Saturday, November 12, 2011

Coping More than Two Years Following an Elective Abortion

Focusing on Lazarus coping theory, I wrote a term paper discussing the need for health coping strategies for women who have had a previous abortion. As a nurse, this focuses on many nursing interventions and even has a paragraph noting appropriate nursing diagnoses. This term paper was an assignment for a nursing writing and theory class. Please read through it. If you have any thoughts or corrections, please comment!

Introduction: Lazarus’ Theory on Coping and Relationship to Elective Abortion

      Richard S. Lazarus is a theorist that has been at the forefront at developing research and published works regarding coping. Coping literally means the ability to deal with stress; it is defined as malleable and practical actions to resolve stress by resolving daily problems (Lazarus & Folkman 1984). Lazarus has described coping as being based in reality and able to adjust freely to lower stress levels associated with difficult events. Lazarus states that coping is different for all people and that there are many different forms of coping that result in the successful ability to deal with stress. Furthermore, stress is different for all people and for all situations; indeed, two people can experience a same event and experience related stress in different ways. Stress can be good and it can be bad. Forms of coping with these stressors are far and wide.
There are a multitude of situations that require coping. The death of a father, an upcoming wedding, and a new addition to a family are all stressful events that require the use of coping strategies. Among the situations in life that require healthy coping strategies is an elective abortion. Indeed, an elective abortion is a stressful occurrence that requires a healthy coping reaction to allow recovery and resolution (Goodwin & Ogden, 2007).
      There are many coping strategies that can be applied to the stressor of an elective abortion and that of other stressful life events. There are four key coping strategies. One is Type A and B personalities, a second is healthy coping, a third is denial or avoidance and a fourth is defensive coping.

Coping: Type A and Type B

      Type A coping involves heavy work towards a goal, high competitiveness, and a fixed faith system (Lazarus & Folkman, 1984). This coping requires a person to make efforts to control the person’s environment because a particular event allowed no control. This attempt at control is a compensatory mechanism. It aids in the coping process but leads to an unhealthy physical and mental lifestyle. This behavior may be exhibited in what many people call “workaholics.” Working excessively hard and being an over-achiever can help someone cope with a person’s history of elective abortion by aiding the person in a sense of “fixing” problems or “making up” for possible wrong doings; for example, it may help a woman who has regretted the decision to abort to “make up” for this wrong. These actions may also serve the purpose of the person attempting to not remember the elective abortion and remain distracted.
      Type B coping is essentially the opposite of Type A. Whilst Type A is motivated by intense competitiveness, lofty goals, control of the environment, and a fixed system of faith, Type B is motivated to receive reduced work-load, wish to achieve goals in an extended time frame, feels largely unable control of the environment, and does not usually believe in a fixed set of values or beliefs (Lazarus & Folkman, 1984). Also, this group of people may be seen as vulnerable to being withdrawn and use this as another coping mechanism. It is easier to visualize this group as avoiding conflict to reduce their stress level. Those whom have had an abortion may use this coping mechanism to avoid situations that may remind them of their abortion (i.e. remaining stagnant keeps them away from different situations that may trigger displeasant memories).

