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1/” WM“

THE RELATIONSHIP BETWEEN HUMOR AND NURTURANCE AND FAMILY
COPING 0F PARENTS WITH CHRONICALLY ILL CHILDREN
By

Dana C. Balander

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1997

ABSTRACT
THE RELATIONSHIP BETWEEN THE USE OF HUMOR AND NURTURANCE
AND FAMILY
COPING OF PARENTS WITH CHRONICALLY ILL CHILDREN
By

Dana C. Balander

Chronic illness is a major concern for health care providers. There are estimates
that there are approximately 20 million children between the ages of birth and 18 that
sufl‘er from a chronic illness or disability in the United States (Heaman, 1995). The
number of families trying to cope with the chronic illness of a child leads to an increased
possibility that Advanced Practice Nurses will care for these families. It has been the
purpose of this study to examine the relationship between the use of humor and nurturance
and family coping of parents with chronically ill children within the framework of The
Double ABCX model of family stress and adaptation (McCubbin and Patterson, 1983).
The results of this study provide evidence that there is a relationship between the use of
humor and nurturance and coping of parents of chronically ill children. Implications
include the individual assessment of each family for their response to a potential crisis

event and the need for a consistent and objective measurement of nurturance.

ACKNOWLEDGMENTS

This thesis would not have been possible without the help and cooperation of many
individuals. I would be in error if I failed to thank those who made this possible: First I
would like to express my appreciation to my committee members Patty Peek and Sharon
King who have endured with good humor my many e-mailings for requests of help, and to
my thesis chair, Linda Spence, who was always gracious with her time and resources. I
would also like to thank my children Sara, Emily, and Joseph who did their best to
cooperate with mom and knew enough to stay far afield when they heard their mom
ranting over the preparation of this thesis. However, I need to make special recognition to
my husband, Richard, who has had to endure more than most and whose technical

expertise with computers has assisted greatly in the preparation of this thesis.

TABLE OF CONTENTS

Page
List of Tables .................................................................................. vi
List of Figures ................................................................................. vii
CHAPTER I: THE PROBLEM
Introduction ................................................................................... 1
Statement of the problem ................................................................. 3
Purpose .......................................................................... 3
Research Questions .................................................................. 4
Definition of Concepts ................................................................. 4
Humor ................................................................................... 4
Nurturance .......................................................................... 4
Coping .......................................................................... 4
Chronic Illness .......................................................................... 5
Health .......................................................................... 5
CHAPTER II. CONCEPTUAL FRAMEWORK
Introduction ................................................................................... 6
The Double ABCX model ................................................................. 6
The Pile-up (aA factor) ........................................................ 9
Family Adaptive Resources (bB factor) .................................... 10
Family Definition and Meaning (cC factor) .................................... 11
Family Adaptation (xX factor) ............................................. ~ 12
CHAPTER III. REVIEW OF LITERATURE
Introduction ................................................................................. 15
Review of Literature ........................................................................ 15
Humor ................................................................................. 15
Nurturance ........................................................................ 19
Family Coping ........................................................................ 20
Summary ................................................................................. 22
CHAPTER IV: METHODS
Design .......................................................................................... 23
Hypotheses ................................................................................. 24
Operational Definitions ............................................................... 24

iv

TABLE OF CONTENTS (continued)

Family Coping ......................................................................... 24
Humor .................................................................................. 25
Nurturance ......................................................................... 26
Sample ........................................................................................... 26
Data Collection ......................................................................... 28
Reliability and Validity ................................................................ 30
Data Analysis .................................................................................. 32
Protection of Human Subjects ................................................................ 32

CHAPTER V: RESULTS

Socio-demographic Data ................................................................ 33
Hypotheses Results ......................................................................... 34
Hypothesis 1 ......................................................................... 38
Hypothesis 2 ......................................................................... 39
Hypothesis 3 ......................................................................... 39
Hypothesis 4 ......................................................................... 4O
Hypothesis 5 ......................................................................... 41
CHAPTER VI DISCUSSION AND IMPLICATIONS
The Double ABCX Model ................................................................ 44
Relation to Methods ......................................................................... 44
Relation to Current Literature ........................ , ............................... 45
Implications for Advanced Practice Nursing .............................................. 47
Hypothesis 1 ......................................................................... 47
Hypothesis 2 ......................................................................... 48
Hypothesis 3 ......................................................................... 49
Hypothesis 4 ......................................................................... 50
Hypothesis 5 ......................................................................... 51
Implications for Research ................................................................ 51
Summary .................................................................................. 52
BIBLIOGRAPHY ......................................................................... 53
APPENDIX

UCRIHS approval letter ....................................................... 57

List of Tables

Table 1 Absolute number of children in family ..................................... 34
Table 2 Amount worked of mother ....................................................... 34
Table 3 Education of mother ................................................................ 35
Table 4 ANOVA of Education of mother .............................................. 35
Table 5 Occupation of mother ....................................................... 36
Table 6 ANOVA of occupation of mother .............................................. 36
Table 7 Education of father ................................................................ 37
Table 8 ANOVA of education of father .............................................. 37
Table 9 Income of the family ................................................................ 38
Table 10 ANOVA of total humor between chronically

ill and comparison families ....................................................... 39
Table 11 ANOVA of total nurturance between chronically .

ill and comparison families ........................................................ 39
Table 12 ANOVA of total coping between chronically

ill and comparison families ....................................................... 40

Table 13 Comparison of means and standard deviations
for variables of humor, nurturance, and coping between

chronically ill and comparison families. . . ..‘ ................................ 40
Table 14 Correlation of total coping with humor ..

and nurturance ................................................................ 41
Table 15 Correlation of low total coping with

humor and nurturance ....................................................... 42
Table 16 Correlation of medium total coping with

humor and nurturance ....................................................... 42

Table 17 Correlation of high total coping with
humor and nurturance ....................................................... 42

List of figures

Figure 1 The Double ABCX model ......................................................... 8
Figure 2 Adaptation of the Double ABCX model ..................................... 13
Figure 3 Adaptation of the Double ABCX model

including variables humor and nurturance ..................................... 13

vii

CHAPTER I
THE PROBLEM
Introduction
Chronic illness is a major concern for health care providers. Despite the fact that chronic
illness afl‘ects proportionally more elderly than the rest of the population, it also remains a
serious problem for children and their families (Clawson, 1996). There are estimates that
approximately 20 million children from birth to age 18 are sufi‘ering with a chronic illness
or disability in the United States (Heaman, 1995). The advances made in control of
infectious diseases, advances in technology, and the increasing life expectancy for a
number of diagnoses lead to an increased possibility that Advanced Practice Nurses will
care for individuals and families who are trying to cope with a child’s chronic illness.
Traditionally the focus has been on the individual with the chronic illness and how
that individual copes with the chronic illness. Over the last decade or so, it has been
documented that families are afi‘ected by and affect the chronic illness of a family member
(Shapiro, 1983). With few exceptions, most families with a member who is chronically ill
are care givers for their chronically ill family member (Gillis, Rose, Hallburg, and
Martinson, 1989). Furthermore there have been documented in the literature several
assumptions regarding chronic illness and families, including:
1. If any family member has a chronic illness it requires the rest of the family to

adapt (Knafl & Deatrick, 1990).

2

2. The experience of chronic illness is multidimensional with similar aspects
regardless of differing disease processes (Canam, 1993).

3. Chronic illness is a stressful event or burden because it places a strain on the
families financial, physical, and emotional resources (Reed, 1990 and Williams,
Lorenzo, & Borja,1993).

4. Families can adapt and grow in response to the chronic illness of a family
member (Canam, 1993).

It is generally assumed that people with a sense of humor and those peOple who
use humor in their daily lives are more capable in dealing with the demands and stresses
placed on them. Another assumption that is often made is that if your background is a
nurturing one you are better equipped to cope with the stresses in life. Nowhere is this
more apparent than in the rationalization of undesirable behavior. Many times people have
been overheard to say “It’s no wonder they turned out the way they did, just look at how
they were brought up.” These assumptions however have not been tested, this is
particularly true in regards to the coping of parents with a chronically ill child. It has been
well documented that there are a variety of factors that influence a families ability to cope
with chronic illness. In this study the focus is on the relationship between the use of

humor and nurturance and family coping strategies of parents with a chronically ill child.

3
Statement of the problem

The current literature is replete with examples of how a childhood chronic illness
afl’ects family functioning and the family’s ability to cope. There are descriptions of
firnctional and dysfunctional coping (McCubbin & Patterson, 1983). The literature
includes descriptions of how chronic illness disrupts family function and structure,
including family role and responsibility distribution (Hauenstein, 1990). There are
descriptions of how extrafamilial support indicate higher levels of family coping (Hamlett,
Pellegrini, and Katz, 1992). There is however, a lack of literature that defines specific
strategies available to health professionals, Advanced Practice Nurses (APN’s) in
particular, to assist families during this stressful time. Specific family typologies or
individual behaviors associated with family coping of parents with a chronically ill child
have not been examined.

