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Original Research

Flexible Coping in Cancer Care

A Concept Analysis

Eto, Miwako RN, MN; Yamamoto, Sena RN, PhD; Arao, Harue RN, PhD

Author Information
Cancer Care Research Online: January 2022 - Volume 2 - Issue 1 - p e016
doi: 10.1097/CR9.0000000000000016
  • Open

Abstract

Introduction

There were 18.08 million cancer cases and 8.97 million cancer-related deaths worldwide in 2018. The number of cancer patients increased by 28% between 2006 and 2016.1 Cancer is the second leading cause of death after ischemic heart disease and, thus, has become an important global health issue,2 even in consideration of regional differences. Depending on the type of cancer, its stage, and the overall condition of a patient, various treatment modalities, such as surgery, radiotherapy, immunotherapy, and chemotherapy, will be used alone or in combination with other therapies.

Cancer patients are in a high-stress state during the trajectory of their illness3,4 and need to cope with stressful situations for prolonged periods of time. They are uncertain about the future and experience anxiety about recurrence.3 They also undergo unexpected changes in their daily life5 and need to continue cancer treatment under these circumstances. Moreover, the physical symptoms caused by cancer itself and cancer treatment, anxiety due to changes in various aspects of the disease, and fear of death have a significant impact on the quality of life of cancer patients.6 Therefore, it is crucial to develop a concept that adequately describes patients’ experiences and coping strategies under long-term, changeable, and stressful situations.

Flexible coping is a significant concept for appropriately capturing diverse and variable stressful situations and analyzing patients’ coping patterns. This concept describes how individuals evaluate situations, change their perceptions, and effectively modify their coping strategies in response to stressful situations.7,8 Individuals with greater coping flexibility are more likely to focus on the task at hand and select proactive coping strategies. Flexible coping involves not only the repertoire of coping strategies available to an individual, but also the internal-situational variability associated with the ability to use a variety of strategies in response to a particular situation. The ability to easily make decisions to discard ineffective coping strategies and seek more effective alternatives is crucial for flexible coping.

Flexible coping has been reported to contribute to psychological recovery, such as recovery from posttraumatic stress disorder9 and complicated grief.10 Previous studies on flexibility demonstrated that flexible coping effectively mitigated the negative effects of stressors, controlled psychological, behavioral, and physical stress responses, and enhanced social adjustment.7,8 Furthermore, individuals with greater coping flexibility were more likely to select active coping strategies to solve problems, and cancer patients who flexibly cope with situations have been able to manage the difficulties associated with the disease, its treatment, and side effects.6

Purpose

This concept analysis aimed to analyze the definition and attributes of flexible coping and discuss its application in nursing practice. The organization of various definitions and perceptions of flexibility as well as the formation of an integrated overview are imperative to the advancement of oncology nursing practice, particularly regarding the care of cancer patients undergoing treatment. An analysis of patients’ coping patterns using the concept’s attributes will contribute to clarifying the nursing care required by patients undergoing cancer treatment, which may, in turn, facilitate successful coping under complex and difficult situations.

Methods

This concept analysis applied Walker and Avant’s11 analytical method to investigate the underlying attributes and internal structure of flexible coping and clarify its nature. The method has eight steps: (1) selecting a concept; (2) defining the purpose of the analysis; (3) identifying all of the concept’s uses; (4) selecting the concept’s defining attributes; (5) creating a model case; (6) creating boundary examples and counterexamples; (7) identifying antecedents and consequences; and (8) clarifying empirical matters.11 In this concept analysis of flexible coping, the concept’s usage was initially examined in a literature review, and contents corresponding to the concept’s attributes, antecedents, and consequences were then consolidated. In addition, model, boundary, and contrary cases were presented to provide a more detailed understanding of the concept.

Literature Search

In 2020, a literature search was conducted using Medline, PsycINFO, and CINAHL. Available full-text articles were searched for using the keywords “coping flexibility” and “flexible coping”. Medline, PsycINFO, and CINAHL returned 102, 187, and 60 articles, respectively. Regarding the Japanese literature, a literature search was conducted on Ichu-Shi Web using the keywords “flexible” and “coping,” resulting in the extraction of 35 articles.

