Quality Of Life and Coping With Stress in Relatives of Patients in Intensive Care Units During COVID-19

All relatives of patients more than 18 years of age who were hospitalized in the anesthesia ICU of Sivas Cumhuriyet University Hospital in Turkey between November 1, 2021, and January 15, 2022, make up the study’s population. The number of participants for each patient was not limited. The research intensive care nurse conducted face-to-face interviews with the participants to complete the questionnaires and scales in the intensive care information room with no additional participants present. The data were gathered by posing questions to the participants. The questionnaires were deemed invalid and excluded from the study if there were questions that the participant did not want to answer.

Three forms were used to gather research data: the individual information form, which the authors created; the Styles of Coping With Stress Scale, which assesses how well people cope with stress; and the 36-Item Short Form Health Survey (SF-36), which assesses people’s quality of life. The data for the study were gathered by the researcher and an intensive care nurse.

The personal information form was developed by the researchers, in light of the literature, and consists of 16 items including questions about demographic information such as age, sex, marital status, educational status, occupational status, income status, social security, and residence, as well as the status, diagnosis, and the cause of the disease of the patient in the ICU.

The scale developed by Folkman and Lazarus in 1980 is a short coping mechanism scale that is valid in various stressful situations. Scores on the scale are associated with symptoms such as depression, loneliness, and psychosomatic problems.¹⁹  Şahini and Durak²⁰  aimed to develop a coping scale related to depression, various psychological symptoms, and loneliness; scores on the items of this scale were compared in groups separated according to depression, various psychological symptoms, and loneliness scores. That comparison yielded 30 items that distinguished 3 of the extreme groups formed on the basis of scores on the Stress Symptoms Scale and the University of California at Los Angeles Loneliness Scales; items with significant relationships to all 3 groups were selected for the short Styles of Coping With Stress Scale.²⁰  The scale measures 2 main styles of coping with stress: a problem-oriented/ active style and an emotional/passive style. Use of active coping styles is indicated by high scores on the following subscales: the seeking social support approach, the optimistic approach, and the confident approach. Use of passive coping styles is indicated by high scores on the following sub-scales: helpless self-accusing approach and submissive approach. Persons who can effectively cope with stress use the confident and optimistic approaches, whereas whose who cannot cope with stress use the submissive and helpless self-accusing approaches more.²⁰  A higher score indicates that the person uses that coping style more.²⁰ 

The SF-36 was created by Ware and Sherbourne²¹  in 1992 and is intended for use in general population studies, clinical practice, research, and individual assessments. Koçyiğit et al²²  conducted the validity study of the Turkish version of the SF-36. The SF-36 consists of 36 questions that measure 8 aspects of health-related quality of life: physical functioning, physical role difficulty, emotional role difficulty, bodily pain, social functioning, mental health, energy/vitality, and general health perception.

The data were analyzed with the IBM SPSS v25 program. In the examination of sociodemographic data, frequency and percentage were used. The conformity of the distribution of the data to the normal distribution was tested by examining the skewness and kurtosis values (+1, −1) with the Kolmogorov Smirnov test. A Student t test and a 1-way analysis of variance test were used to compare normally distributed data. The Pearson correlation coefficient was used to examine the relationship between variables. The level of significance was taken as P<.05.

Before the study was conducted, approval from the Sivas Cumhuriyet University Noninterventional Research Ethics Committee and institutional permission were obtained. The relatives of patients who agreed to participate in the study were informed about the purpose and how the study would be conducted. Their written consent was obtained. The study was conducted according to the principles of the Helsinki Declaration.

Four relatives of patients were excluded because they had to leave before the interview was finished. A total of 162 relatives of patients were more than 18 years of age, agreed to take part in the study, and completed the interview and thus were included in the study. Table 1 lists the sociodemographic characteristics of the participants. Among the participants, 51.2% were male, 66.7% were age 18 to 35, 78.4% reported being married, 38.3% had only a secondary level of education, 30.2% were homemakers, 65.4% lived in a nuclear family, and 52.5% reported that their income matched their expenses. In addition, 69.8% of participants lived in the city center, 80.9% receive social security, 56.8% do not smoke, and 92.0% do not drink. Also 76.5% are free of chronic disease, 91.4% report being able to access information about their relative in the ICU, and 79.0% have not lost loved ones to COVID-19. It was discovered that 51.2% of them had previously spent time in the ICU as a family member of a patient, 52.5% had had COVID-19, 67.9% had experienced stress before visiting the hospital, and 34.0% had medium-level stress.

