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Psychological Hardiness in Women with Paraplegia
A revised model of psychological hardiness suggests that transformational coping, positive health behaviors, and activistic social support may be qualitative indicators of hardiness and an expression of the synergistic presence of commitment, control, and challenge. Hardiness indicators correlate with health rather than illness, and have an indirect effect on the stress-illness relationship through health. Stress and illness also correlate with health. A secondary qualitative analysis of the transcripts of eight women with paraplegia revealed three major themes related to spinal cord injury (SCI): physiological aspects of SCI, associated with the traumatic event and its consequences; psychological aspects of SCI, associated with problem-solving, choices, and challenges; and social aspects of SCI, associated with personal and professional relationships.
A spinal cord injury (SCI) is a stressful life event that can lead to physiological, psychological, and social change that may result in illness. Considerable research has been conducted on personality characteristics that moderate or mediate this connection between stress and illness. The concept of psychological hardiness (Kobasa, 1979) is among these characteristics.
Quantitatively measuring the three general components of hardiness—commitment, control, and challenge—has been the focus of hardiness research. A new model suggests the presence of transformational coping, the practice of positive health behaviors, and the use of activistic social support may be qualitative indicators of hardiness, as well as expressions of the synergistic presence of commitment, control, and challenge. Activistic social support is “support from another individual designed to make the recipient as independent as possible from the support giver” (K. Wallston, personal communication, December 23, 2004).
This article describes the development of a hardiness model, and presents a secondary qualitative data analysis of interviews with eight women with paraplegia. These women lived in the community and had successfully maintained health and prevented SCI-associated complications.The secondary data analysis identified themes that determined success, and expressed the components and indicators of hardiness.
Hardiness. Hardiness has its roots in existentialism. The core of existentialism is the striving for authentic being, which is the acceptance of responsibility for choosing the direction of one’s life (Maddi, 1989). Hardiness encompasses taking the responsibility to make decisions for one’s life (control); demonstrating commitment to the choices one makes and standing by the consequences (commitment); and making stepping stones out of obstacles, constructing possibilities and alternatives (challenge; Maddi, 1998). Kobasa (1979) found that highly stressed people who remained healthy differed from those who became ill, and proposed that a personality structure, hardiness, was a buffer to the stress and illness relationship. Subsequent studies (Kobasa, Maddi, & Kahn, 1982; Kobasa, Maddi, & Puccetti, 1982; Kobasa, Maddi, Puccetti, & Zola, 1985) found that hardiness buffered the effects of stressful life events in producing illness. Those with hardiness used coping strategies that included interaction with the stressor (Kobasa, Maddi, & Kahn, 1982), sought social support, and used transformational coping, which decreased the perception of events as stressful (Kobasa, Maddi, & Puccetti, 1982). Kobasa et al. (1985) suggested people with hardiness also might engage in positive health behaviors, which could delay or prevent the onset of illness.
Health-related hardiness. Pollock (1989) extended the concept of hardiness to populations with chronic illness, and developed the health-related hardiness concept to measure hardiness in persons with health problems. Health-related hardiness had two components: control and commitment/challenge (Nicholas, 1992; Pollock, Christian, & Sands, 1990). Health-related control included actions to promote health and prevent illness; health-related commitment was evidenced by active involvement in promoting health and the view that health is a priority; health-related challenge was demonstrated by reappraisal of the health stressor. Results of studies (Pollock, 1986; Pollock, 1989; Pollock, 1993; Pollock et al., 1990) of health-related hardiness supported its buffering effects.
Hardiness and health practices. Subsequent studies (Nagy & Nix, 1989; Nicholas, 1992; Wiebe & McCallum, 1986) addressed the relationship between hardiness and health practices in the stress-illness relationship. Health practices were believed to play a major role in illness prevention. Wiebe and McCallum (1986) reported that the effect of hardiness on illness was related to its impact on health practices rather than on stress; those with hardiness appeared to engage in positive health practices.
Development of a hardiness model. A review of hardiness models in the literature supported the indirect effect of hardiness on illness, health risk, or perception of health through transformational coping (Kobasa et al., 1982; Kobasa et al., 1985; Nagy & Nix, 1989); social support (Kobasa, Maddi, & Kahn, 1982); and positive health practices (Wiebe & McCallum, 1986). Recurrent links were evident between hardiness and health behavior, hardiness and social support, and hardiness and transformational coping.
In many of the studies (Kobasa, Maddi, & Kahn, 1982; Kobasa, Maddi, & Puccetti, 1982; Kobasa et al., 1985; Wiebe & McCallum, 1986), levels of hardiness predicted illness scores for severity of symptoms or frequency of symptoms. This seemingly implied that health was the absence of illness symptoms. Few studies looked at the correlation between hardiness and health, evidenced by perceived health status (Nicholas, 1992); physiological and psychological adaptation (Pollock, 1989; Pollock, 1993; Pollock et al., 1990); and health risk (Nagy & Nix, 1989). This lack raised the question: Does the presence of hardiness correlate with the absence of illness? Or does the presence of hardiness correlate with health, which is the variable that moderates the stress-illness relationship?
