noteworthy that happens. A situationis composed of a combination of circumstancesat any given moment. A condition is a state ofbeing, and a cue is a feature indicating the natureof something perceived (see Table 1.1).In addition to identifying types of stressors,Werner identified ways to categorize them withrespect to locus (internal or external), duration,and temporality (acute, time limited; chronic,intermittent; and chronic), forecasting (predictableor unpredictable), tone (positive or negative),and impact (normative or catastrophic).Integrating these elements, she proposed anorganizing schema for stressor research in nursing.Although it is unlikely that specific responsesto stressors in any of the categories proposed byWerner would be the same across individuals, itmight be possible to identify common themeswithin specified categories in similar cultures.

8 PART I. INTRODUCTIONTable 1.1Organizing Schema for Stressor Research in NursingStressor categoryLife-RelatedNormative (L-RN)Health/Illness-RelatedNormative (HI-RN)Life-RelatedCatastrophic (L-RC)Health/Illness-RelatedCatastrophic (HI-RC)Working definitionEvents, situations, conditions, or cues which are usually expected, which mostexperience, and which require adjustment or adaptationEvents, situations, conditions, or cues which are related to health or to illness, and/or treatment for these, and which are usually expected, which most experience, andwhich require adjustment or adaptationEvents, situations, conditions, or cues which are generally unpredictable, usuallyinfrequent, and commonly result in dire consequences in addition to requiringadjustment or adaptationEvents, situations, conditions, or cues which are related to health or to illness, and/or treatment for these, and which are generally unpredictable, usually infrequent,and commonly result in dire consequences in addition to requiring adjustment oradaptationSOURCE: From Werner (1993, pp. 17–18). Copyright © 1993 by Sigma Theta Tau International.Stress as a TransactionAs a social-personality psychologist, RichardLazarus became interested in explaining thedynamics of troublesome experiences. He developedand tested a transactional theory of stressand coping (TTSC) (Lazarus, 1966; Lazarus &Folkman, 1984). He believed that stress as a concepthad heuristic value, but in and of itself wasnot measurable as a single factor. Lazarus (1966)contended that stress did not exist in the eventbut rather is a result of a transaction between aperson and his or her environment. As such,stress encompasses a set of cognitive, affective,and coping factors.Precursor models to Lazarus’s TTSC theoryincluded those proposed by Basowitz, Persky,Korchin, and Grinker (1955); Mechanic (1962);and Janis (1954). Each of these models, althoughdifferent in many ways, shared some commonalties.Basowitz et al. defined stress as feelings thattypically occur when an organism is threatened.In Mechanic’s (1962) model of stress, it is definedas “discomforting responses of persons in particularsituations” (p. 7). The factors proposed toinfluence whether or not a situation is experiencedas discomforting include the abilities or capacitiesof the person, skills and constraints produced bygroup practices and traditions, resources availableto the person in the environment, and norms thatdefine where and how the individual could becomfortable in using the means available.Behavior that a person uses to respond todemands is termed coping behavior. Janis (1954)proposed a model of disaster that included threemajor phases of stress: (a) the threat phase, inwhich persons perceive objective signs of danger;(b) the danger impact phase, in which the dangeris proximal and the chance of the person escapinginjury is dependent on the speed and efficiency oftheir protective actions; and (c) the danger-ofvictimizationphase, which occurs immediatelyafter the impact of the danger has terminated orsubsided. In addition to these early models ofstress that introduced the importance of assignedmeaning and coping options to understanding theorigin of discomforts, there were psychosomaticstress models that incorporated personal perceptionas a determinant of organic processes(Alexander, 1950; Dunbar, 1947; Grinker &Speigel, 1945; H. G. Wolf, 1950; C. T. Wolf,Friedman, Hofer, & Mason, 1964).Due in part to the early works of all theaforementioned researchers, by the 1960s stresshad become a popular construct in psychological,psychosomatic, and nursing research.Including his own research findings, Lazarus’s1966 book, Psychological Stress and the CopingProcess, represents an elegant theoretical integrationof all the research findings on stress and

