RAHMAN INSTITUTE OF NURSING AND PARAMEDICAL SCIENCES,

GUWAHATI

SEMINAR

ON

STRES AND ADAPTATION, CRISIS AND ITS INTERVENTION

SUBJECT: ADVANCE NURSING PRACTICE

Submitted to: Submitted by:

Ms. Anamita Borah Malsawmpuii

Asst. Professor M.Sc Nursing 1st Year

Department of Roll No - 1

Mental Health Nursing

Date of Submission: __________________

Date of Presentation: _________________

 CONTENT

 INTRODUCTION
 STRESS
 DEFINITIONS OF STRESS
 TYPES OF STRESS
 STRESSOR
 TYPES OF STRESSORS
 BASIC CONCEPT OF STRESS OR STAGES OF STRESS
 COPING STRATEGIES
 STRESS MANAGEMENT
 NURSING INTERVENTIONS FOR PEOPLE THAT EXPERIENCES STRESS
 ROLE OF NURSE IN STRESS MANAGEMENT
 ADAPTATION
 LEVELS OF ADAPTATIONS
 ENVIRONMENT AND ADAPTATIONS
 ASSUMPTIONS
 CONCEPTS
 COPING MECHANISMS
 GENERAL ADAPTATION SYNDROME
 CRISIS AND ITS INTERVENTION
 DEFINITIONS OF CRISIS
 CHARACTERISTICS OF CRISIS
 TYPES OF CRISIS
 DEVELOPMENTAL PHASES OF CRISIS
 FACTORS RESPONSIBLE FOR AN INDIVIDUAL’S EXPERIENCE OF CRISIS
 PARADIGM SET BY AGUILERA
 CRISIS CONTINUUM
 SIGNS AND SYMPTOMS
 INDICATION FOR CRISIS INTERVENTION
 SETTINGS FOR CRISIS INTERVENTION
 GOALS
 CRISIS INTERVENTION
 PURPOSE
 GOALS OF CRISIS INTERVENTION
 PHASES OF CRISIS INTERVENTION: THE ROLE OF NURSE
 SUMMARY
 CONCLUSION
 BIBLIOGRAPHY
 RELATED RESEARCH STUDY
INTRODUCTION

Human beings have to maintain balance in life, whenever he/she is exposed to stressor or
stressful situation he/she will try to overcome by his/her own way of dealing with problems ,by
his/her own way of dealing with problems, by adapting adequate coping strategy, with the help
of situational support, he/she will try to overcome it. But if the individual is exposed to too much
stress at a time, due to one or more absence of balance factor results in the disruption,
disequilibrium and it may lead into crisis. Modern world is full of hassles, deadlines, frustrations
and demands. For many people stress is so common place that it has become a way of life. Stress
is not always bad, in small doses, it can help you perform under pressure and motivate you to do
your best. A ‘stress’ condition seems ‘relative’ in nature. Today, with the rapid diversification of
human activity, we come face to face with numerous causes of stress and the symptoms of
anxiety and depression. Stress can come from any situation or thought that makes you feel
frustrated, angry, nervous, or anxious. Stress is caused by an existing stress-causing factor or
stressor ‘dealing with a serious illness or caring for someone who can cause a great deal of
stress’.

DEFINITIONS OF STRESS

Stress is an increase in an individual’s level of arousal created by a stimulus. Initially, as stress

levels increase, a person’s performance and ability to focus may actually improve. Attention to
detail sharpens and the person is in a heightened state of readiness to take in the world around
him. Immediately, the body physiologically responds to stress via the brain, which alerts the
adrenal glands to produce adrenaline.

- Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011

This classic “fight or flight” reaction can ensure one’s safety. However, once a stress threshold is
crossed, these benefits are lost and performance and health deteriorate. A sustained stress
response can cause damage to the cardiovascular, immune, and nervous systems, causing chronic
illness and maladaptation.

- U.S. Department of Health and Human Services [DHHS],

2005

‘The nonspecific response of the body to any demand. The nonspecific response is always the
same, it is the degree of the response that changes’.
- Selye, 1958
TYPES OF STRESS

 Eustress
 Marriage
 Birth of a baby
 Winning the lottery
 Distress
 Difficult work environment
 Overwhelming sights and sounds
 Threat of personal injury
Other classification of stress

 ACUTE STRESS- Is a physical response to perceived threat to well-being and constitutes

the most common form of stress. This is the classic Fight or Flight reaction. Acute stress
can be actually helpful by keeping the individual alert, focused and energetic. Acute
stress takes place over a short period of time, thus it usually does not have enough time to
the kinds of extensive damage associated with long terms.

 EPISODIC STRESS- It occurs when the individual experiences acute stress too
frequently. It often hits those who take on too much – those who feel they have self-
imposed pressure external demands vying for their attention. In such cases, hostility and
anger frequently results. Episodic stress also commonly affects those who worry a lot of
time, in return resulting to anxiety and depression.