Inclusion criteria for further consideration in this analysis were as follows: peer-reviewed publications, written, or available in English, and literature addressing some aspects of flexible coping. Only literature that included “flexible coping” or “coping flexibility” was retained for the analysis. In the review of articles, duplicate articles and articles that did not include a definition of flexible coping were excluded. Twenty-four articles were ultimately extracted and used in the analysis (Figure 1). The literature included in this concept analysis was organized according to the term’s use in the publications’ text.

F1
Figure 1.:
Literature search and data evaluation flow chart.

Results

Use of the concept

Since there are few dictionary definitions of “flexible coping” in any field, separate searches were conducted for each of the terms “flexibility” and “coping.” The results obtained are described below. The Daijisen (Japanese dictionary) defines “flexibility” as “the ability to take measures and make judgments according to the situation without adhering to a single position or way of thinking.”12 In the Encyclopedia of Psychology and Clinical Practice,13 “flexibility” is listed among the characteristics of a mentally healthy individual, which rational emotive behavior therapy aims to develop; such an individual is described as “intellectually flexible, open to change, and free from prejudice.”

According to Lazarus’s stress coping theory, “coping” is defined as an individual’s continuous effort to select appropriate actions and make suitable decisions in order to avoid or overcome the confusion or crisis that may arise from a stressful situation.14 This effort is an ever-changing cognitive and behavioral attempt that is made to appropriately handle and control both or either of the compulsions of a particular environment and one’s own internal compulsions, and it occurs consciously based on self-appraisal.15 Factors that influence this effort include internal mediators, such as values acquired through an individual’s life process, sex and role expectations, education, and ego strength as well as social mediators, including social support, all of which contribute to the formation of a unique coping style.14

Applications in the Field of Psychology

Flexible coping is a cognitive and behavioral effort to cope with internal and external stressors caused by situational changes and is considered to effectively eliminate or alleviate stress. In the field of psychology, flexible coping examines how individuals develop the flexibility to cope with different demands in changing situations.8,16 According to Cheng,16 the elements of flexibility are flexible cognitive appraisal, flexible coping patterns, and adaptive strategies. A high level of coping flexibility has been described as the ability to accept situations and generate a variety of alternatives and the ability to perceive difficult situations as controllable.17

Applications in the Medical and Nursing Fields

In the medical and nursing fields, the relationships among coping flexibility, physical functioning, and psychological aspects has been examined in patients with chronic diseases and other prolonged difficulties. Mainly based on academic definitions from the field of psychology, it is described as the ability to respond to occasional situations by flexibly changing behavior and solution methods, and the ability to act with acceptance, mindfulness, and value- or goal-directed behavior.18,19

Defining Attributes

After a review of the relevant literature, seven major attributes were extracted (Table 1). The characteristics of these attributes are described below.

Table 1. - Attributes of Flexible Coping
Attributes References
Cognitive appraisal of difficulties 8,10,18,20–25
Appraisal of controllability 8,16,20,21,26
Diverse repertoire of coping strategies 6,8,20,22,25
Changing coping strategies to suit specific situations 8,10,16,18,20–22,26–31
Discontinuing ineffective coping strategies 8,26,30,31
Devising coping alternatives 8,17,19,26,29–34
Repeated evaluation of and feedback on the coping process 8,16,20,26,31,35

Cognitive Appraisal of Difficulties

Situations that require flexible coping are characterized by persistence,10,20–22 fluctuation,23 and the recognition of challenges that are difficult to surmount using an individual’s usual coping repertoire.22,24 To understand the situation, patients confront difficulties by integrating their perceptions, as drawn from a variety of informational sources,16,20 such as asking medical professionals and independently investigating illnesses and treatments.