PM

The Advanced Practice Nurse, armed with the appropriate strategies could be in a
position to assist and guide families through the challenge of chronic childhood illness. It
is therefore the purpose of this study to identify whether the use of specific behaviors can
effect the family coping of parents with chronically ill children. Specifically, the
relationship the use of humor and nurturance by parents of chronically ill children and

parental coping strategies of parents will be examined.

Research Questions

In this secondary study, the following question will be addressed; “Is there a
relationship between the use of humor and nurturance and family coping of parents with a
chronically ill child?” In addition the following second question will be addressed; “Is
there a difi’erence between families with a chronically ill child and those families with

healthy children in their frequency of use of humor and nurturance?”

Definition of Concepts
Hume:

Humor is a subjective, cognitive, and emotional response that results in the ability
to see the amusing or lighter side of things (Harter, 1986). The use of humor is defined as
an intellectual process that results fiom the synthesis of the cognitive, subjective, and
emotional input that is then transformed into a behavioral response, such as a joke, a
laugh, or a conscious thought of amusement.

Nurturance

Nurturance is the provision of a warm, loving, caring, supportive, and/or devoted
atmosphere by one person that promotes the growth, development, and problem solving
capabilities of individual family members and/or the family unit as a whole (Harter,1986) .
QQELHS

Coping will be defined as both the behavioral responses of individual family
members as well as the responses of the family unit in an attempt to manage a difficult or

problematic situation. Coping also includes the family’s perception of the situation.

5
Therefore coping also is the family’s ability to acquire and use resources needed for the

family’s adaptation (McCubbin and Patterson, 1983).
Chronic Illness

Chronic illness is a diagnosis that persists for at least six months, having occurred
at least one year ago, is not necessarily terminal and does not include developmental
disabilities such as Down’s Syndrome or conditions of mental illness such as bipolar
disorder. In this study the chronic illnesses included asthma, cystic fibrosis, diabetes, and
congenital cardiac disorders. In using four difi’erent diagnostic categories of chronic
illness it is assumed that there are commonalties across categories of chronic illness
irrespective of diagnostic labeling (Stein and Jessop, 1989). That having a chronic illness is
more of an indicator of the adaptation needs than the specific diagnosis.
HeflLh

Health is defined as holistic in nature and composed of difi‘ering dimensions,
including the biological, psychological, social, and spiritual domains. The absence of
chronic disease or developmental disability is also conceptualized to be a condition of

health for the purposes of this study.

CHAPTER II
CONCEPTUAL FRAMEWORK
Introduction

In this study the conceptual framework was based on The Double ABCX model
of family stress and adaptation by H. I. McCubbin and J. M. Patterson (1983). The
Double ABCX model describes how families cope with a perceived stressfirl event over
time (Mays, 1988). It is based on an earlier theory developed by Hill that attempted to
explain why families reacted difi’erently to the same types of events (McCubbin &
Patterson, 1983). The Double ABCX model expands on Hill’s earlier theory (the original
ABCX theory) that focused on pre-crisis variables and how families cope with the initial
stressor. The Double ABCX theory incorporates the original theory of Hill and
elaborates on it in an attempt to explain how families cope with and recover from a crisis
over time (McCubbin & Patterson, 1983). The Double ABCX theory advances the
assumption that the adjustment of a family to any particular stressor is the result of the
interaction of both pre-crisis and post-crisis variables (Mays, 1988).

The Double ABCX Model

McCubbin and Patterson (1983) advance the Double ABCX model as a way of
explaining the great variability among families in response to the stress of a chronic illness
in a family member. Hill (1958) proposed in the original ABCX model that the degree to
which families are susceptible to crisis is dependent on the interaction of the stressor event

6

7
(a factor) with the existing resources (b factor) and with the families perception of the

stressor event (c factor). In families with a child with a chronic illness this can be
demonstrated as the ‘a’ factor being the initial diagnosis of chronic illness. The ‘b’ factor
are the existing family resources, for example extended family members near by to lend
assistance, or a strong mutually supportive marriage so that one parent isn’t feeling the
sole burden for the care of a chronically ill child. The ‘c’ factor or family perception of the
diagnosis of a chronic illness could be the feeling that this chronic illness was God’s will or
that it is a challenge the family will face.

A crisis develops when the family is only able to define the diagnosis of chronic
illness as a catastrophe, whether it be because they lack suficient resources or are unable
to see beyond the stressor event. McCubbin and Patterson (1983) propose that families
develop some sort of adaptation to crisis over a period of time. The Double ABCX
model states that coping is central to the families ability to adapt, and furthermore that
coping is the outcome of the pile-up of demands on the family and is a result of the
interaction between the families resources, perceptions and behavioral responses
(McCubbin and Patterson, 1983) (see figure 1).

The post-crisis variables were developed by McCubbin and Patterson to explain
difl’erences in family adaptation over time. When a crisis occurs the family moves from the
adjustment phase to the adaptation phase. In the adaptation phase the level of family
coping and adaptation results fiom the (a) pile-up of demands, (b) the family’s resources
and strengths, and (c ) the family’s perception of the crisis. The ‘aA’ factor which refers to
the family’s demands or pile-up of stressors. The ‘bB’ factor refers to the family’s

capabilities for meeting the demands that have emerged as a result of the stressor event.

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9
The ‘cC’ factor is the family’s definition and meaning of the situation resulting from the

changes that have occurred as a result of the situation.

The Pile-up (aA factor)

The Double ABCX model suggests that families rarely are dealing with a single
stressor. Instead families with a chronically ill child are dealing with pile-up of demands.
McCubbin and Patterson (1983) describe five types of stressors that add to pile-up: (a)
normative transitions, (b) prior strains, (c ) the initial stressor and its hardships, (d)
intrafamily ambiguity, and (e) consequences of the families ability to cope.

Normative transitions. Even though families are faced with the stressor of having
a child with a chronic illness they are also faced with transitions that have the potential to
add stress to the family system. For example the normal grth and development of the
children in the family (i.e.) children entering adolescence or a new school. The growth
and development of the adult members for example mother returning to work can be
classified as a normative transition. There may be changes in the extended family for
example death of grandparents. Or there may be changes in the family’s life cycle for
example grown children leaving home. These stressors, although normal in the lives of
families occur independently and possibly at the same time as the initial stressor and place
additional stress on the family since they also require adjustment and adaptation.

Prior strains. Contributing to pile-up are those unresolved issues that families
carry with them. These issues are now exacerbated as families become aware of them and
demand their attention. Prior strains may be those unresolved issues from previous
hardships or from an ongoing role strain (McCubbin and Patterson, 1983). A prior strain

might be a disagreement between a couple on specific child rearing practices, discipline

10

issues, or how best to handle financial resources. These issues now become more
problematic as the family now has to deal with the chronic illness of a child as well as the
previously unresolved issues.

Initial Stressor and its Hardships. Specific hardships which increase and intensify
the difficulty families face are those factors associated with the occurrence of the stressor
event. For example one parent having to give up a job in order to care for the chronically
ill child.

WM Since a stressor such as a diagnosis of chronic illness
produces a certain amount of uncertainty about the future ambiguity results. For example
parents may get inconsistent medical advice, or even uncertainty on the prognosis of the
child with the possibility of a shortened life span.

Congguences of Fgfl y Efforts to Cope. This source of pile-up results from
behaviors the family uses to attempt to cope with the initial stressor. For example a father
of a chronically ill child may get a second job in an effort to cope with the added expenses
a chronic medical condition requires.

Famil tive resources B factor

The family’s ability for meeting the demands placed on it from the stressor event
evolve during the adaptation phase. McCubbin and Patterson (1983) describe three types
of resources afi’ecting a family’s ability to adapt, (a) family member’s personal resources,
(b) the family systems internal resources, and (c ) social support. When family member’s
personal resources are sufficient, they are less likely to view a stressor as problematic.
These resources include; economic well being, adequate cognitive abilities to facilitate

problem solving and stress perception, physical and emotional well being, and finally

l l
personality characteristics or psychological resources (McCubbin and Patterson, 1983).

Family systems resources identified by McCubbin and Patterson that facilitate adaptation
are the degree of family cohesion and adaptability inherent in a family. The hypothesis is
that families with moderate levels of each cohesion and adaptability are most likely to be
able to make a successful adaptation to a crisis. The third type of family resource that
affects the family’s ability to adapt is the social support they receive or are able to
develop. This type of resource can be in the form of support groups or from other families
in similar situations. Social support can also be in the form of assistance from fiiends,
neighbors or medical personal. Adequate resources help enable a family to manage the
many demands placed on a family with a chronically ill child.

