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Coping strategies and uncertainty in the woman with gestational diabetes Riddell, Lenore Anne 1992

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COPING STRATEGIES AND UNCERTAINTY IN THE WOMAN WITHGESTATIONAL DIABETESBYLENORE ANNE RIDDELLB.S.N., University of British Columbia, 1986A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FORTHE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIES(School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril 1992© Lenore Anne Riddell, 1992In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(SignatDepartment ofThe University of British ColumbiaVancouver, Canada(,tiuQ.tIc Date ^3i) )9cie_DE-6 (2/88)iiABSTRACTThe purpose of this descriptive correlational study was to describe the level ofuncertainty, the coping strategies, and the relationship between uncertainty and copingstrategies for women with gestational diabetes. Snyder's (1979) holistic model ofchildbearing and Mishel's (1984, 1988) theory of uncertainty served as the theoreticalframework for the study.A convenience sample of 46 subjects who were experiencing gestational diabetes forthe first time completed the Uncertainty Stress Scale (High-Risk Pregnancy Version), theJaloweic Coping Scale (1987), and a patient information sheet. The questionnaires to thesubjects were mailed .For the majority of subjects this was their first pregnancy. The average gestationalage of the subjects was 31.2 weeks. The average maternal age was 31.6 years. The majorityhad a family history of diabetes.Overall, the women with gestational diabetes perceived moderately low levels ofuncertainty however, perceived uncertainty varied from quite low to quite high. The womenalso indicated that gestational diabetes was considered to be fairly serious. The nature of theuncertainty appeared to be generated primarily by concerns over the baby's health and themeaning of the diabetes for the women's pregnancy. Women who were in the 20 to 29weeks pregnancy group perceived the most uncertainty.Women with gestational diabetes used various coping strategies to manage theiruncertainty and the stress it generated. There was a tendency to use optimistic andconfrontive coping strategies the most with problem-focused coping strategies being the mostiiifrequently used in dealing with the stress of gestational diabetes.Findings indicated that the patients with higher levels of uncertainty tended to useemotion-focused coping strategies such as evasive, fatalistic and self-reliant. Findings alsoindicated that although positive feelings may be associated with the uncertainty, positivefeelings were rather low.Based on the findings of this study, implications were suggested for new directions forthe provision of effective nursing care for women with gestational diabetes. It alsorecommended that further research is needed to identify and explore relationships betweenuncertainty and coping strategies, particularly as it relates over time.ivTable of ContentsAbstractTable of Contents ^  ivList of Tables  viList of Figures  viiAcknowledgements  viiiCHAPTER ONE: INTRODUCTIONBackground to the Problem ^  1Problem Statement ^  4^urpose   4Research Questions  4Theoretical Framework  4Snyder's Holistic Model ^  5Mishel's Theory of Uncertainty  10Significance of the Study  15Definition of Terms ^  15Assumptions  16Limitations ^  16Organization of the Thesis  16CHAPTER TWO: REVIEW OF SELECTED LITERATUREIntroduction ^  18Stress and Pregnancy ^  18Uncertainty  22Uncertainty and Illness  22Uncertainty and Pregnancy ^  28Coping Strategies ^  30Relationship of Uncertainty to Coping Strategies ^  33Summary  35CHAPTER THREE: METHODSIntroduction ^  36Research Design  36Sampling  36Data Collection Procedures ^  37Data Collection Instruments  38Uncertainty Stress Scale  38Jaloweic Coping Scale  41Patient Information Sheet ^  44Ethics and Human Rights  44Data Analysis ^  45vCHAPTER FOUR: PRESENTATION AND DISCUSSION OF FINDINGSIntroduction ^  46Characteristics of the Sample ^  46Demographic Characteristics  46Health Characteristics  48Pregnancy Characteristics ^  48^Findings   49Research Question 1: Level and Nature of Uncertainty ^  50Research Question 2: Type and Frequency of Coping Strategies ^ 52Research Question 3: Relationship between Levels of Uncertainty and CopingStrategies ^  56Ancillary Findings ^  57Discussion ^  64Characteristics of the Sample ^  64Uncertainty  65Coping Strategies ^  71Relationship between Uncertainty and Coping Strategies ^  74Ancillary Findings  76Summary ^  78CHAPTER FIVE: SUMMARY, CONCLUSION, IMPLICATIONS, ANDRECOMMENDATIONSIntroduction ^  80Summary  ^80Conclusions  83Implication  84Recommendations for Further Research ^  87REFERENCES ^  90APPENDICESAppendix A:Appendix B:Appendix C:Appendix D:Appendix E:Appendix F:Appendix G:Appendix H:Appendix I:Uncertainty Stress Scale (HRPV) ^  95Jaloweic Coping Scale (revised)  99Patient Information Sheet  105Information Letter ^  108Reminder Letter  110Frequency and distribution of uncertainty items ^  112Rank-ordering of the most used to the least usedcoping strategies ^  116Rank-ordering of the most effective to theleast effective coping strategies ^  120Outline of teaching session in the Diabetes Clinic ^ 124viLIST OF TABLESTable^ PageI. Alpha Coefficients for Use and Effectiveness of Coping Styles ^ 43II. Age Distribution of the Sample ^  46III. Education Level of the Sample  47IV. Employment Status of the Sample ^  47V. Family History of Diabetes  48VI. Gestational Age ^  49VII. Total Uncertainty for Women with Gestational Diabetes ^ 50VIII. Frequency and Distribution of the Top Thirteen Uncertainty Items ^ 51IX. Overall Uncertainty Level ^  52X. Means for Use of each Coping Style ^  53XI. Means for the Effectiveness of each Coping Style ^  53XII. Frequency of Coping Styles Use and Effectiveness  54XIII. Relationship of Uncertainty to Coping Styles ^  56XIV. Frequency of the Total Stress Uncertainty for Womenwith Gestational Diabetes ^  58XV.^Frequency of the Overall Stress from the Uncertainty:Visual Analogue ^  58XVI. Frequency of Overall Threat from the Uncertainty:Visual Analogue  59XVII. Frequency of Overall Positive Feelings ^  60XVIII. Frequency of the Seriousness of Gestational Diabetes:Visual Analogue ^  61XIX. Gestational Age, Coping and Uncertainty ^  63viiLIST OF FIGURESFigure^ Page1. A holistic model of the childbearing experience (Snyder, 1979) ^ 62. The trajectory of childbearing (Snyder, 1979) ^ 93. Some possible alterations of the trajectory of childbearingby highrisk occurrences (Snyder, 1979) ^ 104. Model of perceived uncertainty in illness (Mishel, 1988) ^ 12AcknowledgementsI would like to thank the members of my thesis committee, Professor Elaine Carty(chairperson) and Dr. Ann Hilton for their patience and guidance throughout the past year.Especially, I would like to acknowledge Professor Carty's expertise in keeping me calm andand on track, and Dr. Hilton's incredible patience in dealing with statistical questions and ingiving me the idea in the first place.I wish to extend a special thanks to Dana, Sandy, Herta, and Mary for beingcontinuing sources of encouragement, fun and support. I am also grateful for the support ofmy colleagues; Karen, Maureen, Colleen, and Sharon for their useful comments, assistanceand support.Finally, I would like to acknowledge the individuals who so generously took the timeto participate in this study.IN MEMORY OF ERENDIRA, A MOST SPECIAL CHILDviii1CHAPTER ONEIntroductionBackground to the Problem A pregnancy is considered "high-risk when physiologic and/or psychologic factorsexist in the mother or neonate that imply a threat to the health of the mother-infant unit"(Kemp & Page, 1986, p. 232). One such high-risk condition of pregnancy is gestationaldiabetes (Zigrossi & Riga-Ziegler, 1986). It is defined as carbohydrate intolerance of varyingseverity with onset or recognition during the present pregnancy (Bowering, 1990). Estimatesof incidence vary with the population studied, however, in Canada gestational diabetes occursin approximately four percent of all pregnancies (Bowering, 1990).Gestational diabetes has been associated with increased maternal morbidity andincreased fetal mortality and morbidity. Bowering (1990) notes that "the most commonproblem in untreated, uncontrolled, patients is the development of macrosomia in the infant,but difficulties with neonatal hypoglycemia, polycythemia, hyperbilirubemia, respiratorydistress syndrome, intrauterine death and premature birth are also recognized complications"(p. 228). The mother is at risk for a traumatic vaginal or operative delivery secondary to fetalmacrosomia (Dickinson & Palmer, 1990; Kitsmiller et al. 1988). Further, both mother andinfant are at risk for the development of impaired glucose tolerance or overt diabetes mellitusin later life (Bowering, 1990; Dickinson & Palmer, 1990).The aim of treatment of gestational diabetes is to maintain normoglycemia. Treatmentincludes frequent physician visits, strict diet control, exercise regimens and frequentmonitoring of blood glucose and urine ketone levels. Insulin therapy is instituted if necessaryto control blood glucose levels and prevent ketosis. Further, various obstetrical tests andprocedures such as fetal monitoring, fetal movement counts, ultrasound and amniocentesis are2common for women with gestational diabetes (Bowering, 1990; Creed, 1988; Zigrossi &Riga-Ziegler, 1986). According to Zigrossi and Riga-Ziegler, women who are experiencing apregnancy complicated by gestational diabetes require individualized in-depth nursing care inorder to cope with the stress of medical management. A certain amount of stress is expectedin any pregnancy due to hormonal changes which cause labile emotions, alterations in bodyimage, role changes, fear of labor, fear of the unknown, and worry over sibling arrangements(Zigrossi & Riga-Ziegler, 1986). Corbin (1987) notes that "a woman with a high-riskcondition not only has to contend with and cope with what she perceives to be the 'normal'risks to self and baby associated with any pregnancy, but also with any additional potentialrisks of morbidity and mortality arising from the condition" (p. 318). Creed (1988) concursand states that stress is one of the major maternal complications seen in diabetic pregnancies.Further, "when this stress is compounded by the anxiety that all will not go well with thepregnancy, coping reserves are subject to a massive drain" (Galloway, 1976, p. 294).Coping is an ongoing process that routinely occurs as "people examine what ishappening to them, judge an event as either threatening or challenging, and then determinethe magnitude of the threat or challenge. They respond to that determination with emotionand physiologic arousal, and subsequently, make decisions based on what they haveperceived" (Burckhardt, 1987, p. 543). Effective coping mechanisms are those that keepdistress within a manageable limit, generate hope, maintain or restore self-worth, maintainrelationships with others and enhance a feeling of well-being (Burckhardt, 1987).Penticuff (1982) notes that "any series of events or conditions that are perceived bythe mother as threatening, depleting, or potentially harmful to either the child or herself (orboth) may seriously compromise her capacity to make the several adaptive steps thatcharacterize the modal pregnancy" (p. 72). Armstrong (1987) comments that "it is well3known that adherence to diabetic management behaviors places considerable psychologicalstress on the afflicted person and calls for numerous adaptation and coping processes"(p. 559). A pregnancy that is complicated by a high-risk condition such as gestationaldiabetes requires the individual to adapt to the stress by developing psychological coping orbehavioral coping mechanisms.Stressors such as a "pregnancy complication that threatens either the mother's orinfant's health can decrease the predictability of the outcome for both mother and infant"(Mercer, May, Ferketich, & DeJoseph, 1986, p. 339). This unpredictability can give rise to aperception of uncertainty about the event. Uncertainty may generate stress as the womansearches for the meaning the change has for her life (Sorenson, 1990). Mishel (1981), notesthat uncertainty may affect the person's ability to appraise situations which in turn may limitthe efficiency of coping and also disrupt individual and family functioning.Women with gestational diabetes are subject to the dual stresses of pregnancy and apregnancy complication. According to Sorenson (1990), in pregnancy, "events that areappraised as uncertain may be exceptionally stressful" (p. 293). Managing this stress isessential for the woman with gestational diabetes in order to develop effective copingstrategies. Currently, research has focused primarily on the medical diagnosis, complicationsand treatment of the disorder. However, little is known of the uncertainty and stressexperienced, or the coping strategies used by women with gestational diabetes. A betterunderstanding of the uncertainty experienced by women with gestational diabetes may assistnurses and other health professionals to help these women and their families to cope moreeffectively.4Problem StatementGestational diabetes is an important contributor to perinatal morbidity (Bowering,1990). Women with gestational diabetes are not sure if and how the condition will effect theirpregnancy course and outcome. This unpredictability may give rise to feelings of uncertaintyabout the event. The woman's ability to cope, already stressed by pregnancy, may proveinadequate to deal with this unexpected complication of pregnancy. Little is known aboutlevels of uncertainty experienced by the gestational diabetic. Further, the repertory andeffectiveness of the coping strategies used by the woman to deal with this condition are notwell documented; nor is information available on how the uncertainty level relates to thecoping strategies used.Purpose The purpose of this study was to investigate how women with gestational diabetesviewed the uncertainties of their condition; how the women coped with this pregnancycomplication; and how the uncertainty and coping strategies were related.Research Questions The study was designed to answer the following questions for women newly diagnosedwith gestational diabetes:1) What is their perceived level of uncertainty?2) What coping strategies are used to cope with the uncertainty?3)^What is the relationship between uncertainty and coping strategies?Theoretical FrameworkThe theoretical framework for this study was derived from current theoreticalperspectives -- the model of the childbearing experience as presented by Snyder (1979) andMishel's (1984, 1988) theory of uncertainty. Snyder's (1979) model of the childbearing5experience provided the theoretical framework for viewing pregnancy as a time-limited eventwith a known start (conception) and known finish (delivery or termination of the pregnancy)taking into account relevant social, cultural, psychological and physiological factors. Whenthe experience is threatened by an unexpected pregnancy complication, coping mechanismsmust be readjusted for successful adaptation to occur. The concept of uncertainty was derivedfrom Mishel's (1984, 1988) perspectives of uncertainty where uncertainty is a cognitive statethat occurs in situations where the person is unable to assign definitive values to events orobjects and/or is unable to predict outcomes accurately. The presence of uncertaintyinfluences the way an individual appraises a situation and hence the coping strategies used bythe individual. Thus, how an individual manages the uncertainty associated with an eventmay be an essential part of adaptation.Each of these theoretical perspectives is now presented in detail as background to thequestions of uncertainty and coping strategies in women with gestational diabetes.Snyder's Holistic Model of the Childbearing Experience.Snyder (1979) proposes a holistic model of the childbearing experience which iscommon to all women. In this model, childbearing is viewed as being composed ofinteracting factors which are experienced as unique for each individual. Visually, the modelis represented as a series of concentric circles, each of which relate to the facets of thechildbearing experience (Figure 1).Figure 1 A holistic model of the childbearing experienceadapted from:^Snyder, D.J. (1979). The high-risk mother viewed in relation to aholistic model of the childbearing experience. JOGN, 8, (3), 165.67The core circle relates to the physiological pregnancy. Snyder notes "that thephysiological adaptation of the maternal system to the growing conceptus leads to a vast arrayof feelings and alterations in body function common to all mothers" (p. 165). Thepsychological adaptation to pregnancy is represented by the circle titled 'self system'. Thisrepresents the alterations the woman must make in her self-concept as she prepares formotherhood. Snyder notes that "a great deal of emotional work must be accomplished byeach woman as she incorporates the experience of pregnancy into her self system" (p. 165).The ability to accomplish the tasks of pregnancy is "affected by a multitude of forces relatedto her particular experience" (p. 166). Further, Snyder notes that the importance ofsuccessfully accomplishing the developmental tasks of pregnancy is that the "character of awoman's future relationship with her infant has its roots in this important emotional work ofpregnancy" (p. 166).The peer and family system has a profound impact on the childbearing experience.Snyder defines family in the broadest sense, that is, "not only nuclear and extended family,but also close supportive relationships, whether or not marriage is involved" (p. 166). How awoman defines and integrates the maternal role as well as how she experiences her pregnancyis noted to be affected by the attitudes, beliefs, and practices of the family, the peer groupand also ethnic characteristics.Snyder notes that the childbearing experience must also be perceived within thebroader societal system. Sociological variables such as political influences andsocioeconomic status affect the childbearing experience for each woman. In this circle,Snyder places the health care system and how it interacts and influences the childbearingexperience. She notes that the major determinants of the interactions between health care8professionals and the childbearing woman are values related to health, illness, childbearingand patient responsibilities.The final circle of the model relates to the cultural system within which all the othersystems exist. Snyder includes "all the broad, general attitudes, social forms, racial ornational customs and other values related in any way to childbearing" (p. 166) in herdefinition of culture. The experience of childbearing for the individual woman and her familyis ultimately defined and evaluated by the broad values of the culture within which theyoperate.The element of time is the final component of Snyder's holistic model. She notes thechildbearing experience is dominated by time at all levels of the model as "reflected inprogressive, predictable physiological changes, behavioral manifestations, and societalexpectations" (p. 167). Snyder borrows Glaser and Strauss's concept of a trajectory toillustrate the time dimensions of childbearing (Figure 2).Four characteristics of the childbearing trajectory are identified by Snyder:1) It has a definite duration from conception to termination at delivery.2) It has a definite shape with progressive confirming signs along the course (ie.uterine enlargement, quickening).3) The trajectory is perceived at all levels of the model. In other words, eachwoman, family, peer group, society and cultural system define the pregnancy asit moves along the course.4) The trajectory is a major determinant of the behavior of all those involved inthe model.Figure 2 The trajectory of childbearingadapted from: Snyder, D.J. (1979). The high-risk mother viewed in relation to aholistic model of the childbearing experience. JOGN, a, (3), 167.The above model rests on the assumption that the childbearing experience will be a'normal' experience without pregnancy complications which could interfere with the trajectory.When there is an alteration in the normal course of pregnancy, the trajectory is no longerpredictable. Snyder notes that "the pregnancy may not terminate in a full-term healthy infant,and the health of the mother may be threatened" (p. 168). Alterations in the trajectory affect alllayers of the model. Expectations and coping mechanisms must be readjusted in response to theunexpected situation in addition to coping with the stresses of normal childbearing (Figure 3).Confusion and frustration may ensue when the trajectory is altered because existing copingmechanisms may be inadequate.910-.,^/^ NDelivery I\ /..-- --)--i^/,^ N. /7 ....