Stress associated with hospitalization in patients with COPD: the role of social support and health related quality of life
© Medinas-Amorós et al.; licensee BioMed Central Ltd. 2012
Received: 6 June 2012
Accepted: 19 September 2012
Published: 10 December 2012
The objective of this study was to determine stress levels during hospitalization in patients with Chronic Obstructive Pulmonary Disease (COPD). We wanted to relate stress to previous level of quality of life and patients’ Social Support.
80 patients (70.43; SD = 8.13 years old) with COPD were assessed by means of: Hospital Stress Rating Scale, Nottingham Health Profile, St. George’s Respiratory Questionnaire and Social Support Scale.
COPD patients’ stress levels are lower than expected independently from the severity or number of previous hospitalizations. Linear regression analysis shows the predictive value of Quality of Life and Social Support on stress level during hospitalization (p < 0.0001).
HRQOL and social support can be associated with stress during hospitalization.
KeywordsHospitalization Quality of Life Social Support Stress
The physical and social configuration of hospitals implies the possibility of introducing inpatients to adverse psychological effects. These effects have been described and analyzed by different authors over the past few years[1–4]. Volicer et al. identified hospital experiences related to routine attention that are perceived as stressful during hospitalization, like: difficulties to obtain data concerning their own therapeutic processes, ignorance of the consequences of the disease, dangers that test involves, reduction of intimate space in the room, use of medical language, restriction of visits of own family’s members and friends, etc. Based on these observations the authors drew up the 40 items questionnaire called Hospital Stress Rating Scale. This scale was validated and translated in Spanish by Kendall. Between 1977 and 1978 other studies on stress during hospitalization incorporated the importance of cardiovascular and socio-demographic factors during hospitalization[7–9], coping strategies and psychological impact[10, 11] and severity of the disease, and presence of pain as important variables, affirming that some of them can predict stress level during hospitalization in acute patients. During the 80s, authors focused their interest on factors related to the patients’ difficulties of adjustment to hospital[13–15]. Researches carried out over the two last decades have extended the study of the iatrogenic effects of hospitalization to different pathologies[16, 17] or stress perception differences between patients and health care staff[11, 18, 19].
Chronic Obstructive Pulmonary Disease (COPD) is one of the most prevalent respiratory diseases with a frequent need for hospitalization; these patients suffer acute exacerbations during the year and hospitalization is an important part of patient care. The illness severity and a progressive loss of quality of life and physical mobility deteriorate patients’social and family support. Nevertheless, although poor relations between pulmonary function and quality of life and social support have been reported in the literature, recent studies have shown that improving physical activity (specific rehabilitation programs) can reduce symptoms and associated psychological dysfunctions and increase well-being and quality of life in these patients[23, 24].
Currently, a bibliographic review of databases does not show scientific studies concerning stress or the psychological effects of hospitalization in patients with COPD or in patients with chronic diseases who need frequent hospitalization. Andenaes et al observed high levels of stress in hospitalized COPD patients, concluding that 58.7% of them showed different levels of stress in comparison to non-hospitalized COPD patients. Then, in their follow up study, Andenaes et al observed a decrease in stress levels nine months after hospitalization; so the authors deduced that this had clearly been caused by hospitalization.
In a previous study, we can observe that patients with COPD suffer low stress levels during hospitalization but it is not clear the role of Health Related Quality of Life (HRQOL) and Social Support. For this reason, the aim of this study is to determine stress levels during hospitalization in patients with a chronic disease such as COPD. After that, we want to relate these parameters to the previous level of quality of life and patients’ social support. We have hypothesized that these last two parameters can contribute to diminishing stress levels in COPD patients.