Family Definition and Meaning (cC factor)

When faced with a crisis and a demand for changes imposed by the stressor event
families are faced with a situation that requires them to redefine their particular situation.
This effort to give the crisis a new meaning serves to clarify issues and make them more
manageable. It also decreases the degree of emotional burden associated with the stressor
event and helps facilitate the family to continue with its fundamental function of promoting
the grth and development of the members (McCubbin and Patterson, 1983). Coping, in
the Double ABCX model, includes both the behavioral responses of family members, as
well as the responses of the family unit in an attempt to manage the situation, in addition
to the family’s perception of the crisis. Therefore, coping is the family’s ability to acquire

and use the resources needed for family adaptation (McCubbin and Patterson, 1983).

12

Family Adaptation (xX factor)

The state of a family’s adaptation is the result of its interaction between the
resources available, the perception of the crisis, and coping processes. Adaptation is
viewed on a continuum fiom poor to good. Those families who are at risk for poor
adaptation (maladaptaion) are those families who have a large number of stressors in a
short period of time and/or those families whose resources are overburdened or
delinquent. Adaptation occurs at three levels: individual to family, individual to
community, and family unit to community. When there is only minimal discrepancy or a
balance between the families demands and capabilities good adaptation (bonadaptation) is
said to have occurred.

The Advanced Practice Nurse can use the Double ABCX model with chronically ill
children and their families as a way of analyzing family efforts to adapt to many stressors
or crises over time. Not only can the Advanced Practice Nurse observe how families use
their strengths, resources, and perceptions as a process aimed at achieving adaptation, but
through their observations notice where delinquencies exist and thus assist and guide
families towards strengthening their resources or reframing their perceptions, so that they
may achieve a balance in their lives. This study is using an adapted version of the Double
ABCX model, conceptualized by Spence, Barnes, and Peek (1989), (see figure 2). In
particular this study is focusing on the dimensions of resources and coping (see figure 3)
as outlined in the adapted version of the Double ABCX model. In this study the use of
humor and the parents perception of being nurturing are thought to act as both a family
resource (bB factor) and as an ameliorating factor in the families perception of the event

of chronic illness (cC factor). The relevance of humor and nurturance as important

13

Resources

 

Pile up
Demands ‘———' Coping ——> Adaptation

 

 

 

 

Perception
of
Demands

Figure 2. Adaptation of the Double ABCX Model by Spence, Barnes, and Peek (1989).

     
   
   

Resources
including
Humor and
Nurturance

 

Demands ‘—-——' Coping —-—> Adaptation

 

 

 

 

Figure 3. Adaptation of the Double ABCX Model by Spence, Barnes, and Peek (1989)
including the variables Humor and Nurturance.

l4

concepts is in the contribution to the family’s pool of resources. It makes sense intuitively
that if a family has a greater set of resources to draw from in time of stress the less likely
that family will perceive the stress as a crisis. Also with a larger pool of resources to
utilize the family will have better coping abilities and be better able to achieve

bonadaptation.

CHAPTER III
REVIEW OF THE LITERATURE
Introduction

In this chapter, literature relevant to families with a chronically ill child and coping
abilities will be reviewed. Literature on the use of humor and its possible therapeutic value
will also be reviewed. The use of nurturance and the efi‘ects it has on families will also be
reviewed. Much of the literature on humor and nurturance has been based on individual
anecdotal accounts and not related to family coping. The pros and cons of using humor
and nurturance Will be reviewed in the literature. Some professional use of humor by
health care providers has been incorporated in the literature review because there is so
little empirical literature on the use of humor within families and the efl’ects on coping. The
family coping literature reviewed has much of its focus on the individual family’s or family
member’s response to a chronic illness. Specific strategies usefirl for health care providers
in promoting optimal family coping will be identified and reviewed where available.

Review of Literature

Hu_mo_r

Throughout time humor and laughter have been part of daily life. However, the
use of humor as a valid tool to be used in nursing or used by families or as subject of study
has only recently become acceptable. Why has the use of humor been so lacking in the
nursing literature, when anecdotal information on the therapeutic use of humor can be

15

16
found as far back as biblical times? Proverbs 17:22 states: “A joyful heart is the health of

the body, but a depressed spirit dries up the bones.” More recently Freud (1927) talked
about how humor could change pain to pleasure and used his own personal account of
cancer pain and the use of humor to overcome the discomfort. The same type of
anecdotal account of personal triumph over pain with humor has been related by Norman
Cousins (1979) afier his encounter with a painful collagen disorder. The idea that humor
and laughter could cause the release of endorphins and thus decrease perceived pain by an
individual followed such anecdotal evidence. Perhaps the main reason humor has not been
studied more extensively or received much attention by the profession in research as a tool
for families, lies in the historic roots of the nursing profession. Nursing has its’ origins in
the religious and military orders. It was perceived that nursing was a very serious business
and that laughing, joking, or expressing a sense of humor was unprofessional and
unbecoming (Rosenberg, 1989; Ruxton, 1988).

Recent literature suggests four areas where humor can be of therapeutic value; 1)
as a method of improving interpersonal communication such as learning and rapport
building, 2) as an intervention to improve psychological firnction, 3) as an intervention to
improve physiological function, and 4) as a coping mechanism (Astedt-Luikkonen, 1994,
Bellert, 1989, Davidhizer & Schearer, 1992, Hulse, 1994; Ruxton, 1988).

Humor can be used as a method of improving communication and establishing a
rapport. Basically, humor is a familiar pattern of communication for most people that helps
to diminish discomfort and shows people that you are vulnerable while serving to
strengthen a relationship (Groves, 1991). Humor also improves communication by

facilitating learning, this is accomplished by decreasing anxiety and providing for a non-

l7
threatening environment (Bellert, 1989; Rosenberg, 1989). Problem solving is facilitated

because humor can put people at ease, promoting expression and the exchange of ideas
(Davidhizar & Bowen, 1992). Ziv (1988) studied the role humor has in married life and
found that greater than 92% of married couples used humor with their partner and that
most couples felt humor added a degree of cohesiveness to their relationship. By sharing
a “private joke” they could communicate to each other even with others around. A
variation of the humor as communication builder is play therapy. Play therapy encourages
children to face diflicult situations and allows them to express themselves in a non-
threatening manner (Erdman, 1991).

Humor can improve physiologic function as has been hypothesized in the form of
anecdotal evidence from Norman Cousins (1979) and Freud (1927). Cousins
hypothesized that laughter has an anesthetic efl'ect by perhaps the release of endorphins.
Others (Fry, 1988) suggest the beneficial aspects of laughter are from an initial raise in
blood pressure and heart rate during the active laughing phase that is followed by an
episode of relaxation when heart rate and blood pressure fall to below baseline levels.
Other researchers (Dilon, Minchofi’, & Baker, 1985) suggest that the beneficial efl’ects of
laughter are from the enhancement of the immune system. Elevated levels of IgA were
related to a positive emotional state with increased levels of IgA were found after viewing
a humorous film (Dillon, Minchofi", & Baker, 1985). Indeed psychoneuroinununology, an
entire field of study is devoted to the correlation between mind and body.

Psychologically, we have all experienced the uplifting effects of humor in our daily
lives. Humor has been described as a method to decrease stress, tension, and anxiety. It

allows for expression of emotions that otherwise may have been socially unacceptable or

18
too fiightening to face (Pasquali, 1990). The psychological benefits from humor are

demonstrated every day in hospitals across the country with the use of humor carts and
clowns to lift the spirits of patients.

As a coping mechanism humor can be used to diffuse anxiety or anger, assist
people in coping with change, and allow people a chance to escape from realities that may
otherwise be too overpowering to face such as a terminal illness or death. A joke may
allow a person a temporary reprieve fi'om an otherwise frightening or unpleasant
experience and avoid being overtaken for that moment by a situation in which he is
powerless (Davidhizar & Bowen, 1992). There are only a few empirical studies that have
identified humor specifically as a measurable and effective coping mechanism. Buelow
(1991) identified humor as a coping mechanism for multiple sclerosis patients, and found
that there was a negative correlation between positive coping behaviors (including humor)
and depression. In their work with adolescents with diabetes Grey, Cameron, and Thurber
(1991) found a positive correlation between the use of humor and adaptation. Martin and
Lefcourt (1983) provided evidence in three studies that a sense of humor does indeed
moderate the effect of negative life events and mood disturbances. Ziv (1987)
demonstrated that the use of humor with high school students decreased their level of
fi'ustration after failing to solve test questions.