Table 2 shows the mean scores for the scales and the mean total score on the SF-36. Participants’ mean (SD) scores on the various scales were as follows: physical functioning scale, 62.69 (11.22); physical role difficulty scale, 87.53 (7.62); emotional role difficulty scale, 89.13 (8.27); energy/vitality scale, 48.42 (19.00); mental health scale, 47.74 (19.50); social functioning scale, 54.67 (14.86); pain scale, 64.30 (23.29); and general health perception scale, 53.30 (12.51). The mean (SD) for the total SF-36 score was 62.02 (6.59).

Table 3 shows the mean scores for the subscales and the mean total score on the Styles of Coping With Stress Scale. Participants’ mean (SD) scores on the various subscales were as follows: confident approach subscale, 1.97 (0.67); optimistic approach subscale, 1.91 (0.65), helpless self-accusing approach subscale, 1.39 (0.61); submissive approach subscale, 1.33 (0.60); and seeking social support subscale, 1.80 (0.57). The mean (SD) for the total score on the Styles of Coping With Stress Scale was 1.66 (0.44).

Table 4 shows the distribution of mean scores on the SF-36 according to sociodemographic characteristics. Among individuals aged 56 to 75 years, mean (SD) score for physical functioning was 67.78 (11.52) (P=.002). Among homemakers, the mean (SD) score for physical functioning was 67.87 (11.48) (P=.002) and the mean (SD) score for physical role difficulty was 89.18 (7.45) (P = .001). Among individuals experiencing stress, the mean (SD) score for physical role difficulty was 88.72 (8.13) (P=.001).

Table 5 shows the distribution of the mean scores on the Styles of Coping With Stress Scale according to sociodemographic characteristics. Among university graduates, the mean (SD) score for the helpless self-accusing approach was 1.08 (0.58) and for the submissive approach was 0.99 (0.48) (P=.001). Participants whose income was higher than their expenses had a mean (SD) score for the helpless self-accusing approach of 1.06 (0.71) (P=.001).

Table 6 shows the correlation of the scores on the SF-36 and the Styles of Coping With Stress Scale. A statistically significant positive correlation was found between the participants’ total mean scores on the SF-36 and on the Styles of Coping With Stress Scale (r=0.36; P=.001). Specifically, there were significant correlations between physical functioning and the helpless self-accusing approach (r=0.22; P=.004), between social functioning and the submissive approach (r=0.16; P=.003), and between general health perception and the optimistic approach (r=0.52; P = .001), helpless self-accusing approach (r = 0.28; P = .001), submissive approach (r = 0.29; P = .001), and seeking social support (r = 0.44; P = .001). A correlation also was found between general health perception and the total mean score on the Styles of Coping With Stress Scale (r=0.29; P=.001).

This study examined the quality of life and styles of coping with stress among relatives of patients hospitalized in the ICU during the COVID-19 pandemic. Persons who use passive coping styles are considered to have lower levels of coping with stress than persons who use active coping styles.²³  It was determined that the relatives of the patients experienced stress with their relatives in the ICU and that there was a positive and significant relationship between their level of coping with this stress and their quality of life. Again, in our study, the majority of participants reported that they experienced moderate stress while coming to the hospital and some reported that this stress was related to the COVID-19 pandemic (Table 1). Dorman-Ilan et al²⁴  found that both patients and their relatives experienced high levels of anxiety and stress from the COVID-19 pandemic. In our study, most repondents (55.6%) reported that they were not experiencing stress due to the COVID-19 pandemic (Table 1). This different result may be because our study was done in the last days of the COVID-19 pandemic; the level of stress due to COVID-19 has decreased since the beginning of the pandemic, either because people adapt to the situation more easily or because the probability of losing their relative to COVID-19 is reduced. This may also be related to the fact that the majority of participants received regular information about the patient (Table 1). Özer and İmre²⁵  investigated the satisfaction of relatives of patients and found that the information retrieval status was low. The intensive care team could not devote enough time to informing the patient’s relatives because of the intense pace of work experienced during the pandemic, and the content of the information and procedures was not adequately described. The findings of our study contradict these findings. In exploring the reasons for this discrepancy, we hypothesize that patient visits were more tightly restricted when Özer and İmre conducted their studies during the early days of the pandemic. The discrepancy could also be attributed to differences in institutional approaches.²⁵ 

In our study, the mean scores on the SF-36 scales revealed that the highest average was for physical role difficulty and emotional role difficulty, and the lowest average was for energy/vitality and mental health (Table 2). These findings indicate that the patients’ relatives made an effort to maintain their roles in the face of adversity. The mean scores for the other scales of the SF-36 and the mean total score were moderate, lower than the scores for physical role difficulty and emotional role difficulty. This shows that the social lives of the patients’ relatives were negatively affected at a sustained rate, which can be said because social life and lifestyle are 2 concepts that are closely related. Humans are social beings, and it is difficult to completely isolate oneself from society, no matter how much negativity is experienced. In their study of patients with diabetes, Abdelghani et al²⁶  discovered that COVID-19 infection had a significant negative impact on patients’ quality of life.