-- —9, --->,,,^'V'/ (pregnancy complication)7 \NI\premature \I termination )expected trajectoryaltered trajectoryFigure 3 Some possible alterations of the trajectory of childbearing by high-riskoccurrencesadapted from: Snyder, D.J. (1979). The high-risk mother viewed in relation to aholistic model of the childbearing experience. JOGN, (3), 168.Mishel's Theory of UncertaintyMishel (1984) defines uncertainty as a cognitive state that occurs in situations where theperson is unable to assign definitive values to events or objects and/or is unable to predict out-comes accurately. "Uncertain events are characterized as vague, ambiguous, unpredictable,unfamiliar, inconsistent, or lacking information" (Mishel, 1984, p. 163). When an individual isunable to cognitively structure a stimuli due to uncertainty, the ability to appraise and chooseappropriate actions is limited.There are three major aspects of the uncertainty theory. These are: the antecedents touncertainty, uncertainty appraisal and coping with uncertainty. Figure 4 shows the concepts andrelationships within the process of coping with uncertainty.11The antecedents to uncertainty include the stimuli frame, cognitive capacity and theindividual's structure providers. These elements precede uncertainty and provide theinformation that is processed by the individual.The stimuli frame has three components and refers to the perception the individual hasof the precipitating event. The first component, symptom pattern, is the way the symptomspresent with enough consistency to be perceived as having a pattern or structure. Themeaning of the symptoms is influenced by this pattern. Event familiarity is the secondcomponent and refers to the degree to which the individual recognizes the situation habitual,repetitive or containing recognizable cues. The final component, event congruence, refers to acompatible perception between the expected and the actual experience. When the threecomponents; symptom pattern, event familiarity and event congruence, are perceived as high,uncertainty is low. Conversely, when symptom pattern, event familiarity and eventcongruence are low, uncertainty is high.Cognitive capacity refers to the individual's ability to process information. Mishelnotes that information overload or limited cognitive capacity can impede the ability toperceive the stimuli. Additionally, the presence of pain, the use of drugs (particularlysedatives), and a poor nutritional status can reduce the cognitive capacity.DANGERINFERENCEILLUSIONOPPORTUNITYa.COPING:BUFFERINGSTRATEGIES(+)COGNITIVECAPACITIESSTRUCTUREPROVIDERSCredible authorityEducationSocial supportSTIMULI FRAMESymptom patternEvent familiarityEvent congruencyUNCERTAINTY( )(+)(-)(+)1 ADAPTATION12COPINGMOBILIZINGSTRATEGIESAFFECT -CONTROLSTRATEGIESFigure 4 Model of perceived uncertainty in illnessadapted from:^Mishel, M.H. (1988). Uncertainty in illness. Image: Journal ofNursing Scholarship, 2Q, (4), 226.13The resources available to aid in interpretation of the stimuli frame are referred to asthe structure providers. Structure providers are the individual's education level, social supportand the credible authority of health care professionals. Uncertainty is influenced directly andindirectly by structure providers. Level of education has been shown to have an inverserelationship with uncertainty. The higher the education level the more rapidly uncertainty ismodified, and the lower the education level the longer the uncertainty is experienced.Education can also have a indirect impact on uncertainty. "Education can assist in supplyinga structure to the events in the stimuli frame by enlarging a patient's knowledge base withwhich to associate these events, thus providing meaning and context" (Mishel, 1988, p. 227).Social support indirectly influences uncertainty by clarifying symptom pattern throughinformation sharing and networking with others who have the same symptoms. Directinfluence on uncertainty occurs through the provision of information and material aid in theform of assistance with the tasks of daily living.Credible authority indirectly influences uncertainty by the provision of information byhealth care professionals on the symptom pattern and consequences. Direct influence onuncertainty relates to the power relationship between the health care provider and the patient.Mishel (1988) notes that "trust and confidence in the health care provider leads to a lowerlevel of overall uncertainty, less ambiguity about the state of the illness and less perceivedcomplexity concerning treatment" (p. 228).A cognitive schema for illness events is constructed by an individual from theprocessing of stimuli. It is when a cognitive schema cannot be constructed that uncertaintyoccurs. Mishel (1988) identifies four forms of uncertainty: (a) ambiguity concerning thestate of the illness, (b) complexity regarding treatment and system of care, (c) lack of14information about the diagnosis and seriousness of the illness, and (d) unpredictability of thecourse of the disease and prognosis" (p. 225).Uncertainty is a neutral state until it is appraised. It is neither a dreaded nor a desiredstate until the implications are clear. The two processes involved in the appraisal of anuncertain situation are inference and illusion.The process of inference relates to the application of the individual's past experience,personality traits, knowledge, and the context of the event to the evaluation of uncertainty.Inference appraisal leads to uncertainty being considered a danger. The process of illusionrelates to beliefs which enhance the positive aspect of the event and are not based oncertainty. This process is particularly appropriate when the individual is "helpless toinfluence the outcome or in which the outcome has a negative, downward trajectory" (Mishel,1988, p. 229). Illusion appraisal leads to uncertainty being considered an opportunity.Uncertain events which are appraised as a danger lead to the use of coping strategiesto reduce the uncertainty and/or manage the emotional response to the perception of danger.Coping strategies that reduce the uncertainty are of two types: mobilizing and affect-management. The mobilizing techniques are: direct action, vigilance and informationseeking. If these techniques are not effective in reducing uncertainty, then theaffect-management techniques of faith, disengagement and cognitive support, are summonedto manage the emotional response to uncertainty, particularly anxiety.Those events appraised as an opportunity lead to coping strategies to maintain theuncertainty. Coping strategies that maintain the uncertainty are buffering methods. Theyserve to block any input which might alter the uncertainty. Without the uncertainty, theillusion that a positive outcome will result is destroyed. Strategies such as avoidance,selective ignoring, reordering priorities and neutralizing are used.15Successful adaptation occurs when the coping strategies chosen by the individual areeffective. Mishel (1988) notes that "signs of difficulty in adapting, rather than indicatinguncertainty itself, indicate the individuals' inability to manipulate the uncertainty in thedesired direction" (p. 226).Significance of the Study According to Sorenson (1990), uncertainty in pregnancy is universally experienced.To date, no nursing research has explored this uncertainty. This study marks the first timethe level and nature of the uncertainty experienced by women with gestational diabetes hasbeen explored. Since some of the uncertainty may be preventable or changeable through theuse of nursing interventions, research into the uncertainty experienced by women withgestational diabetes is important.How women cope with having gestational diabetes also has not been researched. Thefindings of this study will provide a perspective on how women cope with gestationaldiabetes. This knowledge will assist nurses and other health professionals as to how bestassist women to cope more effectively throughout their pregnancy.Finally, this study will add to the general knowledge on uncertainty and on copingwith a pregnancy complication.Definition of Terms Gestational diabetes: "Two or more abnormal values on the standard Glucose Tolerance Test(GTT)" (National Diabetes Data Group, 1979, p. 1050).Uncertainty: "Inability to determine the meaning of illness-related events. It is the cognitivestate created when the person cannot adequately structure or categorize an event because ofthe lack of sufficient cues" (Mishel, 1988, p. 225). The perception of uncertainty was16measured by Hilton's (1991) Uncertainty Stress Scale - High Risk Pregnancy Version(USS-HRPV). (Appendix A).Coping: "constantly changing cognitive and behavioral effort to manage specific externaland/or internal demands that are appraised as taxing or exceeding the resources of the person"(Lazarus & Folkman, 1984, p. 141). Problem focused coping strategies are those that relateto managing or altering the actual problem. Emotion-focused coping strategies are those thatrelate to regulating the emotional response. Coping strategies were measured using theJaloweic Coping Scale (1987) (Appendix B).Assumptions 1) Pregnancy is a stressful situation.2) Women with gestational diabetes experience some degree of distress related tothe diabetic condition.3) The uncertainty associated with gestational diabetes may pose a threat to thewoman's usual coping patterns.4) Subjects will respond honestly to questionnaires.Limitations 1) A convenience sample was used thus the findings are not representative of allwomen with gestational diabetes.2) Measurement of coping occurred at only one point in time and thus will notfully represent the process.Organization of the Thesis The thesis is organized into five chapters. Chapter One presented the background tothe problem, the research questions and the conceptual framework. Chapter Two is concernedwith the critical review of the literature. Chapter Three presents the research method in17depth. Chapter Four describes and discusses the research results. Finally, Chapter Five willpresent the summary, conclusions, implications for nursing practice, and recommendations forfurther research.18CHAPTER TWOReview of Selected LiteratureIntroduction There is a dearth of literature which addresses the level of uncertainty experienced andcoping strategies used by women with gestational diabetes. Because of this lack of researchpertaining specifically to the identified problem, the concept of stress associated withhigh-risk pregnancy will be examined. The review of the literature also addresses research onuncertainty, including what is written on pregnancy and uncertainty, and literature on copingstrategies and the relationship between coping strategies and uncertainty.Stress and Pregnancy It is widely recognized that pregnancy is a stressful life experience which involvesboth physiological and psychological adaptation. Clarke (1984), defines stress as arising "outof the individual's appraisal of a mismatch between demands made on him and his ability tocope" (p. 6). She further notes that the "mismatch between demand and coping is less likelyto be perceived for pleasant events than for unpleasant ones" (p. 7).Theorists generally agree that significant developmental tasks need to be successfullynegotiated by the woman (and her family) to ensure a healthy birth and effective parenting(Kemp & Page, 1986). Rubin (1984), a noted researcher in maternal-child adaptationidentifies the following as the major maternal developmental tasks: 1) seeking safe passage;2) acceptance by others; 3) binding in to the child; and 4) giving of oneself. Interferencewith the achievement of the developmental tasks can increase the level of stress. Rubin(1975) also identifies body image and identity changes as contributing to the stressful natureof pregnancy. Glazer (1980) identified concerns related to the baby's health and normalcy asbeing the cause of a great deal of the anxiety generated in a 'healthy' pregnancy. Rubin19(1984), further notes that normal "child-bearing requires an exchange of a known self in aknown world for an unknown self in an unknown world" (p. 52). Lederman (1984) concursand notes that the transition between the two lifestyles, one with child and one without child,account for much of the stress associated with the psychosocial aspect of pregnancy.It is important to differentiate between the 'normal' stress of pregnancy associatedwith the above mentioned developmental tasks and the stress associated with complications ofpregnancy. Mercer, May, Ferketich, DeJoseph and Sollid (1988) define antepartum stress as"undesirable events, negative life events, and at risk conditions (pregnancy risk) that challengethe family's resources for dealing with the events" (p. 168). Antepartum stress has beenlinked with the health status of mothers, fathers, and their infants (Mercer, et al. 1986,Lederman, 1984, Molfese et al. 1987). Mercer et al. (1986) noted "pregnancy risk has adirect positive link with childbirth risk, which in turn has a direct negative link with healthstatus and self-esteem" (p. 343). Wohlreich (1986), a noted psychiatrist concurred withMercer and stated that "a patient's experience during pregnancy can influence her feelingsabout the child and her subsequent adaptation to motherhood" (p. 54).Researchers have begun to look at the assumption that a high-risk pregnancy increasesthe 'normal' level of stress associated with pregnancy. Mercer and Ferketich (1988) foundthat women with high-risk pregnancies experienced greater anxiety, depression, and increasedstress than did a matched group of low-risk women. Kemp and Page (1987) examinedmaternal self-esteem and prenatal attachment in women who were experiencing a normalpregnancy compared with women experiencing a high-risk pregnancy. Deterioration in thelevel of self-esteem was observed in the high-risk group, however, no difference was found inthe level of prenatal attachment.20The dual stress of pregnancy and hospitalization for high-risk conditions wasinvestigated by White and Ritchie (1984) and Loos and Julius (1989). Findings indicated thatthe most stress was experienced by hospitalized antepartum women in relation to separationfrom family, disturbing emotions (powerlessness, boredom, and loneliness), health concerns,and changing self image. The researchers stated that the stress associated with hospitalizationcould interfere with a woman's ability to complete the developmental tasks of pregnancy asoutlined by Rubin. Loos and Julius further indicated that the emotional needs of hospitalizedantepartum women may not be met by current nursing interventions.The impact of social support on stress has also been investigated. Mercer et al (1988)found that both partners in the high-risk pregnancy experienced greater disruption in familyfunctioning than did their low-risk counterparts. In Mercer and Ferketich's 1988 study, themates of high-risk women reported greater anxiety and depression than did the low-riskwomen and their partners. Further, the high-risk mates both received and perceived socialsupport as less than their partners and the low-risk group. The impact of social support andstress on compliance in women with gestational diabetes was examined by Ruggiero, Spirito,Bond, Coustan, & McGarvey (1990). Social support around the diabetes regimen wassignificantly related to compliance with dietary advice and insulin administration. Further,those with increased social support reported fewer minor stressors. The authors concludedthat fostering social support in women with gestational diabetes could facilitate compliancewith the diabetes self-care regimen, particularly diet adherence and insulin administration.The relationship between psychosocial stress factors and metabolic control in pregnantinsulin-dependent diabetic women was tested by Barglow, Hatcher, Berndt and Phelps (1985).A stress scale developed by the authors was administered. Metabolic control was thendetermined by plasma levels of preprandial blood glucose, urinary ketones, and glycosylation21of hemoglobin. A statistically significant increase (P < .05) in plasma glucose levels andketonuria was found in patients with higher psychosocial childbearing stress. It is difficult togeneralize from the results of this quantitative study due to the small sample size (n=39).Zigrossi and Riga-Ziegler (1986) investigated the stress of medical management onpregnant women with diabetes. Their results indicated that women with gestational diabetesfound conforming to a medical regime more stressful, particularly with respect to blood testsand insulin administration, than did chronic diabetics. This study was limited by the smallsample size (n=20), but does indicate that invasive procedures increase stress in the womanwith gestational diabetes.Spirito et al. (1989) examined the psychological impact of the diagnosis of gestationaldiabetes. Women with gestational diabetes were compared with a non-diabetic control group.A scale which measured subjective mood states (Profile of Mood States-Bipolar Form) wasadministered a number of weeks after diagnosis and after the information session with thenurse clinician and dietician. The findings suggested that the majority of pregnant womenadjusted easily to the diagnosis of gestational diabetes. However, the time lag betweendiagnosis and the administration of the scale limits the validity of the study as adaptation mayhave already occurred.The research indicates that stress is an integral part of any pregnancy. However, theaddition of increased stress from a high-risk condition of pregnancy appears to impact on thepregnancy experience and may influence adaptation to parenthood. Little research has beendone on this aspect of pregnancy. Specifically, the impact of stress due to gestationaldiabetes has not been isolated from the general stress of pregnancy. Further, little is knownon how high-risk conditions of pregnancy impact on adaptation to parenthood.22Uncertainty According to Mishel (1984), uncertainty is a cognitive state that occurs when theperson is unable to assign definitive values to events or objects and/or is unable to predictoutcomes accurately. Events which are characterized as being vague, ambiguous,unpredictable, unfamiliar, inconsistent, or lacking information, generate uncertainty. Becauseonly two studies were identified that addressed uncertainty in pregnancy, literature whichfocuses on uncertainty in other groups of patients will also be discussed.Uncertainty and Illness Uncertainty about symptom treatment and outcomes were examined as majorpredictors of stress by Mishel in a 1984 study on patients (n=100) who were hospitalized witha medical problem. The Mishel Uncertainty in Illness Scale (MUIS) was used to measureuncertainty. This version of the MUIS was a 28-item, 5 point Likert scale on a stronglyagree (5) to a strongly disagree (1) continuum. The maximum score possible was 140 and theminimum score possible was 28. No data were given as to the mean level of uncertainty forthe population. Correlational analyses were used to test for relationships between thevariables. The relationship of uncertainty to stress was supported as was the predictedmediating role between seriousness of illness and stress. The strong relationship betweenuncertainty and stress suggested that it was the lack of clarity, vagueness and lack ofinformation about events that resulted in the stressful evaluation rather than the event itself.Those patients with higher levels of uncertainty reported that they experienced more stressfrom isolation from others (r=.22, P < .01) and from separation from their family(r=.15, P < .05).In a 1983 study by Mishel, uncertainty was proposed as a major perceptual variablethat influenced parents' experiences during their child's illness by Mishel in 1983. The23Parent Perception of Uncertainty Scale, a revised version of Mishel's Uncertainty in IllnessScale, was used to gather data from 272 parents of hospitalized children. The highest scorepossible on the 34 item scale was 170 and the lowest score possible was 34. The averagescore was 86.6, indicating a moderate level of uncertainty for this population. It wasproposed that the uncertainty experienced by the parents would contain the factors ofambiguity, lack of clarity, lack of information, and unpredictability.Findings indicated a significant relationship (r=.16, P < .004) between the parents'total uncertainty and the judged seriousness of their child's illness. Significant correlationswere also found for the relationship between judged seriousness of illness and the uncertaintyfactors of ambiguity and unpredictability. Support for uncertainty having a positiveassociation with the seriousness of illness was corroborated by the finding of a negativerelationship between the uncertainty factor of lack of information and judged seriousness ofillness, indicating that with more information, judged seriousness of illness increases. Lack ofclarity, the fourth factor, did not correlate significantly with judged seriousness of illness.Mishel, with Hostetter, King and Graham (1984), explored the influence ofuncertainty, optimism, seriousness of the illness, and control over physical function upon thepsychosocial adjustment of women (n=54) with gynecological cancer. Uncertainty wasmeasured with the 34-item version of the Mishel Uncertainty in Illness Scale. The range ofpossible scores was 34 to 170. No data were supplied as to the mean level of uncertainty forthis population. Multiple regression analysis was used to test for the ability of uncertainty,optimism, seriousness of the illness, and control over physical function to predict psychosocialadjustment. Difficulties with adjustment were predicted by all variables except seriousness ofthe illness. An important finding was that those with more uncertainty and less optimismexperienced more adjustment problems with their immediate and extended families, while24those with less uncertainty and more optimism experienced less adjustment problems withtheir immediate and extended families.A study by Wineman (1990) supported the above work. The relationships betweensocial support, functional disability, perceived uncertainty and psychosocial adaptation wereexplored in 108 people with multiple sclerosis. Uncertainty was measured by the 34-itemMishel Uncertainty in Illness Scale. No data were provided related to the mean level ofuncertainty for the people with multiple sclerosis. The relationship between perceivedunsupportiveness and uncertainty was statistically significant (r=.37, P < .001), as was therelationship between perceived uncertainty and depression (r=.24, P < .01). The findingsindicated that when interactions are perceived as unsupportive more uncertainty is likely to beperceived by the individual, and, more uncertainty is associated with greater levels ofdepression.Mishel, along with Sorenson (1991) tested the uncertainty in illness model todetermine whether the mediating functions of mastery and coping would be strengthened orweakened under conditions of uncertainty. Women receiving treatment for gynecologicalcancer were given questionnaires designed to measure uncertainty, mastery, appraisal, copingand emotional distress. The Mishel Uncertainty in Illness Scale (30-item version) was used tomeasure uncertainty. Correlational analyses were used to test for relationships between thevariables. The findings supported mastery in the mediating role in danger and opportunityappraisal of uncertainty. The results indicated that higher levels of uncertainty reduce theindividual's sense of personal resources (mastery) to manage the specific situation(gynecological cancer).A replication of the above study was undertaken in 1991 by Mishel, Padilla, Grant andSorenson. In this sample, the relationship of uncertainty to mastery was the same as in the25previous study, but the replication did not support the consistency of mastery as a strongmediator in the relationship between uncertainty and opportunity. The researchers proposedthat two moderator variables, the location of the data collection (in hospital for the secondsample), and the increased severity of illness (increased number with a higher disease stagingin the second sample), contributed to the differences in results.Christman et al. (1988) examined the influence of uncertainty in illness and use ofcoping methods on emotional distress and recovery following myocardial