The use of humor does have its limitations. The use of humor would be
inappropriate if it causes hurt feelings or increased anxiety. Ifhumor is used
inappropriately it may be a barrier to the development of a therapeutic nurse client
relationship. The person who uses humor needs to feel that the use of humor has helped

them in the past or at least approve of its’ use and feel it is worthwhile to try. Finally, the

19

use of humor must not be sarcastic, but needs to show respect for the client as an
individual, the need is to laugh with a person not at them.

It is true that the use of humor as a therapeutic tool has its limits. The proposed
benefits of using humor to improve communication, enhance physiological and
psychological well being, and increase coping are all within the scope and interest of
nursing practice. It is the promotion of health and feelings of well being that is one of
main goals of the Advanced Practice Nurse. The potential benefits of using humor within
the families of chronically ill children could include building upon existing family
resources so that the stress of chronic illness might be given a short reprieve, and the
family could refocus their energies on the tasks at hand. Also, a family with a healthy sense
of humor may be more likely to view a situation, such as the chronic illness of a child, with
an optimistic or upbeat attitude.

Nurturance

Nurturance has generally been thought of as a dimension of good parenting . The
words warmth, support, love, approval, attention, and concern have all been used to
define parental nurturing (Buri, 1989). Nurturance is also a concept that is not thought of
as a condition that stands alone, but as a condition that is closely associated with other
psychological measures. For instance, Evans, Thompson, Browne, Barr, and Barton
(1993) found that nurturance, endurance, amliation, and autonomy were all highly
correlated with feelings of psychological well being in adults who were in remission from
acute leukemia.

There are very few empirical studies that report on the direct relationship of

nurturance and coping. McIntre and Dusek (1995) reported on parenting practices and

 

20

styles of coping, and found that adolescents who had parents they perceived as nurturing
used a greater amount of social support and problem focused coping practices than those
who had other parenting styles. Indeed the theme that runs through most research on
parental nurturance is that those young adults who perceived their parents to be nurturing
as they were growing up, believe that it promotes sound mental health, psycho-social
development and self-esteem (Brost & Johnson, 1995, Hopkins & Klien, 1993, and
McIntre & Dusek, 1995).

Lempers, Clark-Lempers, & Simons (1989) demonstrated via path analysis that the
stressor of economic hardship led to a reduction in parental nurturance and subsequent
increase in distress among adolescents. However, this author was unable to find literature
that either supported or refitted the notion that a nurturing family would enhance family
coping. Although common sense tells us that if nurturing parents foster mental health in
their children it would seem to follow that a nurturing family would also foster sound
coping practices for an entire family.

Family Coping

Nursing since the time of Nightingale has recognized the need to include the family
as recipients of care (Whall, 1986). The nursing literature continues to state that an
individuals’ health can be measured to some degree by the health and adaptation of the
family (Anderson & Tomlinson, 1992 and Gillis, 1991). However, the literature on family
coping has been limited.

McCubbin (1979) suggests that for a family to have successful adaptation to stress,
the family must develop two sets of resources. The first set of resources the family must

develop are internal resources. This includes integration and adaptability so that the family

21
can withstand the social and psychological stresses that it may be exposed to

(McCubbin, 1979). McCubbin and Patterson (1983) firrther refine the previously
mentioned two sets of resources in the Double ABCX model, which suggests that when a
crisis occurs (such as the chronic illness of a child) the family moves through the
adjustment phase to the adaptation phase. Ifthis is done successfiilly the family has
adapted, gains a new balance to the family unit, the family strength has improved, and the
family is better equipped to handle firture stresses (McCubbin and Patterson, 1983).

Gallo (1991) suggests that the family’s ability to cope with a chronic childhood
illness is based on a number of factors. Specifically identified as assets to coping are the
ability to make changes in the family system, roles, routines, and interactions among family
members. These concepts have been reinforced by Gibson (1988) in her work in family
coping with children with cystic fibrosis. The theory development work done on family
adaptatiOn in families experiencing new onset epilepsy of a child (Austin, 1996) also point
to significant family adjustments as important factors in coping.

Researchers are in general agreement on how the impact of a chronic illness of a
child places the family under additional stress and acknowledge that a child’s chronic
illness increases a families vulnerability to the stresses of life (Austin, 1996, Clawson,1996,
Gallo, 1991, Hamlett, Pellegrini, & Katz, 1992; Heaman, 1995). However this does not
necessarily mean there will be a disintegration of the family unit. How a family copes with
a chronic illness is individual and dependent on the family’s psychological make-up, the

various ways of normal family interaction, and social factors of the family (Reed, 1991).

22

Summary

The chronic illness of a child affects the entire family. The family attempting to
cope with a chronic illness is faced with many challenges. The studies reviewed suggest
that successfirl adaptation is dependent on the demands on the family’s, the family’s
strengths and resources, and the family’s perception of the crisis (McCubbin and
Patterson, 1983).

It has been shown that humor can be used efi’ectively as a coping mechanism and
as a tool to promote well being. Nurturance has been demonstrated to be efl’ective in
increasing sound mental health. The holistic nature of nursing makes identifying strategies
that can be used by families to increase family coping a valid concern. Family coping,
sound mental health, and the promotion of positive feelings of well being have long been
in the interest of nursing. It would benefit both families and the practice of nursing if
additional strategies can be identified to assist families dealing with the demands of a
chronically ill child. The lack of empirical evidence to support the hypotheses that the use
of humor and nurturance will be reflected in family coping is the rationale behind this
study. Therefore it is the purpose of this study to determine if there is a relationship
between the use of humor and nurturance and family coping by parents with a chronically

ill child.

CHAPTER IV
METHODS
Design

This non-experimental descriptive study is a secondary analysis of data collected
for a larger primary study entitled, “Family Adaptation to Chronic Childhood Illness” that
was conducted by Linda Spence, Carla Barnes, and Patty Peek from the College of
Nursing at Michigan State University. The primary research was firnded by the American
Lung Association of Michigan and by the American Heart Association of Michigan. The
focus of the primary study was to examine the efl‘ects of having a chronically ill child on
the entire family firnctioning. The comparison ex post facto design study included all
members of the family with a chronically ill child. Numerous concepts and instruments
were used, including Harter’s Adult Self-Perception Profile, (1986) and the Family Crisis
Oriented Personal Evaluation Scale (F-COPES) by McCubbin, Olsen,& Larsen, (1981).

Unlike the primary study, this secondary study uses the Adult Self-Perception
ngfi_le_ (Harter, 1986) and F-COPES (McCubbin, et. al.,1981) and focuses solely on the
data collected fi'om the parents of both chronically ill children and healthy comparison
children. The focus of this secondary analysis was on the sense of humor and nurturance
subscales on Harter’s Adult Self-Perception Profile (1986) and their relation to coping on
McCubbin’s F-COPES (1981). The previously collected data on the two groups of
parents in the primary study was utilized to examine the relationship between the use of

23

24
humor and nurturance and the family coping of parents with chronically ill children. The

data was also examined to see if there is a difi’erence between families with chronically ill
children and those comparison families with healthy children in their use of humor and
nurturance.
Hypotheses

The following hypotheses were tested in this study:
1. There is a significant difi’erence in the use of humor between parents of chronically ill
children and parents of healthy children on the humor sub-scale score. With the
chronically ill parents scoring significantly higher than the comparison parents on the
humor scores.
2. There is a significant difi’erence in the nurturance of parents with chronically ill children
and parents of healthy children on the nurturance sub-scale score. With the chronically ill
parents scoring significantly higher nurturance scores.
3. There is no significant difference in the coping of parents of chronically ill children and
parents of healthy children on the mean F-COPES (McCubbin, 1987) scores.
4. There is a positive correlation between the humor sub-scale score and the total F-
COPES (McCubbin, 1987) scores.
5. There is a positive correlation between the nurturance sub-scale score and the total F-
COPES (McCubbin, 1987) scores.

Operational definitions

Family Cpping

Family coping in this study is defined asthe use of problem solving and behavioral

strategies used by families in times of difficulty as defined in F-COPES (McCubbin,

25
Olsen, and Larsen, 1981). F-COPES (McCubbin, 1981) utilizes the coping dimensions in

The Double ABCX model and integrates the factors of pile-up, family resources, and
perception. In this study family coping was operationalized by utilizing the total score that
includes the five subscales of the McCubbin, Olsen, Larsen Family Crisis Oriented
Personal Evaluation Scales that are as follows:
1. Acquiring Social Support. The families ability to actively engage in acquiring
support from fiiends, relatives, neighbors, and extended family. It is measured in
items #1, 2, 5, 8, 10, 16, 20, 25, and 29.
2. Reframing. The families ability to redefine stressful events in order to make
them more manageable. It is measured in items # 3, 7, 11, 13, 15, 19, 22, and 24.
3. Seeking Spiritual Support. The ability of the family to acquire spiritual support
is measured in items # 14, 23, 27, and 30.
4. Mobilizing the Family to Acquire and Accept Help. The families ability to seek
out community resources and accept help from others is measured in items # 4, 6,
9, and 21.
5. Passive Appraisal. The families ability to accept problematic issues minimizing

reactivity is measured in items # 12, 17, 26, and 28.

