The Problem Strategy and Emotion Focus Coping with Pain Intensity

in Post Major Surgery

Friska Ernita Sitorus

, Dewi Tiansa Barus

, Siti Marlina

, Fithri Handayani Lubis

, Yunita Syahputri

Damanik

, G. F. Gustina Siregar

Nursing Faculty of DELI HUSADA Deli Tua Health Institute Deli Tua, Indonesia

Public Health Faculty of DELI HUSADA Deli Tua Health Institute Deli Tua, Indonesia

Midwifery Faculty of DELI HUSADA Deli Tua Health Institute Deli Tua, Indonesia

Keywords: Problem, Emotion Focus Coping, Pain Intensity, Post Mayor Surgery.

Abstract: Adaptive individual coping strategies are needed for post-major surgery patients to minimize the patients’

pain after surgery. If the patient's coping is increasingly adaptive so the patient's pain intensity decreases.

This study used cross sectional design with 96 respondents who were post-major surgery patients in the

category of post-oncology and digestive surgery, with Spearman statistical test. The results showed that

there was relationship between problem (r = 0.445) and emotion focus coping (r = 0.449) with pain intensity

(α <0.005). After identifying the types of coping strategies that majority used by patients are emotion

problem coping with social withdrawal domains and the minority are problem focus coping domain express

emotion. Respondents followed the instructions to minimize pain, and get closer to God..

1 INTRODUCTION

Pain is an unpleasant individual experience that

can cause potential and actual tissue damage (Elahe,

2018). Pain in postoperative patients has

characteristics that involve damage starting from the

integument, muscle tissue, vascular and causing

long-lasting pain effect during recovery (Roht,

2017). Pain in postoperative patients is reported at

severe level (Lamontagne, 2017). Pain is problem

that must receive attention, not only in postoperative

patients, because pain can negatively affect the

health status of patients (Roykulcharoen, 2017).

Individuals who feel pain feel depressed or suffer

and seek efforts to relieve pain. Nurse uses various

interventions to relieve pain or restore comfort. The

nurse cannot see or feel the pain the patient feels.

Pain is subjective, there are no two individuals who

experience the same pain and nothing two similar

pain events generate response or identical feelings

for individuals. Pain is a source of frustration, both

patients and health workers (Potter and Perry, 2017)

Providing analgesics does not the main control

holder to overcome the patient's pain complaints

because it has side effects that increase the recovery

time. In addition to pharmacological therapy, there

are also non-pharmacological therapy options

available to control pain. This method can be

combined with pharmacological methods that focus

on better management in reducing pain (Tetti, 2017).

Coping strategy is the way it is done to change

the environment or the situation or solve the

problem which is being felt or faced. Effective

coping will produce persistent adaptation which is a

new habit and repair from old situations, while

coping which is not effective end up maladaptive

namely behavior the deviant from normative desires

and can hurt yourself or other people or the

environment, each individual Coping is not alone

and not only use one strategy but it can do it varies,

it depends from ability and individual conditions

(Rasmun 2017)

If pain occurs after surgery, the combination of

non-pharmacological techniques with

pharmacologists is the most effective method for

pain relief (Suza, 2017).

According to Marialaura (2017) Coping can

resolve pain in chronic patients, namely

Fibromyalgia. In this study, patients used problem

focus coping. Effective coping will produce

permanent adaptation which is a new habit and

improvement of the old situation, while ineffective

coping ends in maladaptive namely behavior that

deviates from normative desires and can harm

Sitorus, F., Barus, D., Marlina, S., Lubis, F., Damanik, Y. and Siregar, G.

The Problem Strategy and Emotion Focus Coping with Pain Intensity in Post Major Surgery.

DOI: 10.5220/0009974205210527

In Proceedings of the International Conference on Health Informatics and Medical Application Technology (ICHIMAT 2019), pages 521-527

ISBN: 978-989-758-460-2

521

oneself or others or the environment, each individual

in doing coping is not alone and not only use one

strategy but can do it varies, it depends on the

abilities and conditions of the individual (Rasmun

2017).

In addition to coping strategy of Benson's

relaxation in minimizing the intensity of pain in post

section patients, it is very effective to do where the

patient is able to manage his pain, so the patient's

pain intensity decreases (Sedigheh, 2017).