 CHRONIC STRESS- It leads to serious health problems, because it disrupts the nearly
every system of the individual. Part of what makes chronic stress so incidious is its ability
to become normal feeling. This pattern of enduring is what makes chronic stress. Chronic
stress leads to stokes, heart attacks as well as violent behaviour and even suicide. Though
one of the most difficult issues treat, it is never too late to undoing the damage

 TRAUMATIC STRESS- Severe stress reaction can result from a catastrophic event or
intense experience such as a natural disaster, sexual assault, life threatening accident or
participation in a combat. After the initial shock and emotional fallout, many trauma
victims gradually begin to recover. But for some people, the psychological and physical
symptoms triggered by the trauma do not go away, the body does not regain its
equilibrium and life does not return to normal. Common symptoms include flashback or
nightmares about the trauma, avoidance of places and things associated with the trauma,
hyper vigilance for sign of danger, chronic irritability and tension and depression.
STRESSOR

The physical and psychological demand from the environment that cause stress is called
stressors. They create stress or the potential stress or the potential for stress when an individual
perceives them as representing a demand that may exceed that person’s ability to respond. How
an individual experiences stress depends on –

 The person’s perception of the current situation.

 Persons past experience.

 The presence or absence of the support and,

 Individual differences with regard to the stress reactions.

- DON HELLREIEGEL, 2011

TYPES OF STRESSORS

 Internal
 Frustrations
 Conflicts
 Pressures
 External
 Environmental
 Health
 Financial problems
 Psychosocial
 Workplace stress
 Personal relationships

Stress at work:

 Sickness absence
 High staff turnover
 Poor communication between teams
 Lack of feedback on performance
 Value and contribution
 Technological change
 Lack of clarity of roles and responsibilities
 Dissatisfaction with non-monetary benefits
 Working long hours
 Boring and mundane work
  Uncomfortable workplace
 Lack of training

Stress in Nursing Personnel:

“Every day the nurse confronts stark suffering, grief and death as few other people do. Many
nursing tasks are mundane and unrewarding. Many are, by normal standards, distasteful and
disgusting. Others are often degrading; some are simply frightening”.

 Working long hours

 Poor working conditions
 Lengthy hours of duty and split duty
 Less salary, allowances and other incentives
 Less promotional opportunities
 Harassment of nurses by others
 Lack of clarity of roles and responsibilities
 Lack of feedback on performance
 Improper supplies
BASIC CONCEPT OF STRESS OR STAGES OF STRESS:

There are three stages a person goes through while suffering from stress.

Alarm stage:

Look at a student’s face just before he is going to give an exam. Is not the fear and tension
clearly evident? When something has just started stressing you and you feel a fight or flight kind
of attitude, then you are in the alarm stage of stress. It is the start-up stage which defines the first
reaction to the stressor.

This stage experiences an over-acting of the sympathetic nervous system wherein adrenaline and
cortical increase and blood flows away from the brain to the muscles. As a result, dendrites
shrink back in the brain to moderate the flow of information, slowing or closing down the
nonessential body functions. The whole body starts preparing itself to fight against the reason of
stress. The fear, excitement or pressure is evident on the sufferer’s face.

Resistance stage:

When a child is sitting in the examination hall and writing his exam, he is bothered about
completing it in time. He is making full efforts to cope with the situation and his whole body is
engaged in fighting against the condition. This is the resistance stage. In this stage, the body
keeps making continuous efforts to cope with stress and therefore feels run down and exhausted.
The person starts feeling irritated, over-reacts to minor situations and gets mentally and
physically weak. Psychological, physical and behavioral changes are also clearly visible.
Exhaustion stage:

if a student is preparing for his exam and despite every possible effort, he is not able to relate to
his studies, he is bound to get stressed. The stress could reach a height where he/she may feel
completely exhausted and helpless to the extent of committing suicide. This is the exhaustion
stage. This stage is further divided into two phases:

 Initial phase: The stress persists and due to lack of appropriate measures the person is
not able to concentrate and work efficiently.
 Burnout: The person is completely exhausted and drained of all energy reserves. There
is a complete physical, psychological and emotional breakdown. This requires immediate
attention.

COPING STRETEGIES

This refers to the specific efforts, both behavioural and psychological, that people employ to
master, tolerate, reduce or minimize stressful events. Two general coping strategies have been
distinguished:

 Problem solving strategies are effort to do something active to elevate the stressful
circumstances.

 Emotional focused coping strategies involve efforts to regulate the emotional

consequences of stressful or potentially stressful events.

 Research indicates that people who use both type of strategies to combat most stressful
events

- FLOKMAN & LAZAROUS 1980

STRESS MANAGEMENT

 ABC’S of stress management

 Awareness
 Belief
 Commitment
 Diet
 Physical health management
 Take a deep breath!
 Stand-up straight!
 Go to bed early
 Relax
 Take a break
  Eat properly
 Exercise
 Mental health management
 Realistic expectations
 Reframe your thoughts
 Laugh
 Social support
 Massage
 Music therapy: Research has shown that music has a profound effect on your body and
psyche. In fact, there is a growing field of health care known as music therapy, which
uses music to heal.
 Meditation: Practiced 20 minutes ones or twice daily. Meditation has shown to produce a
lasting reduction in blood pressure or other related symptoms.
 Yoga
 Acupuncture
 Biofeedback
 Guided imagery
 Sound therapy
 Kinesiology:
 Providing adrenal support and nutrition for stress
 Checking the atlas and sacrum for lesions
 Pet therapy: Pet therapy works by providing proximity to animals to those who can
benefit by it.
 Get mental:
 Count to ten
 Control your thoughts
 Fantasize
 Congratulate
 Ignore the problem if appropriate, after evaluation
 Perform self-maintenance.
 Talk to a counselor
 Healthy living to conquer stress:
 Examine your diet
 Add to your diet
 Fruits
 Complex carbohydrates
 Vitamins
 Water
 Vegetables
 Keep a stress diary:
 How it made me feel physically
 How I felt mentally
  How did I react to the situation
 What did I say to myself about the situation
 Home Remedies:
 Use of holy basil:The leaves of holy basil are beneficial in the treatment of
stress. They act as anti-stress agent. Recent studies show leaves protect against
stress. Healthy persons should chew twelve leaves of basil morning and evening
for preventing stress.
 Using sage: The herb sage is considered valuable in stress. Tea leaves are given
as a treatment. Tea is prepared by pouring a cup of boiling water, should be
covered and infused for several minutes. It should be stained and sweetened with
honey.
 Using nutrients: Certain nutrients such as vitamins A and B, minerals,
potassium and magnesium which reduce anxiety, irritability, vitamin B have deep
effect on adrenal gland. Potassium is essential for healthy heart. Magnesium is a
nature’s Tranquillizer and preventing heart attack.
 Using other food: Certain food such as yoghurt, blackstrap molasses, seeds and
sprouts. Yoghurt is rich in vitamin A, D, B complex group. It relieves migraine.
 Diet for stress:
 Lifestyle change, optimum diet, and regular exercise and rest: Regular exercise
and adequate rest are advisable. Patient should be placed on optimum diet. Diet
plays important role in preventing stress.
 Food to be avoided during stress: Caffeine in coffee and many soft drinks, salts,
sugar, cigarettes and alcohol.