CHAPTER 1. Stress, Coping, and Health 9its interrelationship with health through theearly 1960s. The theoretical framework thatLazarus posed to explain the complex phenomenonof stress was a major impetus for the fieldof cognitive psychology because his frameworkconsistently emphasized the important role thatappraisal or self-evaluation plays in how a personreacts, feels, and behaves.Lazarus (1966) and Lazarus and Folkman(1984) asserted that the primary mediator ofperson–environment transactions was appraisal.Three types of appraisal were identified: primary,secondary, and reappraisal. Primary appraisal is ajudgment about what the person perceives a situationholds in store for him or her. Specifically, aperson assesses the possible effects of demandsand resources on well-being. If the demands of asituation outweigh available resources, then theindividual may determine that the situation represents(a) a potential for harm or loss (threat) orthat (b) actual harm has already occurred (harm)or (c) the situation has potential for some type ofgain or benefit (challenge). It is important tonote, however, that the perception of challenge inthe absence of perceived potential for harm wasnot considered a stress appraisal.The perception of threat triggers secondaryappraisal, which is the process of determiningwhat coping options or behaviors are availableto deal with a threat and how effective theymight be. Often, primary and secondary appraisalsoccur simultaneously and interact with oneanother, which makes measurement very difficult(Lazarus & Folkman, 1984).Reappraisal is the process of continually evaluating,changing, or relabeling earlier primaryor secondary appraisals as the situation evolves.What was initially perceived as threatening maynow be viewed as a challenge or as benign orirrelevant. Often, reappraisal results in the cognitiveelimination of perceived threat.There are many situational factors that influenceappraisals of threat, including their numberand complexity; person’s values, commitments,and goals; availability of resources; novelty of thesituation; self-esteem; social support; copingskills; situational constraints; degree of uncertaintyand ambiguity; proximity (time andspace), intensity, and duration of the threat; andthe controllability of the threat. What occursduring appraisal processes determines emotionsand coping behaviors (Lazarus, 1966; Lazarus &Folkman, 1984).Other important concepts in Lazarus’s transactionalframework for stress include copingand stress emotions. Unlike the response-basedor stimulus-based orientation to stress discussedearlier, the transactional model explicitlyincludes coping efforts. Coping is defined as“constantly changing cognitive and behavioralefforts to manage specific external and/or internaldemands that are appraised as taxing or exceedingthe resources of the person” (Lazarus &Folkman, 1984, p. 141). This definition clearlydeems coping as a process-oriented phenomenon,not a trait or an outcome, and makes itclear that such effort is different from automaticadaptive behavior that has been learned.Furthermore, coping involves managing thestressful situation; therefore, it does not necessarilymean mastery. Managing may includeefforts to minimize, avoid, tolerate, change, oraccept a stressful situation as a person attemptsto master or handle his or her environment.Lazarus and Folkman (1984) warnedagainst “stage”-type models of coping becausethey tend to create situations in which a person’sbehavior is judged to be inside or outsidethe norm by the way they deal with a stressfulsituation over time. A common example of astage model is that proposed by Kubler-Ross(1969) for death and dying. It is not uncommonfor health care providers to inappropriatelyjudge a person’s grief response because ofthe expectation that a person must experienceall the predicted stages of grief and only cyclethrough them one time. Although there maybe commonalties or patterns in certain situationsthat are similar in terms of both thenature of the situation and the cultural ways ofresponding, there is probably not a dominantpattern of coping.In 1966, Lazarus identified two forms ofcoping: direct action and palliative. In 1984,Lazarus and Folkman changed the names of thesetwo forms to problem-focused and emotionfocused,respectively. Problem-focused copingstrategies are similar to problem-solving tactics.These strategies encompass efforts to define theproblem, generate alternative solutions, weighthe costs and benefits of various actions, takeactions to change what is changeable, and, ifnecessary, learn new skills. Problem-focusedefforts can be directed outward to alter someaspect of the environment or inward to altersome aspect of self. Many of the efforts directed

