The Role of Courage in the Experience of Patients With
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THE ROLE OF COURAGE IN THE EXPERIENCE OF PATIENTS WITH DIABETES COMPLICATIONS A Dissertation Presented to the Faculty of the Department of Nursing Adelphi University In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy by Patricia Donohue-Porter April, 1987 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ADELPHI UNIVERSITY MARION A. BUCKLEY SCHOOL OF NURSING PATRICIA DONOHUE-PORTER We, the dissertation committee for the above candidate for the Doctor of Philosophy degree, hereby recommend acceptance of the dissertation /Barbara Kos-Munson, Ph.D., R.N. Dissertation Chairperson & Associate Professor Marion A. Buckley School of Nursing Stephen GreenjEielsd/, Ph.D. Professor and' Charbserson Department of Religious Studies Barbara Rottkamp, Ed.D., R.N. Associate Professor Marion A. Buckley School of Nursing This dissertation is accepted by the Marion A. Buckley School of Nursing of Adelphi University. llacquieiine Rose Hott, Ph.D. ,R.N. ,F.A.A.N. Dean, Adelphi University Marion A. Buckley School of Nursing ll Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (C) Copyright by Patricia Donohue-Porter 1987 All Rights Reserved Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Abstract The Role of Courage in the Experience of Patients with Diabetes Complications Patricia Donohue-Porter Over ten million Americans have diabetes mellitus, a chronic metabolic disease with multiple complications. The person with diabetes complications may experience progressive debilitation from such serious conditions as blindness, kidney failure, nerve damage and cardiovascular disease. These complications are progressive and life- threatening, requiring treatments which may be painful, exhausting and often unsuccessful. The patients have multiple tasks to perform in order to cope with this devastating physical illness. They are thrust into a unique emotional experience which has not been investigated by nurses. The experience necessitates drawing upon patients' inner resources. Nursing research into their experience is essenti al. In an effort to illuminate the experience of the patient with disabling complications of diabetes so that nurses may be better able to assist individuals through the experience, a phenomenological exploration and philosophical analysis of the role of courage was conducted. Courage has been viewed as a virtue, a gift, a potential to be developed. The role of courage in facing iii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. certain complications of chronic illness bears exploration. The study of courage and its development, with related nursing implications, may better help the patient to face life and death. The related literature for this study included courage, psychosocial adjustment to diabetes and chronic illness, phenomenology, coping and diabetes pathophysiology and complications. The phenomenological method, an inductive, descriptive research method concerned with the investigation and description of all phenomena, was used. The research design consisted of a qualitative approach, using a small sample of miadlescent diabetic patients with disabling complications. These patients were interviewed in home settings. The transcripts of these patient interviews were subjected to thematic analysis in order to generate descriptive profiles of the meaning of courage for these patients. Five theme categories were derived which described the various dimensions of courage in the experience of the patients: philosophical, health care, physical, psychological, and interpersonal. The study of courage was found to have an impact on the practice of nursing and implications were drawn for improved nursing intervention for this group of patients. i v Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. DEDICATION This dissertation is dedicated to my mother, Geraldine McDonald Donohue, who has provided an environment of intellectual stimulation and striving, love and support, throughout my life. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGEMENTS I would like to acknowledge, with tremendous gratitude, the contributions of Dr. Barbara Kos-Munson who as chairperson guided this dissertation as well as my entire doctoral program of study. My gratitude also extends to Dr. Barbara Rottkamp and Dr. Stephen Greenfield whose continued encouragement as committee members was both supportive and challenging. I would also like to thank my readers, Dr. Nancy Noel, Assistant Professor, School of Nursing, and Dr. Wilma Bucci, Associate Professor, Institute of Advanced Psychological Studies; their thoughtful analyses were appreciated. I wish to thank all of the patients who participated in this study. They generously shared their experiences and I feel priviledged to have known them. I would like to thank John F. Aloia, M.D., who shared his ideas and concerns for patient care in the crucial developing stages of this dissertation. My thanks are due to Mary-Jean Long for her professional assistance in the preparation of this manuscript. I also wish to acknowledge the Diabetes Research and Education Foundation for their assistance. Finally, I would like to thank my father, Joseph, and mother, Geraldine, my brother Joseph and sister, Geraldine, for their understanding and support during the process of writing this dissertation. My husband, Russell, has my love vi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and gratitude for all his continued support of my endeavors. My love, too, goes to my daughter, Elizabeth Patricia. vii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TABLE OF CONTENTS PAGE ABSTRACT................................ iii ACKNOWLEDGEMENTS v i CHAPTER I. INTRODUCTION............................................1 Background of the Problem............................ 1 Statement of the Problem............................. 2 Subproblems.............................................3 Definitions of Terms.................................. 4 Delimitations.......................................... 5 Assumptions............................................ 5 Hypothesis.............................................. 5 Significance of the Study............................ 6 II. RELATED LITERATURE................................... 10 Diabetes Mellitus.................................... 10 Complications of Diabetes...........................11 Middlescent Time Frame...............................20 Psychosocial Aspects of Diabetes.................. 21 Psychosocial Aspects of Diabetes Complications..25 Psychosocial Aspects of Chronic Illness.......... 29 Coping..................................................31 Nursing Studies of Courage..........................32 Courage: A Philosophic Discussion................. 34 III. METHODOLOGY......................................... ..53 A Phenomenological Approach........................ 53 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER PAGE Phenomenological Exploration and Philosophical Analysis................................................ 56 Preliminary Fieldwork.........„..... .................59 Combined Qualitative Methodologic Approach........65 Research design............................ ..*,..66 The sample......................................... 66 Data sources....................................... 67 Participant welfare.............................. 67 Interview format.................................. 68 Data analysis......................................70 Validity and reliability.........................71 IV. ANALYSIS OF DATA....................................... 74 Description of Sample................................. 74 Patient Profiles....................................... 74 Protocols............................................... 77 Extraction of Codes................................... 77 Theme Clusters......................................... 78 Theme Categories....................................... 79 Theme category 1 - Philosophical dimension...81 Theme category 2 - Health care dimension..... 88 Theme category 3 - Physical dimension.........96 Theme category 4 - Psychological dimension..102 Theme category 5 - Interpersonal dimension..106 Description of Courage...............................115 Structure of Courage.................................122 i x Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER PAGE Summary of Findings..................................124 V. INTERPRETATION OF FINDINGS......................... 125 Discussion of Findings related to Literature....125 Coping and courage.............................. 125 Hope and courage.........s...................... 126 Suffering and courage...........................127 Vulnerability and courage......................129 Self-esteem and courage........................ 131 Risk-taking and courage........................ 132 Fearlessness and courage.......................134 Love and courage.................................136 Culture and courage..............................137 Control and courage..............................138