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Question Answered step-by-step Discuss at least three of the descriptive statistics that are used in the attached article.         Stress, Cognitive Appraisal, Coping, and Event Free Survival inPatients with Heart FailureAbdullah S. Alhurani, PhD, MSN, RN1,*, Rebecca Dekker, PhD, RN2, Muayyad Ahmad, PhD,RN1, Jennifer Miller, MSN, RN2, Khalil M. Yousef, PhD, RN1, Basel Abdulqader, MSN, RN3,Ibrahim Salami, PhD, RN1, Terry A. Lennie, PhD, RN, FAAN2, David C. Randall, PhD2, andDebra K. Moser, PhD, RN, FAAN21The University of Jordan, Amman, Jordan2University of Kentucky, Lexington, United States3California School for Health Sciences, Garden Grove, United StatesAbstractObjectives—To describe self-reported stress level, cognitive appraisal and coping amongpatients with heart failure (HF), and to examine the association of cognitive appraisal and copingstrategies with event-free survival.Methods—This was a prospective, longitudinal, descriptive study of patients with chronic HF.Assessment of stress, cognitive appraisal, and coping was performed using Perceived Stress Scale,Cognitive Appraisal Health Scale, and Brief COPE scale, respectively. The event-free survival wasdefined as cardiac rehospitalization and all-cause death.Results—A total of 88 HF patients (mean age 58 ± 13 years and 53.4% male) participated.Linear and cox regression showed that harm/loss cognitive appraisal was associated with avoidantemotional coping (β= −0.28; 95% CI: −0.21 - 0.02; p= 0.02) and event free survival (HR= 0.53;95% CI: 0.28 - 1.02; p= 0.05).Conclusions—The cognitive appraisal of the stressors related to HF may lead to negative copingstrategies that are associated with worse event-free survival.KeywordsStress; Cognitive Appraisal; Coping; Heart Failure; Event-Free Survival*Corresponding author. Abdullah S. Alhurani, The University of Jordan, School of Nursing, Amman 11942, Jordan, Tel: +962 65355000. A..i@ju.edu.jo (A.S. Alhurani).Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.Heart failure (HF) is a costly condition with high mortality and morbidity rates.1,2 In 2012,the total costs for HF in the United States were approximately $31 billion, and this amountwill rise to approximately $70 billion by 2030.3 Although biological factors contribute to thehigh morbidity and mortality in HF, there are many unexplored psychosocial factors thatpotentially contribute to poor prognosis.4,5Heart failure is commonly perceived with considerable psychological distress.6-10 Based onthe work Lazarus and Folkman as well as others' in the literature,4,6-22 we developed amodel of HF patients' response to stressors (Figure 1). In this model, HF is the stressor.Stressors have been defined as environmental circumstances or chronic conditions that areappraised in a primary appraisal process, and then are seen as either benign or a threat tophysical and/or psychological health or well-being.23 In those with HF, cognitive appraisal isthe patient's perception of an event or situation, their assessment of the degree to which theevent is stressful, and their perception of the potential impact of the event on personal goalsand resources.22,24 People have considerable differences in their appraisal of and response tostressors.25 Thus, cognitive appraisal is a core component of this as well as other stressmodels.22,26 Stressors can be appraised primarily as: (1) irrelevant when the situation has noeffect on the individual, (2) benign positive when the situation is evaluated as positive, or (3)or stressful.22 When appraised as stressful, the stressor can be further appraised (secondaryappraisal) as: (1) harm/loss resulting in damage to self or social esteem; (2) threat, whichrefers to a suspected pain; or (3) challenge, which allows for the opportunity for gain andgrowth.22 Cognitive appraisal has been shown to play an important role in determining theimpact of the stress response.15 Specifically, appraisal of a stressor in the harm/loss or threatcategories result in poor health outcomes, impaired performance and lower quality of life.14,16 In contrast, appraisal as a challenge has been associated with positive effects oncardiovascular reactivity and task engagement.14,16Cognitive appraisal of HF can predict psychological and physical coping responses.27Lazarus and Folkman (1984) defined coping as "Constantly changing cognitive andbehavioral efforts to manage specific external and/or internal demands that are appraised astaxing or exceeding the resources of the person" while attempting to manage, master, or alterthe stressful situation by reducing or tolerating it.21,28 The following two major types ofcoping have been suggested: emotion-focused and problem