10 PART I. INTRODUCTIONat self fall into the category of reappraisals—for example, changing the meaning of the situationor event, reducing ego involvement, orrecognizing the existence of personal resourcesor strengths.Emotion-focused coping strategies are directedtoward decreasing emotional distress. These tacticsinclude such efforts as distancing, avoiding,selective attention, blaming, minimizing, wishfulthinking, venting emotions, seeking social support,exercising, and meditating. Similar to thecognitive strategies identified in problemfocusedcoping efforts, changing how an encounteris construed without changing the objectivesituation is equivalent to reappraisal. The followingare common examples: “I decided that somethinga lot worse could have happened” or “I justdecided there are more important things in life.”Unlike problem-focused strategies, emotionfocusedstrategies do not change the meaning ofa situation directly. For example, doing vigorousexercise or meditating may help an individualreappraise the meaning of a situation, but theactivity does not directly change the meaning.Emotion-focused coping is the more commonform of coping used when events are not changeable(Lazarus & Folkman, 1984).Lazarus (1966) and Lazarus and Folkman(1984) summarize a large body of empiricalevidence supporting the distinction betweenemotion (palliative) and problem-focused(direct-action) coping. In addition, the evidenceindicates that everyone uses both types of strategiesto deal with stressful encounters or troublesomeexternal or internal demands. Folkman(1997), based on her work in studying AIDSrelatedcaregiving, proposed an extension of themodel regarding the theoretical understandingof coping. Her study involved measurement ofmultiple variables of psychological state (depressivesymptomatology, positive states, and positiveand negative affect), coping, and religious orspiritual beliefs and activities. Each caregiverparticipant was interviewed twice. Although participantsreported a high level of negative psychologicalstates as expected, they also reportedhigh levels of positive affect. Interestingly, theinterview data, when examined along with quantitativeanalyses, revealed that the coping strategiesassociated with positive psychological stateshad a common theme, “. . . searching for andfinding positive meaning. Positive reappraisal,problem-focused coping, spiritual beliefs andpractices, and infusing ordinary events withpositive meaning all involve the activation ofbeliefs, values, or goals that help define the positivesignificance of events” (p. 1215). Folkmancites many studies that support her conclusionthat finding positive meaning in a stressful situationis linked to the experience of well-being.Another important construct in Lazarus’s(1966, 1991) transactional model is emotion—specifically emotions that are considered to bestress emotions. These include, but are not limitedto, anxiety, fear, anger, guilt, and sadness(Lazarus, 1966, 1991; Lazarus & Folkman, 1984).Lazarus (2000) presents cogent arguments forthe explanatory power of the cognitive theory ofemotion. Although thoughts precede emotions,(that is, emotions are shaped by thought processes)emotions can in turn affect thoughts.The primary appraisal of threat and the specificmeaning of the situation to the person triggers aparticular stress emotion consistent with itsmeaning. He presents his evolution of a modelof stress, coping, and discrete emotions in theearlier edition of this text (pp. 195–222). It isreproduced as Chapter 9 here.Lazarus (1966) and Lazarus and Folkman(1984) link stress-related variables to healthrelatedoutcomes. All of the constructs in theirtransactional model, when taken together, affectadaptational outcomes. The theorists proposethree types of adaptational outcomes: (a) functioningin work and social living, (b) morale orlife satisfaction, and (c) somatic health. Theyview the concept of health broadly to encompassphysical (somatic conditions, including illnessand physical functioning), psychological (cognitivefunctional ability and morale—includingpositive and negative effects regarding how peoplefeel about themselves and their life, includinglife satisfaction), and social (social functioning).Table 1.2 presents a comparison of the responsebased,stimulus-based, and transactional-basedconceptualizations of stress, coping, and healthoutcomes. (See Table 1.2.)A recent search of the OVID Nursing DataBase for funded research reports from 2000–2010using the key words “stress and Lazarus” and“coping and Lazarus” generated 48 articles and 34articles, respectively, totaling 82 studies. It is clearthat the transactional or TTSC theory orientationto stress continues to inform nursing research.