Coping: Denial and Avoidance

      Another form of coping is denial or avoidance. Denial can also be described as the reluctance or lack of ability to admit or deal with spiritual or emotional hurt is termed denial (Burke & Reardon, 2002). Further, denial or avoidance is not based in reality (rather, denial denies reality). There are many different forms of denial or avoidance. Indeed, the many different forms of denial are meant to help cope with an uncomfortable experience or reality.
      Many women are at a very difficult time of their lives when they decide to have an elective abortion. It has been found to be common in women who have experienced an elective abortion to utilize avoidance and denial as coping mechanisms (Cougle, Reardon, & Coleman, 2005). With the multitude of stressors pressing on them, the reality of an elective abortion (death of the fetus) is oftentimes not realized and placed as the accomplishment of an elective abortion procedure. Many problems facing women that lead them to the decision of elective abortion does not negate the emotional reality that it produces in the short-term and, especially, long-term aftermath of the procedure. One long-term study demonstrated most post-abortion women involved used avoidance as a coping mechanism to deal with the memory of abortion (Hess 2004). The ineffective coping strategy of denial or avoidance oftentimes occurs due in large part to lack of familial support and societal acceptance (realized or perceived), deemphasizing the problem, and personal shame.
      Lazarus’ studies led him to eventually conclude that denial can have a lessened negative effect if occurring immediately after an event but are illustrative of ineffective coping in the long-term (Lazarus & Folkman 1984). The lacking desire to appropriately address, understand, and accept a problem contributes to ineffective coping. The desire to appropriately grieve can be assisted by aiding in the reversal of a woman’s thought processes of shame, misplaced guilt, perceived lack of support, and dehumanization of the fetus.
Defensive coping may manifest as being mad, using substances to numb the emotional pain, and removing oneself from societal dialogue regarding the stressor of problem. This unhealthy form of coping can be seen in those who have no extensive support system due to not having known access to healthy channels to funnel stress and, thus, healthily cope. Some studies have shown women who have had elective abortions to have an increased risk of substance abuse, mental health problems, and mood disorders (Cole, Coyle, Shuping & Rue, 2009).

Healthy Coping

      Healthy and appropriate coping is characterized by a person’s active participation in the process of coping. It takes recognition that there is or are problem(s) (acceptance) to cope with and a rigorous cognitive effort. The effort of coping following acceptance is different for each situation. There are many different coping mechanisms. Lazarus openly admitted that there is no one healthy coping strategy but many different ones that may lead a person health coping. Lazarus and Folkman (1984) wrote that the appropriateness of a coping strategy is illustrated by how it positively affects the person in the long term. Folkman later wrote with Moskowitz that only the coping processes that maintain an encouraging affect in response to chronic stress could possibly involve meaning to a person (2000). Thus, women who have had an abortion in their past must illicit positive coping strategies tailored to their own needs that will result in a healthy view of themselves and who they are today. However, one common healthy coping mechanism related to past elective abortion, following its acceptance, is grief.

Focus On Long-Term Coping vs. Short-Term Coping

      Many studies that have been published have one glaring fatal flaw. This flaw is that many of them use a very small time of follow-up (two years or less) (Trybulski 2006). In addition to this glaring flaw, many studies on the subject of women’s reaction following an abortion have had poor design, selected samples resulting in bias results, inability to control confounding, and misuse of subjects’ prior mental health (Fergusson, Horwood, & Ridder 2006). Rosanna F. Hess, a Registered Nurse (RN) and Nurse Practitioner (DNP), stated that a woman’s elective abortion resolved and held a different perspective regarding it “as the woman matured;” short-term studies will not capture and have not captured this aspect (Hess, 2004).
      Tybulski published a study that involved one to two hour detailed interviews of women immediately following an elective abortion; the study illustrated that the 16 people interviewed had reported relief (Trybulski, 2006). The term “relief” sounds like an entirely positive response. However, Lazarus states that the feeling of relief is not always a positive emotional response (Lazarus 2000); whilst the immediate response of some women is certainly relief, it does not ensure that the experience was wholly positive. Rather, it indicates that many immediate stressors have been relieved. These stressors are due to the person’s current situation and include such things as pressure from family and mate, lack of support structure, belief that birthing a child would hinder personal and financial achievement among others. Placed in the perspective that women’s view of an elective abortion changes over time, this feeling of relief may transform into other emotions that may or may not be positive. Furthermore, Hess explains that her studies have illustrated that a women’s immediate reaction to abortion can also include “guilt, a sense of loss, and anger” (Hess, 2004).
      Long-term coping is important since there are many ineffective coping skills, such as denial that was mentioned by Lazarus, that can benefit a person in the short-term but not truly resolve the stressor. This results in a stressor needing to be dealt with in the long-term; when a stressor is “put-off” using coping mechanisms such as avoidance, denial, defensive, Type A and Type B it results in increased difficulty in resolving the stressor. Using such coping mechanisms prevents the most appropriate coping mechanisms which is acceptance and grief.