Study design and patients
A cross-sectional sample of patients with COPD was selected and examined comprehensively with lung-function tests and a battery of specific scales described in the measures section. All patients were inpatients and were assessed after 10 days of hospitalization. This study was approved by the Ethical Committee at the Department of Research of GESMA, Balearic Islands, Spain. All patients signed the Informed Consent before the study. Finally, 80 consecutive patients (65 men and 15 women) with a diagnosis of COPD who agreed to participate and who met the Inclusion Criteria were included in our study. Inclusion criteria were as follows: COPD with a ratio of FEV1/forced vital capacity (FVC) < 0.7, FEV1 < 80% of predicted, age 45–90 years. Exclusion Criteria were : another disabling or severe disease that could prevent carrying out all study tests, and/or dementia. Patients with an indicative history of asthma were excluded. No patient had an acute COPD exacerbation at the time of the research.
Clinical data and lung-function tests
All participants were administered a structured clinical interview to obtain the following clinical, social and demographic parameters: age, gender, occupation, education level, degree of severity of COPD based on spirometry, degree of dyspnoea (MRC, Medical Research Scale), number of hospitalizations during the previous year and comorbidities by Charlson Index. Assessment of lung function (FEV1, FVC, absolute and reference values) was based on the 2006 reference spirometry values from Global Initiative for Chronic Obstructive Lung Disease (GOLD Classification).
Questionnaires and scales
Hospital Stress Rating Scale(HSRS): made up of a list of 49 commonly stressful hospital events assessed by patients (9 points: 1 “not at all stressful”, 9 “extremely stressful”) as to whether he or she had experienced it. We applied the author’s score correction (items summation); range of scores was 49 to 441 points.
The Nottingham Health Profile(NHP): The NHP was developed for General Quality of Life measurement. It consists of two parts. Part I contains 38 yes/no items in six dimensions: pain, physical mobility, emotional reactions, energy, social isolation, and sleep. Part II contains seven general yes/no questions on daily living problems. The two parts may be used independently, and part II has not been analyzed in this study. The NHP questionnaire has an adapted, validated Spanish version, which was used in our study. A higher NHP score shows a worse quality of life.
The St. George’s Respiratory Questionnaire (SGRQ): is a standardized self-administered airways disease-specific questionnaire. This questionnaire has an adapted and validated Spanish version used in our study. It contains 50 items divided into three subscales: symptoms (8 items), including several respiratory symptoms, their frequency and severity; activity (16 items), on activities that cause or are limited by breathlessness; and impact (26 items) which covers a wide range of aspects related with social functioning and psychological disturbances resulting from airways disease. The higher is the SGRQ score the lower the general quality of life.
The Medical Research Council Scale (MRC): comprises 5 self-administered statements that describe respiratory disability (Dyspnoea) from none (Grade 1) to almost complete incapacity (Grade 4).
MOS Social Support Survey(MOS). A total of 19 functional support items were developed to assess perceptions of the availability of different functional aspects of support. Subscales of MOS are: Emotional support (4 items), Informational support (4 items), Tangible support (4 items), Affectionate support (3 items) and Positive social interaction (4 items). Higher scores correspond to more social support. The MOS Social Support Survey, Spanish version, was identical to the original version.
Sample selection and later information collection were carried out in the Pneumology Unit of the Joan March Hospital in Majorca, Spain. The final sample was made up of patients diagnosed with COPD, selected consecutively according to when they were admitted to the afore-mentioned hospital. Patients were assessed during the next 10 days, once their clinical state had been stabilized. All patients were assessed by means of two interviews. During the first interview, socio-demographic, clinical data and Informed Consent were registered. In a second interview, the above scales and questionnaires were administered. All assessment was carried out in the patient’s room without a companion to guarantee confidentiality and correct administration of the questionnaires.
Data were analyzed by means of statistical program SPSS 17. For the socio-demographic and clinical data and MRC a descriptive study was conducted. For total stress scores, quality of life and social support variables, the variable’s distribution was analyzed before multiple comparison tests in order to verify our hypothesis. For Multiple Regression analysis (stepwise method), only normal distribution variables were selected. The significance level used was p < 0.05 (Confidence Interval: 95 %).
Clinical characteristics of the sample (n = 80)
FEV1 % ref.
Number of previous hospitalizations/year.