CHAPTER 1. Stress, Coping, and Health 11Table 1.2Stress, Coping, and Health Outcomes as Defined in Stress TheoriesScientific viewResponsebased (Selye,1956, 1983)Stimulus based(Holmes &Rahe, 1967)Transactionbased (Lazarus,1966; Lazarus& Folkman,1984)Conceptualizationof stressStress is the nonspecificresponse to any noxiousstimulus. Thephysiological response isalways the sameregardless of stimulus—the general adaptationsyndrome (GAS).The term stress issynonymous with “lifeevent.” Life events are“stress” that requireadaptation efforts.The term stress is a“rubric” for a complexseries of subjectivephenomena, includingcognitive appraisals(threat, harm, andchallenge), stressemotions, copingresponses, andreappraisals. Stress isexperienced when thedemands of a situationtax or exceed a person’sresources and some typeof harm or loss isanticipated.Conceptualizationof copingThere is noconceptualization ofcoping per se. Instead,Selye used the conceptof “resistance stage,”the purpose of whichis to resist damage(this concept is partof the GAS).Coping is notdefined.Coping isconceptualized asefforts to amelioratethe perceived threator to manage stressemotions (emotionfocusedcoping andproblem-focusedcoping).Health outcomesOn the basis of the assumption thateach person is born with a finiteamount of energy and that each stressencounter depletes energy stores thatcannot be rejuvenated, it was proposedthat stress causes “wear and tear on thebody” that can result in various diseasesbased on the person’s geneticpropensity.A summative accumulation ofadaptation efforts over a thresholdlevel makes a person vulnerable todeveloping a physical or mental illness(operationalized as disease) within1 year.Adaptational health outcomes areconceptualized as short term and longterm.Short-term outcomes include socialfunctioning in a specific encounter,morale in the positive and negativeaffect during and after an encounter,and somatic health in symptomsgenerated by the stressful encounter.Long-term outcomes include socialfunctioning, morale, and somatichealth.Both short-term and long-term healthoutcomes encompass effective, affective,and physiological components.The Concept of HealthEach of the three theoretical perspectivesdescribed above incorporates proposed linksbetween stress and health. It is clear that both thestimulus-based and the response-based modelswere developed based on a biomedical orientationto health in which illness is operationalizedas disease and health is viewed as the absence ofdisease. The transaction model, however, viewshealth as a subjective phenomenon that encompassessomatic sense of self and functional ability.Health is an elusive term. It is a term thatmany people think they understand until theyare asked to define or describe it and then askedhow they would measure it. It has been describedas a value judgment, as an objective state, as asubjective state, as a continuum from illness towellness, and as a utopian state (rarely achievable).Contributing to the confusion about healthare the related concepts of wellness, well-being,and quality of life.Despite the common origin of the wordhealth from hoelth, an Old English word

12 PART I. INTRODUCTIONmeaning safe or sound and whole of body(Dolfman, 1973), there is no one contemporarymeaning for the construct. During the twentiethcentury, many attempts have been made by thelay community to define health in a manner thathas broad applicability. These global definitions,however, are confusing and make it difficult, ifnot impossible, to clearly operationalize. Thisconfusion has particularly important ramificationswhen one considers that health is a targetgoal shared by many professions and the federalgovernment.Health-related professions offer definitionsof health that give rise to discipline-specific focifor diagnosis and treatment. Such definitionsare not necessarily problematic. In fact, thesedifferences have probably contributed to targetedand efficient efforts to generate knowledgeabout different aspects of the human condition.However, there are three important problemswith discipline-specific definitions for which wemust use caution.The first is that discipline-specific healthperspectives partition the holistic phenomenonof health in such a manner that the wholepicture of the human condition and how personsfeel and are doing is lost. The second isthat too often the discipline’s perspective onhealth is adopted by other disciplines whenthere is not a good match in terms of the disciplines’philosophical presuppositions andsocial mandate. An excellent example is thenursing field adopting the medical model definitionof health as the absence of disease. A thirdproblem is that the acceptance of a disciplinespecificview of health by policy-makinggroups necessarily leads to health policy decisionsthat may not be in the best interest of thepopulation as a whole.The Biomedical View of HealthThe most popular and widely held view ofhealth is the biomedical one. Medicine has traditionallyviewed health from an objective stanceand defines it as the absence of disease or discerniblepathology and defines illness as thepresence of same (Engel, 1992; Kleinman, 1981;Millstein & Irwin, 1987). On the basis of thisperspective, medicine’s social mandate has beenthe diagnosis and treatment of disease. Publichealth professionals and government agenciescommonly adopt the biomedical model and usemorbidity and mortality statistics as an index ofthe population’s health.The biomedical model, as noted byAntonovsky (1979), is a dichotomous model.Consistent with this perspective, a person whohas a chronic disease cannot have health or beconsidered well. Furthermore, a logical extensionof the dichotomous model is that a personcannot be healthy in the presence of disease.Nursing’s View