Appraisal of Controllability

This attribute has been described as exploring the possibility of coping with a difficult situation and adjusting one’s coping goals.8,21,26 Rozanski and Kubzamsky21 described flexibility as the ability to appraise stressors, regardless of whether the situation is controllable. Cheng et al.20 reported that flexibility is related to making compromises in changing situations. These researchers stated that flexibility is the ability to appraise controllability and use accommodative coping strategies to adjust personal goals as a means of dealing with stressors amidst a difficult situation.25

Diverse Repertoire of Coping Strategies

Diverse repertoires of coping strategies are necessary to facilitate psychological adjustments.6,8,20,22,26 When individuals perceive themselves as having a number of coping strategies at their disposal, they appraise stressful situations positively and feel a sense of efficacy regarding their ability to cope.22

Changing Coping Strategies to Suit Specific Situations

Flexible individuals utilize coping repertoires comprised of a well-balanced variety of coping strategies.16,22,27 When a problem is difficult to resolve, flexible individuals change their coping strategies by incorporating emotional control, suppressing negative emotions, and altering their thoughts and feelings.10,16,21 Therefore, to adapt to changes in stressful situations, coping strategies are adjusted to suit situational characteristics.8,10,18,20,22,25,28–31,36

Discontinuing Ineffective Coping Strategies

When individuals have the ability to generate a multitude of solutions, they select appropriate strategies to cope with stressful situations, change strategies effectively to suit each particular situations, and respond flexibly.8,30,31 Flexible individuals also have the ability to monitor and evaluate the effectiveness of their coping process and discontinue using ineffective strategies amidst changing situations.8,26,30,31

Devising Coping Alternatives

Flexible coping is associated with creativity.17,26,29 Flexible individuals have the ability to recognize that coping with changing situations is possible, grasp situations from various aspects, and devise and implement alternative coping strategies.19,32–34 These abilities are related to building a diverse coping repertoire.

Repeated Evaluation of and Feedback on the Coping Process

Flexible individuals monitor and evaluate changing situations, as well as their own coping process and outcomes.8,31 This reappraisal means that they periodically reevaluate their situation and outlook,8,31 and find a point of compromise to adapt to changing situations by reflecting on coping goals, strategies, and outcomes.16,20 Monitoring and evaluation are repeated until favorable outcomes are obtained.8

Defining the Concept

Based on its attributes, flexible coping is defined as “a dynamic process that involves appraising controllability amidst a long-term, unpredictable, and changing situation; selecting a strategy for coping with a difficult situation from a diverse repertoire; evaluating the overall process; discontinuing any ineffective strategies; devising valid alternatives; and moving toward adaptation”.

Constructed Cases

Following Walker and Avant’s11 recommendations, the defining attributes of flexible coping were clarified and verified in this analysis in a model case, borderline case, and contrary case.

Model Case

The model case includes all the concept’s defining attributes and highlights its key characteristics.11 Mr. A, a male in his 60s, underwent surgery for gastric cancer and received oral anticancer drugs as adjuvant therapy. After two courses, the patient developed side effects including fatigue, loss of appetite, and dyspepsia (changeability and diverse demands). Mr. A felt stressed and depressed, and wondered how long this situation would continue (cognitive appraisal of difficulties and prolonged difficulties).

Mr. A went to the outpatient clinic, told the doctor about his symptoms, and asked him to prescribe medication for the control of intestinal function. He also asked the nutritionist to advise him on the necessary nutrients to consume. The nurse advised Mr. A to contact the hospital and gave him instructions about how to rest and engage in activities. Since Mr. A had always worked while running his own household, including cooking for himself, and because he had also always self-administered his own medications (diverse repertoire of coping strategies), he considered the medical professional’s advice to be feasible (appraisal of controllability), and he was able to accept and smoothly implement these suggestions (changing coping strategies to suit the specific situation).

When distressing symptoms appeared, Mr. A did not just endure them (discontinuing ineffective coping strategies), he resumed work when he felt more comfortable identifying the pattern of appearance of his symptoms (devising coping alternatives). The continuation of work made life worth living to Mr. A (value/belief and self-efficacy), and he felt calmer than before.

During the period when the severity of side effects increased, Mr. A refrained from working, stayed at home, and sought support from his daughter (social skills and social support). During outpatient visits, he was able to reflect on the coping process and communicate the situation to the medical staff (repeated evaluation of and feedback on the coping process). Although he continued to experience treatment side effects and changes in his physical condition, he was able to expand his repertoire using the advice and support of others (increased coping tolerance), implement coping strategies suited to specific situations, and become mentally stable (improved mental health).