Humor
Humor in this study is operationalized by the humor subscale in Harters’ Adult

Self-Perception Profile (1986). It is measured in items # 13, 26, 38, and 50.

26

Nurturance

Nurturance in this study is operationalized by the nurturance subscale in Harters’
Adult Self- Perception Profile (1986). It is measured by items # 4, 16, 29, and 42.

Sample

The sample in the primary study consisted of 45 families. The 45 families were
recruited for the primary study through the pediatric subspecialty clinics in the Department
of Pediatrics and Human Development at Michigan State University. This convenience
sample was limited to these clinics because of the desire to control any philosophical
difi’erences in the approach to the medical management of chronic childhood illness. The
philosophical approach in these clinics encourages patient and family participation in the
management of chronic illness which may not be true in all settings. It was felt this
encouraged participation may have an efi’ect on family coping and adaptation. Within the
45 total families there were 28 families with a chronically ill school age (8-12 years) child
who had been diagnosed with a chronic illness for at least one year and 17 comparison
families with healthy children. There were 8 families of children with asthma, 6 with
congenital heart disease, 8 with cystic fibrosis, and 6 with insan dependent diabetes
mellitus. In the healthy comparison families the children had no known physical or
developmental abnormalities. Due to the limited number of families in some of the
diagnostic categories all families presenting to the clinics were asked to participate
successively. The comparison families were recruited through university, neighborhood,
and community agency announcement.

Family was defined in the primary study as the parent(s) (biological, adoptive, or

step-parents), the target child, and siblings (biological, half, or step-siblings) eight years of

27

age or older, who were currently living in the same home. The primary study made an
effort to control for the cognitive transitional period that occurs between the ages of 5-7
years because in the primary study the children participated in responding to the
instruments. In this secondary analysis only the parents responses were analyzed. Four
families were randomly selected from each of the four chronic illness categories for the
purpose of matching. The comparison families were matched to one of the selected
chronic illness families on: age, sex, birth order of the target child; number of parents in
the home; approximate family size, and income. Birth order of the target child was
matched on eldest, middle, or youngest. Family size was matched for 1-2 children, 3-5
children, or 6 or more children. Income was matched for under $20,000, $20,000-
$34,999, 835,000-549,999, 350,000-574,999, and over $75,000. Thirteen of the
comparison families were able to be matched to the randomly selected chronic illness
families. The other four comparison families were matched to four non-randomly selected
chronic illness families that were evenly distributed across the diagnostic categories. The
final sample in the primary study consisted of 160 subjects. For the purpose of this
secondary analysis only the 47 parents (28 mothers and 17 fathers) of the 28 target
families and 28 parents (17 mothers and 11 fathers) of the 17 comparison families will be
considered, for a total sample size of 75 parents.

Chi square analysis done by the authors of the primary study revealed that the
mothers in the comparison families had significantly more education, were significantly
more likely to work outside the home in graduate professional positions than the mothers
of the chronic illness families. There were no other significant demographic differences

between the chronically ill and healthy comparison families.

28
Limitations of using this secondary data analysis include such sampling design

problems as the use of a convenience sampling where there may be a greater chance of
sampling bias. The small sample size of only 47 target parents and 28 comparison parents
could be a limitation due to the possibility of sampling error. The inability to match all 17
comparison families also could be a limitation of the study, however, the chi square
analysis revealed only differences on the mothers education and position of employment.
Another limitation of this research design is that it is non-experimental in nature and
therefore any inference for cause and effect relationships would be difficult.
Data Collection

All procedures were the same for the chronically ill families and the comparison
families. Families meeting the criteria received a letter explaining the study and inviting
participation in the study. The letter contained a return postcard indicating a willingness
to participate, the most convenient time for participation, and family makeup. Families
who returned postcards received follow-up phone calls from the investigator to answer
any questions and schedule a time for a home visit with the entire family. At the home
visit the study was explained to the entire family, questions were answered, and informed
consent was obtained. Sociodemographic and illness demographic (for families with
chronically ill children) information were obtained from the parents by interview. The
family was then asked to complete the appropriate instruments.

Of interest in this secondary analysis is the Adult Self-Peertion Profile that
contains 50 items and 12 subscales (Harter, 1986). The Self-Perception Profile (I-Iarter,
1986) was administered to all adult subjects. The 50 item questionnaire consists of 12

subscales which are; Sociability, Job Competence, Nurturance, Athletic Abilities, Physical

29
Appearance, Adequate Provider, Morality, Household Management, Intimate

Relationships, Intelligence, Sense of Humor, and Global Self-Worth. Each of the 11
subscales contain four items, plus the global self-worth scale that contains six items.
Within each subscale half of the items are worded to reflect high competency or adequacy
and the other half are worded to reflect low competency or adequacy. The authors of the
instrument hypothesized that it would be unlikely that an individual would feel equally
competent in all subscales, therefore, the Adult Self-Perception Profile allows for the
examination of an individual’s profile of perceived competence across different domains
(Harter, 1986). The Adult Self-Perception Profile (Hatter, 1986) also allows for the
investigator to determine the relationship between the individual’s competence in each
domain to the perceived importance a person attaches to success in each domain. In this
study the subscales of interest are the Sense of Humor and Nurturance scales.

The Family Crisis Oriented Personal Evaluation Scales (F-COPES) (McCubbin,
Olsen, & Larsen, 1981) was used to measure coping. F-COPES (McCubbin et al., 1981)
was created to identify problem solving and behavioral strategies used by families in
dimcult or problematic situations. The instrument has 30 coping behavior items that
subjects rate on a five point scale from very untrue to very true on how well each
statement describes their own family. The 30 items focus on two levels of family
interaction; 1) ways a family handles difficulties within its members and 2) ways in which a
family externally handles problems or demands that emerge outside its boundaries, but
affect the family and its members. F-COPES (McCubbin et. al., 1981) has a total of five
subscales which are; Acquiring Social Support, Reframing, Seeking Spiritual Support,

Mobilizing the Family to Acquire and Accept Help, and Passive Appraisal. Each subscale

30

can be given a score, plus a total score for the entire instrument. For purposes of this
study only the total score was used.
Reliability and Validity

The internal consistencies for this instrument were based on two samples. The first
sample consisted of 141 parents, who ranged in age from 30-50, had a majority of intact
families, were 95% Caucasian, upper middle class, and for the most part college educated.
The second sample consisted of 2 1 5 mothers of children ages 3 and under who were
equally divided into middle and lower class, 98% were Caucasian, 90% had completed
high school, greater than 50% had attended college, and the mothers had an average of
14.67 years of education. The mothers were also divided into two groups of working
mothers and homemakers. The internal consistency reliabilities for the Adult Self-
Perception Profile (Harter, 1986) are based on Cronbach’s Alpha. The internal
consistency for the subscales are 87-92 for Global self-Worth, 65-75 for Job
Competence, .75-.90 for Intelligence, 84-91 for Athletic Abilities, 81-87 for Physical
Appearance, 63-86 for Sense of Humor, 74-82 for Sociability, 72-88 for Intimate
Relationships, 63-88 for Morality, 67-87 for Nurturance, 82-90 for Household
Management, and 83-90 for Adequate Provider.

The two subscales of interest in this secondary analysis are the Sense of Humor
subscale and the Nurturance subscale. The Sense of Humor subscale has higher internal
consistencies for the homemakers (0.86) and part-time working women (0.82) than for
either the firll-time working women (.63) or firll-time working men (0.63). Nurturance
had the highest internal consistency for firll-time working men (0.87) and the lowest

reported internal consistency for part-time working women (0.67). Construct validity for

3 l
the Adult Self-Perception Profile (Harter, 1986) was established by factor analysis of the

specific domain items. The loadings for the Sense of Humor subscale was .74 with a .04
cross loading to all other items. The Nurturance subscale had loadings of .69 with a .09
cross loading to all other items. The authors of the primary study selected the Adult Self-
Perception Profile (Harter, 1986) for it’s sound psychometric properties. Another factor
in the selection of the Harter instrument was that there are difi'erent forms of the
instrument developed for difi’erent age groups, such as pre-schoolers, school age children,
college age adults, and adults in their mid-years.