Distraction giving in minimizing pain in patients on

intra-spinal injections given for patients who will

undergo effective chemotherapy is done (Shirkey,

2019)

According to International Association for the

Study of Pain (IASP), there are five models used in

dealing with patient pain, including: cognitive /

behavioral models, emotional models, coping

models, fear avoidance models and acceptance

models. From the five models, the coping model is

one of the best models used to insure the pain

experienced by patients. Coping strategy is one of

the strategies used by patients in reducing,

overcoming, dealing with pain that involves the

behavior and cognitive of the patient itself. Effective

coping will produce permanent adaptation which is a

new habit and an improvement from the old

situation, while ineffective coping ends in

maladaptive i.e. behavior that deviates from

normative desires.

2 METHOD

This research was quantitative study by using an

explanatory analytic design with cross-sectional

approach. Research location was in RSUP. H Adam

Malik Medan. The population of this study were

post-major surgery patients with minimum sample

size of 96 people. Taking samples used consecutive

sampling. The selected respondents were

postoperative digestive patients, postoperative

oncology patients, postoperative patients at least 3rd

day, maximum patient pain scale of 6, patients

willing to be respondents, patients understood

instructions both verbally and writing and they were

≥ 18 years old.

The respondent coping strategy was measured by

using coping strategy inventory (CSI) instrument

consisting of 32 statement items, consist of Problem

Solving, Cognitive Restructuring, Express Emotions,

Social Support, Problem Avoidance, Wishful

Thinking, Self Criticism, Social Withdrawal whereas

each each item consist of 4 statements. Pain intensity

was measured by using numeric rating scale (nRs)

on 1-10 scale. Before conducting research, the

instrument is tested for validity and reliability. In the

results of content validity testing given to 3 experts,

value of 0.895 was obtained. While the testing

results of construct validity from 30 respondents

obtained all items of valid statement with a

Cronbach Alpha value of 0.90.

Data were analyzed by using Pearson correlation,

where previously the data were analyzed by

normality test with Kolmogorov-Smirnov.

Figure 1 : Numeric Rating Scale

3 RESULT

3.1 Respondents Characteristics

The sample in this study amounted 96

respondents with characteristics showed the majority

of late adulthood namely 36-45 years as many as 23

people (24%), male sex as many as 35 people

(36.5%), the majority of Islamic religion as many as

72 people (77.1 %), the majority Batak tribe as many

as 34 people (35.4%), with the majority marital

status married as many as 91 people (94.8%), with

senior secondary education as many as 39 people

(40.6), the average job as many as 55 entrepreneurs

(57.3) %), with operations history that had never

been carried out before as many as 52 people (54%)

with the type of oncology surgery as many as 55

people (57%).

3.2 Respondents’ Coping Strategy

In this study coping strategies are divided into

two namely problem focus coping and emotion

focus coping. Based on problem focus coping, it is

found that the highest mean is 9.49 in sub social

support with standard deviation value of 2,294 and

the lowest mean is 9.16 and standard deviation of

2,390 in sub cognitive restructuring. Whereas based

on emotion focus coping, the highest mean is 10.55

with standard deviation of 2,280 in sub social

withdrawal and the lowest mean is 8.98 and a

standard deviation of 2,371 on sub wishful thinking.

ICHIMAT 2019 - International Conference on Health Informatics and Medical Application Technology

522

Table 1: Frequency distribution based on problem focus

coping.

Problem

Avoidance

Cognitive

Restructuring

Express

Emotion

Sosial

Support

96 96 96 96

0 0 0 0

9.89 9.16 9.44 9.49

2.401 2.390 2.214 2.294

12 11 11 11

Table 2: Frequency distribution based on emotion focus

coping.

Problem

Avoidance

Wishful

Thinking

Self

Critism

Social

Withdraw

96 96 96 96

0 0 0 0

9.89 8.98 9.43 10.55

2.401 2.371 2.051 2.280

12 12 10 12

3.3 Pain Intensity

Based on the study result, it was found that the

pain intensity with coping strategies: problem focus

coping experienced mild pain as many as 15 people

(14.4%) and moderate pain as many as 22 people

(21.12%) while in emotion focus coping experienced

mild pain as many as 36 respondents (34.56%) and

moderate pain as many as 23 respondents.