focused.22Emotion-focused coping is an attempt to control emotional response to a stressful situationwhen individuals believe they cannot change the situation.29 These strategies can be dividedinto active emotional coping and avoidant emotional coping.17,18 Active emotional copingincludes venting, positive reframing, humor, acceptance, and emotional support strategies.Avoidant emotional coping includes self-distraction, denial, behavioral disengagement, self-blame, and substance use.19,20 The predominant view of emotion-focused coping is that it isa maladaptive form of coping associated with impaired health outcomes. Emotion-focusedcoping is associated with unhealthy lifestyle practices such as smoking, lack of exercise,drinking, non-compliance with medical regimen, and drug use that may lead to frequenthospitalization and even higher mortality rate.30,31 In contrast, problem-focused coping Manuscriptconsists of cognitive and behavioral strategies to alter or manage the stressor, such asplanning, reaching out for instrumental support, and religion.19,20 These are positivelyassociated with better adjustment and health outcomes such as longer survival and fewerhospitalization compared to those with emotion-focused coping.31Understanding factors that affect survival in patients with HF is important to design futureinterventions to reduce the stress from HF and change how HF patients appraise theircondition and cope with it. The purposes of this study were to describe self-reported stresslevel, cognitive appraisal and coping among patients with HF, and to examine the associationof cognitive appraisal and coping strategies with event-free survival.MethodsDesign, sample, and settingA prospective, longitudinal, descriptive design was used in which patients' follow up wereperformed for 6 months to determine the occurrence of the endpoint of time to re-hospitalization for cardiac causes or death from any cause. The study was approved by thelocal Institutional Review Board. A convenience sample of 88 patients with HF who werehospitalized for cardiac reasons at an academic health care center and a level 1 traumamedical center in Kentucky, USA was used in this study.Patients with a diagnosis of chronic HF were eligible for participation in the study if theywere: 1) admitted to the hospital with a primary or secondary diagnosis of exacerbation ofchronic HF or any other cardiac diagnosis; 2) 21 years or older; 3) able to read and speakEnglish; and 4) not obviously cognitively impaired. Cognitive impairment was defined as thepresence of a diagnosis of dementia or cognitive impairment, the inability of the patient toprovide informed consent, or to provide an accurate description of what was expected in thestudy after the study was explained by research staff. Chronic HF was defined as an existingand confirmed diagnosis of HF from a cardiologist. Only patients with existing HF (versusnew onset) were considered to have chronic HF. Patients were excluded from the study for:1) co-existing terminal illness likely to be fatal within 6 months; 2) presence of a leftventricular assist device, continuous inotropic infusion, or hospice care; 3) active suicidality(defined as choosing option 2 or 3 on item 9 of the Beck Depression Inventory-II); 4) historyof the death of a spouse or child within the past month; 5) history of psychotic illness orbipolar illness; or 6) current alcohol dependence or other substance abuse.Power analysis was performed using G-Power 3.1 with power level of 0.80, level ofsignificance of 0.05, the medium effect size of 0.15, and seven predictors. A minimumsample size of 103 was recommended based on the G-Power analysis.Variables and MeasuresStress—Stress was measured using the brief version of the Perceived Stress Scale.32 Thisversion consists of a four-item scale that has been demonstrated to be reliable and valid,32 ina variety of countries and in multiple populations including those with chronic illness.33,34Each item was rated by patients on a scale ranging from 0 (never) to 5 (very often). Higherscores indicate greater levels of stress. Cronbach's alpha for this instrument in the current. The four items were: (1) how often have you felt that you were unable tocontrol the important things in your life?, (2) how often have you felt confident about yourability to handle your personal problems?, (3) how often have you felt that things were goingyour way?, and (4) how often have you felt difficulties were piling up so high that you couldnot overcome them?Cognitive Appraisal—Cognitive appraisal types (Challenge, Threat, and Harm/Loss)were measured using the brief version of the Cognitive Appraisal Health Scale.35,36 Thisversion contains 13 items derived from