Coping in this study will be evaluated using the Family Crisis Oriented Personal
Evaluation Scales (F-COPES) (McCubbin, Olsen, & Larsen, 1981). The internal
consistency for this scale was measured by using Cronbach’s Alpha. The overall
reliability for this instrument based on two samples was .86 and .87. Test-retest reliability
over a four week period was .81. Cronbach’s Alpha was based on the largest sample of
N=2740 that was randomly split into two halves. The combined scales, based on
Cronbach’s Alpha for the five subscales emerged as .83 for Acquiring Social Support, .82
for Refrarning, .80 for Seeking Spiritual Support, .71 for Mobilizing Family to Accept
Help, and .63 for Passive Appraisal. Construct validity for F-COPES was established
using factor analysis with factor loadings emerging with a range of 39-85 on the eight
factors established by the authors of the instrument. In this secondary analysis F-COPES
(McCubbin et. al., 1981) will be looked at to measure the coping strategies of the parents
of the chronically ill children as compared to the parents of the healthy children.

Examination will utilize the total score and not the individual subscales.

32
Data Analysis

Descriptive statistics were completed for the sample demographic data on the
parents of both the chronically ill children and healthy comparison parents. This data is
displayed in table form (Tables 1-9). In order to show the relationship between the use of
humor and nurturance and family coping, Pearson’s r correlation coefiicient was carried
out on the variables of humor and family coping, and nurturance and family coping on the
two groups of parents. In addition, analysis of variance (ANOVA) was utilized to
determine the difi’erences between the use of humor and nurturance by the parents of the
chronically ill children and parents of the healthy comparison children. These data is
reported in table form for ease of interpretation.

Protection of Human Subjects

The protection of human subjects is insured by several methods. First, the study
proposal was presented to Michigan State University Committee on Research Involving
Human Subjects (UCRIHS) for approval (IRB# 97-134). Secondly, the primary study
(Family Adaptation to Childhood Chronic Illness) initially had obtained approval from the
University Committee on Research Involving Human Subjects, IRB# 89-174. Finally, the
researchers of the primary study had previously coded all information into numeric form
and entered it onto computer disc so that the identities of the subjects were not known to

the researcher carrying out this secondary data analysis.

CHAPTER V
RESULTS

The results reported in this section are the product of the self-reports of the 75
parents who participated in the original study. Included are tables showing the socio-
demographic characteristics of the sample and the results of the hypothesis testing.
Socio-d mo hic haracteristics

The total sample of 75 parents consisted of two groups: 47 parents of chronically
ill children and 28 parents of healthy comparison children. The results reported in Tables
1-9 show the socio-demographic data results. No significant differences were found
between the groups of parents on the absolute number of children (F = 1.317, p g 0.257).
There was no significant differences between groups on the amount worked by mothers
outside the home (F = 0.232, p 3 0.6326). The two groups also were not significantly
difi’erent on the family income level (F = 0.0203, p 5 0.8879). There were however
significant difi’erences between the two groups of parents on education level of the mother
(F-Ratio 16.29, p s 0 .0002) and father (F = 6.253, p _<_ 0.0177). Also a significant
difference was found in the occupation of the mothers (F = 8.838, p s 0.0049). The
amount worked for the fathers and occupation of the fathers was not calculated secondary

to the lack of self-reported data.

33

34
Hypothesis Results

Pearson’s r correlation coeficient was calculated on the variables of humor,

nurturance, and family coping on the two groups of parents to determine if there was a

positive correlation between family coping and humor and nurturance. Additionally, Table

1. Absolute number of children in the family.

 

 

 

 

 

 

 

Value Frequency Frmueng Total Percent
CI Families Healthy Frguengy
1 5 4 9 19.6
2 13 9 22 47.8
3 3 4 7 15.2
4 3 1 4 8.7
5 2 0 2 4.3
6 1 0 1 2.2
missing 1 2.2
Table 2. Amount worked by the mother.
Value Fregueng Fregueng Frequency Percent
CI farnlies Healthy Total
0 9 2 11 23.9
No work outside
the home
1 8 12 20 43 .5
Full time
2 9 4 13 28.3
Part time
missing 1 0 1 2.2

 

35

Table 3. Education of the mother

 

 

 

 

 

 

 

 

 

 

 

Value Frequengy Frequency Freqpengg Percent
g Healthy m1
1 1 0 1 2.36
Less than high
school
2 6 0 6 14
High school
3 5 2 7 16.3
Business. Trade
or J C
4 9 2 11 25.6
Some college
5 4 9 13 30.2
College
6 1 4 5 l 1.6
Post Graduate
Table 4. AN OVA of education level of the mother
Degrees of Sum of Mean F F
Source Freedom Squges Squares Ra_ti_q Probability
Between Groups 20.7505 20.7505 16.290 0.0002"
Within Groups 41 52.2262 1.2738
Total 42 72.9767
*p s 0.05

**p s 0.01

36

Table 5. Occupation of the mother.

 

 

 

 

 

 

 

 

 

 

Value Frequeng Frgquengy Fraueng m
CI famlies Healthy 1913;]
1 9 2 11 23.9
No work outside
home
2 2 0 2 4.3
Unskilled labor
3 7 4 11 23.9
Trade, technical
or clerical
4 2 1 3 6.5
Sales
5 0 1 2.2
Management
6 11 16 34.8
Graduate,
Professional
missing 0 1 2.2
Table 6. ANOVA of occupation of the mother
Degrees of Sum of Mean F F
5.0% m SAM Sam Rania 13mm
Between Groups 1 30.9248 30.9248 8.8380 0.0049"
Within Groups 42 146.9615 3.4991
Total 43 177.8864
*p s 0.05

"p S 0.01

Table 7. Education of the father

37

 

 

 

 

 

 

 

 

 

 

Value Frequency Frequeng Frequengz ngept
CI families Healthy Iptfl
1 1 0 1 2.2
Less than high

school

2 5 0 5 10.9
High school
3 4 2 6 13.0
Business. Trade
or JC
4 5 1 6 13.0
Some college

5 3 4 7 15.2

College
6 4 5 9 19.6

Post Graduate
missing 5 6 1 l 23 .9
Table 8. ANOVA of education level of the father.
Degrees of Sum of Mean F F
Source Freedom Squares Squares Relic Probabilig
Between Groups 12.5775 12.5775 6.2532 00177“
Within Groups 32 64.3636 2.0114
Total 76.9412

*p S 0.05

38

Table 9. Income of the family.

 

Value Frequency Frequency Frguenqy Percent
CI Families Healthy M
1 5 0 5 12.2
<$20,000
2 5 4 9 22.0
$20,000-34,999
3 2 3 5 12.2
$3 5,000-49,999
4 3 0 3 7.3
$50,000-74,999
5 10 9 19 46.4
>$7 5,000

oneway ANOVA was conducted to determine if there were difi’erences in the use of
humor and nurturance in the parents of chronically ill children and those of the healthy
comparison children. The ANOVA was done to test hypotheses 1-3, and the correlation
coefiicient calculated to test hypotheses 4 and 5. Significance, for the purpose of this
study was established to be p s 0.05. The results of the ANOVA and the correlation
coefiicients are discussed in detail below and are summarized in Tables 10-17. Each
hypothesis is discussed separately.

Hypothesis 1: There will be a significant difference in the use of humor in parents of the
chronically ill children and the healthy comparison children. This hypothesis was rejected.
The parents of the chronically ill children scored lower (M = 9.98, sd = 1.22) than the
comparison parents (M = 10.25, sd = 1.94) on the humor domain. However the ANOVA
revealed that the difference between these scores was not significant (F = 0.554, p 2

0.05).

39
Table 10. ANOVA of total humor between chronically ill and comparison families.

 

Degrees of Sum of Mean F F
Source Freedom Squares Squares Ratio Probabilig
Between Groups 1 1.2913 1.2913 0.5537 0.4592
Within Groups 73 170.2287 2.3319
Total 74 171.5200

Hypothesis 2: There will be a significant difl’erence in the nurturance of parents with
chronically ill children and healthy children on the nurturance sub-scale score. This
hypothesis was rejected. The parents of the chronically ill children scored lower (M =
9.53, sd = 1.57) than the comparison parents (M = 9.86, sd = 0.848) on the nurturance

domain. The ANOVA revealed that this difference was insignificant (F = 1.02, p 2 0.05).

Table 11. ANOVA of total nurturance between chronically ill and comparison families.

 

Degrees of Sum of Mean F F
Source Freedom Squares Squares R_a_tio Probability
Between Groups 1 1.8560 1.8560 1.0177 0.3164
Within Groups 73 133.1307 1.8237
Total 74 134.9867

Hypothesis 3: There will be no significant difference in the coping of parents with
chronically ill children and parents of healthy children on the mean F-COPES (McCubbin,
1987) scores. This hypothesis was partially supported. The parents of the chronically ill
children scored higher (M = 107.3, sd = 13.7) on the mean F-COPES (McCubbin, 1987)
score than the parents of healthy children (M = 101.3, sd = 15.2). The ANOVA revealed

no significant difi’erence at a .95 CI. (F = 3.06, p _>. 0.05), however at a .90 CI. (p .<_ 0.10)

40
the parents of the chronically ill children scored significantly higher than the parents of

healthy children on the mean F-COPES (McCubbin, 1987) score.