infarction. Alongitudinal exploratory design was used with responses measured at three intervals. The30-item Mishel Uncertainty in Illness Scale was used. The maximum score possible on theuncertainty scale was 170 and the lowest score possible was 34. The uncertainty score for thefirst interval (within 72 hours of hospital discharge) was 79.15. The uncertainty score for thesecond interval (the first week following discharge) was 75.67. The uncertainty score for thethird interval (the fourth week following discharge) was 76.18. There was a significantdecrease in uncertainty from the first to second interval, however, the decrease from thesecond to third interval in uncertainty was not significant. These results indicate that thispopulation perceived moderate levels of uncertainty with the mean scores about 10 pointsabove the scale midpoint at each measurement interval. At all measurements, emotionaldistress and uncertainty were positively and significantly related to each other.Mason (1985) examined the uncertainty about the nature and management of diabetesmellitus. This prospective study, over a period of one year, focused on uncertainty relatedprimarily to information and the complexity of care. Qualititative analyses indicated that themost uncertainty was generated by concerns about complications of diabetes. A`doctor-centered' style of communication was used and found to be unconducive to26uncertainty resolution by the subjects. Further, the findings indicated that the uncertaintiesencountered by the patients exacerbated their distress.Yarcheski (1988) analyzed differences in length of future time perspectives amongchronically ill adolescents and their parents' levels of uncertainty in illness. Themeasurement of uncertainty for the adolescent group (n=32) was by the Mishel Uncertainty InIllness Scale (34-item version). The range of possible scores was from 34 to 170 with amean uncertainty score of 88.22. The measurement of uncertainty for the parent group(n=32) was by the Parent Perception of Uncertainty Scale (29-item version). The range ofpossible scores was from 29 to 145 with a mean uncertainty score of 74.74. Both of thesescores were above the median, indicating moderate levels of uncertainty.Yarcheski further isolated the uncertainty factor of unpredictability in order to test therelationship between future time perspective and uncertainty about illness. Length of futuretime perspective was defined as "the degree to which the future is perceived as predictable,controllable and structured" (p. 403). The assessment of future time perspective variedsignificantly (F(1,31)=8.65, p=.006) according to whether the adolescents and their parentshad similar or dissimilar levels of unpredictability with regard to course and outcome of theadolescent's illnesses. Yarcheski noted that the interplay of the varying levels ofunpredictability appeared to influence the extent to which adolescents perceived the future aspredictable, structured, and controllable.Using the grounded theory approach, Weitz (1989) examined the uncertainty in thelives of persons (n=23) with AIDS. Weitz noted that the responses to uncertainty changedover time; from risk-taking, presence of symptoms, confirmation of disease, treatment optionsand learning to live with or die from AIDS. Her data suggested that persons with AIDS use27divergent coping strategies such as seeking knowledge or avoiding knowledge in response tothe uncertainties of their illness.Hilton (1987) used Mishel's Uncertainty in Illness Scale (28-item version) in herresearch on exploring the uncertainties and coping strategies of women with breast cancer.The total uncertainty for the women was 58.7 (minimum score possible was 28, maximumscore possible was 140). Her findings indicated that this sample found indefiniteness ofillness course (eg. not knowing their future) provided the most uncertainty, followed by notknowing about their current illness situation. Further uncertainty was provided by notunderstanding explanations, indeterminacy of the treatment effect, lack of clarity and lack ofconsistency about the situation.A phenomenological approach was used by Hilton (1987, 1988a) to describe theexperience of uncertainty for women diagnosed with breast cancer. The women characterizeduncertainty as a perceptual state that existed on a continuum and changed over time.Uncertainty consisted of "not being able to foretell the future, not feeling secure and safefrom danger, being in doubt, being undecided, not being able to rely or count on someone orsomething or vagueness" (p. 220). The perception of uncertainty was influenced by theindividual's beliefs, values, and the characteristics of the cancer situation.Simurda (1988) explored the relationships between uncertainty and quality of lifeindicators in patients recovering from coronary artery bypass graft surgery. Using the MishelUncertainty in Illness Scale (28-item version), the total uncertainty score for primary coronarybypass patients ranged from 32 to 109 with a mean of 60.8 and, for reoperation patients, totaluncertainty ranged from 57 to 85 with a mean of 65.2. The quality of life indicators were thepatient's perception of health status and life satisfaction. Uncertainty was negatively28associated with quality of life indicators. This suggested that a higher perception ofuncertainty for this population contributed to a lower perception of quality of life.Perceptions of uncertainty in adult kidney transplant patients were described in a 1991study by Swanson. Uncertainty was measured by the Hilton Uncertainty Stress Scale (version3). The minimum score possible was 60 and the maximum score possible was 300. The totaluncertainty score for long-term kidney transplant patients ranged from a low of 60 to a highof 220 with a mean of 103.3. The findings indicated that moderately low levels ofuncertainty were perceived by the sample. What uncertainty there was appeared to begenerated primarily by the indeterminateness of the situation. Significant variablescontributing to the uncertainty of these patients were the number of concurrent health ormedical problems and the patient's education level.Uncertainty and PregnancyTwo studies addressed uncertainty inherent in pregnancy. However, neither study usedany of the previously mentioned scales to measure the uncertainty levels, therefore, it isdifficult to elicit comparisons between the studies. To date, all of the research work onuncertainty has focused on the impact of various illness states on uncertainty.Using the grounded theory approach, Patterson, Freese and Goldenberg (1986)explored how women reduce uncertainty through the self-diagnosis of pregnancy. The studywas based on the assumption that women universally engage in a process in response touncertainty concerning pregnancy diagnosis. The urgency around the process relates to themeaning and implications of pregnancy for each woman. Hence, women who suspectpregnancy are searching and/or waiting for definite indicators to reduce the stress associatedwith uncertainty. The researchers developed a conceptualization of the process women gothrough in the search to reduce uncertainty. The steps were: noting salient indicators of29pregnancy (eg. amenorrhea), forming a working interpretation, searching for confirmingindicators (eg. the presence of nausea or vomiting), weighing the evidence, seekingprofessional confirmation (eg. pregnancy test), and self-diagnosis or convincing herself thatshe is indeed pregnant. The researchers noted that understanding the process women gothrough is the first step in designing interventions which reduce uncertainty by promotingconfidence and competence in self-diagnosis.Sorenson (1990) used qualitative data from interviews with pregnant women to explorethe antecedents to uncertainty in pregnancy. She outlined parallels between pregnancy andillness and noted that the changes expected in pregnancy (physiological, cognitive, emotionaland interpersonal) and their interrelations may create difficulty for the woman to understandbecause the meanings of the changes are not always readily apparent. For example, thenausea associated with pregnancy can also be an illness cue. For a pregnant nulliparouswoman this may lead to disruption in event familiarity as they may draw on non-pregnantrelated experiences which may in turn lead to incorrect conclusions about symptoms.Conversely, a multiparous woman who experiences unfamiliar symptoms in a familiarsituation (pregnancy), may have increased uncertainty due to the inability to draw from pastexperiences with pregnancy. Sorenson noted that stress associated with uncertainty is linkedto perinatal complications. Further, caregiver reactions to the uncertainty expressed by thepregnant woman may lead to negative reactions such as indifference, ignorance, andintolerance which in turn can intensify stress. Sorenson concluded that uncertainty isuniversally experienced during pregnancy as the woman strives for meaning from pregnancyrelated events.30Coping Strategies Coping is defined by Lazarus and Folkman (1984) as the "constantly changingcognitive and behavioural efforts to manage specific external and/or internal demands that areappraised as taxing or exceeding the resources of the individual" (p. 141). Coping efforts areof two types which both influence each other and are interactive. Problem focused strategiesare more likely to be chosen when the threat itself is appraised as being changeable.Conversely, emotion-focused strategies are more likely to be chosen when the situation isappraised as being unchangeable or unmodifiable by the individual. Cohen and Lazarus(1979) identified the following five forms of coping: information seeking, direct actions,inhibition of action, intrapsychic processes, and turning to others. Each form serves bothproblem-focused and emotion-focused strategies.Mishel (1988) noted that coping includes cognitive activity in the form of cognitiveappraisal of events and reactions which then determine the course of action based onreappraisal. Inference and illusion are the two processes involved in the appraisal ofuncertainty. Inference appraisal leads to uncertainty being considered a danger and gives riseto the mobilizing and affect-managing types of coping strategies. Mobilizing contains thestrategies of direct action, vigilance and information seeking, while affect-managementcontains the strategies of faith, disengagement and cognitive support. Illusion appraisal leadsto uncertainty being considered an opportunity and gives rise to the buffering type of copingstrategies. Buffering contains the methods of avoidance, selective ignoring, reorderingpriorities and neutralizing.Jaloweic (1991) identified eight types of coping strategies which are similar toMishel's conceptualization. These eight types of coping strategies are: confrontive, emotive,optimistic, supportant, fatalistic, palliative, supportant and self-reliant coping strategies.31Confrontive and self-reliant coping appear to arise primarily from the appraisal of uncertaintyas danger, and evasive, emotive, optimistic, and palliative coping appears to arise primarilyfrom the appraisal of uncertainty as an opportunity. Supportant, fatalistic, and emotive copingstyles arise from both types of uncertainty appraisal. Evasive, emotive and palliative copingfall within the general rubric of emotion-focused category, confrontive into theproblem-focused category; and optimistic, fatalistic, supportant and self-reliant are acomposite of emotion and problem-focused strategies.Confrontive coping depicts those efforts which confront or face up to the problem andinclude constructive problem-solving. These efforts often focus on outlining the problem,choosing actions on the basis of cost and benefit, and action directed at the problem. Theseare similar to the direct action and information seeking types of mobilizing strategiesdescribed by Mishel.Evasive coping reflects efforts which are avoidant by nature in order to deal with aproblematic situation. Essentially, individuals distance themselves from the problem in orderto deal with its emotional fallout. Evasive coping contains the elements of both avoidanceand selective ignoring within the buffering type of coping category.Optimistic coping describes efforts which maintain a positive outlook, positivethinking or positive comparison on a topic and hence maintain or build hope. These areprimarily hopeful by nature, but can also contain a reality distorting aspect. As such, they areclosest to the buffering methods of selective ignoring and reordering priorities.Fatalistic coping refers to efforts which are pessimistic, hopeless, and/or contribute toa feeling of little control. Although these efforts can be characterized as dismal by nature,they can serve the function of reality basing which can elicit a more truthful situation. This32type of coping contains elements of both disengagement (affect-managing) and fatalistic(buffering).Emotive coping describes efforts which set forth emotions and ventilate feelings. Attimes, these strategies are necessary to displace feelings. These efforts appear to containelements of all three types of coping; vigilance (mobilizing), disengagement(affect-managing), and avoidance (buffering).Palliative coping expresses those efforts which try to reduce or control the individual'sdistress by making them feel better. This may refer to attending to one aspect of theproblem, however, they may also support the individual feeling better through avoiding theissue. They appear to be closest to the buffering method of neutralizing.Supportant coping describes the efforts which maintain the individual's sense ofsecurity. This is done through the use of such external sources as personal, professional orspiritual and is most similar to the faith and cognitive support efforts of affect-management.Finally, self-reliant coping refers to those efforts which aid or maintain theindividual's internal sense of control concerning behavior or feelings. These types of copingstrategies appear to be both mobilizing (direct action, vigilance) and buffering (reorderingpriorities) in nature.A review of the literature by this researcher did not locate studies which explored thecoping strategies of women with the diagnosis of gestational diabetes. A limited number ofstudies, (Corbin, 1987; Davis and Dearman, 1991; and Gasper, 1987), were identified whichaddressed the coping strategies used by women with various conditions of pregnancy.Corbin (1987) used an exploratory longitudinal study to explore how women withchronic illness cope with the medical risk factors associated with their pregnancies. Findingsindicated that women used three main strategies to cope with their pregnancy risk. These33strategies were described under the concept of protective governing and were defined as:assessing, balancing, and controlling. The risk level perceived by the women were defined asbeing on course high-risk, off course high-risk, on course non-critical or off-coursenon-critical.The coping strategies of thirty infertile women were explored by Davis and Dearman(1991). A structured investigator-developed interview was used to gather data which werethen subjected to content analysis. Six ways of coping with infertility were identified:distancing, regaining control, being the best, looking for hidden meaning, giving in tofeelings, and sharing the burden. Subjects used a variety of coping strategies dependent onthe situation. The majority of the coping strategies were initiated to manage the fear, anxiety,and disappointment involved with the infertility situation.Gasper (1987) used a descriptive longitudinal case study to examine the nature ofstress in the situation of persistent anemia during pregnancy. To deal with the perceivedthreat, the treatment, and the relationships with caregivers, six coping strategies were used.These strategies were: conditional compliance, expressing affective states, monitoring, usingsupport, replenishing, and using knowledge.Relationship of Uncertainty to Coping Strategies Although studies discussing the influence of uncertainty on coping strategies are moreprevalent in the literature, no studies were identified which described the influence uncertaintyhas on the coping strategies of women with gestational diabetes. Hence, this section focuseson the relationship between uncertainty and coping strategies in other populations.Hilton (1987, 1989) investigated the relationship of uncertainty about the cancersituation, commitments, threat of recurrence, and control of the cancer situation to the set ofcoping strategies used by women with a diagnosis of breast cancer. Commitments "express34what is important, underlie choices, and guide people into or away from situations thatthreaten, harm or benefit them" (Hilton, 1989, p. 41). Using canonical correlation, thefindings indicated that woman who had low commitment and low control together with highuncertainty and high threat of recurrence used escape-avoidance and accepting responsibilitybut not positive reappraisal strategies. Women who had high threat of recurrence and highcontrol used the coping strategies of seeking social support, escape-avoidance, positivereappraisal, planful problem solving, and self-controlling strategies.Swanson (1991) found that kidney transplant patients predominately used optimistic,self-reliant and confrontive coping styles in order to manage uncertainty and the stress itgenerated. Generally, there was a tendency to use the problem-focused type of coping.Nyhlin (1990) used the grounded theory approach to investigate the coping strategiespeople with Type I diabetes used in order to cope with the uncertainty arising from theircondition. Her findings indicated that the problem of uncertainty featured prominently indaily lives of her sample. Three categories of coping strategies were used to manage theuncertainty: coming to terms; keeping going; and making sense. The interviews with thediabetic patients were carried out on two occasions with approximately five year intervals.Nyhlin's findings indicated that the uncertainty which was evident in the first interviewseemed to persist five years later.Weitz's (1989) study on uncertainty and the lives of persons with AIDS supportedNyhlin's findings that the uncertainty persists over time. Weitz's study indicated thatattempting to assert as much control as possible over their lives was the main coping strategyused by this group. Interestingly, this control was expressed through the use of divergentstrategies such as seeking information or avoiding knowledge about their disease.35The study by Christman et al. (1988) mentioned earlier also indicated that uncertaintyinfluenced the responses of patients with myocardial infarction. Three types of copingmethods were measured at the three intervals. Confrontive coping behaviors were used morefrequently than emotive or palliative coping. Those patients who reported greater uncertaintyalso reported greater distress at all three measurement times.Mishel and Sorenson's (1991) study on the mediating function of mastery and copingdid not support coping strategies as mediators between appraised danger or opportunity andemotional distress. In other words, a coping strategy reduced the sense of danger, but did notreduce the emotional distress in their sample.Summary A review of the literature indicates that a certain degree of stress and uncertainty arean integral part of a 'normal' pregnancy. Uncertain events, such as an unexpected pregnancycomplication can be expected to influence the amount and nature of the expected stress. Thepresence of uncertainty influences the way an individual appraises a situation and hence thecoping strategies used. No studies have addressed either the coping strategies used or thelevels of uncertainty perceived by women with gestational diabetes.36CHAPTER THREEMethodsIntroduction This chapter presents the research design, sampling procedure, data collectioninstruments, data collection procedures, ethical considerations, and the statistical proceduresused in data analysis.Research Design A descriptive correlational design was used to achieve the purpose of this study. Thisdesign was appropriate as little was known about how women with gestational diabetesperceive the uncertainties inherent in their condition and what coping strategies they use todeal with the uncertainty. The correlational component allowed the researcher to examine anddescribe the relationships between the variables.Sampling Originally, a convenience sample of 84 women was determined to be needed. Thesample size of 84 was determined by Cohen's (1977) table to test a medium effect of r=.30,based on a power of .8, and a significance level of .05 using a two tailed test. After 16weeks of data collection, 75 questionnaires had been sent to women who met the selectioncriteria. Of these, 48 were returned, representing a 64% return rate. All women wererecruited from the Diabetes in Pregnancy Clinic at the Salvation Army Grace Hospital,Vancouver, B.C.37Participants included those women who met the following criteria:Selection Criteria^ Rationale1) diagnosed as having gestationaldiabetes as defined under thedefinition of terms2) experiencing gestational diabetesfor the first time3) have no other chronic disease4) have no other high-riskpregnancy complications5) are within two weeks ofdiagnosis6) are able to read and understandEnglish7) older than 18 years of agetarget populationprevious pregnancy withgestational diabetes mayconfound the experiencepresence of chronic diseasecould confound the experiencethe concerns of othercomplications could confoundthe experienceotherwise adaptation may occurto facilitate communicationconcerns of adolescent pregnancycould confound the experienceData Collection Procedures Participants were recruited through the Diabetes in Pregnancy Program at GraceHospital. The Salvation Army Grace Hospital Research Coordinating Committee and thethree diabetologists affiliated with the Diabetes in Pregnancy Program granted permission toapproach patients who met the selection criteria. The diabetes nurses (3) reviewed each newpatient during the data collection period to determine those who met the sampling criteria. Aclerk mailed the questionnaire packet to these individuals. Each coded envelope contained aninformation letter (Appendix D), the two questionnaires, the patient information sheet and astamped return envelope. As questionnaires were returned, the researcher would note thecode number and communicate it to the clerk who would then check off the appropriatenumber on the master code list. Each week, the clerk noted those subjects who had