The HSRS results show a lower value than the mean score of the HSRS questionnaire (range of scores: 49 to 441 points); HSRS mean score: 220.5; COPD patients mean score: 166, 4; difference: 54.1 points. COPD patients consider the items related to change of habits, loss of control, loss of autonomy and privacy, as the most stressful items during hospitalization.
Results of HSRS, HRQOL (SGRQ and NHP) and MOS questionnaires for COPD patients (n = 80)
Positive social interaction
Stress level (HSRS) based on NHP SGRQ and MOS subscales (only p < 0.05 results)
Levene test (p)
Student test (p)
Total Score NHP
F = 0.087 (p = 0.769)
t = −2.003 p = 0.050
Physical Movility (PM)
F = 8.692 (p = 0.005)
t = −3.381 p = 0.002
F = 7.597 (p = 0.010)
(t = 2.694) p = 0.009
SGRQ Total Score
F = 2.672 (P = 0.202)
t: -2.597 p = 0.012
F = 2.915 (P = 0.094)
t = −2.412 p = 0.020
MOS Total Score
Without Social Support
F = 4.078 (P = 0.049)
t: 2.204 p = 0.032
With Social Support
Positive Social Interaction (PSI)
F = 1.201 (P = 0.279)
t: 2.262 p = 0.028
Results of Linear Regression analysis (stepwise method) with Stress (HSRS) as dependent variable and NHP, SGRQ, MRC and MOS as independent variables
· HNP Pain
· NHP Pain
· NHP Pain
· Impact (SGRQ)
· Impact (SGRQ)
· Social Isolation(NHP)
· Impact (SGRQ)
· Social Isolation(NHP)
· Positive Social Interaction (MOS)
Stress is a mental and physical strain due to threats, danger, life changes and everyday challenges. Our study shows that COPD patients hospitalized in this chronic hospital perceived hospitalization as a little stressing event, contrary to prior literature findings already exposed. However, these hospitalized chronic patients were exposed to potentially stressing factors and suffered from the same effects of routine and protocols, consolidated throughout their history in these institutions[5, 6] which can affect disease evolution and prognosis. Our analysis confirms that, in COPD patients, the most powerful stress factors were related to environmental factors (for example remaining in the same room and sleeping in a bed different from the habitual one); however, in previous studies, these items occupied the last positions in hospitalized patients in general hospitals[5, 18, 19].
One factor that seems important to explain these results is the chronic condition and previous experiences of our patients. Studies by Becker and Gamarra clearly differentiate acute patients from chronic patients, establishing that in the latter ones the increase in care demands and the necessity to be protected become a high-priority for them. Specially elderly hospitalized COPD patients need continuous health care and consider the hospital for chronic patients as a place with high protection against the consequences of their disease. In fact, our results show that patients with a lesser degree of dyspnoea and more self-care independence, reported the greatest stress levels and patients with severe dyspnoea were less affected by hospital routine.
HRQOL and social support
A descriptive study of specific HRQOL for COPD shows that, on the whole, this was impaired in COPD patients. However, patients with a worse HRQOL experienced more stress during hospitalization than those who presented a better HRQOL.
We believe that our study adds evidence to the association between stress during hospitalization and factors like pain, psychological impact of the disease, dyspnoea, social isolation and social positive interaction in COPD patients. These factors are shown to be good predictors of the stress during hospitalization. Our findings are consistent with the studies by Fernandez et al, McCathie et al and Martin et al while providing new insights into the psychological complications that may occur in patients with low levels of social support during hospitalization.
However, our study presents several limitations. Firstly, the sample size was relatively small, due to the difficulties to include elderly, clinically stable patients and difficulties for exhaustive psychological evaluation in a restricted context. Secondly, there are few research papers and too old scientific evidence that examine stress factors both in general and in patients with COPD.
Chronic Obstructive Pulmonary Disease
Health Related Quality of Life
Hospital Stress Rating Scale
Nottingham Health Profile
St. George’s Respiratory Questionnaire
The authors would like to thank Dr. Joan B Soriano, MD, PhD, Head of Program of Epidemiology and Clinical Research of the Caubet-CimeraFundation (Balearic Islands) for his assistance in the review and translation of this manuscript.