of HealthNursing has been critical of the narrow confinesof the biomedical model as a perspectivefor nursing and its adoption by governmentagencies (Hall & Allan, 1987; Leininger, 1994;Lyon, 1990). Many nurses in practice and nurseeducators, however, commonly adopt the biomedicalview and equate illness and diseaseusing the terms interchangeably. Likewise, conceptsof health and wellness are used interchangeably,logically resulting in the conclusionthat persons who have chronic diseases are notand cannot be described as well. Because healthand wellness are targeted outcomes, it is imperativethat nursing be clear on how it definesthese concepts. This is particularly important indeveloping theoretical models linking stress,coping, and health that can serve as a frameworkfor nursing research and practice. Nursingmust define health in a manner that (a) is consistentwith its philosophical presuppositions,(b) is measurable, (c) is empirically based, and(d) captures outcomes that are sensitive to nursinginterventions or therapeutics.Currently, there is little unity regarding adefinition of health as a central concept for nursing.Considered an essential ingredient of nursing’stheoretical meta-paradigm (i.e., person,environment, health, and nursing), nurse theoristshave elected to define health in the contextof their proposed models. Florence Nightingale(1860/1969) wrote that health is “not only to bewell, but to be able to use well every power we haveto use” (p. 26). Although one cannot be sure whatNightingale actually meant by the word well,Selanders (1995) argues she meant “being the bestyou can be at any given point in time” (p. 26). Thisallows for an individual to be healthy even if notmedically well. Some additional light is shed onthe meaning of wellness because it is clear thatNightingale viewed disease and illness as distinctlydifferent phenomena. It is interesting to

CHAPTER 1. Stress, Coping, and Health 13speculate that if Florence Nightingale were writingher Notes on Nursing today, she most certainlywould have included stress as one of themany nondisease-based causes of symptomsexperienced by patients.Tripp-Reimer (1984) proposed a twodimensionalhealth state with an etic perspective(disease–nondisease) that reflects an objectiveinterpretation of health data and an emic perspective(wellness–illness) that represent thesubjective experience. Four health states are possiblewithin her model. Tripp-Reimer proposesthat this approach is particularly useful crossculturallywhen perceptions of heath differbetween scientifically educated providers andthe client. Newman (1986) views health as thetotality of life processes that are evolving towardexpanded consciousness. Man represents onlyone stage of this evolution. Orem (1995) distinguishesbetween health and wellness. Shedefines health as a state characterized by soundnessor wholeness of human structure andbodily and mental functions. Wellness, she notes,is a state characterized by experiences of contentment,pleasure, and movement toward maturationand achievement of the human potential(personalization). Engagement in self-carefacilitates this process of personalization. Othernurses offering conceptualizations of healthinclude Henderson (1966), King (1981), Lyon(1990), Newman (1986), Parse (1992), Patersonand Zderad (1976), Peplau (1952, 1988), andRogers (1970). Health is defined in many wayswithin the discipline of nursing (See Table 1.3).Commonly shared attributes of health inherentin all of these definitions, however, is that it is asubjective experience that encompasses how aperson is feeling and doing. These commonlyshared attributes are apparent in Keller’s (1981)analysis of definitions of health. A subjectiveorientation to defining health is quite differentfrom the medical definition of health as anobjective phenomenon manifested by theabsence of disease or pathology.Regarding the possibility of a single definitionof health for nursing, Meleis (1990) points outthat, “although diversity should be accepted andreinforced, there is a need for unity in perspectivethat represents the territory of investigation, theterritory for theoretical development” (p. 109).Table 1.3Nursing-Focused Conceptualizations of HealthAuthorHenderson (1966)Peplau (l952, 1988)Rogers (1970,1989)Orem (1971, 1980,1995)King (1971, 1981)Neuman (1989)Parse (1981, 1989)Tripp-Reimer(1984)Lyon (1990)Definition of HealthHealth is viewed in terms of a person’s ability to perform 14 self-care tasks and aquality of life basic to human functioning.Health is defined as forward movement of the personality that is promoted throughinterpersonal processes in the direction of creative, productive, and constructive living.Health is defined as a value term for which meaning is determined by culture or theindividual. Positive health symbolizes wellness.Health is defined as a state that is characterized by soundness or wholeness of bodilyand mental functioning. It includes physical, psychological, interpersonal, and socialaspects. Well-being is the individual’s perceived condition of existence.Health is defined as a dynamic state of the life cycle; illness is an interference in the lifecycle. Health implies continuous adaptation to stress.Health is defined as reflected in the level of wellness.Health is defined as a lived experience—a rhythmic process of being and becoming.Health is defined as encompassing two dimensions, the etic (objective) and the emic(subjective), which include both disease/nondisease and illness/wellness.Health is defined as a person’s subjective expression of the composite evaluation ofsomatic sense of self (how one is feeling) and functional ability (how one is doing).The resulting judgment is manifested in the subjective experience of some degree ofillness or wellness.