not yet38returned their questionnaire. A reminder letter (Appendix E) was sent if no response hadbeen obtained within two weeks.Data Collection Instruments Three data collection tools were used in this study. Hilton's (1991) High RiskPregnancy Version of the Uncertainty Stress Scale (USS-HRPV) was used to measureperceived uncertainty (Appendix A). The Jaloweic Coping Scale (1987) was used to measurecoping strategies (Appendix B). Finally, a patient information sheet was used to collectdemographic, health and pregnancy information (Appendix C).Uncertainty Stress Scale (USS-HRPV) The High Risk Pregnancy Version of the Uncertainty Stress Scale consists of threeparts. Part one is comprised of 56 items and asks participants their perception of uncertaintyin a number of areas related to a high-risk pregnancy condition. It uses a 5 point Likert scalewith a 1 indicating 'no uncertainty' to a 5, indicating 'a great deal of uncertainty'. Part twoasks the participant to indicate their perceived degree of stress related to each of the 56 items.It uses the same Likert scale. Part three consists of four visual analogue scales, each tencentimeters in length, where participants indicate their measurement of global uncertainty,global stress, global threat and perceptions of opportunity generated from the uncertainty intheir high-risk situation.The original scale was developed to measure the degree of uncertainty in cancerpatients. Hilton's 1987 phenomenological study of the experience of women coping withbreast cancer and a theoretical and empirical literature review were the basis for itemdevelopment. The phenomenological study identified uncertainty as: not being able toforetell the future; not feeling secure and safe from danger; being in doubt; being undecided;having a perception of vagueness; and not being able to rely or count on someone or39something. Version 1 was comprised of 55 items using a Likert scale. Content validity wastested based on feedback from nurses, cancer patients, physicians, psychometricians andresearchers on uncertainty.Further refinement resulted in Version 2 which consisted of 48 items. Four aspects ofuncertainty were measured by this version: lack of clarity in interpretation and understandingof the situation; not being able to foretell the future in terms of symptoms and outcomes;dependability/reliability; and being inclined to disbelief, doubts about choices, treatments,strategies and behaviors. This scale was tested on a number of patients including 200 cancerpatients, 94 kidney transplant patients, 120 vascular patients, 10 cardiac patients and 121biological valve patients. Good internal consistency was indicated by alpha coefficients foreach subscale ranging from 0.67 to 0.81. The internal consistency reliability of the total scalewas 0.92 (Hilton, 1988b, unpublished). Version 2 was used by Ford in 1989 in her study onuncertainty and biological valve patients. The internal consistency of Ford's scale was .92and each of the four factors had alpha coefficients ranging from .67 to .81 indicating goodinternal consistency.Version 3 of the USS consisted of 60 items. This version was tested with cancerpatients and post kidney transplant patients. Five factors resulted from factor analysisfollowed by Varimax rotation. The five factors were: indefiniteness; reliability/dependability;probability; doubtfulness, and indeterminateness. Internal consistency ranged from 0.68 to0.95 (Hilton, 1988b, unpublished). Swanson (1991) in her study on uncertainty andlong-term kidney transplant patients reported an internal consistency reliability of .96 usingVersion 3. Each of the five factors had internal consistency reliabilities ranging from 8 to .93indicating good reliability.40Hilton (1991) has tested the validity of the scale. Convergent validity has beensupported by having subjects respond to the Mishel Uncertainty in Illness Scale (communityversion) and Version 2 of the USS. A positive correlation of r =.64 was found, indicatingthat the scales are not the same but tap into the same concept. Predictive validity of the scaleis supported by the significant difference between levels of uncertainty in women with arecurrence of breast cancer versus those without a recurrence of their cancer.In addition, a prediction study on the uncertainty of women who were diagnosed witha breast lump was done. The instrument was administered prior to biopsy for a suspiciousbreast lump, after biopsy, and then, if the result was cancer, after surgery and again threemonths later. Results indicated that uncertainty prior to biopsy was moderate with a meanuncertainty score of 120 (maximum score possible was 300). When the lump was benign, themean uncertainty score was 84 and when the lump was cancerous, the mean uncertainty scorewas 110. There was a significant decrease in uncertainty for those diagnosed with a benignlump (p =.02) After surgery, the mean uncertainty score was 109 and three months later thescore was 119 (Hilton, 1991, unpublished).The Uncertainty Stress Scale has now been used to measure the degree and stress ofuncertainty for individuals with a number of disorders. The version used in this study wasadapted by Hilton and individuals who work with women with high-risk conditions ofpregnancy. All items on the scale were examined and additional items were added whichrelated to the unborn baby. In addition, other small changes were made from informationobtained by version 3 of the USS. As gestational diabetes is considered a high-riskpregnancy related condition, the USS is suitable for this study.The USS-HRPV used in this study had an internal consistency reliability of .97indicating excellent reliability. Scoring in the present study consisted of calculating a total41uncertainty and stress score by adding each subject's response to the scale. The visualanalogue scales were scored by measuring the distance from zero on the ten centimetre scaleindicating the degree of feeling or perception related to total uncertainty, stress, threat, andopportunity.Jaloweic Coping Scale (JCS) Coping strategies were measured by the 1987 version of the Jaloweic Coping Scale.This is a 60 item list of coping strategies along with an effectiveness rating scale for eachstrategy. The degree of use of the coping strategies is rated from a 0 (never used) to a 3(often used). The effectiveness rating scale rates usefulness of the coping strategy from a 0(not helpful) to a 3 (very helpful).The original version (1979) of the JCS was developed to examine the coping methodsused by hypertensive and emergency room patients. Items on the scale were based on acomprehensive and critical review of the literature on stress, coping and adaptation (Jaloweic,Murphy & Powers, 1984, p. 157). The 40 items were classified as either problem oriented oraffective oriented by twenty judges. Agreement by the judges was 85%.To measure reliability, test-retest procedures were done. Stability was supported byreliability coefficients from two test-retests of 0.79 and 0.78 respectively. An alphacoefficient of 0.86 was obtained (n=141) which indicated homogeneity. Internal consistencywas also measured within each subscale with alpha coefficients ranging from 0.77 to 0.86.Content validity was obtained through the use of the literature and the systematic manner oftool development. To provide evidence of the scale's construct validity, factor analysis wascarried out using Varimax rotation. This showed 80% of the problem orientated items loadedon Factor I, however, only 36% of the affective orientated items loaded on Factor II (Jaloweicet al., 1984).42Further testing and refinement of the scale was done based on a sample of 1400subjects. Three factors evolved from factor analysis. These factors were: confrontive copingstrategies, emotive coping strategies, and palliative coping strategies. This resulted in the1985 version of the JCS which consisted of a 40 item list of coping behaviors. The degree ofuse was rated 1 (never) to 5 (almost always). Overall reliability coefficients of the 1985version was 0.95. The alpha coefficients were 0.85 for confrontive coping strategies, 0.70 foremotive coping strategies and 0.75 for palliative coping strategies.The above mentioned versions of the JCS have been widely used in nursing research.Based on these studies, the list of coping strategies was expanded from 40 to 60 items.Subjects are now asked to rank the helpfulness of each strategy. Eight coping styles wereidentified by Jaloweic. These are: confrontive coping style; evasive coping style; optimisticcoping style; fatalistic coping style; emotive coping style; palliative coping style; supportantcoping style; and self-reliant coping style. These coping styles have been described inChapter 2.Good internal consistency has been established for the latest version of the scale. Thescale has been used on a diverse group of 744 subjects with the Cronbach alpha reliabilitiesreported as ranging from .64 to .97 with a mean alpha of .86 for overall use score. The totaleffectiveness Cronbach alphas ranged from .84 to 6. However, the alpha coefficients for eachuse of the eight coping subscales are below .70 with the exception of confrontive and evasivecoping subscales. Effectiveness reliability coefficients for the subscales also are below .70with the exception of confrontive, evasive and optimistic •subscales (Jaloweic, 1991). Basedon these preliminary psychometric results, internal consistency is somewhat less than desired.However, results from Swanson's 1991 study on coping strategies used by long-term kidney43transplant patients indicate excellent internal consistency except for fatalistic coping andpalliative coping effectiveness.In this study, the internal consistency coefficient for overall use and for overalleffectiveness was .94. The internal consistency for use and effectiveness is presented inTable I.Table IAlpha Coefficients for Use and Effectiveness of Coping Styles Coping Style^ Use^EffectivenessConfrontive .86 .85Evasive^ .81^.79Optimistic .78 .75Fatalistic .35 .58Emotive .74^.58Palliative^ .71 .59Supportant .51 .46Self-Reliant .79^.73Content validity of the 1987 JCS is supported by the broad literature and empiricalbase from which the items were drawn, the large number of items used to tap the conceptualdomain of coping and the inclusion of diverse types of coping behaviors (Jaloweic, 1991).Construct validity testing was done to examine the dimensionality of the revised JCS.Twenty-five nurse researchers were asked to determine the extent of agreement withJaloweic's classification of the 60 items into the 8 subscales. Percent of agreement of thepanel with Jaloweic's classifications ranged from a low of 54% (emotive) to a high of 94%(supportant). Average agreement was 75%.Predictive validity is supported by Jaloweic's data on cardiac transplant patients.Patients who used more optimistic coping (r=.17) felt they would do better post-operatively,and were also more satisfied with their life (r=.29). Those who rated their coping as more44effective needed less help with illness related tasks (r=.19) and those who used moresupportant coping felt they had a larger social support network (r=.32), and were moresatisfied with their social support resources (r=.20) (Jaloweic, 1991). Further psychometrictesting is ongoing.Patient Information SheetThe patient information sheet was designed by the researcher to obtain relevantdemographic and pregnancy information. Items include information about the participants'age, number of pregnancies, education level, pregnancy complications, employment history,marital status and family history of diabetes (Appendix C).Ethics and Human Rights The rights of the participants were protected in the following manner:1) Permission was granted to conduct this study by the University of British Columbia'sBehavioral Sciences Screening Committee for Research and the Salvation Army GraceHospital Research Coordinating Committee.2) Confidentiality was assured. The participants name was not on the questionnaire.Each participant was assigned a code number by a clerk. This researcher did not haveaccess to the list of names. Data were reviewed only by the researcher and the thesiscommittee. At no time did any names appear on any material.3) All potential participants received an introductory letter by mail. The letter describedthe study and the participants' role. All potential participants were informed that theywere not obliged to participate and could refuse to answer any questions without effectto their future or current health care.4) Permission was obtained from each of the three diabetologists affiliated with the GraceHospital Diabetes in Pregnancy Program.45Data Analysis Raw data from the questionnaires were coded, entered into a computer file, verified bya colleague and analyzed using the Statistical Package for the Social Sciences (SPSS:X).Descriptive statistics were used to describe the sample characteristics and to addressresearch questions one and two. To address research question three, regarding therelationship between uncertainty and the coping strategy, non parametric tests were used.Nonparametric tests were used because a convenience sample of small size was obtained,therefore, a normal distribution was not assured. The level of significance for this study wasset at .05.46^•CHAPTER FOURPresentation and Discussion of FindingsIntroduction This chapter is arranged under three headings: characteristics of the sample; findings;and discussion of results.Characteristics of the Sample A total of 75 questionnaires were mailed to eligible subjects and after one reminderletter the response rate was 64%. Two questionnaires were returned unanswered and were notentered into the sample. Therefore, the sample consisted of 46 adult pregnant women whowere diagnosed as having gestational diabetes for the first time. Characteristics collectedfrom the sample included demographic, health and pregnancy data.Demographic Characteristics Demographic data collected from the subjects were age, marital status, educationallevel, employment status, and occupation.Age of the subjects ranged from 21 to 37 years-31.6, SD=3.8) (see Table II).Eighty seven percent (n=40) of the sample were married, 8.7% (n=4) were living in acommon-law relationship, 2.2% (n=1) were single, and 2.2% (n=1) were widowed.Table IIAge Distribution of the Sample Age Frequency Percent20 - 24 1 2.225 - 29 13 28.330 - 34 19 41.335 - 40 13 28.3Total 46 100.047The educational level of the sample is presented in Table III. All but one of thesubjects had at least a high-school education, and approximately two thirds of the subjectshad attained college/university level.Table IIIEducational Level of the Sample Education Level^Frequency^PercentUp to Grade 12 1 2.2Completed High School^15 32.6Completed College 13^ 28.3Completed University^17 37.0Total^ 46 100.0Employment characteristics revealed that the approximately half of the subjects wereemployed full-time outside the home (Table IV). Subjects' occupations were categorized asprofessional, support staff or service. The majority of subjects were either professional(43.9%) or support staff (48.8%). Three subjects (7.3%) were in the service category and fivesubjects (13%) did not indicate their occupation.Table IVEmployment Status of the Sample Employment Status^Frequency^PercentFull-time^ 21 45.7Part-time 3 6.5Homemaker 6^ 13.0Maternity Leave^7 15.2Unemployed 2 4.3Self Employed 5^ 10.9Sick Leave^ 1 2.2No answer 1 2.2Total 46^ 100.048Health Characteristics of the Sample Health information collected was concerned with the family history of diabetes. Sixtyone percent of the subjects reported a family history of diabetes. Twenty four percent hadmore than one relative with diabetes. Of those who had a history of diabetes, 58% had TypeII diabetes, however, this number may be much higher as 28% of the subjects did not knowwhat type of diabetes their relative had (see Table V).Table VFamily History of Diabetes (n=28)Type ofDiabetes ParentsGrandParents Siblings ,Other* Totaln% n% n%n%nType I 0 0 0 0 0 0 4 7.1 4 7.1Type II 15 26.8 10 17.8 1 1.8 7 12.5 33 58.9Gest. Diabetes 1 1.7 0 0 2 3.6 0 0 3 5.3Unknown Type 4 7.1 7 12.5 0 0 5 8.9 16 28.6Total 20 35.6 17 30.3 3 5.4 16 28.5 56 100* Other = Aunts, uncles and cousins.Pregnancy Characteristics For 67.4% (n=31) of the subjects this was their first pregnancy. Of those withchildren, the majority (87%) had only one child. No one reported more than two children.The age of the children ranged from one to thirteen years M=3.7). Thirty percent (n=14) ofthe women had had a previous pregnancy loss, which had occurred from eight to twenty-nineweeks gestation (M=13.8).49The majority of the subjects were greater than 30 weeks gestation C/A=31.2, SD=6.5).Table VI presents the gestational age of the sample at the time of completing thequestionnaires. The range of gestational age was from 12 to 38 weeks.Table VIGestational Age G estational Age (weeks)^Frequency^Percent0 - 10 0 0.011 - 15 2 4.316 - 20 1 2.221 - 25 0 0.026 - 30 15 32.531 - 35 16 34.736 - 40 12 26.0Total 46 100.0Eighty four percent (n=40) reported having no other pregnancy complications otherthan gestational diabetes. The complications mentioned by six of the subjects were: chronicback pain, low lying placenta, increased B.P. for two weeks, puritis, tachycardia and fluidretention. No one had more than one pregnancy complication.Findings The findings of the study will be presented in relation to each of the three researchquestions. The level and nature of uncertainty and the degree and the use of coping strategieswere examined using descriptive statistics. The relationship between uncertainty and each ofthe coping strategies was examined by the non-parametric test of Spearman's rho rankcorrelation coefficient.50Research Question 1: Level and nature of uncertainty for women with gestational diabetes The total score on the uncertainty scale for women with gestational diabetes rangedfrom 59 to 216 (M=109.8, SD=37.5) (see Table VII). The most frequently occurring scorewas 84 and the median score was 102.5. Although the majority of the subjects had lowlevels of uncertainty, 19.6% (n=9) had scores above 135 indicating high levels of uncertaintyfor these subjects.Table VIITotal Uncertainty for Women with Gestational Diabetes Total Score^ Frequency^Percent56 - 75 (low uncertainty)^8 17.376 - 95 11^23.996 - 115^ 11 23.9116 - 135 7 15.2136 - 155 3^6.5156 - 175 2 4.3176 - 195^ 3 6.5196 - 215 (high uncertainty)^1^2.2Total 46 100.0Note: 56 items each scored from 1 to 5. Minimum score possible is 56 and maximum scorepossible is 280.Frequency and distribution of the thirteen items which elicited the most uncertainty onthe USS-HRPV are presented in Table VIII. Three of the items of the uncertainty scalepertain directly to the baby. As shown in the table, these three items were in the top fiveitems chosen by women with gestational diabetes. Rank ordering of the total scale fromthose that elicited the highest score to the those that elicited the lowest score is described inAppendix F.51The visual analogue scale measuring overall level of uncertainty was also examined.The range of overall uncertainty was from 0 to 92 =42.2, SD=24) (see Table IX). Twentypercent (n=9) had moderate to high overall levels of uncertainty with scores above 60.Table VIIIFrequency and Distribution of the Top Thirteen Uncertainty Items Item^Mean Median Mode Rank15. About my baby's chance to be healthy 3.21^3.5^4^116. Whether my condition will be thesame with the next pregnancy^2.79^3.0^1^226. Whether my condition risks mybaby's life^ 2.73^2.0^2^345. Whether they might find somethingwrong when I go for a check-up^2.73^2.0^2^335. Whether delays in my treatment willinfluence my baby's chances^2.68^2.0^2^42. About the stability of my condition^2.56^2.0^2^536. About the seriousness of my condition 2.55^2.0^2^612. What to say to other about mycondition^ 2.45^2.0^2^738. About the unpredictability of mysymptoms 2.41^2.0^2^814. About my chances to be well duringthis pregnancy^ 2.41^2.0^2^8^10. Whether my condition is under control 2.41^2.0^2^841. How long my symptoms will last^2.35^2.0^2^939. Whether I will have any difficultycoping with my situation^2.33^2.0^2^1052Table IXOverall Uncertainty Level: Visual AnalogueTotal Score^ Frequency^Percent0 - 10 (low uncertainty)^5 10.911 - 20 5 10.921 - 30^ 8^ 17.431 -40 2 4.341 - 50 8 17.451 - 60^ 9^ 19.661 - 70 3 6.571 - 80 2 4.381 -90^ 2^ 4.391 - 100 (high uncertainty)^2 4.3Total 46 100.0Note: 100rrun visual analogue scale. Minimum score possible is 0 and maximum scorepossible is 100.Research Question 2: Type and frequency of use of coping strategies In terms of numbers of coping strategies used by the subjects, the range was from oneto sixty. Subjects were also asked to rate the effectiveness of each coping strategy. This alsoranged from one to sixty. The use and effectiveness of each coping style for each of theeight subscales were assessed. Table X presents the mean use for each of the eight copingstyles. The optimistic, confrontive, supportant, self-reliant coping styles were used mostoften, and, the fatalistic, palliative, emotive, and evasive coping styles were used least often.Table XI presents the mean effectiveness of each of the coping styles. The mosteffective coping styles were confrontive, supportant, optimistic, and self-reliant. Palliative,fatalistic, evasive, and emotive were rated the least effective coping styles.Table XMeans for Use of each Coping StyleCoping Style Mean SD Item MeanConfrontive (10 items) 19.37 6.22 1.93Evasive (13 items) 13.71 6.46 1.05Optimistic (9 items) 17.45 4.96 1.93Fatalistic (4 items) 4.93 2.12 1.23Emotive (5 items) 5.91 2.03 1.18Palliative (7 items) 7.76 3.45 1.10Supportant (5 items) 8.65 2.98 1.73Self-Reliant (7 items) 11.19 4.60 1.59Total (60 items) 88.97 32.82Note: Maximum score possible: Confrontive=30, Evasive=39,Optimistic=27, Fatalistic=12, Emotive=15, Palliative=21,Supportant=15, Self-Reliant=21Table XIMeans for the Effectiveness of each Coping Style Coping Style Mean SD Item MeanConfrontive (10 items) 18.39 6.36 1.83Evasive (13 items) 9.93 5.95 .76Optimistic (9 items) 15.06 4.98 1.67Fatalistic (4 items) 3.14 2.10 .78Emotive (5 items) 3.02 2.56 .60Palliative (7 items) 7.32 3.64 1.04Supportant (5 items) 8.43 2.64 1.68Self-Reliant (7 items) 9.45 4.30 1.35Total (60 items) 74.74 32.53Note: Maximum score possible: Confrontive=30, Evasive=39,Optimistic=27, Fatalistic=12, Emotive=15,Palliative=21, Supportant=15, Self-Reliant=21.Rank ordering of the most-used to the least-used coping strategies is described inAppendix G. Rank ordering of the most-effective to the least effective coping strategies