NURSING INTERVENTIONS FOR PEOPLE THAT EXPERIENCE’S STRESS

Nurses, by recognizing the patient’s needs and reactions, they should choose those interventions
that it will be the most effective for the particular patient. Most important intervention for
alleviating stress are: anxiety reduction, anger management, relaxation and sleep, proper diet,
physical exercise, relaxation techniques and effective time management.

 Anxiety Reduction - Nurses should take all necessary measures in order to reduce stress
and anxiety that their patients experiencing. For example, nurses could encourage
patients to take a deep breath before an injection, provide the necessary information
before a procedure and offer support to both patients and their families. Nurses are aware
that direct interventions are necessary for preventing the spreading of Stress-Concepts,
Theoretical Models and Nursing Interventions anxiety, in which an individual’s anxiety
may negatively effect and others around him such other patients, relatives even health
professionals.
 Anger Management - Patients that are experiencing stress can often exhibit anger.
Managing a patients' anger is one frequent difficulty that nurses face. Nursing care of the
patients that are experiencing anger is mainly difficult for two reasons:

i. Patients rarely are expressing their anger or the cause of it verbally. Instead
they are usually refusing treatment, are becoming verbally aggressive, they are
demanding and threaten to use violence. Their observations rarely are
reflecting the cause of their anger.

ii. Patient's anger can often cause fear and anger to nurses. Thus, nurses are
usually responding to it in such way that may increase patient’s anger, as to
the point of violence. Furthermore, nurses under such circumstances tend act
in a way that reduces their own stress and not the patient’s stress.

iii. Healthcare professionals implementing anger management strategies in

patients. Those strategies including understanding the reaction, acceptance of
the patient’s right to be angry, trying to communicate with the patient in order
to identify sources and meaning of anger. Moreover, they apply interventions
for reassuring, they use silence and time supply as therapeutic means and last
in difficult situations of risk, they intervening in such way in order to ensure
patient’s, family members and staff’s safety.

 Rest and Sleep - Those are two important factors in stress management, because while
the body is resting is retrieving the desired energy levels. However, for enable patients to
rest, some nursing interventions may be required to ensure comfort, potential pain
management and promote to spiritual serenity.

 Nutrition - A healthy diet is increasing body’s resistance to stress. In order to reduce

negative effects of stress individuals should avoid substances such as caffeine, salt, sugar
and fat and include in their diet enough vitamins and minerals.

 Physical Exercise - A normal exercise can promote biological and emotional health. The
biological benefits are the improvement of muscle tone, cardiopulmonary function and
weight control. Psychological benefits are relieving from tension and relaxation.
Generally, health standards are recommending exercise at least three times a week for 30
to 45 minutes

 Relaxation Techniques - Many relaxation techniques can be used to relief stress Nurses
can teach those techniques to patients and encourage them to use when they facing
stressful situations outside the hospital. Relaxation techniques that are often applied are
breathing exercises, massage, progressive relaxation, guiding use of images, biofeedback,
therapeutic touch, music therapy, humor and laughter and finally meditation.
  Management of Time - People who manage their time properly are experiencing less
stress because they feel that everything is under control. Controlling other people’s’
demands is an important element in proper time management, because many times their
demands cannot be addressed. Sometimes people need to be taught which demands can
fulfill without experiencing any stress, which to negotiate and which to reject. As it
comes to time management it is important to consider, what goals can be achieved during
the day and during the week. In addition, it is necessary for people to consider what is
important to them and what can be achieved.

