Factors Affecting Stress and Coping

Crises

A crisis is a threatening situation triggered by a precipitating event to which an individual experiences a strong behavioral, emotional, or psychiatric response. This kind of emotionally significant life event or major change in an individual’s life pushes the person well beyond their ability to effectively cope. Crises may include an unexpected or unanticipated event with insufficient time to prepare or respond, a highly threatening incident or disaster, or a radical change in one’s life with a corresponding lack of ability to respond effectively. Examples include traumatic injury, natural disasters, and loss of financial security. 

crisis

Levels of crisis severity range from Level 1 (least severe) to Level 4 (highest level). Whenever a risk of harm to self (suicide) or to others (homicide) is present, providers must swing into action to prevent and address it immediately. Nurses must assess their clients for risk factors and warning signs related to these potential acts of violence and apply interventions to mitigate and treat the risk to self and others. Individuals who commit violence against others may have risk factors such as a history of substance misuse and addiction, a history of violence toward animals and people, and a history of psychiatric illness. Other risk factors are associated with acts of violence directed toward oneself, including a history of depression and suicidal behavior, a family history of abuse and neglect, and ongoing relationship problems. 

Because of the intensity of the crisis, the individual may also be out of touch with reality and severely agitated; if left untreated, this condition may result in a medical or mental health emergency. During a crisis, the person may threaten suicide, display highly erratic or unusual behavior, misuse alcohol and other substances, and refuse intervention. Evidence that a person is experiencing a mental health emergency includes acting on a suicide threat, displaying hostile and belligerent behaviors, throwing or breaking items, or threatening harm.  

Types of Crises

Crises are experienced by people of all ages, backgrounds, cultures, and environments. Sometimes a crisis may seem obvious, such as experiencing the death of a loved one or dealing with a natural disaster. At other times, a crisis may be less apparent, such as an internal fear of being exposed to an infectious disease. In either case, the crisis often creates a sense of imbalance and confusion, and a situation where usual coping skills may be inadequate. Although crises can arise from many different sources, they are often categorized as stemming from situational, developmental (maturational), adventitious, socioeconomic, and cultural stressors. 

Situational Stressors

Situational stressors are created by personal, family, or work-related issues. Examples of personal stressors include being diagnosed and living with a chronic illness, financial strain, and being a victim of a motor vehicle accident. Family stressors may include the death of a loved one, a change in marital status, being unable to conceive, or experiencing an unwanted pregnancy. Work-related issues may include downsizing, sheltering in place, or changing work roles and responsibilities. Nurses and other health care workers need to be particularly alert to the potential for work-related stress in themselves, as this stressor may lead to burnout, compassion fatigue, and moral distress. Moral distress occurs when the nurse is placed in a difficult situation where the actions taken are different from what the nurse feels is ethically correct. These situations complicate the nurse’s ability to balance their moral, emotional, and professional duties to their clients as well as themselves. Both physical and psychological manifestations can occur when a nurse is experiencing moral distress. These may include feelings of frustration, guilt, insomnia, fatigue, and may result in withdrawal and depersonalization of clients. Although moral distress can occur at any time during nursing care of clients, it is often heightened during a time of crisis, disaster, or tragedy. Nurses who suspect they may be experiencing moral distress should ask for professional assistance in identifying the underlying issues and communicate with leadership to find a solution to support nurses in the delivery of quality care to the client.  

situational stressors

Developmental Stressors

Developmental (maturational) stressors vary throughout the lifespan and occur as an individual moves through the stages of life. Children and preadolescents often identify stressors related to physical appearance, family, friends, and school. Adolescents may experience stress related to friendships, belongingness, identity formation, and leaving the family home. Adult stressors may include marriage, beginning a family, launching a career, and accepting physical aging. Seniors and older adults may be stressed by health problems and changes in mobility and cognition. 

developmental (maturational) stressors

Adventitious Stressors

Adventitious stressors are also called disaster events because they are generally rare and unexpected. Such stressors can result from natural disasters such as floods, earthquakes, and war, or from interpersonal disasters such as physical or sexual assault. Acts of terrorism may also be considered adventitious events since previous methods of coping may not be sufficient for dealing with the magnitude of the stress. 

adventitious stressors

Socioeconomic Stressors

The adverse effects of low socioeconomic status (SES) on mental and physical health are well documented. Factors such as poverty, lower SES, and homelessness contribute to nearly every measure of mental health, including measures of self-reported distress. While the relationship between low SES and mental health disparities has been consistently demonstrated, the potential consequences of socioeconomic stressors are not necessarily fixed or universal. For example, some studies have shown that stress responses may be influenced by age, physical health, and gender. Resilience research seeks to identify protective factors that can reduce or mitigate the negative psychological consequences of low SES and other stressors. 