isdescribed in Appendix H.5354To allow for clarification and comparison, the frequencies of the use and effectivenessof each coping style are presented in Table XII. Confrontive, optimistic, and self-reliantcoping styles were used most frequently; fatalistic and emotive were used least often.Confrontive, optimistic, and self-reliant coping styles were also the most effective, withfatalistic and emotive also the least effective.The subjects were also given the opportunity to add any additional ways of coping.Only one respondent did so. She added "crying" as a coping strategy and rated the use as 2(sometimes used) and the effectiveness as 1 (slightly helpful).Table XIIFrequency of Coping Style Use and Effectiveness Score Use EffectivenessFrequency^PercentConfrontive Coping StylesFrequency Percent0 - 6 2^4.3 2 4.37 - 13 6 13.0 9 19.614 - 20 18 39.1 15 32.621 - 27 15 32.6 18 39.628 - 34 5 10.8 2 4.3Evasive Coping Styles0 - 16 6 13.0 15 32.47 - 13 15 32.6 16 34.714 - 20 19 41.3 15 32.621 -27 6 13.0 0 0.0Optimistic Coping Style0 - 6 2 4.3 2 4.37 - 13 4 10.8 13 28.314 - 20 24 52.2 25 54.321 - 27 16 34.8 6 13.0Fatalistic Coping Style0 - 6 35 76.0 43 94.47 - 13 11 24.0 3 6.6Emotive Coping Style0 - 6 26 56.5 39 84.87 - 13 20 43.5 7 15.2Palliative Coping Style0 - 6 15 32.6 17 36.97 - 13 30 65.2 28 60.914 - 20 1 2.2 1 2.2Supportant Coping Style0 - 6 10 21.7 10 21.77 - 13 36 78.3 36 78.35556Score^Use^EffectivenessFrequency^Percent^Frequency^PercentSelf-Reliant Coping Style0 - 6 8 17.4 10 21.77 - 13 22 47.8 31 67.314 - 20 16 34.8 5 10.8Note: Maximum score possible: Confrontive=30, Evasive=39, Optimistic=27,Fatalistic=12, Emotive=15, Palliative=21, Supportant=15, Self-Reliant=21.The subjects were also given the opportunity to add any additional ways of coping.Only one respondent did so. She added "crying" as a coping strategy and rated the use as 2(sometimes used) and the effectiveness as 1 (slightly helpful).Research Question 3: The relationship between levels of uncertainty and coping strategies used by the woman with gestational diabetes. The Spearman rho rank correlation coefficient was used to examine the relationshipbetween levels of uncertainty and coping strategies because the assumption of normality wasnot met due to the small sample. Significant positive correlations were found betweenuncertainty and the use of evasive, fatalistic and self-reliant coping styles. Significantpositive correlations were also found between uncertainty and the effectiveness of confrontive,palliative and self-reliant coping styles (see Table XIII).57Table XIIIRelationship of Uncertainty to Coping Styles Coping StyleUse(rho)Effectiveness(rho)Confrontive .21 .24*Evasive .30* .21Optimistic .11 .13Fatalistic .33** .19Emotive .16 .08Palliative .20 .30*Supportant .23 .23Self-Reliant .30* .26*Note: * p < .05** p < .01Ancillary Findings Overall stress, threat and the subject's perception of any opportunity inherent in theuncertainty state were examined in addition to the three research questions. The relationshipsbetween the sample characteristics, uncertainty, and coping styles were also examined.Stress of Uncertainty The second part of the Uncertainty Stress Scale (HRPV) measures the stress thesubject feels related to the uncertainty identified for the 56 items. The total score on thestress scale for women with gestational diabetes ranged from 56 to 136 (rrVI_=89.3, SD=19.1)(see Table XIV). The majority (n=36) had overall low levels of stress associated withuncertainty with scores below 105. However, 13% (n=6) had relatively high levels of stressassociated with uncertainty with scores above 120.58Table XIVFrequency of the Total Stress Uncertainty Score for Women with Gestational DiabetesTotal Score^ Frequency^Percent56 - 74 (low stress)^12 26.175 - 94 17 36.995 - 114^ 11^23.9115 - 134 5 10.8135 - 154 (high stress)^1 2.2Total^ 46^100.0Note: 56 items scored from 1 to 5. Minimum score possible is 56 and maximum scorepossible is 280.The visual analogue scale measuring the overall level of stress derived from theuncertainty was also examined. The range of overall stress was from 0 to 100 (M=46.9,SD=27.3) (see Table XV). Twenty-four percent of the sample indicated relatively high levelsof stress with scores above 70.Table XVFrequency of the Overall Stress from the Uncertainty: Visual Analogue Total Score^Frequency^Percent0 - 9 (no stress) 3 6.5^10 - 19 5 10.820 - 29^ 7^15.230 - 39 2 4.340 - 49 3 6.550 - 59 8^17.460 - 69^ 7 15.270 - 79 4 8.780 - 89 3^ 6.590 - 99^ 3 6.5100 (high stress)^1 2.2Total 46^100.0Note: 100mm visual analogue scale. Minimum score possible is 0 and maximum scorepossible is 100.59The relationship between uncertainty and the stress of uncertainty was examined usingthe Spearman rho correlation coefficient. A significant positive correlation was foundbetween uncertainty and stress (rho=.91, p < .001). Additionally, there was a positivecorrelation between uncertainty and the stress visual analogue (rho=.73, p < .001). Thus, forthis sample, the higher the uncertainty, the higher the perception of stress from theuncertainty.Uncertainty and ThreatThe visual analogue scale measuring the threat the subject feels from the uncertaintywas examined. The range of scores for overall threat was from 0 to 100 (M=42.54,SD=28.15) (see Table XVI). Thirty five percent (n=16) had scores above 60, indicating fairlyhigh levels of threat because of their uncertainty.Table XVIFrequency of Overall Threat from Uncertainty: Visual Analogue Total Score^Frequency^Percent0 - 9 7 15.2^10 - 19 6 13.020 - 29^ 4^8.730 - 39 3 6.540 - 49 3 6.550 - 59 7^15.260 - 69^ 7 15.270 - 79 4 8.780 - 89 2 4.390 - 99^ 2^4.3100 1 2.2Total 46 100.0Note: 100mm visual analogue scale. Minimum score possible is 0 and maximum scorepossible is 100.60There was a significant positive correlation (rho=.61, p < .001) between uncertaintyand threat, indicating that higher uncertainty is associated with a higher perception of threat.Uncertainty and Positive Feelings The subjects were asked to identify any positive feelings associated with theiruncertainty. Over fifty percent (n=24) had positive feelings because of the uncertainty. Thelevel of positive feelings ranged from 0 to 94.-=33.7, SD=34.8). However, a large numberof the subjects (45.7%) had scores less than 10, indicating a low level of positive feelings(see Table XVII). There was a significant negative correlation (rho=-.33, p < .05) betweenuncertainty and positive feelings from the uncertainty. In other words, the higher theuncertainty, the lower the positive feelings.Table XVIIFrequency of Overall Positive Feelings Total Score^ Frequency^Percent0 - 9 21 45.7^10 - 19 1 2.220 - 29^ 0^ 0.030 - 39 1 2.240 - 49 6 13.050 - 59^ 3^ 6.560 - 69 5 10.870 - 79 1 2.280 - 89^ 3^ 6.590 - 99 5 10.8100 0 0.0Total^ 46^ 100.0Note: 100mm visual analogue scale. Minimum score possible is 0 and maximum scorepossible is 10061The Seriousness of Gestational DiabetesWith the use of a visual analogue scale, subjects were asked to indicate how seriousthey considered gestational diabetes to be for their pregnancy. The score ranged from 0 to100 (M=64.7, SD=20.3). The majority or 63 percent, had a seriousness level of above 60,indicating they assessed gestational diabetes as being fairly serious (see Table XVIII). Therewas a significant positive correlation (rho=.41, p < .01) between uncertainty and theseriousness of gestational diabetes. In other words, the higher the uncertainty, the moreserious the diabetes was for the subject and the lower the uncertainty, the less serious thediabetes was for the subject.Table XVIIIFrequency of the Seriousness of Gestational Diabetes: Visual Analogue Score^ Frequency^Percent0 - 9 2 4.310 - 19 0 020 - 29^ 0^ 030 - 39 1 2.240 - 49 3 6.550 - 59^ 12^26.060 - 69 7 15.270 - 79 8 17.380 - 89^ 10^21.390 - 99 1 2.2100 2 4.3Total^ 46^100.0Note: 100mm visual analogue scale. Minimum score possible is 0 and maximum scorepossible is 100.Uncertainty and Sample Characteristics The Spearman rho rank correlation coefficient was used to examine relationshipsbetween uncertainty and the number of weeks gestation and uncertainty and age. There was a62significant negative (rho=-.30, p < .05) relationship between uncertainty and the weeksgestation. That is, women at a greater gestational age appeared to have lower levels ofuncertainty. Although not statistically significant (rho.-.16, p < .13), it is interesting to notethat as age went up, uncertainty was less. There was no increase in uncertainty in those whohad had a previous pregnancy loss or those who had a family history of diabetes.Additionally, there were no significant relationships between uncertainty and marital status,uncertainty and educational level, uncertainty and occupation, and uncertainty and otherpregnancies.Coping and Sample Characteristics The Spearman rho rank correlation coefficient was used to examine relationshipsbetween coping styles and number of weeks gestation and coping styles and age. There wasa significant negative relationship (rho=-.29, p < .05) between the frequency of use of copingstrategies and the number of weeks gestation. There was also a significant negativerelationship (rho=-.27, p < .05) between the effectiveness of coping strategies and the numberof weeks gestation. In other words, as the pregnancy progressed the subject used less copingstrategies and also found the ones she did use less effective. There was not a significantrelationship between age and coping.Number of Weeks Gestation, Uncertainty and CopingBivariate relationships were evident between uncertainty and gestational age anduncertainty and the frequency of total use of coping strategies. In order to examine thecombination, gestational age was recoded into groups according to early pregnancy (8 to 19weeks); second trimester (20 to 29 weeks); and third trimester (30 to 40 weeks). TheKruskal-Wallis 1-Way Anova was used to examine the relationships. Table XIX presents therelationships between gestational age, the total uncertainty score and the total use score for63each of the eight coping styles. There were no significant relationships, however, certaintrends are interesting to note.The subjects whose gestational age was between twenty and twenty-nine weeks hadthe highest mean uncertainty score (A =137.5). This gestational age group tended to useconfrontive, optimistic and supportant coping styles most often and palliative and evasiveleast often. Those women of earlier gestational age, (< 20 weeks) and those of the latergestational age (>30 weeks) had similar levels of uncertainty^=101.50, M=102.18),however, the use of coping styles differed. Those between eight and nineteen weeks gestationtended to use confrontive, optimistic, self-reliant and supportant coping styles the most.Those between thirty and forty weeks gestation tended to use confrontive, supportant andself-reliant coping styles the most. Optimistic coping styles were the least used.Table XIXGestational age, Coping and Uncertainty GestationalAgeUncertaintyMean Means of each Coping Stylesn 1 2 3 4 5 6 7 88 - 19 weeks 101.50 2 23 22 21 6 6 10 10 1420 - 29 weeks 137.50 10 20 14 16 5 6 9 9 1030 - 40 weeks 102.18 34 18 12 17 4 5 7 8 11Note: Maximum coping score possible: Confrontive (1)=30,Evasive (2)=39, Optimistic (3)=27, Fatalistic (4)=12,Emotive (5)=15, Palliative (6)=21, Supportant (7)=15,Self-Reliant (8)=21.Note: Uncertainty score from 1 to 56. Minimum score possible is 56 and maximum scorepossible is 280.64Discussion The discussion of the results will take place under five major headings: samplecharacteristics, uncertainty, coping strategies, the relationship between uncertainty and copingstrategies, and the ancillary findings. The results will also be discussed in relation tomethodological problems inherent in the study.Characteristics of the Sample The sample for this study fits reasonably well with samples described in other studiesof gestational diabetes. The mean age of women at the time of data collection was 31.6, witha range of 21 to 37 years. Zigrossi and Riga-Ziegler (1986) established a mean age of 29.5in their study of stress and gestational diabetes. The Spirito et al. (1989) study revealed anaverage age of 28.5 years in their work on the psychological impact of gestational diabetes.Further, Kitsmiller et al. (1988) noted that 79% of women with gestational diabetes were overthe age of 25. In this study 97% were over the age of 25.No statistics are available with which to compare education level or occupation.However, the sample appears to be quite highly educated (68% college education or higher),and the majority were in a professional category of employment. In addition, as theeducation level and occupation status is unknown for those who did not return thequestionnaires, it is difficult to establish the representativeness of the sample in terms of thesevariables.With respect to gestational age at the time of diagnosis, the sample is representative.Current recommendation is that all pregnant women be screened for gestational diabetesbetween 24 and 28 weeks gestation. Considering an average lag time of two weeks fromscreening to the diagnostic test and allowing for time to obtain an appointment with the65diabetes clinic, the average gestational age at the time of participating in the study of 31weeks is reasonably representative.One of the risk factors for gestational diabetes is a family history of diabetes(Dickinson and Palmer, 1990), so the number of women with relatives with diabetes (58%)appears representative of the population of gestational diabetics. As one of the inclusioncriteria in the study was that the woman have no other pregnancy complication, it is notsurprising that few (13%) women completed that particular question. Of those who did, thecomplications appear either time limited or relatively minor and of little consequence to thestudy results.The small sample size and the convenience method of sampling may have resulted ina sample that is not truly representative of the population of women with gestational diabeteswithin the province. However, it is likely that the sample is reasonably representative inrespect to age, number of weeks gestation and family history of diabetes. The response rateof 64% indicates a reasonably good rate, however, it is unknown whether the nonrespondersdiffered from responders in significant ways.Uncertainty In the following section, the perceived level of uncertainty of women with gestationaldiabetes is discussed and possible reasons for the variability in perceived uncertainty arepresented. Findings in the literature and theoretical expectations are related to the areas ofuncertainty experienced by women with gestational diabetes. Finally, difficulties related tothe use of the USS-HRPV are presented.The results indicate that this sample of women perceived moderately low levels ofuncertainty with a mean score of 109.6 (maximum possible was 280). Whereas 56.5% of the66subjects had uncertainty scores below the mean, indicating quite low levels of uncertainty,19.6% had scores above 135, indicating fairly high levels of uncertainty.There were no studies found in the literature that measured uncertainty in gestationaldiabetics. However, a current study by Clauson (1992) used the same scale in measuring theperceived levels of uncertainty in women hospitalized with a high-risk pregnancy. Herpreliminary results indicated that pregnant women, when initially hospitalized, had moderatelylow levels of uncertainty with a mean score of 113.9. This is a similar level of uncertainty tothe findings of this study. When the pregnant women were discharged home the perceiveduncertainty level was reduced to 95.6. Items which generated the most uncertainty were:what caused her condition; the baby's chances to be healthy: how long the symptoms wouldlast; and the cause of the symptoms. In contrast, this study indicated that the mostuncertainty was generated by concerns around the baby's health. Relatively little uncertaintywas perceived concerning the cause of the symptoms or the cause of gestational diabetes.The different ranking of uncertainty items for this study may be due to the intensiveeducation sessions each subject has had on the causes and the predictability of gestationaldiabetes.Ford's (1989) study on uncertainty for biological valve patients (USS 52-item version),rated not being able to foretell the future in terms of symptoms and outcomes generated thehighest level of uncertainty. The mean uncertainty score was 111.7 (maximum=260).Swanson's (1991) study on uncertainty (USS 60-item version) and long-term kidneytransplant patients also determined that uncertainty was generated primarily by theindeterminateness of the situation. The five items which generated the highest uncertaintywere those that related to not knowing the future and feeling that the future outcome of their67illness was unpredictable. The mean uncertainty score was also moderately low at 103.3(maximum=300).According to the theoretical framework used in this study, uncertainty occurs insituations where the person is unable to assign definitive value to events or objects and/or isunable to predict outcomes accurately. The event examined in this study was the diagnosis ofgestational diabetes in women who otherwise had no pregnancy complications or otherchronic diseases.Since pregnancy itself creates an uncertain state, one would expect the level ofuncertainty to be higher for this population. Further, uncertainty increases when the symptompattern is difficult to interpret. For women with gestational diabetes the symptoms may bevague and difficult to discern from pregnancy symptoms (fatigue, hunger, increasedurination). The moderately low levels of uncertainty in this population may be explained bythe sample being unable to distinguish between the uncertainty generated by the gestationaldiabetes and the uncertainty generated by pregnancy. Hence, lower levels of uncertaintyrelated to the gestational diabetes may reflect higher levels of uncertainty related to pregnancyin general. Until a normative study of pregnancy and uncertainty is done, differentiationbetween the uncertainty generated by high-risk conditions of pregnancy and the uncertaintygenerated by pregnancy is difficult. However, for those women with gestational diabetes whodo have recognizable symptoms, the diagnosis of gestational diabetes may alleviate theirconcern by identifying the problem and hence decrease uncertainty.Event familiarity may be particularly pertinent since three quarters of the sample wereexperiencing pregnancy for the first time and had no prior experience to draw upon.Sorenson (1990) noted that when a woman lacks event familiarity they may draw on familiar,nonpregnant experiences. Although the pregnancy may have been unfamiliar, the majority of68the women in the sample had relatives with diabetes. Familiarity with diabetes in generalmay have led to a lessened perception of uncertainty. In this study there was not a significantrelationship between level of uncertainty and a family history of diabetes.Event congruence refers to consistency between the expected and the experiencedevent. For these women, gestational diabetes was not an expected event and one wouldtherefore expect uncertainty to be evident. One explanation for the low level of uncertaintymay lie in the time lag between the teaching session and the completion of the questionnaires.It is reasonable to expect that the uncertainty related to gestational diabetes would have beenhigher had the women filled out the questionnaires at the time of diagnosis. Indeed, two ofthe subjects noted on their questionnaire that they were "no longer feeling as stressed". Thisnotion is supported by the study by Spirito et al. (1989) which noted that being informed ofgestational diabetes had a relatively short-lived negative impact on the pregnant woman.Another reason for the moderately low levels of uncertainty may be the difference inthe woman's sense of well-being following initial treatment of diabetes. Women withgestational diabetes often comment that they didn't know they were feeling ill until theystarted to feel better as a result of nutritional counselling. Further, with the use of homeblood glucose monitoring, the women can continuously assess their blood glucose levels, thuspossibly reducing the uncertainty, particularly if their blood glucose levels are within thenormal range or respond to dietary management. The level of uncertainty in this study issimilar to the levels of uncertainty in Ford's (1989) study on biological valve patients andSwanson's (1991) study on long-term kidney transplant patients. Both researcher's state thatone of the reasons for the moderately low levels of uncertainty in their samples could be dueto the enhanced state of health following treatment.69Another explanation for the low level of uncertainty may be a function of the structureproviders. These are the individual's education level, social support and credible authority.Uncertainty can be rapidly modified by those with a higher education level and is positivelyinfluenced by those with supportive others. The study population had high levels ofeducation (all but one greater than high school) and almost all were married. Althoughmarriage is no guarantee that emotional support is provided, another form of support mighthave been available for the women with gestational diabetes through interaction with otherwomen with gestational diabetes at the weekly follow-up clinics. Sorenson (1990) noted thatsupportive others offer information and validation for the pregnant woman and thus mayalleviate uncertainty.Uncertainty is also indirectly influenced by the provision of information by health careprofessionals on the symptom pattern and consequences. The level of uncertainty perceivedby this sample may be lower than expected because each woman had had at least a two hourinformation session with the diabetes clinic staff designed to alleviate stress and provideinformation. Appendix I provides an outline of topics covered in the initial two hour teachingsession. Additionally, each woman had had various information/teaching sessions with herprimary physician. Women with gestational diabetes are also encouraged to call in if theyhave any concerns or questions about their condition which may in turn assist in lowering thelevels of uncertainty. The items on the uncertainty scale which elicited the least amount ofuncertainty referred to confidence in the health care workers. For example, the second leastused item was uncertainty "about my doctor's abilities".Although the majority of the sample had fairly low levels of uncertainty, somesubjects did indicate moderate to