Signs of Ineffective Coping

      Burke, a psychiatrist who started his career specializing in eating disorders, found that many women have found elective abortion to be a traumatic occurrence resulting in ineffective coping (Burke & Reardon 2002). This ineffective coping has led to the finding that elective abortion is associated with rates of mental disorder (Fergusson, Horwood, & Ridder, 2006). Recognizing the possibility of unhealthy behaviors may be exhibited in women who have had elective abortion is important. Some of these unhealthy behaviors including using passive-aggressive behaviors to gain control, keeping an elective abortion secretive, conjuring up images and fantasized situations if the women did not have the abortion, and involvement in ceremonies (Hess, 2004). Another sign of ineffective coping is the lessened ability to choose healthy relationships. Some may choose to remain in abusive relationships with the father of the aborted unborn child to help maintain the only remaining connection.

Emotional Responses Triggered by Events

      Avoidance and denial may exhibit by strong emotional reactions that are triggered by events that remind women of their elective abortion. Worden (2009) described succinctly that, in his experience, a negative response, such as grief, may be displayed at the due date of the pregnancy and even when infertility occurs. Furthermore, when a woman who has had abortion discovers the more human features of the fetus that was killed in the abortion procedure, it will often result in increased negative reactions (Goodwin & Ogden, 2007).

Nursing Intervention: Discussion

      Nurses in Labor and Delivery are often unlikely to allow assignment to care for women who have are scheduled to have an elective abortion (Marek, 2004). This indicates the extreme moral issue surrounding elective abortion that nurses have been uncomfortable with. No matter how uncomfortable a nurse is with elective abortion, it is important to remain impartial and nonjudgmental to women who have had an abortion. It is important to remember that once an elective abortion has taken place, nothing is going to reverse what happened.
      Open and non-judgmental discussion regarding difficult aspects of a person’s past that has been difficult to cope with has been proven to be successful. Nurses and all professionals in contact with those using coping mechanisms dealing with stressful situations need to be sensitive in their approach. Being non-judgmental, allowing the person to lead conversation, giving him ample time for discussion (not “over-talking”), expressing concern over the appropriate concepts at appropriate times, and not interjecting a personal opinion into the discussion all can help a person appropriately and healthily cope. Gentle guidance to help people accept the reality of what has happened is important since denial is generally an ineffective coping mechanism and a barrier to a healthy grieving process.

Nursing Intervention: Referral

      Nurses and other professionals, once gaining the trust of a person, can then refer them to appropriate counseling groups, organizations, and events. One such organization that provides support for women who have had elective abortions Rachel’s Vineyard. Founded in 1995 by Doctor Theresa Burke, Rachel’s Vineyard now holds over 700 weekend retreats annually to provide group counseling for women who have had elective abortions (Rachel’s Vineyard 2010).
      Referrals are important because they provide a resource for those in need. It also provides concrete evidence to post-elective abortion patients that not only is there support for them, but that there are other women who have had similar experiences and are willing to help. Hess (2004) has written that nurses need to discuss with women who have had an elective abortion regarding utilizing therapy and group counseling. Support is indeed important in healthy coping.

Nursing Intervention: Prevention

      Since many women have reported negative reactions in the long-term following an elective abortion, it is important to teach women and men techniques for primary prevention of pregnancy and, thus, elective abortion (Hess, 2004). If the destruction of the unborn child is desired to be avoided, it is important to teach patients one possible mechanism of action of low dose birth control; this mechanism of action is changes in the endometrial lining leading to the reduced likelihood of an embryo properly implanting resulting in embryonic death (Bayer Pharmaceuticals, 2011). Furthermore, teach patients that intra-uterine devices (IUDs) also have a similar mechanism of action. Educate patients regarding all of their birth control options such as barrier methods, natural family planning (NFP), and abstinence.
      When discussion prevention strategies with men, it is important to teach men to provide support and assistance to their mate especially when she is pregnant. It has been demonstrated that pregnant women who have been abandoned or left without support by their mate were much more likely to have an elective abortion (Kimport, Foster, & Weitz, 2011).