Kessler's scale, which is one of the most commonlyused measures of cognitive appraisal of stressful and non-stressful events.24 Validity wassupported by component factor analysis and reliability has been shown in previous studies.35,36 The responses in this scale range from 0 (strongly agree) to 5 (strongly disagree).Higher scores indicate that the patient does not commonly use that type of appraisal.Cronbach's alpha in this study was 0.78.Coping—Coping was measured using the Brief COPE scale.37 This 28-item scale is anabbreviated version of the COPE Inventory.37 The reliability and validity of the brief COPEhave been demonstrated in multiple patient populations, and used in those with chronicconditions and with HF.37,38 The responses to items on this scale range from 1 (I haven'tbeen doing this at all) to 4 (I have been doing this a lot). Based on conceptual and empiricalliterature the 14-subscales were grouped in three coping strategies which are activeemotional coping, avoidant emotional coping, and problem focused coping.12,22,39 Higherscores on the subscales indicate that the patient commonly used that coping strategy. TheCronbach's alpha for the COPE in this study was 0.78.Event-free survival—Event-free survival was defined as the combined endpoint ofcardiac hospitalization or all-cause death. Hospitalization data were determined through acombination of patient and family interviews and a review of medical records.Hospitalizations were verified and documented by trained research assistants who reviewedmedical records and clinic notes on a weekly basis. Given the possibility that patients couldhave been hospitalized at different facilities, trained research assistants carefully questionedthe patients or family members by phone to determine if hospitalization had occurredelsewhere.All-cause death was determined by reviewing medical records and contacting the patient'sfamily. At enrollment, the patient was asked for contact information for a close friend orfamily member in case the patient could not be contacted. At follow-up if a patient could notbe reached by phone, hospital records were searched. When information regarding thepatient was not available, family members or friends were contacted.Demographic and clinical variables—These variables included age, gender, ethnicity,and New York Heart Association (NYHA) class. NYHA class indicated the level offunctional impairment reported by patients as a result of symptoms. These variables wereselected because of their effects on the outcome as suggested in the literature.40,41Hospitalized patients were identified by clinicians and referred to researchstaff who determined each patient's eligibility. The study and its voluntary nature werethoroughly explained to each patient and signed informed consent was obtained afteranswering any questions patients had about the study. The research staff met with thepatients to administer study questionnaires via the web based Survey Monkey. Thequestionnaires took approximately 20 minutes to complete. A paper copy was offered to thepatient if they did not feel comfortable with the web based survey.Patients were contacted by phone at two weeks, three months, and six months from hospitaldischarge. At each telephone contact, the research staff asked the patient whether he or shehas been hospitalized or visited the emergency unit. At the end of the study period, hospitalrecords were reviewed to confirm deaths, re-hospitalizations or emergency department visits.Statistical Analyses—Data were analyzed using SPSS software, version 20.0 (SPSS Inc.,Chicago, IL). Descriptive statistics, including means, standard deviations and frequencydistributions, were used to describe sample characteristics. Two tailed Pearson correlationcoefficients were used to determine bivariate relationship among the variables. Multiplelinear regressions were used to determine the association between stress and cognitiveappraisal type, stress and coping style, and cognitive appraisal and coping style. Age,gender, and NYHA class were controlled in those three multiple linear regressions. Twogroups, low and high perceived stress level, were created based on the median of perceivedstress level and used in this analysis. The median was used to create the groups becausethere are no published cut-points to define high and low stress levels.To examine the association of cognitive appraisal and coping strategies with event-freesurvival (cardiac hospitalization or all-cause death), adjusted Cox regression analysis(survival analysis) was used to determine whether different types of cognitive appraisal andcoping styles, independently predict event-free survival. Each type of cognitive appraisal(Challenge, Threat, and