ROLE OF A NURSE IN STRESS MANAGEMENT

Assessment:

The nurse should-

 Identify the actual or potential stressors

 Identify client’s appraisal of stressor
 Assess the available coping resources
 Positive health behavior: Exercise, avoid high fat, relaxation, positive lifestyle
 Positive health behavior: Exercise, avoid high fat, relaxation, positive lifestyle
 Maladaptive coping behavior: Smoking drinking etc
 Maladaptive coping behavior: Smoking drinking, etc
 Adherence to healthy practices: Nutritional habits, exercise, use of seat belts, etc
Interventions:

 Teaching healthy activities of daily living: exercise, rest and sleep nutrition
 Encourage the use of support systems
 Encouraging the use of stress management techniques.
 Benefits of exercise -
 Reduced feelings of anxiety, depression, frustration, aggression, anger and hostility
 Alleviation of insomnia
 An opportunity to develop new friendships
 Allows for the development of discipline
 Provides the opportunity to do something enjoyable and constructive that will lead to
better health and total well-being
 Provides the opportunity to do something enjoyable and constructive that will lead to
better health and total well-being.
 Provides the opportunity to do something enjoyable and constructive that will lead to
better health and total well-being
 Nutrition and stress -
 Well-nourished bodies are better prepared to cope with stress
  Obesity and malnutrition are major stressors and greatly increase the risk of illness
 Reduce caffeine, sugar, salt, animal fat, and cholesterol.
 Avoid alcohol, cigarette, drug abuse (these are stress inducers)

ADAPTATION

Adaptation is the process by which the organism makes itself suitable to live in the particular
environment. Human beings are the most intelligent of all the organisms, and due to its high
degree of intelligence and other capacities, he is able to make better adaptation to environment.

LEVELS OF ADAPTATION

 Physical adaptation - By physical adaptation it is meant adjustment to the physical

environment. This adaptation is not voluntary because, physical conditions are inevitable
and organism has to make adjustment in order to survive. Physical adaptation remains
with all its compulsion.
 Biological adaptation - Every organism is adapted to live in a particular environment. If
they are taken out of the environment, life or even survival may be difficult. Human
beings are capable of making adaptation in this area also. For example – a person
adapted to hot climate will try to make adjustments even in the cold climate by making
adaptations.
 Social Adaptations - Social adaptation is the process of adjusting in the socio – cultural
environment. Human beings are capable not only in the adapting in the environment, but
also making adaptation to suit his/her needs.

ENVIRONMENT AND ADAPTATIONS

The environment in which human beings live may be favourable or un favorable. For example –
Fertile land, availability of water, moderate climate, presence of natural resources etc are
favorable conditions in the natural environment. Whereas the mountain land extreme climate,
natural calamities like flood famine and earth quake, lack of natural resources etc are
unfavorable natural conditions. Similarly in the social situation also, a person may find
favourable or unfavorable conditions. A happy home is responsible parents, healthy
neighbourhood, good friends etc, are all favourable social situation, where as poverty, death of
parents, slum dwelling/criminal neighbourhood are unfavorable social conditions

 It is a consequence of coping efforts and denotes mastery and adjustments resulting from
the responses to problems or new challenges (Mechanic, 1974; Moos, 1977)

Adaptation results when the individual is able to effect a series of behaviours and mental process
to neutralise the stress experience and re establish the integrity of function . Adaptation involves
achieving a balance between perceived demands ( stress) and marshalled resources ( coping ) , a
state of reduced anxiety and enhanced well- being.

 Stuart Stress Adaptation Model is a model of of psychiatric nursing care, which integrates
biological, psychological, sociocultural, environmental, and legal-ethical aspects of
patient care into a unified framework for practice.

 The Stuart Stress Adaptation Model of health and wellness provides a consistent nursing-
oriented framework (Stuart, 2009).

ASSUMPTIONS

 "Nature is ordered as a social hierarchy from the simplest unit to the most complex and
the individual is a part of family, group, community, society, and the larger biosphere."

 "Nursing care is provided within a biological, psychological, sociocultural,

environmental, and legal-ethical context."

  Health/illness and adaptation/maladaptation (nursing world view) are two distinct

continuums. 

 The model includes the primary, secondary, and tertiary levels of prevention by
describing four discrete stages of psychiatric treatment: crisis, acute, maintenance, and
health promotion.

 Nursing care is based on the use of the nursing process and the standards of care and
professional performance for psychiatric nurses.

CONCEPTS

 Biopsychosocial approach - a holistic perspective that integrates biological,

psychological, and sociocultural aspects of care.

 Predisposing factors -risk factors such as genetic background.

 Precipitating stressors - stimuli that the person perceives as challenging such as life
events.

 Appraisal of stressor - an evaluation of the significance of a stressor.

 Coping resources - options or strategies that help determine what can be done as well as
what is at stake.

 Adaptation/maladaptation -

 Levels of Prevention
 o Primary

o Secondary

o Tertiary

o Four stages of psychiatric treatment & nursing care- The final aspect of the Stuart
Stress Adaptation Model is the integration of the theoretical basis,
biopsychosocial components, patterns of response, and nursing activities based on
the patient's treatment stage. Once patterns of coping responses have been
identified, the nurse determines which treatment stage the patient is in and
implements the most appropriate nursing activities

o Crisis stage

o Acute stage

o Maintenance stage

o Health promotion stage

COPING MECHANISMS

Coping mechanisms are any efforts directed at stress management. The three main types of
coping mechanisms are as follows:

 Problem-focused coping mechanisms, which involve tasks and direct efforts to cope
with the treat itself. Examples include negotiation, confrontation, and seeking advice

 Cognitively focused coping mechanisms, by which the person attempts to control the
meaning of the problem and thus neutralize it. Examples include positive comparison,
selective ignorance, substitution of rewards, and the devaluation of desired objects

 .Emotion-focused coping mechanisms, by which the patient is oriented to moderating

emotional distress. Examples include the use of ego defense mechanisms, such as denial,
suppression, or projection. A detailed discussion of coping and defense mechanisms.
Coping mechanisms can be constructive or destructive.