- Barr DP: Hazards of modern diagnosis and therapy, the price we pay. JAMA. 1955, 159: 1452-56.View Article
- Schimmel EM: The hazards of hospitalization. Ann Intern Med. 1964, 60: 100-110.View ArticlePubMed
- Barnes E: People in Hospital. 1961, London, United Kingdom: The Macmillan Company
- Mathew KV: Emotional aspects of hospitalized patients. J Chr Med As Ind. 1962, 37: 632-636.
- Volicer BJ, Bohannon MW: A hospital stress rating scale. Nurs Res. 1975, 24: 352-9.PubMed
- Kendal PC: Procedimientos médicos que generan estrés, estrategias cognitivo-conductuales para el control del estrés. Prevención y reducción del estrés. Edited by: Meichembaum y D, Jarenko ME. 1987, Bilbao: DDB
- Ferrer-Pérez V, Fornés J, GonzáIez-Barrón R, Manassero-Más MA: Factorialización de la escala HSRS de Volicer v Bohannon en una muestra española. 1992, Comunication: Iberoamerican Congress of Psychology
- Volicer BJ, Burns MW: Preexisting correlates of hospital stress. Nurs Res. 1977, 26: 408-415. 10.1097/00006199-197711000-00005.View ArticlePubMed
- Volicer BJ, Isenberg M, Burns MW: Medical surgical differences in hospital stress factors. J Hum Stress. 1977, 3: 3-13.View Article
- Rodriguez-Marin J: El impacto psicológico de la hospitalización. An Mod Con. 1986, 12: 421-439.
- Rodriguez J, Zurriaga R: Estrés, enfermedad y hospitalización. 1997, Escuela Andaluza de Salud Pública: Granada
- Volicer BJ, Volicer L: Cardiovascular changes associated with stress during hospitalization. J Psychosom Res. 1978, 22: 159-168. 10.1016/0022-3999(78)90019-3.View ArticlePubMed
- Monsinjon P: The psychosocial consequences of illness and hospitalization. Cardiology. 1985, 33: 37-48.
- Tagliacozzo DM, Ima K: Knowledge of illness as a predictor of patient behavior. J Chron Dis. 1970, 22: 765-75. 10.1016/0021-9681(70)90052-4.View ArticlePubMed
- Taylor SE: Health Psychology. 1986, Nueva York: Random House
- Feedland K, Rich M, Skala J, Carney R, Davila-Roman V, Jaffe A: Prevalence of depression in hospitalized patients with congestive heart failure. Psychosom Med. 2003, 65: 119-128. 10.1097/01.PSY.0000038938.67401.85.View Article
- Van Servellen GM, Lewis CE, Leake BD: Nurses’ knowledge, attitudes, and fears about AIDS. J Nur Sci Prac. 1988, 1: 1-7.
- Carr JA, Powers MJ: Stressors associated with coronary bypass surgery. Nurs Res. 1986, 35: 243-246.View ArticlePubMed
- Ricard M, Cabrero J, Reig A: Hospitalización y estrés en el paciente, percepción diferencial de estresores entre paciente y personal de enfermería. An Mod Con. 1993, 19: 75-85.
- Gudmundsson G, Gislason T, Janson C, Lindberg E, Hallin R, Ulrik CS, Brøndum E, Nieminen MM, Aine T, Bakke P: Risk factors for rehospitalisation in COPD: role of health status, anxiety and depression. Eur Respir J. 2005, 26: 414-419. 10.1183/09031936.05.00078504.View ArticlePubMed
- Reardon JZ, Lareau SC, Zuwallack R: Functional status and Quality of life in chronic obstructive pulmonary disease. Am J Med. 2006, 119 (10 Suppl 1): 32-7.View ArticlePubMed
- Kohler CL, Fish LG, Greene PG: The relationship of perceived self-efficacy to quality of life in chronic obstructive pulmonary disease. Health Psychol. 2002, 21: 610-614.View ArticlePubMed
- Emery C, Shermer C, Hauck R, Hsiao E, MacIntyre E, Neil R: Cognitive and psychological outcomes of exercise in a 1-year follow-up study of patients with chronic obstructive pulmonary disease. Health Psyc. 2003, 22: 598-604.View Article
- De Voogd JM, Sanderman R, Postema K, Sonderen E, Wempe JB: Relationship between anxiety and dyspnea on exertion in patients with chronic obstructive pulmonary disease. An St Cop. 2011, 24: 439-449.