Nursing Intervention: Teaching Healthy Coping Skills

      For those patients that you encounter that have an elective abortion in their history, teach these women techniques to appropriate cope. Stress the importance with the patient of surrounding herself with supporting family and avoiding negative contacts; it has been shown that a lack of support from others results in an increased negative coping (Goodwin & Ogden, 2007). Hess (2004) also suggested suggesting to women to name, give a gender, and dictate a letter to the fetus that was aborted to solidify the importance of using the grieving process as a healthy coping mechanism.

Appropriate NANDA Nursing Diagnoses

      Appropriate NANDA nursing diagnoses include Anxiety, Moral Distress, Ineffective Coping, Ineffective Denial, Defensive Coping and Complicated Grieving. Anxiety is appropriate due to some research that has indicated generalized anxiety surrounding the elective abortion (Cougle, Reardon, & Coleman, 2005). Moral Distress is appropriate due to the question of a fetus’ humanity in the mind of a post-elective-abortion woman and her surrounding support systems. Ineffective coping is appropriate due to the use of unhealthy coping mechanisms such as denial, avoidance, Type A and Type B personalities, personal shame, among others. Ineffective Denial is appropriate because the higher levels of denial lead to ineffective coping. Defensive Coping is appropriate because it employs unhealthy tactics to remove negative feelings of the mind such as substance abuse (Cole, Coyle, Shuping & Rue, 2009). The last appropriate nursing diagnosis is complicated grieving; this diagnosis is specifically appropriate because it fits the portions of this topic where grieving for a fetus that is legally and socially accepted to kill without consequences is taboo.


      Richard Lazarus describes that coping is unique for all people and changes depending on the situation. However, he also described that there are general types of coping such as denial, avoidance, defensive, healthy, and Type A and Type B. When women have an elective abortion it may result in a period of relief among other emotions. As the woman matures or is separated from the experience, a clearer image of what occurred surfaces. Many of these reactions in the long-term, and sometimes short-term, are negative due to the utilization of ineffective coping strategies.
      In conclusion, it is important for nurses to teach the use of effective coping strategies, use of conception prevention and elective abortion prevention strategies, remain nonjudgmental, allow patients to lead conversation, refer women to appropriate support groups, among other interventions. To appropriately help women following an elective abortion that has happened years in the past, it is important to recognize signs of ineffective coping. Nurses have a responsibility to assist patients in properly coping with an elective abortion that has occurred in their past.


About us. (2010). Retrieved November 11, 2011, from Rachel's Vineyard website:

Burke, T. K., & Reardon, D. C. (2002). Forbidden grief: The unspoken pain of abortion. Acorn Books.

Coleman, P. , Coyle, C. , Shuping, M. , & Rue, V. (2009). Induced abortion and anxiety, mood, and substance abuse disorders: Isolating the effects of abortion in the national comorbidity survey. Journal of Psychiatric Research, 43(8), 770-776.

Cougle, J. , Reardon, D. , & Coleman, P. (2005). Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: A cohort study of the 1995 national survey of family growth. Journal of Anxiety Disorders, 19(1), 137-142.

Fergusson, D. M., Horwood, L., & Ridder, E. M. (2006). Abortion in young women and subsequent mental health. Journal of Child Psychology & Psychiatry, 47(1), 16-24. doi:10.1111/j.1469-7610.2005.01538.x

Folkman, S. K., & Moskowitz, J. T. (2000). Positive affect and the other side of coping. American Psychologist, 55, 647–654.