Nagy and Nix (1989) suggested that hardiness and health behavior were related rather than independent concepts. Thus, hardiness and health behavior might be measures of the same characteristic. Nicholas (1992) found that the variables of hardiness and self-care practices correlated with 46% shared variance, and might be redundant concepts. Hardiness also was found to correlate with social support (Kobasa et al., 1985), suggesting overlap of these concepts. A review of the concepts of self-care (Orem, 1991) and transformational coping (Lazarus & Folkman, 1984) revealed that they incorporate the three components of hardiness in their definitions (Table 1). Do positive health behaviors, transformational coping, and activistic social support—synergistic expressions of commitment, control, and challenge—also indicate hardiness? If positive health behaviors, transformational coping, and activistic social support indicate hardiness, they may correlate with health, which would moderate the stress response and the development of subsequent illness.
True to its existential roots, Kinder’s model (Figure 1) first illustrates the concept of hardiness as the synergistic expression of commitment, control, and challenge. In this model, the components of hardiness are inseparably expressed and integrated into the indicators of hardiness. Hardiness is indicated by the use of activistic social support, the practice of positive health behaviors, and the presence of transformational coping. Hardiness indicators correlate with health rather than with illness, and have an indirect effect on the stress-illness relationship through health. Stress and illness correlate with health in this model.
Application of the Kinder model
When applying the Kinder model to research on pressure ulcers in a paraplegia population, stress is defined as the acute SCI, chronic lifestyle changes, and the physiological effects of decreased mobility and sensory perception. Health is defined as skin integrity; illness is defined as the presence of a pressure ulcer. The definition of health and illness is specific to the research. When an acute SCI is sustained, the person’s health at the time of injury moderates the stress-illness relationship—this may affect the development of pressure ulcers. If the SCI patient demonstrates commitment, control, and challenge (hardiness), he or she will use transformational coping, practice positive health behaviors, and use activistic social support, which will affect skin integrity. Skin integrity at the time of acute SCI stress and during the chronic stress of living with SCI may influence whether pressure ulcers will result. In turn, the physiological effects of stress, as well as pressure ulcer development, will affect skin integrity.
Secondary qualitative data analysis
The Institutional Review Board at Vanderbilt University and the Research and Development Committee at the Department of Veterans Affairs approved the study before the principal investigator obtained the interview transcripts.
Methodology. A qualitative data analysis technique (Miles & Huberman, 1994) was used to review the transcripts of interviews with eight women with paraplegia. The purpose of the study was to identify data themes that determined success and could express hardiness components or indicators. The technique used data reduction to select, focus, simplify, and transform the data; data display in the form of graphs, charts, or networks as part of the data analysis; and conclusion drawing and verification (Miles & Huberman, 1994).
Sample. The eight interview transcripts were selected from the study, Rehabilitation Concerns of Female Veterans with Spinal Cord Injuries (Bach, 2000), by a faculty advisor. The subjects were living in the community and successfully maintained health and prevented complications associated with SCI. Fuhrer, Garber, Rintala, Clearman, and Hart (1993) suggested lack of capability to practice self-care in persons with quadriplegia may explain the association between extent of paralysis and prevalence of complications, such as pressure ulcers. This study’s population only included women who could practice self-care.
The subjects ranged from 23 to 51 years of age (M = 37). Five women were Caucasian, two women were African-American, and one woman identified herself as other. The level of SCI ranged from T4 to L1, and the length of time since SCI ranged from 2 to 21 years (M = 11). Three women had a complete SCI, and five women had an incomplete SCI.
Data analysis. The investigator used transcripts of interviews to conduct the data analysis. The investigator assigned codes to units of meaning line by line. A faculty advisor independently assigned codes to the transcripts and met with the investigator. Intercoder agreement on the assignment of codes exceeded 90%. The investigator also recoded the transcripts at 3-month intervals, with greater than 90% intracoder agreement. The codes were then clustered into larger units of meaning, which were organized into categories and three major themes. Definitions for the themes and the categories were developed.
Findings. The three major themes were physiological aspects of SCI, with categories associated with the traumatic event and its consequences; psychological aspects of SCI, with categories associated with problem-solving, choices, and challenges; and social aspects of SCI, with categories associated with personal and professional relationships.