Harm/Loss) and each style of coping (Problem focused coping,Active emotional coping, and Avoidant emotional coping) was entered in separate Coxregression analysis to predict event-free survival. The following covariates were consideredin the adjusted analyses: age, gender, and NYHA class. The assumptions of all Coxregressions and multiple linear regressions were tested for violations, and none were noted.A p-value of ≤ 0.05 was considered statistically significant.ResultsDemographic and clinical characteristics of patients (N = 88) are summarized in Table 1.The average stress score in this sample was 9.44 ± 3.86, with a range of 4 to 20. The averagecognitive appraisals scores were as following: threat appraisal 2.46 ± 0.87, challengeappraisal 2.47 ± 0.77, and harm/loss appraisal 2.65 ± 0.88. The average coping styles scoreswere as follows: problem-focused coping 2.82 ± 0.66, active-emotional coping 2.57± 0.56,and avoidant-emotional coping 1.56 ± 0.38. A total of 29 (32.9%) patients had an event:seven (7.9%) died and 22 (25%) were hospitalized for cardiac reasons.Author Manuscript Author Manuscript Author Manuscript Author ManuscriptThe two tailed Pearson correlations showed that harm/loss cognitive appraisal wassignificantly correlated with stress level (r= −0.342, p = 0.005). Specifically, higher levels ofstress were associated with the more common use of harm/loss appraisal. Stress level wasalso significantly correlated with avoidant emotional coping (r= 0.429, p < 0.001). Theavoidant emotional coping style was associated with higher levels of stress. In addition,threat cognitive appraisal was significantly correlated with avoidant emotional coping (r=−0.372, p = 0.002). Furthermore, harm/loss cognitive appraisal was significantly correlatedwith the avoidant emotional coping (r= −0.433, p < 0.001).In adjusted analyses, and with regard to prediction of cognitive appraisal, multiple linearregressions showed that none of the demographic, clinical, or stress variables was asignificant predictor of challenge (Table 2). The only significant predictors of cognitiveappraisal as threat were age (β 0.39; 95% CI: 0.01 - 0.04; p = 0.01) and gender (β −0.23;95% CI: −0.81-0.01; p = 0.05). Specifically, older age and female gender were associatedwith cognitive appraisal as a threat. Finally, age (β 0.06; 95% CI: −0.01 - 0.02; p = 0.05)and stress (β −0.37; 95% CI: −1.11 - 0.23; p < 0.001) were the only significant predictors ofcognitive appraisal as harm/loss. Specifically, older age and higher stress level wereassociated with harm/loss cognitive appraisal.Significant predictors of avoidant emotional coping included harm/loss cognitive appraisal(β −0.28; 95% CI: −0.21 - −0.02; p = 0.02) and stress level (β 0.30; 95% CI: 0.04 - 0.38; p= 0.02); controlling for age, gender, and NYHA class (Table 3). Higher levels of stress andgreater use of harm/loss cognitive appraisal were associated with avoidant emotional copingstyle.In analyses adjusted for age, gender and NYHA class, where cognitive appraisal types werethe independent variables, none of the demographics, clinical characteristics, or cognitiveappraisal variables was significant predictors of event-free survival (Table 4). Where copingstyles were the independent variables, none of the demographics, clinical characteristics orcoping styles were significant predictors (Table 5).DiscussionDespite the medical and surgical advances in HF treatment, mortality and morbidity rates arestill substantial even in comparison to some aggressive types of cancer.42-45 Wehypothesized the relationships among the study variables (stress, cognitive appraisal, andcoping) depicted in the model (Figure 1) that was developed based on the literature to date.In this study, we investigated whether cognitive appraisal type predicted 6-month event-freesurvival. Our findings suggest that greater use of harm/loss cognitive appraisal predictedshorter event-free survival in HF. None of the other cognitive appraisal types weresignificant predictors. These findings suggest that threat and harm/loss cognitive appraisalsmay lead to negative coping styles such as avoidant emotional coping that also predictedshorter event-free survival in the unadjusted model. This result can be explained by theassociation of the harm/loss cognitive appraisal with other negative psychosocial factorssuch as depression and anxiety that been found to short event free survival among HFof appraisal and coping in response to stress. Cognitive behavioral therapy is effective inassisting patients assume healthier appraisal and coping strategies, which are associated withbetter health outcomes, greater self-efficacy, and less depression and anxiety.48,49We found also that higher