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NURSING Crisis Interventions: Providing

PRACTICE &
SKILL What is Providing Crisis Interventions?
A crisis is defined as any situation in which a threat or other stressful life event
overwhelms the ability of a person or population to cope effectively with the perceived
threat or event
What: The term crisis intervention refers to emergency patient care activities that are
performed to achieve the following goals:
Assist persons who are affected by a crisis in developing coping skills that are adequate
to resolve the issue causing the crisis and/or learn skills for coping with the crisis and
its aftermath
Treat and resolve medical conditions and injury, if present
Assist persons who are affected by a crisis with strategies that restore equilibrium to
their biopsychosocial functioning (e.g., ability to fulfill the normal family role and
responsibilities) so they can return to their normal activities of daily living
Minimize the potential for short- and long-term psychological trauma related to the
crisis
How: Procedural steps for providing crisis interventions presented in this Nursing
Practice & Skill are based on the Assessment, Crisis Intervention, and Trauma
Treatment (ACT) model for crisis intervention (Roberts, 2002). This model, which was
developed as a response to the September 11, 2001, terrorist acts in the United States,
involves a 3-stage plan consisting of strategies for assessment, crisis intervention, and
trauma treatment that can be used in a variety of crisis situations
Where: Crisis intervention is performed in all healthcare settings, including inpatient,
outpatient, in-home care, and community settings
Who: Interventions designed to assist and treat patients who are experiencing crisis
are performed by nurses, physicians, therapists who specialize in crisis intervention,
social workers, members of the clergy, and other trained professionals. Interventions
cannot be delegated to assistive personnel. Family members may be present during crisis
interventions and encouraged to be present if their availability or participation in the
patients care could be of benefit to the patient
Authors
Nathalie Smith, RN, MSN, CNP
Cinahl Information Systems, Glendale, CA What is the Desired Outcome of Providing Crisis
Mary Woten, RN, BSN Interventions?
Cinahl Information Systems, Glendale, CA
The desired outcome of providing crisis interventions is for affected persons to
Reviewers develop coping skills that are adequate to resolve the issue causing the crisis and/or learn
Darlene Strayer, RN, MBA skills for coping with the crisis and its aftermath
Cinahl Information Systems, Glendale, CA receive effective treatment and have resolution of any medical conditions and/or injury
Nursing Executive Practice Council
have restored equilibrium of biopsychosocial functioning and be able to return to normal
Glendale Adventist Medical Center,
Glendale, CA activities of daily living
avoid short- or long-term psychological trauma related to the crisis
Editor
Diane Pravikoff, RN, PhD, FAAN Why is Providing Crisis Interventions Important?
Cinahl Information Systems, Glendale, CA
Providing crisis interventions is important because it promotes patients ability to develop
coping skills, restores equilibrium to biopsychosocial functioning, and minimizes
psychological trauma
October 23, 2015

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright2016, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Facts and Figures
25% of American women experience domestic violence during their lifetimes (King, 2012)
One in four children experiences the financial, social, and emotional crisis of living in poverty (King, 2012)
Crisis-based interventions with mothers and children who were victims of domestic violence resulted in significantly
improved mother-child relations and improved child play skills (Waldman-Levi et al., 2015)