The physiological aspects of SCI had tremendous impact on the lives of the women with paraplegia. Five categories clustered around this theme. The women spoke of the experience of Having a SCI and the SCI’s effect on their lives. Their statements referred to the traumatic event, rehabilitation, and the treatment plan, as well as the changes they now faced regarding physical appearance and self-care. “I had just finished pilot instructor school . . . and on the way home was when it happened.” “Your concept of self changes . . . am I attractive?” They also discussed their lives Before SCI. Five of the women had been involved in careers, sports, and education. They were energetic and active. “I’d always been an athlete, and I just assumed that I would … always be that way.”
The women had come to realize that living with SCI was normal, but it was A New Normal. They accepted that life was now different, but they found they could do the things they did before SCI once they learned how. “You’re at a different level mentally, physically. Everything’s all changed. … You’ll get used to your body.” “So far, I’ve come across nothing that I cannot do.”
Time was an important concern—the time it took to meet basic needs; to discover solutions, learn strategies, and find shortcuts; to become more independent and reach more acceptance. “I don’t think people realize how much . . . really takes a chunk out of your day when you start looking at how much time it takes to prepare.” The women also voiced a need for Information, including options for treatments and medications, counseling for themselves and their families, and SCI level-specific resources. “Information is invaluable . . . and doing it firsthand is the way to find out about it.” “Just give them all the information, all the whatever they can possibly get, and let ‘em have that dream.” Initially, the women said they did not know what to ask, and the lack of access to or availability of information was stressful.
A second theme that emerged from the data was psychological aspects of SCI. Five categories clustered around this theme. The women with paraplegia were confronted with many Problems and Obstacles. These problems ranged from “chair stigma,” which caused people to look at them differently; to the effects of decreased maneuverability and accessibility; to the fears of being alone, hurting oneself, or falling. “There’s still too many barriers out in the real world.” “That was difficult to get used to, and people staring at you. You have to learn to do all that stuff.” The women overcame the obstacles, however, Figuring Out solutions on their own or devising new ways of performing activities. Problem solving included journaling, making lists, or “rolling away for a while.” The women brainstormed to find what worked in terms of bowel and bladder care, exercise, and self-care. “Sometimes to figure out a solution is most fun … And once you get it figured out, it’s figured out for life.”
The women wanted somebody to discuss options with them and to make Choices. They wanted an active voice in decisions regarding their care, and not accept medical opinions as “carved in stone.” “I pretty much listen to what they (physicians) have to say, but use your better judgment, thinking of yourself first.” “I say, hey, I haven’t come in here with any . . . problems. You better get me the chair I want, the catheter I want.” The women also made statements that reflected taking responsibility for their choices and for Care of Myself (their physical fitness, personal safety, spirituality, and health care). This involved planning for everything in life, and being assertive. “I’m one of those people that ask and get … just get your point across, and just let ‘em listen.” “Try to stay in touch with your own body.”
The women demonstrated perseverance and Determination to accomplish their goals, meet their needs, find solutions, and maintain independence. They liked to “push the comfort zone” and do things on their own. They did not give up the goals they set before SCI, believing that, “As long as you have the idea that you can, it can be done.” Several of the women became role models for other women with SCI, offered peer counseling, and challenged the community’s attitudes about people with SCI. “It’s tedious, and it’s hard, and hot, and you’re cussing, and you’re doing all this stuff, but ya did it.” “So I was out there all day. Well by the end of the day, I could pull the chair in and out (of the car).”
The third theme that emerged from the data was sociological aspects of SCI. This theme encompasses four categories. The women actively participated in life, Get Out and Do, and emphasized the importance of activities such as travel, driving, exercise, participation in the workforce, college attendance, and volunteer work. “Get involved with something . . . just get out and do.” “When you see that finish line of anything, whether you’ve won or lost, it’s just the fact ya did it.” The women emphasized the importance of having Positive Thoughts and feeling good about themselves. They felt “kinda lucky” that they had survived the accident, were healthy, had family and friends, or had accessible homes. They had personal goals and felt accepted by others; they had made a connection with their lives before SCI. Life was not over. “I try to be as positive as possible so I could have all that good energy.” “It comes from within . . . what type of person you were before your injury.”
Relationships and interactions with Others with SCI were important for networking, socializing, providing peer counseling, and having a mentor. The women realized they were not the only ones with SCI when they found “someone who is like me.” It made it easier to accept life in a wheelchair. They still wished to maintain their individuality and be perceived as the person they were before SCI, however. “People will ask me questions, and it’s like, I’ve been there. You’ve dealt with it.” “What I saw in him was me . . . he was bouncy, up, smiling . . .I wanna get back to like you are.”
Relationships and interactions with Others, family and friends as well as healthcare professionals, were important. Family members were overwhelmed by the SCI, and significant others could not always accept or handle the injury’s aftermath. “Being there,” “stopping by,” acceptance, and caring by friends and family were important to the women. Caring, availability, and encouragement extended by healthcare professionals also were valued. “All my family members switched turns, and that made all the difference in the world.” “And a lot of really good nurses that went above and beyond the call of duty . . . making sure I was okay.”
