Informational Coping Style and Depressive Symptoms in Family Decision Makers

Ronald L. Hickman, Jr, RN, PhD, ACNP-BC, Barbara J. Daly, RN, PhD, Sara L. Douglas, RN, PhD, CRNP, and John M. Clochesy, RN, PhD


American Journal of Critical Care. 2010;19(5):410-420. 

In This Article


The traditional approach to understanding the relationship between stress and coping employs a transactional model. The most common philosophical approach explaining stress and coping is a transactional process that entails the cognitive appraisal of a stressor as potentially harmful and the initiation of coping behaviors to mitigate the effects of the stressor.[6] The second philosophical approach applied to the stress and coping process assumes that individuals initiate preferential coping behaviors based on personality traits without regard to the context or psychological stressor; this form of dispositional coping is known as the individual's coping style.[7]

Many classifications of coping styles exist. Approach and avoidance coping styles are 2 of the most well-known methods of classifying the ways that individuals cope with psychological threats.[8,9] During a stressful event, some individuals attempt to gain closer proximity with the stressful situation through information seeking; this coping behavior is characteristic of approach coping. In contrast, individuals who prefer to withdraw from the stressor have an avoidant coping style. Approach and avoidance coping styles reflect cognitive and emotional activity and orient the person either toward or away from the threat.[9] In this article, we further examine informational coping style, a variation of approach and avoidance coping that describes an individual's disposition for processing information while exposed to stressful conditions, such as being the FDM for a cognitively impaired CCI patient.

In the early 1980s, the concept of informational coping style emerged as a method of categorizing informational coping behaviors. The Cognitive-Social Health Information Processing (CSHIP) model developed by Miller et al[10] consists of a cognitive-affective construct that categorizes individuals on the basis of their informational coping disposition as either "monitors" or "blunters." The CSHIP model assumes that monitoring and blunting coping styles are conceptually independent and a person is likely to use both dimensions, with a primary dimension being the most preferential.

Informational Coping Style

Dispositional coping styles, information seeking (monitoring) and information avoidance (blunting), are stable characteristics of the individual. Individuals who consistently seek additional, detailed information from nurses, physicians, and the environment as a method of coping with psychological stress exemplify monitoring behaviors. When information from these sources is insufficient, monitors may have alterations in their psychological well-being, because of their loss of the predictability, control and certainty acquired from gaining information.[11,12]

Information for individuals classified as monitors can mitigate or perpetuate the effects of exposure to threatening health information. The persistent psychological arousal related to the constant scan for information and the fixation on the negative aspects of the stressor contribute to the psychological distress in individuals classified as monitors; however, when sufficient information is available, psychological arousal will decrease.[13] FDMs who are monitors are likely to report more depressive symptoms and a greater amount of perceived stress associated with being a surrogate decision maker if the information available is limited or their informational needs are not satisfied.[14]

Unlike monitors, blunters will avoid or distract themselves from sources of information deemed as threatening. The avoidance behaviors of blunters toward information are protective preferences, and exposing these individuals to a great deal of detailed information may actually be harmful to their psychological well-being.[11] Blunting behaviors in the FDMs of a CCI patient may appear as resistance to meeting with health care providers or passive participation by the FDM in the decision-making process.

The preference for avoidance of informational sources by FDMs could be thwarted by the recommended practice of a shared medical decision-making paradigm, resulting in unwanted exposure to sources of threatening information. In contrast to monitors, individuals who are blunters perceive information as stress inducing, and when they are no longer exposed to sources of threatening information, their psychological arousal is likely to subside.[15] However, to date, no one has studied the patterns of informational coping style in blunter FDMs.

Role Stress

Family members of critically ill patients are exposed to multiple sources of psychological stress. Those family members designated as FDMs may experience additional stress from being in the role of surrogate decision maker. FDMs must understand complex medical terminology, deliberate on the decision choices, and then make a decision that is in accordance with the patient's preferences. Results of several studies[16–18] validate the perception of role stress in FDMs of cognitively impaired persons who were faced with life-limiting or life-sustaining decisions. Experiencing role stress may reduce the FDM's ability to make appropriate treatment decisions and can further increase the risk for impaired psychological well-being.

Informational Satisfaction

Results of previous studies[19–23] show that family members of critically ill patients perceive the amount and quality of the information they receive as being insufficient and not satisfying their informational needs. Lilly and Daly[24] suggest the use of a structured communication system during formal family meetings, in an effort to provide sufficient informational support, to enhance informational satisfaction, and to reduce unnecessary consumption of intensive care resources. However, these clinical recommendations may support only the informational coping style of individuals who use the monitoring informational coping style and may induce unintended psychological harm for those who use the blunting informational coping style to manage threatening health information.

Depressive Symptoms

Few researchers have explored the psychological impairment of family members of CCI patients. As a consequence of a loved one's critical illness, family members of critically ill patients have symptoms associated with anxiety, posttraumatic stress disorder, and depression that contribute to their impaired psychological well-being.[25,26] Douglas and coworkers[27,28] were among the first to cite the psychological impairment of caregivers of CCI patients, as part of a clinical trial of a posthospital disease management program for families of patients who required prolonged mechanical ventilation. Their findings indicate that at hospital discharge most caregivers (51.2%) were at risk of clinical depression (depression score>16), although symptoms of depression were significantly reduced by 6 months after hospital discharge. Adding to this scant body of literature, Im et al[29] and Van Pelt et al[30] noted that a third of caregivers of patients who required 48 hours or more of mechanical ventilation were at risk for clinical depression 2 months after the start of prolonged mechanical ventilation, and, contrary to the findings of Douglas and coworkers, these symptoms did not decrease significantly over time in caregivers of CCI patients.


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