What You Need to Know Before Providing Crisis Interventions


Nurses in all specialty areas have daily contact with patients and family members who are experiencing crisis. Common
causes of crisis include
developmental issues, including marriage and death of a family member
situational issues, including difficulties in a relationship and illness
social/public/environmental issues (also called mass trauma events), including shootings at a school, terrorist attacks, and
natural disasters
Risk factors for experiencing a crisis include the following:
The presence of concurrent or multiple physical and/or emotional stressors
Multiple losses, unexpected life changes, and/or unresolved difficulties
Limited adaptive ability and/or coping skills
Chronic disability
Chronic pain
Concurrent psychiatric disorders (e.g., depression, anxiety disorder, substance abuse)
Suicidality
Poor social support networks
Limited access to healthcare services
Immediate biopsychosocial responses to crisis include
physiologic manifestations, including nausea, vomiting, tremors, and profuse sweating
dizziness
denial
dissociative behavior
confusion
disorganized thinking
difficulty making decisions
Patients generally seek care approximately 12 weeks following the crisis; some resolution to the crisis is generally achieved
after approximately 6 weeks
Following successful coping with or resolution of the crisis, the patient must acknowledge that he/she has been changed
and the effects of the crisis may be felt for years or for a life time
The long-term reaction of individuals and families emerging from a crisis situation can range from functioning more
effectively to becoming completely dysfunctional
The ACT model for crisis intervention (Roberts, 2002) involves a 3-stage plan of assessment, crisis intervention, and trauma
treatment that can be used in a variety of crisis situations. Because the nature of a crisis often precludes orderly progression
of patient care, there is repetition in the type of patient information collected during each stage of this model
The assessment stage involves
determining identity, age, and gender of the patient and immediate patient needs
triaging to determine the level of care required
taking a brief medical history, including asking about current medications and when the most recent doses were taken,
chronic conditions, recent exposure to communicable diseases or potential toxins, mobility status, and for female patients,
the possibility of pregnancy, miscarriage, or active labor
performing a psychosocial assessment, including asking about the
- presence of supportive or dependent family members and friends
- patients perception of the crisis to assess his/her mental status, ability to communicate, and ability to focus and follow
directions
The crisis intervention stage focuses on developing an individualized treatment plan and initiating strategies to resolve
crisis-relatedmedical conditions, stress, psychological trauma, and emotional conflicts in order to help the patient find
meaning in the crisis event
Perceiving meaning in the crisis event is important because it allows the patient to gain a sense of mastery in coping with
the crisis
The trauma treatment stage focuses on evaluating the patients emotional status with the goal of preventing or resolving
signs and symptoms of PTSD (for information on PTSD and its treatment, see Quick Lesson About Post-Traumatic
Stress Disorder , Quick Lesson About Post-Traumatic Stress Disorder in Children , and Evidence-Based Care Sheet:
Post-Traumatic Stress Disorder and Military Personnel ); this stage involves
patient assessment and serial screening (e.g., during scheduled appointments for follow-up care)
encouraging the patient to talk about the crisis events
clinician/patient collaboration to formulate a longer-term,individualized treatment plan
referral to clinician specialists (e.g., a mental health clinician and/or social worker), as appropriate
Necessary nursing skills and nursing knowledge include the following:
Knowledge of the principles of patient communication and the ability to effectively interact using these principles
Awareness of the specific strategies for crisis intervention that are likely to be effective in the patients crisis circumstances
Preliminary steps that should be performed before initiating crisis interventions include the following:
Review the facility/unit-specific protocol for providing crisis interventions, if one is available
Review the treating clinicians order related to crisis intervention (e.g., referral to social services)
Review the patients medical history/medical record for
patient history related to the crisis (e.g., information regarding the type of crisis experienced) and any previous crisis
intervention received
any allergies (e.g., to latex, medications, or other substances); use alternative materials, as appropriate
Verify completion of facility informed consent documents
The general consent for treatment executed by patients at the outset of admission to a healthcare facility commonly
contains provisions that include providing crisis intervention
Gather the following supplies:
Personal protective equipment (PPE; e.g., sterile/nonsterile gloves, gown, mask, eye protection); typically, no PPE is
necessary during crisis intervention unless exposure to body fluids is anticipated
Equipment for taking vital signs
First aid supplies and other treatment-related supplies, as appropriate
Written information, if available, to reinforce verbal education