14 PART I. INTRODUCTIONThis unity in perspective would also help to shapethe target goals of nursing’s unique contributionsto society and could serve as a practical guidelinefor assessment, diagnosis, and intervention. Theimportance of using a definition of health thatcan be operationalized and used to guide nursingpractice and research cannot be overemphasized.A nursing-oriented definition of health consistentwith the theme that health is a subjectivephenomenon that is operationalizable has beenproposed by Lyon (1990). Lyon defined health asa subjective representation of a person’s compositeevaluation of somatic sense of self (how one is feeling)and functional ability (how one is doing). Assuch, health is manifested in the subjective judgmentthat one is experiencing wellness or illness.These subjective experiences are dynamic andare an outgrowth of person and environmentalinteractions. As long as a person is capable ofevaluating how he or she is feeling and doing atsome level, the person has health. For example,an infant, although unable to utter words, iscapable of evaluating somatic sensations andfunctional ability. Likewise, a fundamentalassumption underlying nursing practice is thatall persons who have brain waves have the capabilityof sensing their environment and thecapability of experiencing discomfort or comfort.Therefore, even persons who are unconsciousshould be treated in a manner thatassumes that they can sense discomfort andcomfort. Defined in this manner, both illnessand wellness are health outcomes. The targetgoals for nursing care are to promote and maintainwellness (comfortable somatic sensationsand functional ability at capability level) and toprevent or alleviate illness (somatic discomfortand a decline in functional ability below capabilitylevel). Illness and wellness are conceptualizedas different phenomena, not as opposite or polarends of the same phenomenon.Illness as defined by Lyon (1990) is the subjectiveexperience of somatic discomfort (emotionalor physical or both) that is accompaniedby some degree of functional decline below theperson’s perceived capability level. Illness occurson a continuum from low (“I’m not feelingwell”) to high (“I’m very ill or sick”). The experienceof somatic discomfort and a decline infunctional ability can be the consequence ofboth disease and, importantly for nursing, factorsother than disease (nondisease-based factors)that are amenable to nursing interventions(Lyon, 2010) (see Figure 1.1).Nursing’s unique health-related contributionto society is the prevention of and diagnosis andtreatment of factors other than disease contributingto or causing illness (Lyon, 1990). No otherdiscipline focuses on the prevention or alleviationof nondisease-based etiologies of illness. Infact, it is interesting to note that the concept ofcure is applicable to illness experiences. That is,in addition to preventing somatic discomfortsand functional disability caused by nondiseasebasedfactors, nursing therapeutics also can cureillness by eliminating or altering nondiseasebasedfactors that are causing symptoms (Loomis& Wood, 1983). Symptoms such as pain, fatigue,nausea, and a decline in functional ability, suchas skin breakdown, falling, and inability to swallow,need to be addressed.Wellness is characterized by Lyon (1990) as theexperience of somatic comfort (emotional andphysical) and a functional ability level at or nearthe person’s perceived capability level. There isan abundance of research to demonstrate thatpeople commonly judge themselves to feel welleven in the presence of chronic, debilitating, orlife-threatening diseases when they are somaticallycomfortable and can function at theirhighest capability level (Dasback, Klein, Klein, &Moss, 1994; Long & Weinert, 1992; Okun,Zautra, & Robinson, 1988; Stuifbergen, Becker,Ingalsbe, & Sands, 1990). Evaluation of somaticsense of self and functional ability is ongoing andcan change from moment to moment. Theimportant distinction in Lyon’s (1990) definitionof functional ability is that a person’s subjectiveevaluation of functional ability is a comparisonbetween what the individual believes his or hercapability level is and what he or she is actuallyable to do. This view allows for adjustments ofperceived capability downward or upward.Therefore, during the early phases after diagnosisof rheumatoid arthritis, a person may not onlybe experiencing physical discomfort but also beviewing their self as not being able to measure upto previously held standards and expectations offunctional ability. As a consequence, the personjudges himself or herself to be experiencing somedegree of illness. After a diminished level of functioninghas become the person’s norm (alongwith learning to live with some degree of discomfort),however, the individual with rheumatoidarthritis actually might judge himself orherself as quite well.Some in nursing may, at first glance, beconcerned about using a subjective definition