Commitment, control, and challenge (Kobasa, 1979) were exhibited by this group of women with paraplegia. The women demonstrated control by making their own decisions, asking for options for self-care, and being active participants in seeking alternative treatments. They demonstrated commitment by attaining what they needed, accomplishing goals, and maintaining independence. It was noted that the need for independence emerged throughout the categories. The women also demonstrated challenge by finding solutions to their problems and overcoming obstacles (Figure 2).
If these women possessed commitment, control, and challenge, did these components express themselves synergistically? The themes that emerged demonstrate the women sought the support and advice of family, friends, and healthcare providers. They were strengthened by their presence, yet not dependent upon them (activistic social support). The women performed self-care, maintained their yearly physical examinations, and led physically active lives (positive health behaviors). The women also overcame the social, physical, and psychological obstacles associated with paraplegia. They made their lives less stressful by accepting a new normal, and seeing barriers as obstacles that can be overcome (transformational coping). These women may be maintaining their health and decreasing the effects of stress on illness. They lived successfully in the community, and they prevented complications associated with SCI.
The major themes and categories that emerged in this study were similar to those identified by women with breast cancer (Craft, 1999). The two major characteristics of hardiness that emerged were Strong Sense of Purpose, which was manifested in self-care, meaningful activities, and striving for normalcy; and Ability to Endure, which was manifested as hope and optimism, appropriate expectations, and physical perserverance (Craft, 1999). In Craft’s model of feminine hardiness, there is an internal dimension of acceptance of reality, as well as outcomes of determination, inner strength, altered relationships, change in perspective, and personal growth. Women with breast cancer, similar to women with paraplegia, found a new normal, took responsibility for self-care, maintained relationships, and overcame obstacles.
In a study of five women with SCI who returned to the community after completing intensive rehabilitation programs, Quigley (1995) found the women had developed a new role of self-advocate; they used the processes of adaptation and negotiation in their daily routines, relationships, and environment.
In a study of 2 women and 12 men with quadriplegia, Bach and McDaniel (1993) found similar categories related to quality of life and health, including inner strength and survival needed for ongoing adjustment to disability, relationships, health, level of activity, assertiveness, and independence/ dependence. These findings also reflected physiological, psychological, and social aspects of SCI and their underlying categories.
Implications for nursing
This study has implications for nurses working in rehabilitation settings. In this study, the women who successfully prevented SCI complications were found to use activistic social support, perform positive health behaviors, and use transformational coping. Assessing these hardiness indicators during rehabilitation in those with SCI can guide nursing interventions focused on maintaining health in the community. This assessment can identify those at risk for SCI-associated complications.
Those with SCI should receive information specific to their level of injury during rehabilitation to enhance their self-care abilities and positive health behaviors. They also should be provided with a network of people with similar SCI for peer support and counseling to promote activistic social support. Rehabilitation nurses who provide simulations related to physical, psychological, social barriers, and opportunities to problem-solve can strengthen transformational coping skills.
The limitations of this study include small sample size. The women in the study were qualified for rehabilitation at military facilities, and used VA centers for health care. A question arises: Do women who enlist for military service demonstrate hardiness? If so, this sample may not be representative of persons with paraplegia in the general population.
Additional qualitative studies of people with paraplegia are recommended to obtain a subjective view of their experience with SCI and to identify themes that lead to successful life roles. Will the findings support the model? The studies should begin with subjects’ first encounter with health care, and continue through the rehabilitation experience, subsequent encounters with health care, and into community life. The sample should include men and women with paraplegia and quadriplegia and people with complete and incomplete injuries. Sample research questions could include: Describe your life since SCI. How would you describe a successful life? What experiences since SCI have contributed to leading a successful or unsuccessful life? What motivated you to return to the community? What experiences since SCI motivated you to maintain your health and self-care? Have you developed any complications related to SCI? If yes, what do you think led to these complications?
It is important to think about people with SCI who live in the community and are at risk for SCI-associated complications in a framework that relates factors that contribute to health. Focus on a personality trait such as hardiness and the way it can serve as a motivator to maintain health through activistic social support, positive health behaviors, and transformational coping.
I thank Carole Ann Bach, PhD RN CRRN, who was a faculty research advisor at Vanderbilt University, and who kindly reviewed this manuscript.
About the Authors
Rachel A. Kinder is a doctoral student at Vanderbilt University, and assistant professor at Western Kentucky University, Department of Nursing, Bowling Green, KY. Address correspondence to Rachel A. Kinder, Department of Nursing, Western Kentucky University, 1 Big Red Way, Bowling Green, KY 42101, or e-mail Rachel.email@example.com.
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