How to Provide Crisis Interventions


Perform hand hygiene
Don PPE as appropriate to avoid transfer of microorganisms
Identify the patient according to facility protocol
Introduce yourself to the patient and family members, if present, and explain that you will be providing crisis interventions
Evaluate whether the patient/family require special considerations regarding communication (e.g., due to illiteracy,
language barriers, or deafness); make arrangements to meet these needs, if present
Follow facility protocols for using a professional certified medical interpreter, either in person or via phone, when a
language barrier exists
Assess the patient/family for knowledge deficits and anxiety regarding receiving crisis interventions; provide emotional
support and additional information, as needed
As appropriate, perform the following to assess the patient as the first stage of the ACT model:
Ask about/assess the immediate needs of the patient, including relief of pain, resolution of bleeding, and/or providing
information urgently requested by the patient/family
Take vital signs and perform triage assessment to determine the need for immediate referral to emergency medical care or
outpatient medical care
Patients who require emergent medical care should receive first aid, as appropriate, and be immediately referred/
transported to a healthcare facility/temporary medical station for more extensive treatment
If immediate referral/transfer is not required, take a brief patient history to collect information relevant to formulation of
the treatment plan, including
patient identity, age, and gender
physical or somatic complaints or stressors related to the crisis
known medical or other conditions (e.g., mental illness)
current medications (including herbs, over-the-counter drugs, and homeopathic remedies) and the date and time each was
most recently taken
recent exposure to communicable diseases or potential toxins
mobility status
the possibility of pregnancy, miscarriage, or active labor in female patients of reproductive age
Perform a psychosocial assessment to collect information about the patients usual environment, existing interpersonal
relationships, and crisis state (i.e., psychological status related to perception of the crisis), including
other persons who are dependent on or supportive of the patient
primary psychological or other stressors
perception of the event(s) that precipitated the crisis
mental status and ability to communicate
ability to focus and follow directions
predominant defense mechanisms (e.g., denial, minimization), if present
coping skills that the patient used successfully during past stressful situations
feelings and insights the patient expresses about the crisis and ensuing activity
any expression of intent to injure self or others
patient behaviors (e.g., agitated, controlled, nonverbal, tearful)
the appearance of or any report of substance abuse
any patient report of victimization or violence
Initiate the following strategies for crisis intervention as the second stage of the ACT model to resolve crisis-related medical
conditions, stress, psychological trauma, and emotional conflicts:
Assess/reassess the patients physical status and administer prescribed treatment for medical needs, if present and the
patient is not transferred/transported. Monitor physiologic status and response to treatment closely, as appropriate
Ask about factors related to the crisis and encourage the patient to discuss his/her experience and feelings regarding the
crisis event
Assess for and identify coping mechanisms the patient uses regarding the crisis, and collaborate with the patient/family to
explore healthy alternative coping mechanisms, as appropriate
Changing the patients coping mechanisms is typically the most difficult step in providing crisis interventions
Collaborate with the treating clinician and the patient/family to develop an individualized treatment plan (e.g., referral to
a mental health clinician for counseling; referral to a social worker for identification of local resources for support groups)
that will help the patient find meaning in the crisis event and gain a sense of mastery in coping with the crisis
Schedule and emphasize the importance of keeping scheduled follow-upappointments for serial evaluation of patient status
and progress toward effective coping
As appropriate immediately after the crisis or during a subsequently scheduled patient care appointment, perform the
following as the third stage of trauma treatment:
Evaluate the patients emotional status for signs and symptoms of PTSD to prevent or resolve PTSD
Evaluate the danger to or safety of the victim, clinician, and others present in the immediate area; if follow-up serial
screening is being performed, evaluate the danger posed by the patient to self and others
Assess physiologic status and provide prescribed treatment for ongoing medical conditions
Assess for continued biopsychosocial responses/manifestations of traumatic stress, including
physiologic manifestations of nausea, vomiting, tremors, and profuse sweating
dizziness
denial
dissociative behavior
confusion
disorganized thinking
difficulty making decisions
disordered sleep
Encourage the patient to talk about his/her experiences during and after the crisis, including current experiences
Review the established treatment plan and evaluate the effectiveness of the prescribed strategies
Ask the patient/family how effective they perceive the prescribed treatment strategies have been
In collaboration with the treating clinician, modify the prescribed treatment plan as appropriate, including requesting
referral to other healthcare clinicians (e.g., a social worker; a mental health clinician)
Schedule a follow-up appointment for continued patient evaluation, as appropriate
Dispose of used procedure materials according to facility protocol
Remove PPE, discard appropriately, and perform hand hygiene
Update the patients plan of care, if appropriate, and document performing crisis interventions in the patients medical
record, including the following information:
Date and time of crisis intervention
Patient assessment findings
Specific strategies performed, including referrals to other healthcare clinicians
Patients response to the crisis intervention
Any unexpected events or outcomes, interventions performed, and whether or not the treating clinician was notified
Patient/family member education, including topics presented, response to education provided/discussed, plan for follow-up
education, barriers to communication, and techniques that promoted successful communication