Table 12. ANOVA of total coping between chronically ill and comparison families

 

Degrees of Sum of Mean F F
Source Freedom Squares Squares Ratio Probability
Between Groups 1 628.1649 628.1649 3.0622 0.0843
Within Groups 73 14974.9818 205.1367
Total 74 15603.1467

Table 13. Comparison of Mean i Standard Deviation for variables of: Coping,
Nurturance, and Humor between parents of chronically ill and healthy families.

Chronically Ill Healthy

Mean i S.D. Me__an;SJ)_.
Coping 107.34 i 13.75 101.36: 15.25
Nurturance 9.53 i 1.57 9.86 i 0.85
Humor 9.98 i 1.22 10.25 i 1.94

Hypothesis 4: There will be a positive correlation between the humor subscale score and
the total F-COPES (McCubbin, 1987) scores. This hypothesis was supported. Pearson’s r
was calculated to be 0.24 on total coping and the humor subscale, showing a positive
correlation between the variables. This hypothesis was firrther supported when the total
coping score was subdivided into high, medium , and low total coping scores. High

coping was calculated to be greater than one standard deviation above the mean. Medium

41

coping was calculated to be within one standard deviation above or below the mean. Low
coping was calculated to be more than one standard deviation below the mean. Among
the parents with high total coping score the correlation between humor and coping was r =
0.5564 (see Table 17).

Hypothesis 5. There will be a positive correlation between the nurturance subscale score
and the total F-COPES (McCubbin, 1987) scores. This hypothesis was rejected initially.
Pearson’s r was calculated to be not significant at -0.16 on the total coping and
nurturance subscale score, showing no positive correlation between the variables.
However, as with humor , when total coping was subdivided into high, medium, and low
total coping scores a positive correlation was found between nurturance and coping (r =
0.2659). This finding lead to the subsequent decision to accept the hypothesis.
Additionally, a significant negative correlation was noted between low total coping and

nurturance.

Table 14. Correlation of total coping score with total humor and total nurturance
subscales.

Total Coping Total Humor Total Nprturance
Total Coping 1 0.2405“ -0. 1648
Total Humor 0.2405* 1 -0.0060
Total Nurturance -0.1648 -0.0060 1

*p s 0.05

42

Table 15. Correlation of low total coping score with total humor and total nurturance
subscales.

Low Total Coping Total Humor Total Nurturance
Low Total Coping 1 -0.0741 -0.5376**
Total Humor -0.0741 1 0.2315
Total Nurturance -0.5376** 0.2315 1

Table 16. Correlation of medium total coping score with total humor and total nurturance
subscales.

Medium Total Total Humor Total Nurturance
Coping
Medium Total Coping 1 0.0272 0.1941
Total Humor 0.0272 1 -0.03 24
Total Nurturance 0.1941 -0.0324 1

Table 17. Correlation of high total coping score with total humor and total nurturance
subscales.

High Total Coping Total Humor Total Nurturance
High Total Coping 1 0.5564“ 0.2659
Total Humor 05564“ 1 0.2843
Total Nurturance 0.2659 0.2843 1

*p s 0.10
"p _<_ 0.05

43
The results of this study have been presented as they pertain to the five hypotheses

tested. Two of the hypotheses were rejected, hypotheses numbers 1 and 2. and three
were eventually accepted. Hypotheses numbers 3 and 5 were accepted afier total coping
was subdivided into high medium and low coping. Hypothesis number 4 was accepted
prior to the subdivision of total coping and was strengthened by the subdividing total
coping. An interpretation of the findings with respect to the conceptual fimnework,

current literature, and methods in the study follow in the next section.

CHAPTER VI
DISCUSSION and IMPLICATIONS

The Double ABCX model

The aspects of the Double ABCX model as adapted by Spence, Barnes, and Peek
(1989) that were of interest in this study were the bB factors or resources of humor and
nurturance and how they may be related to family coping. While there was a positive
correlation found between humor and coping and a weaker correlation between the
variables of nurturance and coping the strength of the relationship was not as strong as
anticipated. A possible explanation for this may be found in the multidimensional nature of
the variable of coping. As conceptualized, coping is the result of the interaction between
the pile up of demands, resources the family possesses or is able to attain, and their
perception of the demands. By focusing solely on humor and nurturance as resources the
researcher may have limited the efi‘ect on coping by not taking into account the plethora of
other factors that may influence a families ability to adapt to the chronic illness of a child.
Methods

Characteristics of the sample that may influence the data interpretation are
numerous. First there is a relatively small sample size of only a total of 75 parents. The
sample is also fairly homogenous in terms of demographics with no significant difl’erences
noted in income, amount of work outside the home, or in absolute number of children.
While homogeneity is helpfirl for comparison purposes the same characteristics make

44

45
results diflicult to generalize to other groups. Demographic data that did have significant

differences between groups was the educational level of both mothers and fathers with the
parents of the comparison children having significant higher levels of education than the
parents of the chronically ill children. Also the mothers of the comparison children were
employed in a significantly higher number of professional positions than the mothers of the
chronically ill children. These are potentially confounding variables and may influence the
results. However, there was no literature found that indicated coping was in any way
related to educational level of the parents. Another factor that may influence the results
of the data analysis may be that in the Adult Self-Perception Profile (Harter, 1986) not
only is a person’s perception of competence measured but the importance a person
attaches to a particular domain is also part of the equation. It may be that the reason there
was no significant differences found in the use of humor and nurturance between groups
was that some of the parents felt it was not particularly important to be competent in those
domains and perceived themselves accordingly. An additional confounding variable may
be that humor and nurturance were measured indirectly as individuals rated themselves on
their perceived competence in those domains rather than an actual objective measurement
of their use of humor and nurturance.
Current Literature

The current literature does not support or refiite the relationship between the use
of humor and nurturance and coping with parents of chronically ill children. The fact that
there was very limited literature found on the subject was one of the reasons why the
subject was selected for this study. The current coping literature suggests several

behavioral strategies which may have a positive impact on the coping of parents with

46
chronically ill children. Communication has been identified as a strategy that has a positive

effect on coping (Canam, 1987, Gibson, 1988, and Shapiro, 1983). Acquiring social
support has also been indicated as strategy that is associated with parental coping
(Hamlett, Pelegrini, & Katz, 1992). Viewing humor as a method of communication and
acquiring social support as a dimension of nurturance the results of this study are
consistent with those of previous studies.

The findings in this study support the conceptual model in that humor and
nurturance do have a positive correlation to the coping of parents with chronically ill
children. The strength of that relationship can also be partially explained by the
multifaceted nature of coping with no single indicator being solely predictive of parental
coping. The fact that parental coping scores had higher values for the chronically ill
parents than the comparison parents with significant differences at the .90 CI. lends
firrther support to the multifaceted nature of parental coping. Should similar studies be
undertaken in the future it may be helpfirl to also account for individuals importance
ratings when correlating for difi’erences in total coping as is done in the Adult Self-
Perception Profile (Harter, 1986). However, in general terms the results in this study are
similar to those of previous studies, such as those reported by Martin & Lefcourt (1983)
who showed significant support for the idea that humor has a moderating efl’ect on
negative life events. Perceived parental nurturance is associated with coping of everyday
stress (Hardy, Power, & Jaedicke, 1993) these results are also consistent with the results

of this study.

47
Implications

The results of this study indicated no significant differences in the use of humor or
nurturance between groups of parents regardless of their child’s health status, this may
give some measure of comfort to families who are confi'onted with the diagnosis of a
childhood chronic illness. The implications for Advanced Practice Nursing are discussed
in this section as they relate to each hypothesis individually. Implications and
recommendations for firrther research follow. A general summary of the implications for
nursing practice in primary care as they relate to these findings conclude this study.

Hypothesis 1: There will be a significant difference in the use of humor by parents
of chronically ill children and the comparison parents. The results showed no significant
difference between groups on parental use of humor. This result led the researcher to
believe that humor is an equally important or unimportant factor in the lives of all parents
regardless of health status of the children. The Advanced Practice Nurse should
remember that this behavior is individual and not all persons place the same value on
humor depending on each person’s unique value system. Those who have expressed
positive outcomes with past experiences using humor or feel that there may be some value
in using humor as part of their coping repertoire should be encouraged to do so by the
Advanced Practice Nurse, whether or not they have a chronically ill child. However the
use of humor should remain conditional, in that it should not be used at the expense of
another, and the people for whom it is used find a similar value in it’s use. In assessing
this information the Advanced Practice Nurse would need to ask direct and specific

questions of family members. For example, How do you cope with stressful situations?