GENERAL ADAPTATION SYNDROME

Hans Selye first identified the body’s reaction to physiological stress through research he
performed in 1956 on laboratory animals. Termed the general adaptation syndrome, he identified
three stages of a person’s reaction to stress and the accompanying responses experienced. Since
his initial research, additional studies have shown that this response occurs not only when a
person is subjected to physiological stress but also when subjected to psychological or emotional
stress.

Alarm Stage
In this stage, the body is stimulated by a stressor. This causes the hypothalamus, in turn, to
stimulate the sympathetic nervous system, which leads to innervation of the glands, such as the
pituitary and adrenal glands and various body systems to prepare the body to defend itself
against the stressor. 

Resistance and Recovery Stage

In the resistance and recovery stage, the body continues to maintain its preparedness against the
stressor and adapt to the situation. If the person is able to adapt, the stressor abates and the body
recovers, returning to its normal state. However, if the stress continues, the person progresses to
the next stage.

Exhaustion Stage
The exhaustion stage occurs when the person is no longer able to adapt to the continued stress.
The defense mechanisms and reserves of the body are depleted. If intervention does not occur,
exhaustion continues, which can lead to death.

CRISIS AND ITS INTERVENTION

DEFINITIONS OF CRISIS

Crisis is a sudden event in one’s life that disturbs homeostasis, during which the individual’s
usual coping mechanisms solve the problem.

- Lagerquist, 2001

A crisis is self-limited and can last from a few hours to weeks. It is characterized by an initial
phase in which anxiety and tension rise, followed by a phase in which problem-solving
mechanisms are set in motion.

- Kaplan and Saddock, 1998

CHARACTERISTICS OF A CRISIS

1. Crisis occurs in all individual at one time or another and is not necessary equated with
psychopathology.
2. Crisis is participated by the specific identifiable events.
3. Crisis is personal in nature.
4. Crisis is acute, not chronic and will be resolve in one way or within a short period.
5. A crisis situation contains the potential for psychological growth or deterioration.
TYPES OF CRISIS

o A MATURATIONAL CRISIS occurs during an individual’s normal growth and

development at any point of change. Examples of maturational crises include leaving
home for college (for either the child who is leaving or the parent who is left behind),
getting married, having children, or retirement. These normal events occur in everyone’s
life, but can be identified as an actual or perceived threat that could lead to crisis. When
the response to these life transitions is negative or overwhelming and the individual feels
a lack of control, crisis occurs and professional intervention may become necessary. In
this instance, an internal arrest of development stalls the person’s journey through
Maslow’s (1968) hierarchy of needs, which progress from the most basic level
(physiological needs) to the highest level of actualization (Maslow; Gorman & Sultan,
2008). The priority is to assist the individuals to recognize the specific point of conflict
and readjust their capacity to resolve the conflict and move along life’s path. Providing
support, helping to define the problem and develop an action plan, and connecting the
person to appropriate community resources are important interventions.
o A SITUATIONAL CRISIS stems from an unanticipated life event that threatens one’s
sense of self or security. The threat can be internal such as a disease, or it can be external
such as family illness, the unexpected death of a loved one, foreclosure on a home, death
of a pet, and being fired from a job. Any of these examples could lead to an individual’s
inability to cope. A person’s ability to resolve this type of crisis depends on his or her
unique perception of the event, adequacy of a support system, and his or her repertoire of
coping mechanisms (Downey, Andress, & Schultz, 2013). The loss of personal control
associated with situational crises may leave the person unable to complete tasks of
everyday living. In this instance, the use of past coping skills along with new alternative
coping strategies, support, active listening, and connection to community resources are
helpful.
o A SOCIAL CRISIS, also called an adventitious crisis, results from an unexpected and
unusual social or environmental catastrophe that can either be a natural or man-made
disaster. The crisis can affect an individual, families, communities, a specific geographic
area, and millions of people. Earthquakes, tsunamis, and hurricanes are all natural
disasters that have left thousands, perhaps millions, of people facing crisis. Man-made
crises include crimes of rape and murder, city-wide riots, terrorist attacks, and global
wars. In these instances, the individuals are overwhelmed by the events that typically
involve trauma, injury, destruction, or sacrifice (Boyd, 2008). The widespread media
coverage of various disasters can result in crisis for persons who are far removed from
the area but subsequently are exposed to the repeated depictions of the injuries and
devastation.

DEVELOPMENTAL PHASES OF CRISIS

Caplan (1964) outlined 4 phases.

Individuals progress through this in response to a precipitating stressor and that culminate in the
state of acute crisis.
Phase-I

 The individual is exposed to a precipitating stressor.

 Anxiety increases and the previous problem-solving techniques are used.
Phase-II

 When the previous problem-solving techniques do not relieve the stressor, anxiety
increases further.
 The individual begins to feel great deal of discomfort at this point.
 Coping techniques that have worked in the past are attempted
 When they are not successful, that will create feeling of helplessness.
 Feeling of confusion and disorganization prevails.
Phase-III

 All possible resources- both internal and external- are called onto solve the problems and
relieve the discomfort.
 The individual may try to look at the problem from different perspectives.
 New problem-solving techniques may be used.
 If effective, the individual will come out of the stressful situation.
Phase-IV

 If resolution does not occur, the tension mounts beyond the threshold and individual
reaches to a breaking point.
 Anxiety will reach to a panic level.
 Cognitive functions get disordered.
 Behavior may reflect presence of psychotic thinking.

FACTORS RESPONSIBLE FOR AN INDIVIDUAL’S EXPERIENCE OF A CRISIS

 The individual’s perception of the event

 The availability of situational support
 The availability of adequate coping mechanisms.