Table 3: Pain intensity

Category frequensy percent

Mild 50 52

Moderate 46 48

Total 96 100

3.4 Normally Test

The results of the study explain that data is not

normally distributed by using Kolmogorov-smirnov

with a p-value of 0,000 Where p-value <0.05 means

data is not normally distributed.

Table 4: Data normally test problem focus coping with

pain intensity

Problem focus

coping

Kolmogorov-Smirnov

Statistic Df Sig.

Mild .452 22 .000

Moderate .361 74 .000

Emotion focus coping normality test results with

pain intensity explain that that data is not normally

distributed by using Kolmogorov-smirnov with a p-

value of 0,000 Where p-value <0.05 means data is

not normally distributed.

Table 5: Data normally test emotion focus coping with

pain intensity

Emotion focus

coping

Kolmogorov-Smirnov

Statistic Df Sig.

Mild .456 19 .000

Moderate .357 77 .000

3.5 The Relationship between Coping

Strategy with Pain Intensity

The study results about the relationship between

coping strategies: problem focus coping with pain

intensity obtained results with p-value of 0.02 with

correlation value of 0.430 in the negative direction

where if the coping strategy is good then pain

decreases

Table 6: Relationship problem focus coping with pain

intensity

Problem

focus coping

Pain

intensity

Problem

focus

Coping

Correlation

Coefficient

1.000 .430

Sig. (2-tailed) . .027

N 96 96

Pain

intensity

Correlation

Coefficient

.430

1.000

Sig. (2-tailed) .027 .

N 96 96

The result between emotion focus coping with

pain intensity obtained results with p-value of 0,000

with correlation value of 0.449 means there is

relationship between coping strategies with the pain

intensity in post-major surgery patients with

negative direction where if we use the the better

coping, so the pain that feels decreases

Table 7: Relationship emotionfocus coping with pain

intensity

Problem

focus coping

Pain

intensity

Emotion

focus

Coping

Correlation

Coefficient

1.000 .449

Sig. (2-tailed) . .000

N 96 96

Pain

intensity

Correlation

Coefficient

.449

1.000

Sig. (2-tailed) .000 .

N 96 96

The Problem Strategy and Emotion Focus Coping with Pain Intensity in Post Major Surgery

523

4 DISCUSSION

4.1 Coping Strategy

Coping is a process that continually strives to

change the cognitive and behavioral efforts of both

external and internal demands where the judgment is

obtained from humans themselves (Garbee.D, 2017).

Coping strategies are ways that individuals do in

solving problems, adjusting to changes, and

responding to threatening situations (Keliat, 2016).

If an individual is under stress, he will use variety of

ways to overcome it, individuals can use one or

more available coping sources (Rasmun, 2017).

Reportedly, in general the coping strategy that is

often used by post-major surgery patients is adaptive

coping strategy (Kaczynski, 2017). These results are

reinforced by studies conducted by Kaczynski that

based on respondents' coping strategies, it shows

that coping strategies used by post-major surgery

patients are generally adaptive obtained from social

or family support, trust in God and ability in

emotional management (DeGraff, 2018). It is also

illustrated from the results of research conducted by

Wong (2017) that coping strategies used by post-

major surgery patients are generally adaptive coping

strategies where family support plays an important

role in the recovery period for pain felt by patients.

According to DeGraff the most universal coping

strategy used by respondents is emotion focus

coping which aims to minimize the perceived stress

that triggers pain in spinal injury (DeGraff, 2018).

Likewise, Borland expressed that post-oncology

patients used emotion focus coping more identical in

dealing with perceived problems (Lily M, 2018). It

is also supported by studies conducted by Lilly that

patients who experience identical collisions or

accidents use emotion focus coping, where patients

who use emotion focus coping at least more often

experience more pain symptoms (Mandl, 2017).