- Andenaes R, Kalfoss MH, Wahl AK: Coping and psychological distress in hospitalized patients with chronic obstructive pulmonary disease. Heart Lung. 2006, 35: 46-57. 10.1016/j.hrtlng.2005.09.009.View ArticlePubMed
- Andenaes R, Moum T, Kalfoss MH, Wahl AK: Changes in health status, psychological distress and Quality of life in COPD patients after hospitalization. Qual Life Res. 2006, 15: 249-57. 10.1007/s11136-005-0890-7.View ArticlePubMed
- Medinas-Amorós M, Mas-Tous C, Truyols M, Alorda C, Martín B: Estrés en el hospital sociosanitario: principales factores iatrogénicos en pacientes con enfermedad respiratoria crónica. Ans Estr. 2009, 15: 167-179.
- Fletcher CM: Standardized questionnaire on respiratory symptoms: a statement prepared and approved by the MRC Committee on the Aetiology of Chronic Bronchitis (MRC breathlessness score). BMJ. 1960, 2: 1665-
- Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987, 40: 373-383. 10.1016/0021-9681(87)90171-8.View ArticlePubMed
- Hunt SM, McEwen J: The development of a subjective health indicator. Sociol Heal Ill. 1983, 2: 231-45.View Article
- Alonso J, Antó JM, Moreno C: Spanish version of the Nottingham Health Profile: translation and preliminary validity. Am J Public Health. 1990, 80: 704-708. 10.2105/AJPH.80.6.704.PubMed CentralView ArticlePubMed
- Jones P, Quirck F, Baveystock C: The St. George’s respiratory questionnaire. Respir Med. 1991, 85 (suppl. B): 25-31.View ArticlePubMed
- Ferrer M, Alonso J, Prieto L, Plaza V, Monsó E, Marrades R, Aguar MC, Khala A, Antó JM: Validity and reliability of the St George’s Respiratory Questionnaire after adaptation to a different language and culture: the Spanish example. Eur Resp J. 1996, 9: 1160-1166. 10.1183/09031936.96.09061160.View Article
- Sherbourne CD, Stewart AL: The MOS social support survey. Soc Sci Med. 1991, 32: 705-714. 10.1016/0277-9536(91)90150-B.View ArticlePubMed
- Becker PM, McVey U: Hospital acquired complications in a randomized controlled trial of a geriatric consultation team. JAMA. 1987, 257: 231-7.View Article
- Gamarra-Samaniego P: Consecuencias de la hospitalización en el anciano. Bol Soc Per Med Int. 2003, 14: 3-16.
- Elías M, Ortega F, Sánchez R, Otero R, Gil R, Motemayor T: Papel de la disnea en la calidad de vida del paciente con Enfermedad Pulmonar Obstructiva Crónica. Arch Bronc. 1999, 35: 261-266.View Article
- Fernández AM, Bujalance MJ, Leiva F, Martos F, García AJ, Sánchez de la Cuesta F: Salud autopercibida, apoyo social y familiar de los pacientes con enfermedad pulmonar obstructiva crónica. Aten Pri. 2001, 28: 579-589.View Article
- McCathie F, Spence S, Tate RL: Adjustment to chronic obstructive pulmonary disease: the importance of psychological factors. Eur Respir J. 2002, 19: 47-53. 10.1183/09031936.02.00240702.View ArticlePubMed
- Martin M, Grünendahl M, Martin P: Age differences in stress, social resources, and well-being in middle and older age. J Gerontol B Psychol Sci Soc Sci. 2001, 56: 214-222. 10.1093/geronb/56.4.P214.View Article
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.