PARADIGM SET BY AGUILERA

Aguilera suggest that whether or not an individual experiences a crisis in response to a stressful
situation depends upon the following three factors.

1. Individual perception of the event: If the event is perceived, realistically, the individual
is more likely to draw upon adequate resources to restore equilibrium. If the perception of
 the event is distorted, attempts at problem solving are likely to be ineffective, and
restoration of equilibrium goes unresolved.
2. The availability of situational supports: A Aguilera states, situational supports are those
persons who are available in the environment and who can be dependent on to help solve
the problem. Without adequate situational supports during a stressful situation, an
individual is most likely to feel overwhelmed and alone.
3. The availability of adequate coping mechanism: When a stressful situation occurs,
individuals draw upon behavioural strategies that have been successful from them in the
past. If this coping strategies, work, a crisis may be diverted. If not, this equilibrium may
continue and tension and anxiety increase.

CRISIS CONTINUUM

1. Potential crisis step

Whenever any acute problem or serious threat occurs, individuals will become tense and
employs emergency problem solving methods to resolve crisis, but it is ineffective.
2. Pre-crisis state
When person has high probability of exposure to stressful events, in an adequate support,
lack of coping abilities, poor history of handling stress will be more upset and enter into a
state of dis-equlibrium.
3. Immediate crisis state
As tensions continue to built, they mobilise all internal and external resources to restore
the equilibrium.
4. Intermediate crisis state
The problem may be re-evaluated and attacked from a new angle or the problem may be
distorted and viewed as unsolvable.
5. Advanced Crisis state
Persons who have continued to draw all inner resources, have continued failing in
attempts to resolve the problems , emotional pressures continue to build an people
become completely disorganised or immobilised owing to serve anxiety or depression
state.
6. Full crisis state
Person, who has failed in all attempts to solve the problems, beliefs that all resources
have been used feels more stress.

SIGNS AND SYMPTOMS

 Heavy burden of free floating anxiety, e.g. heightened emotional tension, the drive to act.
 Depression
  Anger, guilt, tension, fear.
 Neglects in performing self care activities
 Irrational and blaming others
 Helplessness, hopelessness, uselessness
 Panic
 Low self esteem
 Uncontrollable crying
 Lack of confidence
 Withdrawal behaviour, aloofness
 Irritable
 Rigid in nature, denial
 Disorganised behaviour, unable to think realistically
 Impaired judgement
 Lack of self control

INDICATION FOR CRISIS INTERVENTION

 Abstinence
 Paediatric
 Geriatric
 Adolescence/maturational crisis
 People who attempted suicide
 Psychosomatic patients
 Violent behaviour
 Accident victims
 Family crisis
 High risk families e.g. Ill members, recent deaths
 Severe depression
 Severe anxiety
 Marital conflicts
 Illicit drug abuse
 Traumatic events or traumatic experience
 Intra group staff issues
 Client management issue

SETTINGS FOR CRISIS INTERVENTION

 Hospitals – OPD, inward emergency room settings

 Mental health care centres
 Community settings
 a. Home visit
b. Outreach centres
 Telephonic counselling and hotline
a. Information calls
 Suicide prevention and crisis intervention centres
 Schools, offices, private practice

GOALS

 To return to the precrisis level of functioning.

 To provide real perception of the situation by the client.
 To assist the individual in managing the intrinsic and overwhelming feelings associated
with crisis.
 To reserve the crisis situation.

CRISIS INTERVENTION

Crisis intervention refers to the methods used to offer immediate, short-term help to individuals
who experience an event that produces emotional, mental, physical and behavioral distress or
problems.

Crisis intervention is a short term therapy focused on solving the immediate problem. It is
usually limited to 6 weeks.

PURPOSE

 To reduce the intensity of an individual’s emotional, mental, physical and behavioral

reactions to a crisis.
 To help individuals return to their level of functioning before the crisis.
 To assist the individual in recovering from the crisis and to prevent serious long-term
problems from developing.

GOALS OF CRISIS INTERVENTION

 Reduction in disequilibrium or relief of symptoms of crisis.

 Restoration to pre-crisis level of functioning.
 Some understanding of the relevant precipitating events.
 Identification of remedial measures.
 Connecting the current situation with past life experiences and conflicts.
PHASES OF CRISIS INTERVENTION: THE ROLE OF NURSE

Phase 1: Assessment

 Ask the individual to describe the event that precipitated the crisis
 Determine when it occurred
 Assess the individual’s physical and the mental status
 Determine if the individual has experienced this stressor before. If so, what method of
coping was used? Have these methods been tried this time?
 If previous coping methods were tried, what was the result?
 If new coping methods were tried, what was the result?
 Assess suicide and homicide potential, plan and means
 Assess the adequacy of support systems
 Determine level of pre-crisis functioning. Assess the usual coping methods, available
support systems and ability to problem solving.
 Assess the individual’s perception of personal strengths and limitations.
 Assess the individual’s use of substances.
Phase 2: Planning of therapeutic intervention

 In planning the interventions, the type of crisis, as well as the individual’s strengths and
available resources for support, are taken into consideration.
 Goals are established for crisis resolutions and a return to, or increase in, the pre-crisis
level of functioning.
Phase 3: Interventions

 Use a reality oriented approach. The focus of the problem is on the here and now.
 Remain with the individual who is experiencing panic anxiety.
 Establish a rapid working relationship by showing unconditional acceptance, by active
listening and by attending to immediate needs.
 Discourage lengthy explanation or rationalization of the situation, promote an atmosphere
for verbalization of true feelings.
 Set firm limits on aggressive, destructive behaviors.