Our results show that the level of coping with stress among relatives of the patients was low during the COVID-19 pandemic (Table 3). Özer and İmre found that patients’ relatives used the effective coping styles of confidence, optimism, and seeking social support more than other approaches.²⁵  Erdoğan²⁷  reported that patients’ relatives mostly used the confident approach, followed by the helpless approach, which is an ineffective coping method.Other coping methods were used less often.²⁷  According to Erdoğan’s 2019 study, seeking social support is the least preferred coping strategy, which contradicts our findings.

In our study, homemakers’ mean scores for physical functioning were higher than those of other occupational groups (Table 4; P=.002). Bulut and Deveci²⁸  reported that homemakers scored higher than others on physical functioning. The high scores of homemakers in maintaining physical functioning may be attributed to their planning of daily activities with the understanding that their main role is parenting and that family members, especially their children, can fulfill their responsibilities for the maintenance of their daily lives.

In our study, the educational status, income status, and smoking status of the participants differed significantly on some subscales of the stress coping scale. As the education level increased, the mean scores on the helpless self-accusing and submissive subscales decreased (P=.001; Table 5). Sabancioğullari and Ertekin Pinar²⁹  found that illiterate caregivers used ineffective coping methods more than did other participants. This result suggests that as the level of education increases, ineffective coping methods are used less. A similar situation applies to occupations. Civil servants had a lower mean score for the submissive approach than did participants with other occupations (P=.04; Table 5). Rahmani et al³⁰  examined the stress coping status of patients’ relatives in Iran and concluded that caregivers with higher education do not have problems in finding support because they can work in better jobs and have a higher income and they can cope with problems better. In our study, the occupation group with the highest education level was civil servants. This further suggests that low scores of submissive coping style, which is one of the ineffective coping methods, are related to the level of education. In addition, those participants with higher income levels had lower mean scores for the helpless self-accusing approach (P=.001; Table 5). Vallejo et al³¹  found that stress levels were higher in participants with low income levels. This result may be related to the feeling of psychological comfort and competence given by thinking that they are doing their best financially.

Our results showed a statistically significant positive correlation between the mean total scores of the SF-36 and the Styles of Coping With Stress (r = 0.36; P = .001; Table 6). Dehghan et al³²  reported that the intense stress experienced by the patients in their study neatively affected the patients’ quality of life. Similarly, Li et al³³  found a significant relationship between stress and quality of life. From this point of view, one could say that individuals with a high quality of life use their coping mechanisms more effectively and, therefore, can cope with stress more effectively than individuals with a lower quality of life.

We found a statistically significant relationship between the quality of life and the stress coping strategies of patients’ relatives. The individual who feels strong copes more easily. As the quality of life of the participant increases, their level of coping with stress increases in direct proportion. In this context, it is very important to improve the level of coping with stress of individuals who are relatives of patients in the ICU as well as to increase their quality of life.

The study was conducted in a single ICU, which may affect the generalizability of the results. In addition, the study data were collected by the face-to-face interview method to increase reliability of the data and prevent participants from filling out forms without reading them. However, the face-to-face interview method may also discourage participants from giving sincere answers.

Developing coping skills is very important. Being separated by admission to an ICU creates stress for both the patient and the patient’s relatives. Many factors, such as the fear of the patient dying in the ICU, the uncertainty of the cause of the disease, and the inability to obtain sufficient information about the patient, cause stress for the patient’s relatives. This intense stress directly affects individuals’ quality of life. In this context, it is very important that nurses, who evaluate people as a whole biologically, psychologically, and socially, support patients’ relatives in coping with stress. It is part of the role of consultant nurse to recommend that individuals recognize and use opportunities and resources to protect and improve family and community health, improve quality of life, and cope with problems related to disease. In this context, it will be useful to make appropriate referrals to social and religious services for persons whose relatives are ICU patients. At the same time, it is very important that these individuals be referred to social support groups and that people in the same situation support one another. In this situation, the consultant and supportive roles of the nurse are essential.