high levels of uncertainty. One of the reasons that higherlevels of uncertainty were perceived may be related to cognitive considerations. Mishel70(1984) noted that the ability to perceive stimuli can be impeded by information overload,limited cognitive capacity, presence of pain, drugs or a poor nutritional status. Sorenson(1990) noted that a "wide variety of cognitive impairments frequently occur duringpregnancy" (p. 192). She noted that the chronic fatigue associated with pregnancy mayactually impede cognitive capacity. It is implied that all of these factors may increase theperceived uncertainty by interfering with the ability to process information.Another reason for those with higher levels of uncertainty may be related to theirblood glucose status. It is reasonable to expect that women who have higher levels of bloodglucose may experience more uncertainty as the course and treatment of their condition maybe more complicated. Insulin therapy has been noted by Zigrossi and Riga-Ziegler (1986) tobe particularly stressful for women with gestational diabetes. Hence, women with higherblood glucose levels may experience increased levels of uncertainty as they are not sure ifinsulin therapy will be recommended for them. This is supported by the high rating the itemsrelating to symptoms had on the uncertainty scale. This indicates that some of the uncertaintyexperienced by women with gestational diabetes is generated by not knowing what symptomsmean in terms of the diabetes. This confirms this researcher's clinical experience that womenwith gestational diabetes attribute symptoms to the diabetes when they may well be related tothe pregnant condition instead.The items which elicited the highest uncertainty were related to concern about thehealth of the baby. This is not surprising as Rubin (1984), cited 'safe passage' as one of thematernal tasks of pregnancy. The majority of the sample were in the second and thirdtrimester (mean gestation age=31.2 weeks). Safe passage during this gestational age isreflected in the pregnant woman becoming increasingly "aware of child within her andattaching so much value" (p. 54). Further, the concern is directed towards "dangers within71and external to her body" (p. 57). Also, the structure of the teaching on gestational diabetesis aimed at minimizing risk to the baby, so it is not surprising that two of the respondentsindicated how concerned they were by adding comments to their questionnaires -- "I'mworried about my baby's health" and "I just hope the baby will be O.K.".The version of the USS used in this study (HRPV) had an internal consistencyreliability of .97 indicating excellent reliability. Two subjects, however, commented ondifficulties interpreting scale items. One comment related to the use of the term 'doctors' as"I have four doctors--which ones do you mean". Another objected to the term 'condition'since "pregnancy is my condition--diabetes is my disease". One of the problems inherent inthe scale is that it is difficult to distinguish between pregnancy as the uncertain state and thegestational diabetes as the uncertain state. Administering the scale to a normative populationof pregnant women may help alleviate some of this confusion.Coping Strategies The study sample used all of the coping styles at various times, however two copingstyles; optimistic and confrontive; were chosen most often, these were followed in order bythe use of supportant, self-reliant, fatalistic, emotive, palliative and evasive coping styles.Optimistic coping styles are the strategies which emphasize a positive outlook, positivethinking, and positive comparisons. Confrontive coping strategies are ones which face up toor confront the problem and include constructive problem-solving techniques. It is feasiblethat the increased use of these types of strategies in the study sample relate to what Lazarus(1966) noted concerning the implications of a perceived threat. When a situation isambiguous or uncertain, vagueness results as to what can be done about the event. When thethreat can be localized and clear direction given, as in gestational diabetes, strategies arechosen based on anticipated effectiveness. The choice of coping strategies such as "tried to72keep the situation under control", "tried to find out more about the problem" and "tried tothink positively" illustrate this construct. The confrontive coping strategy of "trying to findout more about the problem" was ranked as the single most effective coping strategy.Supportant coping strategies were the third most frequently chosen style and wereranked as third most effective. This style of coping relates to using support systems;personal, professional and spiritual. This is a similar finding to the Davis and Dearman(1991) study on the coping strategies of infertile women. That study found that depending onfamily and viewing the situation as God's will assisted in coping with the situation ofinfertility. In this study "talking the problem over with family and friends" was the highestrated supportant coping strategy (ranked 2 overall for use and ranked 5 for effectiveness). Inother words, pregnant women would rather seek out advice from others than rely on their ownselves. This phenomena is supported by Rubin (1984), who noted that in the second trimesterpregnant women will seek out prenatal care and information in every form available, such asbooks, magazines, nurses, neighbors etc.Self-reliant coping strategies are ones which illustrate a dependence on self rather thanothers. These strategies are aimed at maintaining a sense of control over the situation and thefeelings generated by the situation. Clarke (1984) noted that when individuals see theirability to cope as greater than the demand placed on them by the situation, a greater sense ofcontrol will ensue and a positive outlook is likely. The most frequently chosen self-reliantcoping strategy for subjects in this study was "thought about how you had handled otherproblems in the past" (ranked 11 overall). The most effective self-reliant coping strategy was"told yourself you could handle anything no matter how hard" (ranked 16 overall).Palliative, fatalistic, emotive and evasive coping styles were the least used and overallthe least effective for alleviating stress in this sample. These are reasonably close to what73Cohen and Lazarus (1979) call the intrapsychic processes or what are traditionally thought ofas defense mechanisms of denial, intellectualization, avoidance and detachment. When littlecan be done directly by the patient, these modes aid in providing structure to the situation.Thus "accepting the situation because little could be done" which was a highly chosen(ranked 4) coping strategy is reasonable for this population who are awaiting the outcome oftheir pregnancy.The least used and the least effective coping strategy related to drinking as a methodof making oneself feel better. This is not surprising in light of the evidence linking alcoholto adverse fetal outcomes. The majority of women in the sample were highly educated andthus could be expected to be cognizant of things which would jeopardize their baby's health.It is also feasible that since it is increasingly socially unacceptable to drink during pregnancy,that those who did choose to use this strategy did not admit it.Lazarus and Folkman's (1984) theory on coping states that coping efforts are generallyeither problem-focused or emotion-focused. Problem-focused efforts are likely to be chosenwhen the threat itself is appraised as being changeable and emotion-focused when the threat isappraised as being unchangeable. In Jaloweic's scale, the confrontive coping style is clearlyproblem-focused. The optimistic, fatalistic, supportant and self-reliant coping styles are amix, and the evasive, emotive and palliative coping are clearly emotion-focused. Given thetime-limited nature of pregnancy, the concrete direction for management of gestationaldiabetes, and the frequency of support available through follow-up clinics, it is not surprisingthat women with gestational diabetes most frequently chose problem-focused strategies.The findings of the reliability analysis are supportive of the internal consistency of theJaloweic Coping Scale, however, the low alpha coefficients for some subscales bearconsideration. The eight coping factors had internal consistencies ranging from .32 to .86 on74the use scale and .46 to .85 on the effectiveness scale. According to the alpha reliabilities thefatalistic, emotive and supportant use subscales were not satisfactory with alphas less than.70. The emotive, palliative and supportant effectiveness subscales were not satisfactory withalphas less than .70. This is similar to data reported by Jaloweic (1991) where the alphas forfatalistic, emotive, palliative and supportant use subscales were less than .70 and the alphasfor optimistic, fatalistic, emotive, palliative, supportant and self-reliant effectiveness subscaleswere unsatisfactory with alphas less than .70. It is possible that the lower alphas represent anambiguous interpretation or that there are more types of coping than previously thought.Relationship between Uncertainty and Coping Strategies According to the theoretical framework used in this study, uncertainty is a neutral stateuntil it is appraised. Uncertainty essentially is a decision about a situation. How the situationis appraised, either as a danger or as an opportunity, influences the choice of copingstrategies. Mishel and Sorenson (1991) noted that when uncertainty is appraised as anopportunity, problem-focused coping efforts are expected to be used since the opportunityappraisal indicates that more than one response is possible. When uncertainty is appraised asa danger, emotion-focused coping efforts are expected to be used since the danger appraisalindicates that the situation is unmanageable with the individual's self-control efforts. For thissample of women with gestational diabetes, uncertainty was appraised as both an opportunityand as a danger.In this study, significant positive correlations were found between uncertainty and theuse of particular coping styles. Specifically, higher uncertainty was associated with the use offatalistic, evasive and self-reliant coping styles.Fatalistic coping strategies are pessimistic in nature and relate to the buffering methodof coping which arises from illusion appraisal. They are emotion focused in that the subject75attempts to deal with the negative emotions by assuming a doubtful stance. In other words,when nothing can be done about the situation, the woman relies on fatalistic coping tomaintain her uncertainty. Mishel (1988) noted that maintenance of uncertainty is necessaryfor the opportunity appraisal to continue. Without opportunity appraisal the woman mustrecognize the negative situation and this in turn, destroys the possibility of a positiveoutcome. This notion is supported by Barglow et al.'s (1989) work on the psychologicalimpact of gestational diabetes. The study found that the majority of pregnant women adaptedreadily to the diagnosis of gestational diabetes and showed no increase in stress over thosewith chronic diabetes. However, Mishel (1984) found that women who were more uncertainand pessimistic had increased adjustment problems with the diagnosis of gynecologicalcancer.Evasive coping activities are avoidant in nature and also relate to the buffering methodof coping which arises from illusion appraisal. This relates to beliefs which enhance thepositive view of the situation but may not be based on reality. Thus, the women in thissample with higher uncertainty may have chosen to detach themselves emotionally from thetroubling situation through the use of avoidant strategies. The greater use of evasive copingmay be related to the woman with gestational diabetes focusing on the high possibility of apositive outcome or on misunderstanding the seriousness of the disorder. The last is unlikelysince the mean seriousness for the sample was moderately high^=64.7). Or, as uncertaintyincreases, the woman may experience less feelings of control over the situation and thus useavoidant strategies to deal with the emotional distress.There was a positive correlation between the use of self-reliant coping and uncertainty.These coping methods are ones where the individual attempts to increase one's sense ofcontrol and regulate one's feelings and, as such, are closest to the affect-managing method of76coping which arises from inference appraisal. The use of these efforts may be related to thewoman trying to increase her sense of control over the situation by relying on herself ratherthan others. The women in this sample had access to information and support providersconcerning their gestational diabetes. Those with higher levels of uncertainty might not havebeen able to find access to the resources or may not have found the resources appropriate forthem.Ancillary Findings The subjects of this study perceived moderately low levels of stress related to theuncertainty^=89.3, SD=19.1). Swanson (1991) also noted a moderately low level of stressusing Version 3 of the USS (M=102.3, SD=42.7). Two studies were found which addressedthe stress of women with gestational diabetes. Barglow et al., (1989) noted that stress relatedto the diagnosis of gestational diabetes was quickly alleviated and postulated this was a resultof the self-limiting nature of the disorder. The study further found that contrary to clinicallore, the administration of insulin did not increase the stress for women with gestationaldiabetes. Zigrossi and Riga-Ziegler (1986) compared the stress of medical managementbetween women with gestational diabetes and those with chronic diabetes. Women withgestational diabetes were found to have increased stress related to invasive procedures such asinsulin administration and blood testing. Although the researchers indicated that stress forwomen with gestational diabetes may be initially high, no measurements were taken.Therefore, what stress there is appears to be quickly reduced. There is conflicting evidenceabout the stress of invasive procedures in the management of gestational diabetes. It may bereasonable to expect that the time lag between diagnosis and administration of thequestionnaires created a false indication of stress for the gestational diabetic. This issupported by this researcher's clinical experience that women with gestational diabetes are77very stressed at the initial teaching session. Further, the findings indicate that the majority ofsubjects considered gestational diabetes moderately serious, yet the stress was moderately low.One could reasonably conclude that the level of stress was higher prior to nursing andmedical interventions.The study found that the subjects had overall low levels of threat =42.54) from theuncertainty. However, thirty five percent indicated fairly high levels of threat. This may berelated to fear that as the pregnancy progresses the diabetic condition may worsen.Swanson's (1991) study also indicated low levels of threat from the uncertainty^=24.8)related to long-term kidney transplant patients. No studies were identified which addressedthe threat women with gestational diabetes attribute to the threat of uncertainty.The findings indicate that just over half the women had positive feelings because ofthe uncertainty (52.2%). However, the level of positive feelings was quite low 1v =33.7%).No studies were found that evaluated the positive feelings associated with uncertainty inwomen with any condition of pregnancy. When a pregnant woman is diagnosed as having ahigh-risk condition of pregnancy, she (and her family) must cope with a number of concernsrelated to the course of the pregnancy, the outcome, and long-term consequences. It may bethat for women with gestational diabetes, the low level of positive feelings may be associatedwith fear of the future, specifically related to knowledge that they are at risk for thedevelopment of overt diabetes later in life.The subjects indicated that they considered gestational diabetes as being fairly serious64.7). Additionally, the higher the uncertainty, the higher the seriousness level. Nostudies were identified which outlined the perception of seriousness of gestational diabetes. Itmay be that women with gestational diabetes perceive the possible negative impact of the78disorder as quite high. Thus, if a woman considers gestational diabetes as a serious threat toher health or to the baby's health, her perception of uncertainty rises.Uncertainty was highest between twenty and twenty-nine weeks gestation. This groupalso tended to use problem-focused coping strategies in order to deal with the uncertainty.This is not surprising since it is at this gestational age that women focus on self and baby(Rubin, 1975). The use of problem-focused coping indicated that women with gestationaldiabetes perceive they have the ability to face up to the problem.Summary The sample consisted of 46 pregnant women with the diagnosis of gestational diabetesfor the first time. All women participated voluntarily in the study. The majority weremarried, had at least a high school education, and were employed. The average age was 31.7years and the average gestational age was 31.6 weeks. For the majority, this was their firstpregnancy. Additionally, the majority had a history of diabetes in their family. Overall, thewomen noted relatively moderate levels of uncertainty, however, there was variability in theirperceptions. The nature of the uncertainty appeared to be generated primarily by concernsover the baby's health. Possible reasons for the low levels of uncertainty included suchfactors as difficulty separating the uncertainty of pregnancy from the uncertainty inherent ingestational diabetes, familiarity with diabetes, time since education session, the resourcesavailable to the women and an improved sense of health from therapy. The high levels ofuncertainty perceived by some of the sample could be explained by factors such asinformation overload, fatigue related to pregnancy, and the blood glucose status. Overall,subjects used coping strategies from all eight coping styles identified by Jaloweic.Confrontive and optimistic coping styles were chosen most often. There appeared to be atendency to use problem-focused coping in dealing with the stress of gestational diabetes.79There were significant relationships between uncertainty and coping styles.Specifically, those with higher uncertainty tended to use evasive, fatalistic and self-reliantcoping methods.Women with gestational diabetes in this study perceived relatively low levels of stressand threat from the uncertainty. The findings indicated that subjects did find some positivefeelings associated with the uncertainty, but when measured, the positive feelings were ratherlow. The sample indicated that gestational diabetes was considered fairly serious. Women inthis sample who were in the gestational age group of twenty to twenty-nine weeks perceivedthe most uncertainty.80CHAPTER FIVESummary, Conclusions, Implications and RecommendationsIntroduction This study was designed to investigate the perceived level and nature of uncertaintyand the coping strategies used by women with gestational diabetes for the first time.Additionally, the study was designed to explore the relationship between uncertainty andcoping strategies in women with gestational diabetes. An overview of the study is presentedin this chapter followed by conclusions, implications for nursing practice, andrecommendations for future research.SummaryA review of the literature revealed that uncertainty is an important variable associatedwith physical illness (Mishel, 1984; Mishel, 1988; Hilton, 1988; Simurda, 1988; Swanson,1991). Uncertainty has also been reported as an inherent part of the pregnancy experience(Patterson, Freese & Goldenberg, 1986; Sorenson, 1990). However, no research was foundwhich addressed the uncertainty experienced by women with gestational diabetes nor howthey coped with the uncertainty. Furthermore, no research was located which looked at therelationship between levels of uncertainty and the type and nature of coping strategies used bywomen with gestational diabetes. The purpose of this study was to fill the gaps identified inthe literature and to further understand these phenomenan as they pertain to women withgestational diabetes.This descriptive correlational study was conducted in a large city in western Canada.Data were collected from a convenience sample of 46 subjects from a follow-up clinic at thetertiary maternity care hospital who met the criteria. The women were English speaking,81adult, free of chronic disease or other pregnancy complications, and experiencing gestationaldiabetes for the first time. Anonymity of researcher to subjects was maintained.All subjects completed Hilton's (1991) Uncertainty Stress Scale (High-Risk PregnancyVersion), the Jaloweic Coping Scale (1987 version) and a patient information sheet.Perceptions of uncertainty and the use of coping strategies were measured at only one point intime. The data were analyzed using descriptive and nonparametric statistics.The mean age of the gestational diabetics was 31.6 years. The majority of thesubjects were married (87%). Approximately half the subjects were currently employedoutside the home (52.2%), with a further 15% on maternity leave from their employment.The majority of the employed women were either employed in professional jobs or supportjobs. All but one of the sample had at least a high school education with 65% having collegeor university education.For the majority of the sample, this was their first pregnancy (67.4%). For those withchildren, most had only one other child (87%). Thirty percent of the women had had aprevious pregnancy loss. The mean gestational age was 31.2 weeks. The majority of thesample had relatives with diabetes (58%).Overall, the woman with gestational diabetes perceived relatively low levels ofuncertainty as measured by the USS-HRPV. These findings support research on theuncertainty experienced by women hospitalized with a high-risk condition of pregnancy andthe uncertainty experienced by long-term kidney transplant patients and biological valveimplant patients.The moderately low levels of uncertainty may be explained by pregnancy itself beingan uncertain event and the sample may not have been able to distinguish between theuncertainty of pregnancy itself and the uncertainty experienced as a result of gestational82diabetes. Additional reasons for the lower than expected level of uncertainty includefamiliarity with diabetes in general, the length of time passed since diagnosis, the