After being identified from the types of coping

strategies, social withdrawal is a type of coping

strategy that the majority of patients use in reducing

the intensity of pain that is felt around 88.7% which

is part of emotion focus coping. In this case the

patient is more identical to follow the instructions to

overcome the pain felt, pray to God, and try to

convince themselves with the situation experienced

by the patient. Social withdrawal is a principle of

coping strategy where the individual sees the

positive side of pain experienced in his life by

looking for the meaning or benefit of the experience.

Mandl said that patients who can see the positive

side of what is experienced are far better than

patients who are always anxious about their

conditions (Folkman, 2017). Lenti (2017) conducted

postoperative patients who do not try to see the

positive side of themselves in their recovery are

more likely to experience more serious and ongoing

pain.

The study results also found that the most

minorities of coping strategies used by patients is

79.4% express emotion. Express emotion is an

individual trying to find support and use the

assistance from others in the form of advice or

action in overcoming the problem (Gallo, 2017). The

study results are strengthened from Gallo's research

result where postoperative patients are very

commonly experiencing cognitive and emotional

function decline. When analyzed that the decline in

perception of cognitive function can cause decrease

in emotional function, which after being investigated

between cognitive declines is strongly associated

with decreased emotional function in postoperative

patients (Owen, 2016). Likewise, research

conducted by Owen in postoperative oncology

patients, where express emotion is always followed

by a change in the level of patient cognition. Even

though the results do not show strong relationship,

each patient's express emotion is always

accompanied by cognitive change in the patient

(Sharpe, 2017). Furthermore Sharpe reported that

problem solving and cognitive restructuring have a

role in reducing stress, where pain that occurs with

postoperative patients can also be caused by stress

(Aubun, 2017).

4.2 Pain Intensity

Pain intensity is description about how severe

pain is felt by individuals, measurement of pain

intensity is very subjective and individual and the

possibility of pain in the same intensity is felt very

differently by two different people. Pain

measurement with the most likely objective

approach used the body's physiological response to

pain itself. However, measurements with this

technique also cannot provide a definite picture of

the pain itself (Tamsuri, 2017).

According to Benedetti (1990), intense pain

stimulates stress reactions that adversely affect the

heart and immune systems. When pain impulses are

transmitted, muscle tension increases, as does local

vasoconstriction. Ischemia at the site of pain causes

further stimulation of pain receptors. When these

painful impulses spread centrally, sympathetic

activity is exacerbated, which increases myocardial

demand and oxygen consumption.

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The study results are same as Smeltzer & Bare

report which states that after undergoing surgery, the

patient feels postoperative pain stimulation because

it is caused by mechanical stimulation of the wound

which causes the body to produce pain chemical

mediators. Besides this, patients with severe pain are

absent, high pain intensity usually occurs on 2nd day

(Logan, 2017).

There are several factors that affect the pain

itself, including age, gender, ethnicity, etc. From the

study results, the majority of respondents

experienced moderate pain in late adulthood. Pain in

late adult patients can be complex because it is

related to pharmacodynamics and pharmacokinetics

which can affect the body's response to pain (Suza,

2017). From the study results also found that women

tend to experience mild pain compared to men. It is

in line with Logan & Rosen study where women

tend to show pain compared to men due to

anticipatory pressure. Whereas in ethnicity term, it is

found that Batak tribe show more pain than other

tribes (Guyton, 2017). It is supported by Suza's

research that Batak tribe responds the pain by

crying, screaming, or angry (Lamontagne, 2018).

According to gate control theory, pain impulses

can be regulated or inhibited by defense mechanisms

throughout the central nervous system. This theory

says that pain impulses are delivered when defense

is opened and an impulse is inhibited when defense

is closed. The effort for closing defense is the basis

theory of pain relief. It can be done by modifying the

patient's coping strategy (Guyton, 2018).

The study results are also almost same with

Lamontagne research that postoperative pain will

decrease on the 2nd day. An effective coping

strategy is given after 2nd day to minimize pain

[24]. Likewise, Roth research that pain decreases on

3rd day, especially if it’s adapative patient’s coping

(Aubun, 2017).

According to Elizabeth G (2012), patients often

report that pain has subsided on the 3rd day after

surgery. Pain will increase if the mood, sleep quality

and stress cannot be maintained, during this pain

period it is expected that family can provide support

to respondents in minimizing the pain experienced.