Other Tests, Treatments, or Procedures That May Be Necessary Before or After


Providing Crisis Interventions
Clinicians can experience psychological effects (e.g., anxiety, depression, PTSD) resulting from emotional trauma related
to providing crises interventions. Healthcare organizations should promote the mental health of clinicians by encouraging
clinicians to schedule mental health counseling from services made available by the organizations

What to Expect After Providing Crisis Interventions


The patient develops or enhances coping skills that are effective in resolving his/her crisis responses
The patient returns to the level of biopsychosocial functioning he/she experienced before the crisis
The patient does not develop PTSD or other psychological impairment related to the crisis; if the patient develops PTSD, he/
she receives prompt treatment that resolves the manifestations of PTSD

Red Flags
Monitor closely for signs and symptoms of clinical depression; request referral to a mental health clinician for evaluation and
treatment of clinical depression if the patient/family members develop one or more of the following manifestations (for more
information, see Quick Lesson Depression: Major Depressive Disorder ):
Difficulty concentrating, remembering details, and making decisions
Fatigue and decreased energy
Feelings of guilt, worthlessness, and/or helplessness
Feelings of hopelessness and/or pessimism
Insomnia, early-morning wakefulness, or excessive sleeping
Irritability and restlessness
Loss of interest in activities or hobbies that were once pleasurable, including sex
Overeating or loss of appetite
Persistent aches or pains, headaches, cramps, or digestive problems that do not resolve with treatment
Persistent sad, anxious, or empty feelings
Suicidal ideation and/or suicide attempts
Monitor closely for suicide risk and follow facility protocols for emergency intervention if the patient is at increased risk
(for more information, see the CINAHL series of papers on suicide)

What Do I Need to Tell the Patient/Patients Family?


Educate the patient/family about what to expect during and after crisis intervention and what outcome to expect. Encourage
questions, and provide appropriate answers
If laboratory tests or other diagnostic procedures are ordered, explain how these tests and/or procedures are performed and
when the results will likely become available
Explain how the patient/family can contact the treating clinician if questions or problems arise
Explain the importance of keeping scheduled follow-up appointments for continued assessment and follow-up care
Provide written information, if available, to reinforce verbal education
References
1. Baier, M. (2013). Stress and coping. In P. A. Potter, A. G. Perry, P. A. Stockert, & A. M. Hall (Eds.), Fundamentals of nursing (8th ed., pp. 741-743). St. Louis, MO: Elsevier
Mosby.
2. King, D. E. (2012). Crisis: Theory and intervention. In K. M. Fortinash, & P. A. Holoday Worret (Eds.), Psychiatric mental health nursing (5th ed., pp. 489-496). St. Louis, MO:
Elsevier Mosby.
3. Psychiatric care. (2009). In J. P. Kowalak (Ed.), Lippincott's nursing procedures (5th ed., pp. 831). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
4. Roberts, A. R. (2002). Assessment, crisis intervention, and trauma treatment: The integrative ACT intervention model. Brief Treatment and Crisis Intervention, 2(1), 1-22.
5. Townsend, M. C. (2015). Crisis intervention. In Psychiatric mental health nursing: Concepts of care in evidence-based practice (8th ed., pp. 217-234). Philadelphia, PA: F. A.
Davis Company.
6. Waldman-Levi, A., & Weintraub, N. (2015). Efficacy of a crisis intervention in improving mother-child interaction and childrens play functioning. American Journal of
Occupational Therapy, 69(1), 1-11.