nature ofthe resources available, and an improved sense of health from therapy. While the majority ofthe sample experienced relatively low levels of uncertainty, some subjects had moderate tohigh levels of uncertainty. The higher levels of uncertainty may be associated with suchfactors as information overload, fatigue interfering with cognitive capacity and the woman'sblood glucose status.Findings indicated that women with gestational diabetes use a wide variety of copingstrategies to deal with the uncertainty and stress of having a high-risk pregnancycomplication. Optimistic and confrontive coping styles were used most often. Generally,problem-focused methods of coping, which are used when the threat is appraised as beingchangeable were used the most. Emotion-focused coping efforts, such as evasive, palliativeand emotive were used the least. Not surprisingly, the most frequently used coping strategiesfocused on gathering information.The findings suggested significant positive relationships between uncertainty andcoping styles. Specifically, the use of evasive, fatalistic and self-reliant coping styles wereassociated with higher levels of uncertainty in women with gestational diabetes. Generally,with higher levels of uncertainty, there were greater use of emotion-focused coping styles.Mishel's (1984, 1988) theory of uncertainty was utilized to explain the relationshipbetween uncertainty and coping. In this theory, there are two appraisal processes which areused to evaluate the uncertainty -- inference and illusion. The inference appraisal refers tothe appraisal of uncertainty based on past examples. If the inference is seen as positive, thenthe uncertainty is evaluated as an opportunity and coping efforts will be employed to maintainthe uncertainty. If the inference is seen as negative, then the uncertainty is evaluated as a83danger and coping efforts will be employed to reduce the uncertainty. The illusion processrefers to the appraisal of uncertainty based on beliefs with generally a positive outlook.Uncertainty is then seen as an opportunity and coping efforts will be used which maintain theuncertainty. According to Mishel (1988), mobilizing techniques and affect managingtechniques reduce the uncertainty from a danger appraisal. Buffering methods are used tomaintain the uncertainty from an opportunity appraisal. In this sample, uncertainty wasappraised as both a danger and an opportunity. Those with a higher perception of uncertaintyused buffering methods (evasive and fatalistic) to maintain the uncertainty andaffect-managing methods (self-reliant coping style) to reduce the uncertainty.Women with gestational diabetes perceived relatively low levels of stress generated bytheir uncertainty. This is consistent with other research that as uncertainty rises, so does theperception of stress. Overall, women with gestational diabetes perceived relatively low levelsof positive feelings from their uncertainty. However, the sample also rated the seriousness ofgestational diabetes as fairly high.Conclusions Due to the convenience method of sampling and the small sample size, the results ofthis study cannot be generalized. However, the findings of this study suggest somesimilarities, differences and trends among subjects. The following conclusions are based onthe findings of this study.Overall, women with gestational diabetes perceive moderately low levels ofuncertainty. The nature of the uncertainty seems to be generated primarily by concerns overthe baby's health and concerns over her own symptoms. Those in the middle part of theirpregnancy (20 - 29 weeks) seem more uncertain than those in the earlier or later part of theirpregnancy. Women with gestational diabetes use various coping efforts to manage the84uncertainty generated by having gestational diabetes. The strategies used relate to bothproblem-focused and emotion-focused types of coping. Optimistic and confrontive copingstrategies appear to be used the most by women with gestational diabetes. This may relate tothe subjects being able to localize the threat and identify that there is something constructivewhich can be done.Associations exist between uncertainty and the use of coping strategies. Higheruncertainty appears to be associated with the use of emotion-focused coping styles such asfatalistic, evasive and self-reliant coping. This may suggest that women with gestationaldiabetes who have higher levels of uncertainty appraise the threat as being unchangeable andhence choose strategies that deal with the resultant emotional distress.Maternal age and a family history of diabetes does not appear to be a significantfactor in the level of uncertainty or the use of coping strategies for this population. Therewas a trend for those of later gestational age to use fewer coping strategies.Implications The findings of this study are not generalizable, however, important implications fornursing practice, theory, and education are evident. This section presents the implications fornursing practice, theory, and education.Nurses need to gain a broader understanding of the experience of women withgestational diabetes in order to provide thorough consistent nursing care. Although manywomen have low uncertainty, this study found a significant number who had moderately highuncertainty levels. Therefore, an understanding of the factors which influence the woman'sexperience will assist the nurse in planning and implementing interventions which lessen thewoman's stress and increase her understanding.85Nurses are closely involved with the teaching and counselling of women withgestational diabetes both in the outpatient setting and the hospital environment. A thoroughindividualized assessment is needed to identify the degree and nature of uncertainty for thesepatients. When uncertainty is generated by misconceptions or a lack of clarity, patienteducation can be used to reduce the uncertainty. This study showed that most uncertaintywas generated by fears for the baby's health and/or concern about her own symptoms ofdiabetes. Providing a forum to talk about these concerns and/or providing information mayalleviate some of the uncertainty. Patient education material such as pamphlets or posterscould be generated which explain the nature of symptoms of diabetes. These could be usedas assessment tools for the nurse to identify which symptoms are of concern to the woman.Again, misconceptions or lack of information could easily be addressed in a short teachingsession.This study indicated that some women with gestational diabetes viewed uncertainty asan opportunity. This viewpoint may be necessary for the patient to maintain a hopefulperspective. Nurses would then need to assess those aspects which the woman sees aspositive and aid in restructuring those aspects not based on reality. This could be done by thenurse exploring with the patient what the patient's view is on how gestational diabetes has animpact on her pregnancy, her health, her family situation and her lifestyle behaviors. Positiveaspects of gestational diabetes could be emphasized, such as the increased knowledge aboutnutrition which can be an asset for the entire family, and may, decrease the woman's chanceof developing Type II diabetes later in life.This study indicated that the use of confrontive and optimistic coping efforts werehelpful for this population. The use of these constructive-problem solving techniques andpositive comparisons should be encouraged by nurses. Nurses need to assess both real and86potential coping efforts in order to enhance and support patient efforts. When the copingstrategy is deemed inefficient, exploration with the patient as to alternative strategies shouldbe done.The use of supportant coping strategies also appeared to be useful for this population.These efforts could be enhanced through the establishment of a support group made up ofother women with gestational diabetes (either currently pregnant or already delivered).Alternatively, the woman newly diagnosed with gestational diabetes could be given phonenumbers of volunteer former patients who could be of assistance in working through some oftheir concerns.Nursing curricula need to be developed which incorporate the theories of uncertaintyand coping. Nursing students need a broad theoretical background and practical experience inassessment techniques, particularly those which relate to assessing the uncertainty and copingstrategies used in the high-risk pregnancy condition of gestational diabetes. A simplescreening tool, such as a ten centimetre visual analogue scale, could be used to identify thosewith high levels of uncertainty. Those who indicate a higher level of uncertainty (over 7)would then complete a more detailed questionnaire. From this, it would be possible toidentify what areas the subjects are most uncertain about and then develop nursinginterventions to modify the uncertainty.Finally, the theoretical frameworks used to guide this study helped provide directionfor understanding the relationships between coping, uncertainty and the childbearingexperience. The model of uncertainty as developed by Mishel (1984, 1988), is useful inidentifying areas that are antecedents of uncertainty and hence could be applicable inmodifying uncertainty by developing nursing interventions designed to reduce or restructureuncertainty. Understanding the implications of uncertainty on coping strategies aids in87assessing the usefulness of coping efforts. Further, greater use and understanding of thewhole childbearing experience as outlined in Snyder's (1979) model could aid nurses in theprovision of nursing care to these groups of patients.Recommendations for Further Research Findings of this study suggest ideas for further research in a number of areas.1) Given the small sample size and the convenience method of sampling, this studyshould be replicated to substantiate and further identify relationships betweenuncertainty and coping.2) Since uncertainty and coping were measured at only one point in time, it was notpossible to measure changes in the perception of uncertainty or of coping for thispopulation. A prospective study would provide a more thorough assessment ofthe uncertainty experienced by women with gestational diabetes over time and thecoping processes used to manage the uncertainty. Uncertainty and copingstrategies could be measured at three points in time: when first diagnosed, twoweeks after the start of treatment and one week postpartum.3) The moderately low levels of uncertainty experienced by women with gestationaldiabetes may have been related to inability to distinguish between the uncertaintyof gestational diabetes and the uncertainty of pregnancy. The uncertaintyinstrument should be administered to a large sample of pregnant women withoutpregnancy complications in order to identify the 'normal' levels of uncertainty inpregnant women.4) The same can be said of the coping scale. To this researcher's knowledge, thescale has not been administered to a normative group of pregnant women. Thiswould be helpful in establishing the parameters of coping in a population without88pregnancy complications and may aid in identifying strategies which could assistthose with complications in coping with the situation.5) Further investigation using qualitative research may identify other uncertaintieswomen with gestational diabetes may be experiencing. This would not only beuseful in confirming the degree and nature of uncertainty but could also aid inexploring the impact that uncertainty has on their childbearing experience.6) The sample for this study were all English speaking. It is important to determinethe level of uncertainty and the coping strategies used in other cultural groups.To do this, the instruments would need to be translated into a variety oflanguages. However, this information would enrich our knowledge of uncertaintyand coping and may assist in addressing the needs of a group of patients whooften are excluded from studies on the basis of language.7) Subjects in this study were quite highly educated. This population may be biasedtowards participating in studies. It is not known how the non-responders differedfrom the responders. Those of a lower educational level may have had difficultyunderstanding the purpose of the study and the instruments used. Data collectioninstruments could be simplified to encourage participation.8) Neither of the data collection instruments addressed the uncertainties or copingstrategies of the families. Since the family system can have a profound impact onthe childbearing experience, it is important to assess the uncertainty experiencedby the family members, particularly the father of the infant. This could be doneby administering a revised version of the USS-HRPV to concerned familymembers.899) Subjects in this study experienced either high levels of uncertainty or low levelsof. uncertainty. In-depth interviews with those on either end of the scale mayelicit information which would help to better understand the impact uncertaintyhas on the high-risk condition of gestational diabetes.In conclusion, it is this researcher's hope that further research is conducted whichcontributes to expanding the body of nursing knowledge about the degree and nature ofuncertainty and the coping strategies used by women with gestational diabetes, and byindividuals with other illnesses or conditions of pregnancy.90ReferencesArmstrong,N.(1987). Coping with diabetes mellitus. Nursing Clinics of North America,22, (3), 559-568.Barglow, P., Hatcher, R., Berndt, D., & Phelps, R. (1985). Psychosocial childbearing stressand metabolic control in pregnant diabetics. 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Research inNursing and Health, 3, 107-113.Hilton, B. A. (1987). Coping with the uncertainties of breast cancer: Appraisal and copingstrategies. Ann Arbor, MI: University Microfilms International. No. 87-00, 205.Hilton, B. A. (1988a). The phenomenon of uncertainty in women with breast cancer. Issuesin Mental Health Nursing, 9, 217-238.Hilton, B.A. (1988b). The development and psychometric testing of the Uncertainty Stress Scale. Unpublished manuscript.Hilton, B. A. (1989). The relationship of uncertainty, control, commitment, and threat ofrecurrence to coping strategies used by women diagnosed with breast cancer. Journalof Behavioral Medicine, 12 (1), 39-54.Hilton, B.A. (1991a). The uncertainty stress scale - High-risk pregnancy version. Unpublishedmanuscript.Hilton, B.A. (1991b). The predictive value of the uncertainty stress scale in womendiagnosed with a suspicious breast lump. Unpublished manuscript.Jalowiec, A. (1985). Updated psychometric information on the Jalowiec coping scale. 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New York: Springer.Ruggiero, L., Spirito, A., Bond, A., Coustan, D., & McGarvey, S. (1990). Impact of socialsupport and stress on compliance: Women with gestational diabetes. Diabetes Care, 12, (4), 441-443.Simurda, L. (1988). Differences in uncertainty and quality of life between primary andreoperation coronary artery bypass patients. Unpublished master's thesis, Universityof British Columbia, Vancouver.Sorenson, D.L. (1990). Uncertainty in pregnancy. NAACOGS Clinical Issues in Perinatal and Women's Health Nursing, 1, (3),289-296.Snyder, D., (1979). The high-risk mother viewed in relation to a holistic model of thechildbearing experience. Journal of Obstetric, Gynecologic and Neonatal Nursing, May/June, 164-170.Spirito, A., Williams, C., Ruggiero, L., Bond, A., McGarvey, S. T., & Coustan, D. (1989).Psychological impact of the diagnosis of gestational diabetes. Obstetrics and Gynecology, 73, (4), 562-566.Swanson, R. (1991). The relationship between uncertainty and coping strategies used bylong-term kidney transplant patients. Unpublished master's thesis. University ofBritish Columbia.Weitz, R. (1989). Uncertainty in the lives of persons with AIDS. Journal of Health andSocial Behavior, 10, 270-281.White, M., & Ritchie, J., (1984). Psychological stressors in antepartum hospitalization:Reports from pregnant women. Maternal Child Nursing, 13, (1), 47-56.94Wineman, N. (1990). Adaptation to multiple sclerosis: The role of social support, functionaldisability, and perceived uncertainty. Nursing Research, 39 (5), 294-299.Wohlreich, M. (1986). Psychiatric aspects of high-risk pregnancy. Psychiatric Clinics ofNorth America, 10 (1), 53-68.Yarcheski, A. (1988). Uncertainty in illness and the future. Western Journal of Nursing Research, 10, (4), 401-403.Zigrossi, S. T., & Riga-Ziegler, M. (1986). The stress of medical management on pregnantdiabetics. Maternal-Child Nursing Journal, 11 320-323.Appendix AUncertainty Stress Scale--High-Risk Pregnancy Version9596UNCERTAINTY STRESS SCALEHIGH-RISK PREGNANCY VERSIONPlease read the following statements. To the right of each statement you will see five columns labelledfrom 1 - No uncertainty to 5 - A great deal of uncertainty. Circle the number that most closelymeasures how you feel now about your uncertainties related to your high -risk condition.To the far right of each statement you will find three more columns of numbers. Circle the number inthe column that most closely reflects the degreee of stress you feel related to the uncertainty youidentified.Please respond to every statement. There are no "right" or "wrong" answers. If any question does notapply, and there is no uncertainty about it, please circle "No uncertainty".1) No uncertainty^1) No stress2) Some uncertainty 2) Some stress3) Moderate uncertainty^3) A great deal4) Considerable uncertainty^of stressI am uncertain:^ 5) A great deal of uncertainty1. whether changes in my condition will be detected early^2. about the stability of my condition^3. what caused my condition 4. whether I will be able to maintain my present level of functioning ^5. about the present state of my condition^6. what questions to ask my doctors about my condition^7. whether changing my lifestyle behaviours will help my condition(e.g. diet, activity, smoking, etc.) ^8. how to make sense of what I am told about my condition ^9. about the effectiveness of my treatments ^10. whether my condition is under control 11. whether my condition will cause me to have symptoms^12. what to say to others about my condition ^13. about differing explanations I have been given14. about my chances to be well during this pregnancy ^15. about my baby's chances to be healthy^16. whether my condition will be the same with the next pregnancy ^17. whether my symptoms can be controlled ^18. whether my condition will interfere with my ability to do myregular activities ^12345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 12312345 123971) No uncertainty^1) No stress2) Some uncertainty 2) Some stress3) Moderate uncertainty^3) A great deal4) Considerable uncertainty^of stressI am uncertain:^ 5) A great deal of uncertainty19. about my doctors' abilities ^20. how to manage my symptoms (e.g. bleeding, contractions, etc.) ....21. about choices I have made regarding my treatments^22. whether my condition will return in this pregnancy 23. about the adequacy of the follow-up I am having^24. about my understanding of the treatments I have receivedand am receiving ^25. how to approach health care workers about my care(e.g. nurses, doctors, social workers, dieticians) ^26. whether my condition risks my baby's life 27. whether my condition risks my life^28. whether my treatments eliminated my condition^29. whether changes in my pregnancy from normal to high-riskaffect my relationships within the family 30. whether changes in my pregnancy from normal to high-riskaffect my relationships outside my family^31. whether my condition will affect my life goals 32. whether what I am doing about my condition will help me^33. whether I can depend on test results as an indicator of my condition .34. whether my condition will affect my sex life ^35. whether delays in treatment will influence my baby's chances ^36. about the seriousness of my condition ^37. about my ability to handle my emotions related to my condition ^38. about the unpredictability of my symptoms^39. whether I will have difficulty coping with my condition^40. about the quality of the information I have ^41. how long my symptoms will last ^42. whether I am being told the truth about my condition ^1 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 312 3 4 5 12 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 343. whether I would choose to have all the treatments recommendedto me^44. what unusual symptoms mean in terms of my condition^1 2 3 4 5 1231 2 3 4 5 1 2 3981) No uncertainty^1) No stress2) Some uncertainty 2) Some stress3) Moderate uncertainty^3) A great deal4) Considerable uncertainty^of stressI am uncertain:^ 5) A great deal of uncertainty45. whether they might find something wrong when I go for a check-up(e.g. ultrasound, amniocentesis) ^46. whether I will be well cared for by the nurses^47. whether I will be well cared for by the health professionals otherthan nurses^48. about the cause of my symptoms^49. whether I can depend on people who are important to me to beto be there when I need them50. whether I can get insurance^51. whether I can manage financially because of my condition ^52. what symptoms I should be aware of^53. about how to choose the treatments I will have^54. whether my following the treatment plan recommended to mewill help ^55. what to look for to check the state of my condition^56. whether treatments I will be having will eliminate the condition ^The following five questions relate to levels of a particular feeling or perception. Please make a cross(x) on the line which best indicates your level right now.1. Overall, my uncertainty level about my situation is:0^ I 100No uncertainty^50 Very high uncertainty2. Overall, the stress I feel from my uncertainty is:0No stress^ 50100Very high stress3. Overall, the threat I feel from my uncertainty is:0  100No threat^ 50^Very high threatSome people find that uncertainty can have positive feelings (such as hope) associated with it becauseof the possibility that things will work out well.4. Do you have any positive feelings because of your uncertainty?Yes^No ^5. If yes, the level of my positive feelings is:0 ^ 100Very highpositive feelingsNo positivefeelings501 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 12 3^ 1 2 3 4 5 1 2 31 2 3 4 5 1 2 3^ 1 2 3 4 5 1 2 31 2 3 4 5 1 2 31 2 3 4 5 1231 2 3 4 5 1 2 31 2 3 4 5 1 2 3Appendix BJaloweic Coping Scale (1987 version)99PERMISSION FOR USE OF JCS100PERMISSION IS HEREBY GRANTED TOLenore RiddellTO USE THE JALOWIEC COPING SCALEIN A STUDY OR PROJECTANNE JALOWIEC, RN, PHDLOYOLA UNIVERSITY OF CHICAGODATE:^9/9/91CD 1977, 1987 Anne Jalowiec, PhD, RNJALOWIEC COPING SCALEThis questionnaire is about how you cope with stress and tension, and what you do tohandle stressful situations. In particular, I am interested in how you have coped with thestress of:This questionnaire lists many different ways of coping with stress. Some people use alot of different coping methods; some people use only a few.You will be asked two questions about each different way of coping with stress:101Study #Part AHow often have you used that coping method to handle the stress listed above?For each coping method listed, circle one number in Part A to show how often you haveused that method to cope with the stress listed above. The meaning of the numbers inPart A is as follows:0^never used1^seldom used2 = sometimes uses3 = often usedPart BIf you have used that coping method, how helpful was it In dealing with that stress?For each coping method that you have used, circle a number in Part B to show howhelpful that method was in coping with the stress listed above. The meaning of thenumbers in Part B is as follows:not helpfulslightly helpfulfairly helpfulvery helpfulIf you did not use a particular coping method, then do not circle any number InPart B for that coping method_0 =12 =3 =102COPING METHODSPart AHow often have you usedeach coping method?Never Seldom^Sometimes OftenUsed^Used^Used^UsedPart BIf you have usedthat coping method,how helpful was It?Not^Slightly^Fairly^VeryHelpful^Helpful^Helpful^Helpful1. Worried about the problem 0 1 2 3 0 1 2 32. Hoped that things would get better 0 1 2 3 0 1 2 33. Ate or smoked more than usual 0 1 2 3 0 1 2 34. Thought out different ways tohandle the situation 0 1 2 3 0 1 2 35. Told yourself that things could bemuch worse 0 1 2 3 0 1 2 36. Exercised or did some physicalactivity 0 1 2 3 0 1 2 37. Tried to get away from the problemfor a while 0 1 2 3 0 1 2 38. Got mad and let off steam 0 1 2 3 0 1 2 39. Expected the worst that couldhappen 0 1 2 3 0 1 2 310. Tried to put the problem out of yourmind and think of something else 0 1 2 3 0 1 2 311. Talked the problem over with familyor friends 0 1 2 3 0 1 2 312. Accepted the situation because verylittle could be done 0 1 2 3 0 1 2 313. -I vied to look at the problemobjectively and see all sides 0 1 2 3 0 1 2 314. Daydreamed about a better life 0 1 2 3i., 0 1 2 315. Talked the problem over with aprofessional person (such as adoctor, nurse, minister, teacher,counselor)0 1 2 3 0 1 2 316. Tried to keep the situation undercontrol 0 1 2 3 0 1 2 317. Prayed or put your trust in God 0 1 2 3 0 1 2 318. Tried to get out of the situation 0 1 2 3 0 1 2 319. Kept your feelings to yourself 0 1 2 3 0 1 2 320. Told yourself that the problem wassomeone else's fault 0 1 2 3 0 1 2 321. Waited to see what would happen 0 1 2 3 0 1 2 322. Wanted to be alone to think thingsout 0 1 2 3 0 1 2 323.