INTERVENTIONS ACCORDING TO TYPES OF CRISIS

Class 1: Dispositional crisis

Definition: An acute response to an external situational stressor.

Interventions:

 The mental health counselor provided support and guidance in terms of presenting
alternatives to him/her.
 Needs and issues were clarified and referrals for agency assistance were made.
Class 2: Crisis of anticipated life transitions

Definition: Normal life-cycle transitions that may be anticipated but over which the individual
may feel a lack of control.

Interventions:

 Physical examination should be performed and ventilation of feelings encouraged

 Reassurance and support should be provided as needed
 Services that can provide financial and other types of needed assistance
Class 3: Crisis resulting from traumatic stress

Definition: Crisis precipitated by unexpected external stresses over which the individual has little
or no control and from which he or she feels emotionally overwhelmed and defeated.

Interventions:

 The nurse should encourage her to talk about the experience and to express her feelings
associated with it.
 The nurse should offer reassurance and support.
 Discuss stages of grief and how rape causes a loss of self-worth, triggering the grief
response.
  Identify support systems that can help her to resume her normal activities.
 Explore new methods of coping with emotions arising from a situation with which she
has had no previous experience.
Class 4: Maturational/Developmental crises

Definition: Crisis that occur in response to situations that trigger emotions related to unresolved
conflicts in one’s life. These crisis are of internal origin and reflect underlying developmental
issues that involve dependency, value conflicts, sexual identity, control, capacity for emotional
intimacy.

Interventions:

 The primary intervention is to help the individual identify the unresolved developmental
issue that is creating the conflict.
 Support and guidance are offered during the initial crisis period.
 Then assistance is given to help the individual work through the underlying conflict in an
effort to change response patterns.
Class 5: Crisis reflecting psychopathology

Definition: emotional crisis in which preexisting psychopathology has been instrumental in

precipitating the crisis or in which psychopathology significantly impairs or complicates
adaptive resolution. Example of psychopathology that may precipitate crisis include borderline
personality, severe neuroses or schizophrenia.

Interventions:

 The initial intervention is to help bring down the level of anxiety that has created the
feeling of unreality in him/her.
 After the feelings of panic anxiety have subsided, she should be encouraged to verbalize
the feelings of abandonment.
 Regressive behavior should be discouraged.
 Positive reinforcement should be given for independent activities and accomplishments.
 Referral to the long-term care facility may be required.
Class 6: psychiatric emergencies

Definition: Crisis situations in which general functioning has been severely impaired and the
individual rendered incompetent or unable to assume personal responsibility. Examples include
acutely suicidal individuals, drug overdoses, and reactions to hallucinogenic drugs, acute
psychoses, uncontrollable anger and alcohol intoxication.

Interventions:

 Monitor vital signs

  Maintenance of an adequate airway
 Initial gastric lavage
 Administer activated charcoal to minimize absorption
 Encourage to ventilate her feelings
 Establish more adaptive ways of coping with the stressful situations.
Techniques:

 Catharsis
 Clarification
 Suggestions
 Support of defenses
 Raising self-esteem
 Exploration of the solutions
Medications:

 Benzodiazepines
 Antianxiety
 Sedative hypnotic agent

Phase 4: Evaluation of crisis resolution and anticipatory planning

During the evaluation period, the nurse and client summarize what has occurred during the
intervention. They review what the individual has learned and “anticipated” how he or she will
respond in the future. A determination is made regarding follow-up therapy; if needed, the nurse
provides referral information.

SUMMARY

Stress, either physiological or biological or psychological is an organism’s response to a stressor

such as an environmental condition. Stress is the body’s method of reacting to a condition such
as threat, challenge or psychological or physical barrier. Stimuli that alter an organism’s
environment are responded to by multiple systems in the body.

CONCLUSION

Stress is a central concept for understanding both life and evolution. All creatures face threats to
homeostasis, which must be met with adaptive responses. Our future as individuals and as a
species depends on our ability to adapt to potent stressors. At a societal level, we face a lack of
institutional resources (e.g., inadequate health insurance), pestilence (e.g., HIV/AIDS), war, and
international terrorism that has reached our shores. At an individual level, we live with the
insecurities of our daily existence including job stress, marital stress, and unsafe schools and
neighborhoods. These are not an entirely new condition as, in the last century alone, the world
suffered from instances of mass starvation, genocide, revolutions, civil wars, major infectious
disease epidemics, two world wars, and a pernicious cold war that threatened the world order.
Although we have chosen not to focus on these global threats in this paper, they do provide the
backdrop for our consideration of the relationship between stress and health.
A widely used definition of stressful situations is one in which the demands of the situation
threaten to exceed the resources of the individual (Lazarus & Folkman 1984). It is clear that all
of us are exposed to stressful situations at the societal, community, and interpersonal level. How
we meet these challenges will tell us about the health of our society and ourselves. Acute stress
responses in young, healthy individuals may be adaptive and typically do not impose a health
burden. Indeed, individuals who are optimistic and have good coping responses may benefit
from such experiences and do well dealing with chronic stressors (Garmezy 1991, Glanz &
Johnson 1999). In contrast, if stressors are too strong and too persistent in individuals who are
biologically vulnerable because of age, genetic, or constitutional factors, stressors may lead to
disease. This is particularly the case if the person has few psychosocial resources and poor
coping skills. In this chapter, we have documented associations between stressors and disease
and have described how endocrine-immune interactions appear to mediate the relationship. We
have also described how psychosocial stressors influence mental health and how psychosocial
treatments may ameliorate both mental and physical disorders. There is much we do not yet
know about the relationship between stress and health, but scientific findings being made in the
areas of cognitive-emotional psychology, molecular biology, neuroscience, clinical psychology,
and medicine will undoubtedly lead to improved health outcomes.