Goodwin, P., & Ogden, J. (2007). Women's reflections upon their past abortions: An exploration of how and why emotional reactions change over time. Psychology & Health, 22(2), 231-248.

Hess, R. (2004). Dimensions of women's long-term postabortion experience. The American Journal of Maternal Child Nursing, 29(3), 193-198.

Kimport, K. , Foster, K. , & Weitz, T. (2011). Social sources of women's emotional difficulty after abortion: Lessons from women's abortion narratives. Perspectives on Sexual and Reprod Health, 43(2), 103-109.

Lazarus, R. S., & Folkman, S. (n.d.). Stress, appraisal, and coping. (Original work published 1984) Retrieved from

Marek, M. J. (2004), Nurses' attitudes toward pregnancy termination in the labor and delivery setting. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 33: 472–479. doi: 10.1177/0884217504266912

Trybulski, J. (2006). Women and abortion: the past reaches into the present. Journal of Advanced Nursing, 54(6), 683-690.

Worden, J. W. (2009). Grief counseling and grief therapy (S. Sussman & J. Rosen, Eds., 4th ed.). New York: Springer Publishing Company.

Yaz official FDA information, side effects, and uses. (2011, March). Retrieved November 11, 2011, from Bayer Healthcare Pharmaceuticals Inc via website:

Monday, November 7, 2011

Experiencing Death in Hospice

I have not been writing much on this blog due to being extremely busy. I am working full-time, going to school, and taking care of two sons alongside my wife. This is a post that I made in the online portion of a nursing class. It is regarding how me, my coworkers, and our hospice organization deals with the deaths of our patients.

Death. At times it is a relief. Even in times of relief, there is always an element of grief. Death of a patient is never easy no matter how much it was expected nor how much suffering was experienced by the patient. Every human being's life is a blessing and is eternally valued. After experiencing many deaths with whom there is an element of compassion, nurses and other health professionals "may...experience a state of exhaustion and a biological, psychological, and social dysfunction called...compassion fatigue" (Papadatou 2000).

In experiencing a death, I pray, reach out for support from my immediate supervisor, discuss the experience with other nurses, get a hug from my wife, and watch my children be happy. Other times the endless amount of paperwork and other job responsibilities distract me from being required to appropriate grieve.

In supporting a coworker who has experienced a patient loss, I direct conversations regarding the patient to them. I ask my coworker what the patient was like. If I know the patient, then I mention the positive qualities that I noticed regarding the patient.

Our organization is a small business and has a lot of work to do. Admission, death, admission, death... it never seems to stop. I have asked management a number of times to institute a biweekly meeting for all of the staff to give support to one another regarding patient death. However, nothing has yet been implemented. There is such a great need for this type of institutionalized support for our workers. I have felt the need for such a meeting a great number of times. I can tell that the stress of paperwork, patient care, time-management, overtime, and patient death has put a heavy burden on many of my coworkers. It is sorely needed and I will again make the suggestion. Our company does not allow any paid time off to attend funerals although they are always very willing to grant time-off.

Grief is something that all people will experience. It is not always from the loss of a loved one. However, the loss of a loved one is one of the most dramatic losses. The loss of a patient can also be very dramatic and requires support systems from coworkers, family, and institutional assistance. Our organization needs to address the compassion fatigue that many of us have been experiencing.

This is a long quote, but Suzanne Rich in 2005 published words that explain my feelings really well:

When a patient under our care dies, we may feel an acute sense of loss, both professionally and personally. Professionally, if a particular treatment or intervention fails, and a patient clearly shows signs of dying, we may feel eesponsible, guilty, angry, depressed, or helpless. On a personal level, if we are unable to relieve or control a patient's symptoms, such as nausea or pain, we may feel incapable of dealing with a dying patient.

Papadatou, D. (2000). A proposed model of health professionals' grieving process. Omega: Journal of Death and Dying, 41(1), 59-77.
Rich, S. (2005). Providing quality end-of-life care. Journal of Cardiovascular Nursing, 20(2), 141-145.