^Resigned yourself to the situationbecause things looked hopeless 0 1 2 3 0 1 2 3103COPING METHODSPart AHow often have you usedeach coping method?Never^Seldom^Sometimes^OftenUsed^Used^Used^UsedPart BIf you have usedthat coping method,how helpful was ft?Not^Slightly^FairlyHelpful^Helpful^HelpfulVeryHelpful24. Took out your tensions on someoneelse 0 1 2 3 0 1 2 325. Tried to change the situation 0 1 2 3 0 1 2 326. Used relaxation techniques 0 1 2 3 0 -I-^- 327. Tried to find out more about theproblem 0 1 2 3 0 1 2 328. Slept more than usual 0 1 2 3 0 1 2 329. Tried to handle things one step at atime 0 1 2 3 0 1 2 330. Tried to keep your life as normal aspossible and not let the probleminterfere0 1 2 3 0 1 2 331. Thought about how you had handledother problems in the past 0 1 2 3 0 1 2 332. Told yourself not to worry becauseeverything would work out fine 0 1 2 3 0 1 2 333. Tried to work out a compromise 0 1 2 3 0 1 2 334. Took a drink to make yourself feelbetter 0 1 2 3 0 1 2 335. Let time take care of the problem 0 1 2 3 0 1 2 336^Tried to distract yourself by doingsomething that you enjoy 0 1 2 3 0 1 2 337. Told yourself that you could handleanything no matter how hard 0 1 2 3 0 1 2 338. Set up a plan of action 0 1 2 3 0 1 2 339. Tried to keep a sense of humor 0 1 2 3 0 1 2 340. Put off facing up to the problem 0 1 2 3 0 1 2 341. Tried to keep your feelings undercontrol 0 1 2 3 0 1 2 342. Talked the problem over withsomeone who had been in a similarsituation0 1 2 3 0 1 2 343.^Practiced in your mind what had tobe done 0 1 2 3 0 1 2 34. .^ Tried to keep busy 0 1 2 3 0 1 2 345. Learned something new in order todeal with the problem 0 1 2 3 0 1 2 346. Did something impulsive or riskythat you would not usually do 0 1 2 3,J 0 1 2 3104COPING METHODSPart AHow often have you usedeach coping method?Never^Seldom^Sometimes^OftenUsed^Used^Used^UsedPart BIf you have usedthat coping method,how helpful was it?^Not ^Slightly^Fairly^Helpful^Helpful^HelpfulVeryHelpful47. Thought about the good things inyour life 0 1 2 3 0 1 2 348. Tried to ignore or avoid the problem 0 1 2 3 0 1 2 349. Compared yourself with otherpeople who were in the samesituation0 1 2 3 0 1 2 350. Tried to think positively 0 1 2 3 0 1 2 351. Blamed yourself for getting intosuch a situation 0 1 2 3 0 1 2 352. Preferred- to work things out yourself 0 1 2 3 0 1 2 353. Took medications to reduce tension 0 1 2 3 0 1 2 354. Tried to see the good side of thesituation 0 1 2 3 0 1 2 355. Told yourself that this problem wasreally not that important 0 1 2 3 0 1 2 356. Avoided being with people 0 1 2 3 0 1 2 357. Tried to improve yourself in someway so you could handle thesituation better0 1 2 3 0 1 2 358. Wished that the problem would goaway^- 0 1 2 3 0 1 2 359. Depended on others to help you out 0 1 2 3 0 1 2 360. Told yourself that you were lusthaving some bad luck 0 1 2 3 0 1 2 3If there are any other things you did to handle the stress mentioned at the beginning,that are not on this list, please write those coping methods in the spaces below. Thencircle how often you have used each coping method, and how helpful each copingmethod has been.61. 1 2 3 0 1 2 362. 1 2 3 0 1 2,_ 363. 1 2 3 0 1 2 37/90Appendix CPatient Information Sheet105106PATIENT INFORMATION SHEET1) WHAT IS YOUR AGE?^ years2) WHAT IS YOUR MARITAL STATUS?^ single ^ divorced ^ widowed^ married ^ commonlaw relationship3) WHAT IS YOUR EDUCATIONAL LEVEL?^grade school high school ^ college^ technical school^ university4) WHAT IS YOUR CURRENT EMPLOYMENT STATUS?^ employed full-time outside the home^ employed part-time outside the home^ full-time homemaker^ maternity leave^ unemployed^ other: explain^5) WHAT IS YOUR OCCUPATION? ^6) DO YOU HAVE ANY CHILDREN LIVING AT HOME?^  YES ^ NOIf yes, what age is the child?child one^child two^child three1077) HAVE YOU EVER HAD A PREGNANCY LOSS? (i.e.: miscarriage, abortion,stillbirth) YES^ NO^If yes, how many weeks pregnant were you?^8) OTHER THAN GESTATIONAL DIABETES, DO YOU HAVE ANY PREGNANCYCOMPLICATIONS? YES^NOIf yes, what are they? 9) HOW MANY WEEKS PREGNANT ARE YOU? ^ Weeks10) DO YOU HAVE ANY RELATIVES WITH DIABETES? YES^ NOIf yes, who has/had diabetes and what kind?grandparent^  Type: ^^  Type: parent  Type: ^^  Type: sibling ^  Type: ^other  Type: PLEASE MARK ON THE LINE BELOW HOW SERIOUS YOU CONSIDERGESTATIONAL DIABETES TO BE FOR YOUR PREGNANCY.not serious^ extremelyat all seriousTHANK YOU FOR COMPLETING THIS INFORMATION SHEET.Appendix DInformation Letter108THE UNIVERSITY OF BRITISH COLUMBIA 109The School of NursingT. 206-2211 Wesbrook MallVancouver, B.C. Canada V6T 2B5I am a registered nurse and a student in the Master ofNursing Program at the University of British Columbia. I amwriting to invite you to participate in a research project onhow women cope with having gestational diabetes. It is hopedthat the information gained from this study will help us tofind ways to better meet the needs of women with gestationaldiabetes.Your participation is very valuable and your involvementin the study consists of responding to each question containedin the enclosed questionnaires and returning it in the enclosedstamped envelope. The total time to complete the questionnairesis approximately 45 minutes. Completion and return of thequestionnaires implies that you have consented to participatein the study.All information is confidential and will be used for thepurposes of this study only. All questionnaire packets'havebeen coded and mailed to you by a clerk. I will not have accessto the code list so anonymity will be assured. Participationin this study is entirely optional and will in no way influencethe medical care you receive. The study will hold no risk orbenefit for you, but it may benefit others like you in thefuture. If you have any questions or concerns, please feelfree to telephone me at 873-5401, or my thesis. supervisorProfessor Elaine Carty at 822-7444. I appreciate your willingnessto participate in this study.Sincerely yours.Lenore Riddell, R.N.. E.Sc.N.Appendix EReminder Letter110THE UNIVERSITY OF BRITISH COLUMBIAThe School of Nut -singT. 206 -2211 Wcsbrook MallVancouver, B.C. Canada V6T 2B5Two weeks ago you received a letter and two questionnairesfrom me with an invitation to participate in a study on howwomen cope with having gestational diabetes_ If you intend tocomplete the questionnaires, please return them to me in theenvelope provided_ If your questionnaires are already in themail, please disregard this letter_If you have any questions or concerns. please feel free totelephone me at 873-5401_ I would like to thank you for yourparticipation in my study.Sincerely yours,Lenore Riddell R.N.. B.S.N.Appendix FFrequency and Distribution of Uncertainty Items112113Table F-1: Frequency and Distribution of Uncertainty Items Item Mean Rank15. About my baby's chances to be healthy 3.21 116. Whether my condition will be the same with the nextpregnancy 2.79 226. Whether my condition risks my baby's life 2.73 345. Whether they might find something wrong when I gofor a check-up 2.73 335. Whether delays in my treatment will influence mybaby's chances 2.68 42. About the stability of my condition 2.56 536. About the seriousness of my condition 2.55 612. What to say to others about my condition 2.45 738. About the unpredictability of my symptoms 2.41 814. About my chances to be well during this pregnancy 2.41 810. Whether my condition is under control 2.41 841. How long my symptoms will last 2.35 939. Whether I will have difficulty coping with mycondition 2.33 1052. What symptoms I should be aware of 2.31 1144. What unusual symptoms mean in terms of mycondition 2.28 124. Whether I will be able to maintain my present levelof functioning 2.26 1356. Whether treatments I will be having will eliminatethe condition 2.24 1454. Whether my following the treatment planrecommended to me will help 2.23 155. About the present state of my condition 2.23 1533. Whether I can depend on test results as an indicatorof my condition 2.15 1617. Whether my symptoms can be controlled 2.15 1620. About how to manage my symptoms 2.10 17114Item Mean Rank37. About my abilities to handle my emotions related tomy condition 2.01 1818. Whether my condition will interfere with my abilityto do my regular activities 2.04 189. About the effectiveness of my treatments 2.02 1928. Whether my treatments eliminated my condition 2.01 191. Whether changes in my condition will be detectedearly 2.00 206. What questions to ask my doctors about my condition 2.00 2048. About the cause of my symptoms 1.98 2111. Whether my condition will cause me to havesymptoms 1.95 2253. About how to choose the treatments I will have 1.93 233. What caused my condition 1.93 2349. Whether I can depend on people who are importantto me to be there when I need them 1.91 2432. Whether what I am doing about my condition willhelp me 1.88 2555. What to look for to check the state of my condition 1.84 2634. Whether my condition will affect my sex life 1.78 2721. About choices I have made regarding my treatment 1.77 287. Whether changing my lifestyle behaviors will helpmy condition 1.76 2946. Whether I will be well cared for by the nurses 1.76 2947. Whether I will be well cared for by healthprofessionals other than nurses 1.76 2943. Whether I would choose to have all the treatmentsrecommended to me 1.75 3040. About the quality of information I have 1.73 3127. Whether my condition risks my life 1.73 3151. Whether I can manage financially because of mycondition 1.67 32115Item Mean Rank24. About my understanding of the treatments I havereceived and am receiving 1.67 3242. Whether I am being told the truth about my condition 1.64 3322. Whether my condition will return in this pregnancy 1.64 3323. About the adequacy of the follow-up I am having 1.61 348. How to make sense of what I am told about mycondition 1.60 3531. Whether my condition will affect my life goals 1.60 3529. Whether changes in my pregnancy from normal tohigh-risk affect my relationships within the family 1.48 3630. Whether changes in my pregnancy from normal tohigh-risk affect my relationships outside my family 1.43 3725. How to approach health care workers about my care 1.41 3813. About differing explanation I have been given 1.32 3919. About my doctor's abilities 1.28 4050. Whether I can get insurance 1.17 41Appendix GRank-ordering of the most used to the least used coping strategies116Table G-1: Rank Ordering of Coping Strategies UseCoping Strategy Mean Rank16. Tried to keep the situation under control (CO) 2.413 127. Tried to find out more about the problem (CO) 2.413 113. Tried to look at the problem objectively and see all sides(CO) 2.304 250. Tried to think positively (OP) 2.304 211. Talked the problem over with family or friends (SU) 2.304 230. Tried to keep your life as normal as possible and not letproblem interfere (OP) 2.261 312. Accepted the situation because little could be done (FA) 2.130 429. Tried to handle things one step at a time (CO) 2.130 447. Thought about the good things in your life (OP) 2.043 539. Tried to keep a sense of humor (OP) 2.043 544. Tried to keep busy (PA) 2.000 61. Worried about the problem (EM) 1.978 74. Thought about different ways to handle the situation (CO) 1.957 838. Set up a plan of action (CO) 1.957 85. Told yourself things could be much worse (OP) 1.913 96. Exercised or did some physical activity (PA) 1.891 1037. Told yourself that you could handle anything no matter howhard (SR) 1.870 1131. Thought about how you had handled other problems in thepast (SR) 1.870 1141. Tried to keep your feelings under control (SR) 1.844 1232. Told yourself not to worry because everything would probablywork out fine (OP) 1.804 1317. Prayed or put your trust in God (SU) 1.795 142. Hoped that things would get better (OP) 1.783 1542. Talked the problem over with people who had been in asimilar situation (SU) 1.739 1654. Tried to see the good side of the situation (OP) 1.739 16117Coping Strategy Mean Rank45. Learned something new in order to deal with the problem(CO) 1.717 1710. Tried to get the problem out of your mind and think ofsomething else (EV) 1.696 1815. Talked the problem over with a professional person (such as adoctor, nurse, minister, teacher or counsellor) (SU) 1.674 1943. Practiced in your mind what had to be done (CO) 1.652 2057. Tried to improve yourself in some way so you could handlethe situation better (SR) 1.609 2152. Preferred to work things out yourself (SR) 1.543 2258. Wished that the problem would go away (EV) 1.543 2249. Compared yourself with other people who were in the samesituation (OP) 1.533 2325. Tried to change the situation (CO) 1.522 2436. Tried to distract yourself by doing something that you enjoy(PA) 1.478 257. Tried to get away from the problem for a while (EV) 1.444 269. Expected the worst that could happen (FA) 1.413 278. Got mad and let off steam (EM) 1.378 2833. Tried to work out a compromise (CO) 1.304 2919. Kept your feelings to yourself (SR) 1.304 2922. Wanted to be alone to think things out (SR) 1.261 3021. Waited to see what would happen (EV) 1.261 3055. Told yourself that this problem was really not that important(EV) 1.261 3026. Used relaxation techniques (PA) 1.239 3159. Depended on others to help you out (SU) 1.217 3224. Took your tensions on someone else (EM) 1.174 3328. Slept more than usual (EV) 1.74 3335. Let time take care of the problem (EV) 1.109 3451. Blamed yourself for getting into such a situation (EM) .957 3560. Told yourself that you were just having some bad luck (FA) .935 36118Coping Strategy Mean Rank48. Tried to ignore or avoid the problem (EV) better (PA) .870 3740. Put off facing up to the problem (EV) .826 3856. Avoided being with people (EV) .795 3914. Daydreamed about a better life (EV) .756 4018. Tried to get out of the situation (EV) .744 413. Ate or smoked more than usual (PA) .600 4223. Resigned yourself to the situation because things lookedhopeless (FA) .457 4346. Did something impulsive or risky that you would not usuallydo (EM) .456 4420. Told yourself that the problem was someone else's fault (EV) .378 4553. Took medications to reduce tension (PA) .304 4634. Took a drink to make yourself feel better (PA) .261 47CO = Confrontive Coping StyleEV = Evasive Coping StyleOP = Optimistic Coping StyleFA = Fatalistic Coping StyleEM = Emotive Coping StylePA = Palliative Coping StyleSU = Supportant Coping StyleSR = Self-Reliant Coping Style119Appendix HRank ordering of most-effective coping strategies to least-effective coping strategies120121Table H-1: Rank Ordering of Coping Strategy Effectiveness Coping Strategy Mean Rank27. Tried to find out more about the problem (CO) 2.348 116. Tried to keep the situation under control (CO) 2.217 250. Tried to think positively (OP) 2.152 33. Tried to look at the problem objectively and see all sides (CO) 2.174 411. Talked the problem over with family and friends (SU) 2.111 529. Tried to handle things one step at a time (CO) 2.087 639. Tried to keep a sense of humor (OP) 2.022 730. Tried to keep your life as normal as possible and not let theproblem interfere (OP) 2.022 744. Tried to keep busy (PA) 2.000 86. Exercised or did some physical activity (PA) 1.953 942. Talked the problem over with people who had been in a similarsituation (SU) 1.870 1045. Learned something new in order to deal with the problem (CO) 1.848 1147. Thought about the good things in your life (OP) 1.848 1138. Set up a plan of action (OP) 1.844 1212. Accepted the situation because very little could be done (FA) 1.844 1217. Prayed or put your trust in God (SU) 1.814 1343. Practiced in your mind what had to be done (CO) 1.717 144. Thought out different ways to handle the situation (CO) 1.711 1515. Talked the problem over with a professional person (such as adoctor, nurse, minister, teacher or counsellor) (SU) 1.711 1537. Told yourself you could handle anything no matter how hard (SR) 1.667 165. Told yourself that things could be much worse (SU) 1.667 1657. Tried to improve yourself in some way so you could handle thesituation better (SR) 1.652 1731. Thought about how you had handled other problems in the past(SR) 1.609 1754. Tried to see the good side of the situation (OP) 1.587 18122Coping Strategy Mean Rank32. Told yourself not to worry because everything would probablywork out fine (OP) 1.457 1936. Tried to distract yourself by doing something that you enjoy (PA) 1.370 2052. Preferred to work things out yourself (SR) 1.348 2133. Tried to work out a compromise (CO) 1.333 2210. Tried to put the problem out of your mind and think of somethingelse (EV) 1.289 232. Hoped that things would get better (OP) 1.283 247. Tried to get away from the problem for awhile (EV) 1.279 2526. Used relaxation techniques (PA) 1.261 2641. Tried to keep your feelings under control (SR) 1.222 2725. Tried to change the situation (CO) 1.217 2822. Wanted to be alone to think things out (SR) 1.200 2959. Depended on others to help you out (SU) 1.156 3049. Compared yourself with other people who were in the samesituation (OP) 1.133 318. Got mad and let off steam (EM) 1.133 3155. Told yourself that this problem was really not that important (EV) 1.067 3228. Slept more than usual (EV) 1.044 3321. Waited to see what would happen (EV) 1.023 3435. Let time take care of the problem (EV) 1.000 359. Expected the worst that could happen (FA) .932 3619. Kept your feelings to yourself (SR) .886 3724. Took out your tensions on someone else (EM) .687 3818. Tried to get out of the situation (EV) .667 3940. Put off facing up to the problem (EV) .659 401. Worried about the problem (EM) .609 4156. Avoided being with people (EV) .545 4214. Daydreamed about a better life (EV) .523 4353. Took medications to reduce tension (PA) .512 44123Coping Strategy Mean Rank48. Tried to ignore or avoid the problem (EV) .511 4558. Wished that the problem would go away (EV) .457 4651. Blamed yourself for getting into such a situation (EM) .413 4760. Told yourself that you were just having some bad luck (FA) .391 4823. Resigned yourself to the situation because things looked hopeless(FA) .349 4920. Told yourself that the problem was someone else's fault (EV) .293 503. Ate or smoked more than usual (PA) .275 5146. Did something impulsive or risky that you would not usually do(EM) .227 5234. Took a drink to make yourself feel better (PA) .182 53CO = Confrontive Coping StyleEV = Evasive Coping StyleOP = Optimistic Coping StyleFA = Fatalistic Coping StyleEM = Emotive Coping StylePA = Palliative Coping StyleSU = Supportant Coping StyleSR = Self-Reliant Coping StyleAppendix IOutline of Teaching Session in the Diabetes Clinic124125Outline of Teaching Session for Women with Gestational Diabetes 1. Brief overview of diabetes in general is given.2. The need for increased insulin during pregnancy is outlined. Why gestational diabetesdevelops is explained.3. The impact of gestational diabetes on the baby is explained. The most commoncomplication is a large baby.4. How blood glucose levels are managed is outlined. The importance of diet therapy andactivity management is emphasized. A brief overview of insulin therapy is given.5. Blood glucose monitoring is taught. This includes maintenance of the meter, obtaining ablood sample, use of the meter, keeping track of the results, and how to obtain supplies.Testing for urine ketones is taught. A financial assessment is done and resources offeredas applicable. Consents and insurance documents are completed. The woman isencouraged to phone the diabetes nurse if she has any concerns.6. A diet history is taken by the dietician and a meal plan is developed taking into accountpersonal preferences, culture, financial situation, etc. The importance of preventingurinary ketones is emphasized.Close contact with the dietician is encouraged.7. Finally, an appointment is made to return to one of the follow-up clinics.

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