Borderline Case

A borderline case contains some, but not all, of the attributes of the concept.11 Mr. B, a 60-year-old male colorectal cancer patient, was receiving adjuvant therapy, experienced a decline in physical strength after surgery (cognitive appraisal of difficulties and prolonged difficulties), and needed his wife’s support in daily life (social skills and social support). When side effects appeared, the patient endured them until they subsided. Mr. B informed his doctor about his symptoms and asked for adjustments to his treatment schedule and dosage as well as a prescription for nutritional supplements (changing coping strategies to suit specific situations). When Mr. B was no longer able to garden as a hobby, he felt even weaker and stressed, which made him more depressed. Therefore, he did as much gardening as possible and stopped when symptoms were strong; however, he always felt exhausted when he was finished.

The nurse advised him about nutrition for the times when he experienced strong side effects. The nurse also advised him to balance activity and rest. Using this information, Mr. and Mrs. B worked on Mr. B’s nutritional intake (devising coping alternatives). Mr. B continued gardening as usual, and although he felt calmer (improved mental health), his coping repertoire and tolerance remained the same (no evaluation of or feedback on the coping process, diverse coping strategy repertoire, or discontinuation of effective coping strategies).

Contrary Case

A contrary case is a counterexample of the concept being analyzed.11 Mr. C, a 70-year-old male patient with colorectal cancer, underwent adjuvant therapy after surgery. When side effects appeared, he was unable to enjoy his hobbies and socialize with friends, and he felt depressed and disconnected from his family. When the doctor discussed Mr. C’s physical condition and treatment plan, Mr. and Mrs. C, along with their eldest son, listened, and Mr. C. said, “I leave it to the doctor.” Mr. C acknowledged the stressful situation, but made no effort to evaluate and cope with the stressors.

Antecedents

Antecedents are shown in Table 2.

Table 2. - Antecedents of Flexible Coping
Antecedents References
• Personal factors
Value/Belief 6,35
Self-efficacy 6,22,24,35
Social skills and social support 6,23,24,28
• Environmental factors
Changeability 23,25,26
Unpredictability 6,18,23,24,26,35
Diverse demands 6,18,23,24,26,35
Prolonged difficulties 18,23,24,26,29,35

Personal Factors

The antecedents related to personal factors were identified as value/belief, self-efficacy, and social skills and social support. The value an individual ascribes to and the belief they have in their ability to draw on a diverse repertoire of coping strategies in order to adjust their approach to suit the situation6,35 were indicated among the antecedents. Self-efficacy, or the recognition of the ability to cope with difficult situations, was also mentioned,6,22,24 along with social support for expressing emotions and gaining intimacy and security through relationships with others,17,23,24 and social skills for verbalizing and discussing challenges.24

Environmental Factors

The antecedents related to environmental factors were extracted as changeability, unpredictability, diverse demands, and prolonged difficulties. The process a cancer patient undergoes, namely, the suspicion/diagnosis of cancer; pretreatment, treatment, and posttreatment; recurrence and metastasis; the continuation of treatment with no guarantee of a favorable outcome; and prolonged suffering due to a progressive, unpredictable disease, is fraught with stressful situations that are changeable and unpredictable, and always accompanied by anxiety and other psychological distress.

Receiving treatment for a progressive chronic disease is a situation with diverse demands, such as dealing with the symptoms of the disease and the side effects of treatment,26 which repeatedly cause distress and pain, affecting daily life.26,35 Depending on the disease and treatment, alterations in and the permanent loss of bodily functions23,24 as well as coexisting physical and psychological issues10,16 have been identified among the various prolonged difficulties.

Consequences of Flexible Coping

Consequences are shown in Table 3.