BIBLIOGRAPHY

1. Basheer S.P, Khan S.Y. A concise Textbook of Advanced Nursing Practice. 2 nd edition,
Bangalore: Emmess Medical Publishers;2017. p- 592-603.
2. Benjamin JS, Virgina AS. Comprehensive textbook of psychiatry. 7 th edition.
Philadelphia, Lippincott, p1834-46.
3. Brar K.N, Rawat Hc. Textbook of Advanced Nursing Practice. First Edition, 2015.
Jaypee Brothers Medical Publishers. New Delhi. p- 865-885.
4. Sharma S.K, Madhari S. Brunner and Suddarth. Textbook of Medical Surgical Nursing.
South Asian Edition. 14th Edition. New Delhi. Wolter Kluwer, India; 2018. p – 382-8.
5. I Clement. Text book of Nursing Foundation. 2nd edition 2017. Jaypee brothers medical
publication. p - 529- 545.
6. Balmus IM, Robea M, Ciobica A, Timofte D. Perceived stress and gastrointestinal habits
in college students. April,2019. Available from: http://pubmed.ncbi.nlm.nih.gov.
7. Arnetz E.J, Goetz M.C, Arnetz B.B, Arble B. Nurse Reports of Stressful Situations
during the Covid-19 Pandemic; Qualitative Analysis of Survey Responses. November,
2020. Available from: http://pubmed.ncbi.nlm.nih.gov.
RELATED RESEARCH STUDY

A.

Title: Nurse Reports of Stressful Situations during the Covid-19 Pandemic; Qualitative Analysis
of Survey Responses

Authors: Judith E. Arnetz, Courtney M. Goetz, Bengt B. Arnetz and Eamonn Arble

Date of published: November, 2020

Abstract-

Context: The corona virus disease (COVID-19) pandemic has exposed nurses to conditions that
threaten their health, well-being, and ability to work. It is therefore critical to study nurses’
experiences and well-being during the current crisis in order to identify risk groups for ill health
and potential sources of organizational intervention.

Objective: To explore perceptions of the most salient sources of stress in the early stages of the
corona virus pandemic in a sample of U.S nurses.

Design: A cross-sectional survey study of nurses was conducted in May 2020. The 85 item
questionnaire was developed by the research team for the purpose of the study. It included
measures regarding demographic and work related factors, as well as COVID-19 experiences
concerning patient contact, emergency preparedness, personal protective equipment, fear and
mental health and well-being. In addition to the 84 forced choice items, the final question of the
survey was open ended and asked nurses to describe ‘the most stressful situations you have dealt
with during the COVID-19 pandemic’. In this study, qualitative content analysis was used to
examine nurses’ responses to this question.

Subject and Methods: During the survey period, 695 responses from nurses were collected. Of
these, 455 nurses also responded to the open-ended question (65.47%) and it is the nurses’
responses that are examined in the current study. The survey questionnaire was distributed
directly to nurse members using a snowball recruitment technique.

Results: Six distinct themes emerged from the analysis: exposure/infection-self; illness/death-
others; workplace; personal protective equipment/supplies; unknowns; opinions/politics. More
than half of all comments concerned stress related to problems in workplace response to the
pandemic.

Conclusions: Exploration of nurses’ perceptions of stress during the pandemic’s early phase
provides important insight into the nature of nurses’ experiences and potential measures that
healthcare institutions can take to mitigate nurses’ stress. Providing nurses with adequate
personal protective equipment is one concrete measure that can help to keep nurses safe and to
alleviate their fear of becoming infected. Healthcare units should provide opportunities for
nurses to discuss the stress they are experiencing, support one another, and make suggestions for
workplace adaptations during this pandemic.

B.

Title: Perceived Stress and Gastrointestinal Habits in College Students

Authors: I M Balmus, M Robea, D Timofte

Date of published: April, 2019

Abstract -

Context: Many negative effects of stress regarding cognitive performances and gastrointestinal
habits were previously reported in both animals and human participants.

Objective: To compare perceived stress levels with declared gastrointestinal habits changes in a
small cohort of college students during academic acquisition and evaluation periods.

Design: College students were recruited and divided into two groups: the control group
evaluated during acquisition period of the academic year and the stressed group evaluated during
the examination period.

Subject and Methods: The student’s psychological and gastrointestinal status was evaluated
using a common stress questionnaire and a gastrointestinal stress habits survey.

Results: Results showed increased perceived stress in college students during stressful
conditions, as compared to lesser demanding periods. Similarly, more than 40% of the
participants declared that gastrointestinal habits changes occurred during stressful periods. They
observed significant correlations between the perceived stress levels and gastrointestinal habits
changes.

Conclusions: This small sized survey study showed that the occurrence of the stressful event in
young adults recorded higher perceived stress scores and frequent functional gastrointestinal
symptoms, as compared to the lower stressful periods. Also, they showed that functional
gastrointestinal symptoms are rather common and could be regarded as a negative response to
stress.