4.3 The Relationship between Coping

Strategy with Pain Intensity

Postoperative patient pain is caused by a tissue

incision in the operating area, besides that the pain

will also increase along with the patient's stress

which can disrupt sleep patterns, the patient's

appetite for anxiety. All of these things will

stimulate the amyglada which is part of the limbic

system associated with emotional components of the

brain. The neurological response of the amygdala is

transmitted and stimulated the hormonal response of

hypothalamus. The hypothalamus releases the

hormone Corticotropin-Releasing Factor (CRF)

which stimulates the pituitary to release another

hormone, adrenocorticotropic hormone (ACTH),

into blood. ACTH instead stimulates the adrenal

glands to produce cortisol, a small gland that is

above the kidney which will stimulate

vasoconstriction of blood vessels which will cause

pain (Shirkey, 2018). Coping strategy is one way

that can be used by patients in reduce and resolve

pain that involves the patient's own behavior and

cognitive. Adaptive and appropriate coping will

provide the ability for patients to adjust and be ready

to deal with stressors in the form of: pain, loss of

function or damage to body tissue and decreased

mobility, etc.

According to Mandl, it is reported that about 8%

of postoperative patients have coping strategies by

using Social withdrawal, and it was also described

that almost three times occur pain intensity decrease.

The pain intensity that occurs in patients on scale of

moderate to severe pain on postoperative at first day

and in this case the patient is more identical use

pharmacological drugs to reduce pain that is felt, and

pain will decrease on a moderate to mild scale on the

3rd day post operation. In this study Social

withdrawal appears to be more important for patients

who have recently undergone surgery, where in this

case the patient has more leverage to follow the

instructions to reduce the pain that is felt, and it has

started to accept the situation that occurs with an

approach to God [26]. It is same with Borland

research results (2018), that the intensity of pain

decreases with the adaptive coping strategies usage

in chronic patients undergoing dialysis

(Haemodialisa). In this case the patient has entered

into palliative care where the patient must be able to

make strategies in minimizing the pain that is felt.

Research conducted by Shirkey and Kezia on

Dispositional versus Episode Specific Assessment of

children's coping with pain with sample of 116

children who experience abdominal pain. The results

show that coping is higher level of all variables that

can reduce pain. Children are assisted by family or

parents in order to relieve the pain felt by the child.

Likewise, research conducted on the

effectiveness of coping usage in adolescent patients

after spinal surgery, it is obtained good results of

coping will minimize pain, coping strategies can be

used during recovery to reduce pain after surgery,

The Problem Strategy and Emotion Focus Coping with Pain Intensity in Post Major Surgery

525

and it is done on the 2nd day post surgery (Marie,

2018).

Based on the study results, from the types of

coping strategies namely problem focus coping and

emotion focus coping, it was found that emotion

focus coping has high value in minimizing pain even

though problem focus coping has another role. It is

done in post mastectomy patients. In this case in

addition to coping strategies, the patient's cognitive

regulation must also be done because in addition to

the pain that is felt there is also loss of limbs which

can increase the patient's pain (Moore, 2018).

Patient coping strategies in post-hysterectomy

surgery are emotion focus coping, for example, the

acceptance of pain that is felt, seeking support and

diversion to the pain felt by patients, the emotion

focus coping usage can not be separated from coping

strategies with problem focus coping, the results

show that patients use emotion focus coping is

always followed by problem focus coping and in this

case it is difficult to identify patient coping because

each patient has different amount of coping (Moore,

2018).

Likewise the study conducted where the research

is done on post mastectomy patients, the results

obtained that coping has strong contribution in

minimizing postoperative pain (Lamontagne, 2017).

Thus it can be clearly seen that the respondent

coping strategy has very important role to minimize

the pain intensity in post-major surgery patients.

5 CONCLUSIONS

There is relationship problem (r = 0.449) and

emotion focus coping (r = 0.445) with the pain

intensity where the increasing coping of the

individual, the intensity of pain decreases with the

direction of negative correlation. Emotion focus

coping is more used by patients to minimize the pain

felt. Emotional settings were given starting on the

2nd day after the operation.

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