Table 3. - Consequences of Flexible Coping
Effects References
Increased coping tolerance 6,17,18,23,26,27,30
Improved mental health 6,10,18,23,25,26,30,31,35

Increased Coping Tolerance

One of the consequences of implementing flexible coping strategies is increased coping tolerance. Patients apply the coping process to stressful situations and acquire effective coping strategies.6,26,30 This successful experience leads to increased coping tolerance in difficult situations.6,17,18,23 As a result of this process, patients also gain a sense of efficacy in dealing with difficult situations17,27 and become more motivated in terms of self-management.6

Improved Mental Health

Flexible coping encourages patients to accept their disease and adapt to their situation23,25,35; this, in turn, leads to positive changes in patients’ thinking6,35 and satisfaction with their relationships with others.6 Furthermore, patients learn effective coping strategies through successful experiences and their use of flexible coping tends to reduce their anxiety and depression.6,10,18,26,30,31,35

Empirical References

Previous studies examined the concept of flexible coping and the development of measurement tools. The self-perception of flexible coping with stress measurement assesses beliefs about responding effectively to stressors and difficulties, using multiple strategies as needed, adapting strategies to suit particular situations, and responding to stressful events.22

Kato8 defined “coping flexibility” as being comprised of abandonment coping (i.e., abandoning ineffective coping strategies), recoping (i.e., devising and implementing different coping strategies to replace ineffective ones), and meta-coping (monitoring the effectiveness of the flexible coping process as a whole), and developed a measurement tool that consists of 12 items on a 4-point scale.

Although the importance of adaptability and flexibility in cognition, emotional responses, and coping has been proposed in various academic fields, such as psychology, only a few studies have been conducted in the field of nursing. Another issue is that methods to measure an individual’s self-assessed ability to cope with changing situations, avoid the use of a single strategy, and utilize strategies from their repertoire flexibly have not yet been sufficiently developed.22

Discussion

This concept analysis of flexible coping extracted seven attributes, seven antecedents, and two consequences, using Walker and Avant’s method (Figure 2). Research conducted to date on stress coping has examined specific coping strategies and their effects on physical, psychological, and behavioral responses to stressors.8 Research on flexible coping has focused on coping as diverse and fluid, and this concept analysis extracted attributes such as the cognitive appraisal of difficulties and changing coping strategies to suit specific situations. In addition to having a diverse repertoire of coping strategies, the ability to take an overview of the big picture with respect to stressful situations and the coping process and discontinue the use of ineffective strategies were also found to be distinguishing features of flexible coping. The meta-cognitive ability to monitor and appropriately evaluate situations as they evolve as well as the efficacy of one’s coping strategies are important for effective flexible coping.8 Improvements in metacognition through self-awareness and thought regulation may help individuals to gain coping flexibility and reduce depression.31

F2
Figure 2.:
Conceptual framework of flexible coping.

The attributes extracted in this conceptual analysis provide suggestions for nursing practice aimed at assisting cancer patients to manage stressful situations. An analysis of the coping styles of patients using the attributes may reveal weaknesses in their individual coping processes and contribute to the selection of an appropriate nursing intervention. These attributes may be useful for assessing the coping characteristics and patterns of patients, and nurses may then discuss and evaluate the coping process with patients in order to help them effectively cope with situations, readjust their goals, and identify appropriate coping strategies. If patients experience a successful coping process, they may build a coping repertoire and improve their metacognitive abilities, which, in turn, may lead to reduced stress reactions and improved mental health.

Patients in treatment for cancer experience a variety of unpredictable stressful situations during the trajectory of their illness. By using the concept of flexible coping, support for the individualized promotion of patients’ coping flexibility will encourage situational adaptability and lead to good mental health. It is important to promote nursing research and practice in this field.

Limitations

The purpose of this concept analysis was to analyze the definition and clinical use of flexible coping and discuss its applicability to nursing practice and research. Since nursing research literature in this area is still limited, literature from other fields, such as psychology, was included. Flexible coping was useful for understanding the situation of cancer patients living in stressful situations as well as for considering and implementing support for stress coping. Additional research is needed to further refine this concept, utilize it for patients receiving cancer treatment who are coping with stressful situations, and facilitate its adoption in practice.

Conclusion

This concept analysis revealed the characteristic attributes of flexible coping. The metacognitive abilities to monitor and evaluate stressful situations as well as the coping process were found to be important for effective flexible coping. Further research to clarify the relationship between stressful situations and flexible coping in cancer patients will contribute to the practical application of these findings in this area.

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