CHAPTER 1. Stress, Coping, and Health 15Figure 1.1Disease-Based and Nondisease-Based Etiologies of Illness With Medical andNursing InterventionsIllnessObjectivesigns ofdisease orinjurySymptomsSomatic discomfort(affective or physical)(e.g., anxiety, shortnessof breath, dizziness, pain,nausea)Functional ProblemsADLs, physical, cognitive,social(e.g., difficulty makingdecisions, unable tofulfill social roles, fatigue,dysfunctional behavior,difficulty remembering)Disease/Injury Etiologies(Target of interventions)Examples:PathologyStructural abnormalityBacteria, virusesMedical treatments (ratrogenic)Medical interventions, includingbut not limited to, pharmacologicaland surgical treatments that alterdisease/pathology-basedetiologies or prevent theiroccurrenceExamples:Nondisease-Based Etiologies(Target of interventions)Demands>resources (overload)Perceived threatDistorted thinkingIneffective copingInadequate knowledgeInadequate self-careDe-conditioningInadequate nutritionInadequate hydrationImproper positioningInadequate movement (e.g., immobility)Improper body mechanicsPoor hygieneInsufficient sleep/restEnvironment factors (e.g., pollens, noise,temperature)Nursing interventions that alter thenondisease-based etiologies or preventtheir occurenceSOURCE: Reproduced with permission from B. L. Lyon © 1995.of health as a framework to guide nursingpractice. That is, what do you do with the personwho has had a stroke yet perceives himselfor herself as well? Nothing? Of course not, it isimportant to note, however, that the individualwith a stroke may not do anything unless he or

16 PART I. INTRODUCTIONshe deems his actions (e.g., taking medicationsand changing lifestyle) as both salient andimportant. Helping patients to elevate and tomaximize their awareness of slight somatic discomforts(e.g., extremity weakness) or slightproblems with functional ability (e.g., decreasedmobility) is important in stimulating therapeuticself-care actions (Lyon, 2002). Figure 1.2 presentsof graphic of this perspective.The understanding that both illness and wellnesscan be experienced in the presence orabsence of disease and that nursing’s unique contributionis focusing on the diagnosis and treatmentof factors other than disease (nondiseasebased) contributing to illness is a fundamentalcornerstone of nursing. Grasping this idea is whatmakes it possible for nurses to see possibilitiesfor patients to experience wellness in the presenceof a chronic and/or life-threatening disease.Knowledge about nondisease-based factors, suchas stress, that can contribute to somatic (physicalor emotional) discomfort and declines in functionalability increases a nurse’s repertoire ofintervention possibilities to help patients. It isimperative that nursing develop and/or adoptmeasurements of health outcomes that demonstratethe efficacy of stress- and coping-focusednursing interventions. In Chapter 22, Lyon andFigure 1.2Linking Nursing Interventions to Health OutcomesILLNESSSomatic discomfort(e.g., stress emotions)(e.g., uncomfortable physicalsensations such as fatigue, pain)Decline in functional abilitybelow perceived capability level(e.g., difficulty concentrating ormaking decisions)WELLNESSSomatic comfort(e.g., emotions/mood—calmness,pleasure, joy, relief, happiness)(e.g., physical sensations such asrested, energized)Functional ability at or nearperceived capability level(e.g., able to meet social roleresponsibilities, able to accomplishgoals, able to learn, able to meetintimacy needs)NONDISEASE - BASEDETIOLOGIES(e.g., excess of controllabledemands, distorted thinking, unmetexpectations, unjustified self-blame)NONDISEASE - BASEDETIOLOGIES(e.g., balances demands andresources, rationall/non-toxicthinking, positive focusing, realisticexpectations)NURSING INTERVENTIONS/THERAPEUTICSto assist with eliminatingor modifying etiologiesNURSING INTERVENTIONS/PREVENTIVE MEASURESto assist with maintenance ofetiologies or prevention of otherstress etiologies

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