stress levels were associated with greater use of harm/losscognitive appraisal. This finding suggests that patients with HF respond negatively to higherstress levels with an appraisal type that is associated with negative health outcomes, and areunable to marshal a positive coping response to stress. Other healthy and chronically illsubjects have demonstrated the ability to respond to the stress imposed by their conditionwith a healthier type of cognitive appraisal, challenge, which is associated with betteradherence and outcomes.14,15In a study conducted among patients with the human immunodeficiency virus, psychologicalstress was associated with threat cognitive appraisal.50 Our findings suggest that HF patientsmay have a different appraisal for the stressful situation since a higher level of stress wasassociated with harm/loss cognitive appraisal. However, these findings demonstrate thatcognitive appraisal plays a role in the stress response.15In our study, only stress and harm/loss cognitive appraisal were predictors of avoidantemotional coping style. Our findings suggest that higher levels of stress and greater use ofharm/loss cognitive appraisal were associated with the avoidant emotional coping style.Thus, the dominant type of cognitive appraisal in our sample of patients with HF isassociated with a coping style that has negative health outcomes and a negative impact onemotional well-being. Similar findings have been reported in the literature.51-55Our study was the first to investigate stress, cognitive appraisal, coping, and event-freesurvival in HF patients. Many of our findings were consistent with other investigationsconducted on different groups of healthy and ill subjects.50,56-58 However, our findings didnot support all the relationship in the hypothesized model. A potential explanation is that themeasures did not adequately capture stress and coping styles. We used brief stress andcoping scales that contains 4 and 28 items respectively. Both shortened measures have beendemonstrated to be valid and reliable; nonetheless, the full instruments may have providedmore complete information about stress level, and coping styles than the shorter versions.32,37,59,60 Another potential explanation is that the 6 month follow up period may have beentoo short to capture the effect of coping styles on the health outcomes in patients with HF.Also, the role of the culture in response to stress and coping style may have affected ourresults. The sample was recruited from a large city in Kentucky, USA called Lexington.However, this city is in the heart of Appalachia. The Appalachians are well known for theirunhealthy lifestyle that may consider as a way of coping with the stressors. We recommendto include the cultural factor in the future studies. A final possible explanation is that there isno relationship between the variables and outcomes in patients with HF.The strengths of our study include the use of valid and reliable instruments to measurestress, cognitive appraisal, coping, and other covariates. Furthermore, we investigatedmultiple associations among the variables of this study and our findings form a foundationThe small sample size is one of the limitations of this study that may affect our ability tofind significant association similar to those that were presented in the literature. We also didnot adjust the analysis for the length of time from diagnosis which may have affected theperception of HF in this population. Including this variable in the analysis could haveprovided more insights into our finding. Furthermore, choosing the unhealthy style of copingto manage the stressors associated with HF, it can be a chance to develop anxiety anddepression among those patients which may affect their survival. Thus, not including anxietyand depression as variables may consider a limitation in this study.ConclusionOur findings suggest that there is an association between stress level and harm/loss cognitiveappraisal that is associated with shorter event free survival among HF patients. In addition,harm /loss cognitive appraisal is associated with avoidant emotional coping that is associatedwith negative health outcomes and shorter event-free survival. Thus, to improve healthoutcomes in patients with HF, interventions are needed to reduce the stress from HF andchange how HF patients appraise their condition and cope with it. Cognitive restructuringmay be useful among patients with HF who negatively appraise the stress of HF as suchappraisal leads to negative coping strategies that are associated with worse event-freesurvival.    Health Science Science Nursing NUR 903 Share QuestionEmailCopy link Comments (0)
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