48
Do you and your family share in joking, and find humor in your daily lives? Do you

believe that using humor within your family is a realistic or helpfirl coping strategy?
Hypothesis 2: There will be a significant difi’erence in the use of nurturance in
parents of chronically ill children compared to parents of healthy children. The results of
this study showed no significant difl’erences between groups in the use of parental
nurturance. This could in part be due to the fact that there is a lack of means for a parent
to accurately judge their use of nurturance. The universally expected value in our society
is that if you are a parent part of your role is to be nurturing towards your children
irrespective of their health status. For the Advanced Practice Nurse in primary care the
development of a few questions incorporated into a family history may give a more
objective and quantitative measure of parental nurturance. For example, asking parents
what part of their role as a parent they find contributes to the growth and development of
their children, and then a tally of the perceived nurturing behaviors to obtain a numeric
value that can easily be quantified and used for comparison purposes may be usefirl. Also
observation of the parent-child interaction by the Advanced Practice Nurse may be helpfirl
in noting parental nurturance. Other more subjective measures could be questions
regarding knowledge and involvement with children’s activities. Questions regarding
perceived barriers they view as inhibiting them in reaching their potential for nurturing
may also be useful. For instance if parents are preoccupied with scraping together enough
money to just feed the family they may not have the enhancement of their children’s
growth and development uppermost in their minds. Additionally parents of chronically ill
children may have there own differences in what they perceive as nurturing behavior

compared to the parents of healthy children. The parent of a chronically ill child may

49

perceive nurturing behavior to be the maintenance of a rigorous medical regime dictated
by their child’s diagnosis. For example, the maintenance of tight blood sugar control for a
diabetic or vigilant monitoring of symptoms and delivery of breathing treatments to the
asthmatic. The Advanced Practice Nurse needs to be carefirl that she use the parents
definition of nurturing behavior and not her/his own when assessing the use of nurturance.

Hypothesis 3: There will be no significant difl‘erence in the coping of parents of
chronically ill children and those parents of healthy children on the total FCOPES
(McCubbin, 1987) score. The results of this study found no significant difi’erences in
parental coping at the .95 01. However, at the .90 Cl. there was a significant difference
in the coping scores of the two groups, with the parents of the chronically ill children
scoring significantly higher on coping than the parents of healthy children. The differences
may in part be explained by the fact that parents of healthy children may not have
experienced a potential crisis situation and have not had the opportunity to explore some
of the coping behaviors described in F-COPES (McCubbin, 1987). Additionally,
according to the Double ABCX model some adjustment does take place over time, this
adjustment may be perceived by the family to be coping. Or the chronically ill families
may just have a different perception of coping that facilitates higher scores on F-COPES
(McCubbin, 1987).

Implications for the Advanced Practice Nurse in Primary care may be that the
nurse should assess a family’s coping strategies prior to the onset of a crisis. Perhaps at a
routine check up when the Advanced Practice Nurse is doing teaching and counseling
she/he should provide parents with information related to the child’s state of emotional

and cognitive development. Providing parents with the opportunity to discuss issues that

50
are of concern to them regarding their family and children. Asking parents at that time

whether or not they are aware of particular community resources available to them and if
they would be willing to accept that type of assistance may give the nurse additional
information regarding c0ping behaviors. The Advanced Practice Nurse could also ask
about information related to how the family copes with the every day stresses.
Encouraging behaviors that in general promote coping; such as open communication
between family members, making sure the family has time together for group and
individual interests, and such basic behaviors as obtaining adequate rest and nutrition. All
of these behaviors have been shown to be helpfirl in allowing families to cope with the
demands placed on them, so if the time comes when there are additional burdens such as a
child’s chronic illness the family has a strong foundation upon which to build.

Hypothesis 4: There will be a positive correlation between the humor subscale
score and the total F-COPES (McCubbin, 1987) score. The results of this study found a
positive relationship between the humor subscale and total coping scores. Also it was
demonstrated that the strength of the relationship increased as the total coping scores
increased. The implications this has for the Advanced Practice nurse in primary care are
to carefirlly assess each family as to how they cope with stressfirl situations, and for the
Advanced Practice Nurse not to dismiss a patient’s or family’s attempt at levity, but to
perhaps recognize it to be an attempt for the members to cope with a dimcult situation. If
after assessing a family it has been mutually determined that the use of humor is a valued
coping strategy then the family may be assisted in finding ways to channel the coping
behavior to their benefit, for example, reminiscing within the family on a humorous story

involving family members, or allowing some unstructured time for horseplay or supporting

51

a child’s attempts at making jokes, or simple everyday activities such as sharing a comedy
movie together. It would also be important for the family to teach the children
appropriate and inappropriate uses for humor.

Hypothesis 5: There will be a positive correlation between the nurturance subscale
scores and total F-COPES (McCubbin, 1987) scores. The relationship between
nurturance and coping was not found to be as strong as that for humor, however it too did
increase in strength as the total coping scores increased. This relationship, however was
not linear which makes interpretation of the results more difficult. The reasons for these
results could be due to a number of factors; the inconsistent definition of nurturance, or
the result of outcome, resource, or unrelated variables. Implications for advanced practice
include obtaining an accurate meaning of what each parent perceives as nurturing and
assessing for whether or not parents believe that the development of these behaviors
would lead to increased coping. It may be that parents do not view particular behaviors as
essential to coping with the chronic illness of a child. Parents may also view nurturance
as an outcome of their competency as parents rather than an aspect of parenting.
Implications for research

Due to the small sample size and relative homogenous nature of the sample the
results would be more conclusive if the results obtained in this study could be replicated
on a larger and more diverse sample. This would assist in generalizing the results to a
broader population. With increased heterogeneity, factors such as the number of parents
in a home, and a wider household income range could be examined for their impact on the
results. Also since the nature of chronic illness and it’s efi’ects on families continues over

time it would be helpfirl to do longitudinal research to see how coping changes over time,

52

if the use of humor and nurturance change over time, and if the meaning of coping, humor,
or nurturance changes over time as it pertains to parents of chronically ill children. A
more precise definition of nurturance which can be quantified with more case may also be
helpfiil in demonstrating significant results. Additionally, if firture researchers examine any
relationship that may exist between depression, nurturance, and coping it may help to
clarify whether parents view nurturance as an outcome of parenting, a component of

parenting, or a result of coping.

Summary

Families are receiving a great deal of information from various sources (the media,
health care professionals, and research reports) on how their lives are becoming more
complicated with more demands being placed on the family. Every family has its own
ways of adapting and adjusting to those demands. The Advanced Practice Nurse can
assist families in identifying internal and external resources available or obtainable to them
in order to cope with the additional demands of a chronically ill child to prevent the family
from developing into a crisis. If in assessing a family’s resources the use of humor and
nurturance are identified as having a potential value to the family they should not be
overlooked. The Advanced Practice Nurse can then guide the family in ways to foster and
promote the use of their unique set of resources in order to cope with and subsequently

promote bonadaptation.

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RESEARCH
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57

MICHIGAN STATE
u N r v E a s I T Y

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10: Linda 5 nos
A230 Li e Sciences

RI: IRBI: ’7-130
TITLI: THE RELATIONSHIP BBTNIIN NUNOR AND NURTURANCI
AND FAMILY CODING OP PARINTB NITN CNRONICALLY
panes 39;}: “mm
REVISION TED:
CATEGORY:‘ l-I
APPROVAL DATE: 03/03/97

The university Committee on Research Involving Human Bubiects'IUCRIRSI
review of this project is complete. I am pleased to adv so that the
rights and welfare of the human subjects appear to be adequately
rotected and methods to obtain informed consent are a ropriate.
gherefore. the UCRIHS approved this project and any rev sions listed

Illlllbi UCRIHS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project be nd one year must use the green renewal
fore (enclosed with t e original a roval letter or when a
project is renewed) to seek u t certification. There is a
maXimum of four such expedite renewals sible. Investigators
wishing to continue a roject beyond tha time need to submit it
again or complete rev ew.

RIVISIOII: UCRIHS must review any changes in rocedures involving human
subjects. rior to in tiation of t e change. If this is done at
the time o renewal. please use the green renewal form. To
revise an approved protocol at an 0 her time during the year,
send your written request to the IRS Chair. requesting revised
approval and referenCing the project's ran I and title. Include
in your request a description of the change and any revised
instruments. consent forms or advertisements that are applicable.

Should either of the followi arise during the course of the
work. investigators must noti UCRIHS romptly: (l) roblems
(uni cted side effects, comp aints, e c.) involving uman
sub) cts or (2) changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed approved.

If we can be of any future hel . lease do not hesitate to contact us
at (517)355-2180 or FAX (51714 2- I71.

.3—

Sincerely.

vid 3. Hright
UCRIHS Chair

DEN:bed

"‘{/;:;a Balander

   

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