socioeconomic stressors

Cultural Stressors

Leininger’s Transcultural Nursing Theory, also known as Culture Care Theory, involves knowing, understanding, and appreciating different cultures, beliefs, and values that influence nursing care. Leininger’s theory advocates for meaningful and effective nursing care in accordance with an individual’s cultural values, beliefs, and patterns of behavior. Individuals may experience cultural stressors when they live within a society in which they do not culturally fit or when they receive care that ignores their cultural beliefs. Cultural factors include beliefs and values that influence how an individual perceives and responds to stress, since all individuals appraise stressors within the context of their culture. Thus, a stressor that is perceived as highly stressful in one culture may be viewed as a minor stressor within another culture. Coping strategies also vary from culture to culture. 

During a crisis, the nurse establishes and maintains a therapeutic nurse–client relationship using effective communication skills and by providing a safe, calming environment. Clients in crisis often require frequent or constant observation and, in some cases, pharmacologic and medical intervention to achieve an optimal level of functioning and health. Crisis intervention is not process-oriented, but rather action and situation-focused. The goal is to help the client identify precipitating events leading up to the crisis; utilize skills, resources, and available support systems to effectively deal with the crisis; and formulate a plan of care for current and future critical events. One model for crisis intervention is known as the Seven-Stage Model of Crisis Intervention.  

Seven-Stage Model of Crisis Intervention

Defense Mechanisms

Cramer defined an ego defense mechanism as a mental operation that occurs outside of conscious awareness and that functions to protect an individual’s self-esteem, keep the person from experiencing excessive anxiety, and, in extreme cases, protect the integration of the self. Defense mechanisms are understood as subconscious internal strategies that individuals employ to protect themselves, tackle stress and discord, uphold their self-worth, and sustain a feeling of mastery. Instances of these psychological tactics encompass projection (blaming one's own undesirable tendencies on others), denial, disavowal (ignoring or not admitting to distressing thoughts or emotions), rationalization (explaining away improper actions by making them seem logical or justifiable), using humor, deliberately ignoring certain thoughts (suppression), and unconsciously burying memories or feelings (repression). A normal and natural part of psychological development, these mechanisms are useful in protecting the human psyche from anxiety and fear. In some cases, defense mechanisms can be misused or distorted, leading to cognitive distortions or thinking errors. Thinking errors are faulty patterns of thinking and unhealthy ways of coping that become self-defeating and often occur unconsciously.  

Role of the Nurse: Clients Experiencing Stress

The role of the nurse includes conducting a comprehensive assessment of the client’s condition. Several evidence-based assessment tools exist that are designed to evaluate the physiological, psychological, emotional, and behavioral signs and symptoms of stress. For example, the Psychological General Well-Being Index (PGWBI) measures a client’s level of subjective psychological well-being and self-representations of affective or emotional states, which reflects the client’s sense of subjective well-being or distress. The full scale provides subscales to assess anxiety, depression, positive well-being, self-control, general health, and vitality. Other valid measures include the Beck Depression Inventory and the Ways of Coping Questionnaire.

Before conducting an assessment, the nurse must first establish rapport and build a trusting nurse–client relationship to provide a safe, confidential environment conducive to sharing personal and sensitive information. Nurses use several therapeutic communication techniques to build trusting relationships, including active listening, asking open-ended questions, seeking clarification, and offering observations.

Nurses in all areas of nursing practice need to recognize the physiological and psychological signs and symptoms of stress in their clients, implement and evaluate effective interventions, and provide ongoing client education on this topic. Signs and symptoms of stress and associated health alterations can manifest in a variety of ways and with varying levels of severity.

Steps of the Nursing Process

The nursing process provides a five-step, systematic approach to assess a client’s condition and implement a client-centered, individualized, holistic plan of care. The five sequential steps in this process are assessment, diagnosis, planning, implementation, and evaluation.

Assessment

The nursing process begins with a detailed assessment of the client’s condition. Objective and subjective client information is obtained through interviews, observation, and examination. Ideally, client interviews will take place in a private, quiet, uninterrupted setting that is free from distractions.

During the initial assessment, the nurse conducts a mental status exam and gathers relevant client information such as presenting symptoms, personal and family health history, substance use or abuse history, previous hospitalizations and mental health treatment, coping strategies, and health beliefs and practices. Examples of objective client information include vital signs, appearance, behavior, and physical exam findings. Vital signs often vary depending on the level of anxiety the client is experiencing. A client with mild anxiety may exhibit minimal or no physiological manifestations of anxiety, whereas a client with moderate anxiety may appear animated and have slightly elevated vital signs. Signs of anxiety include shakiness, increased heart rate, chest tightness, increased respiratory rate, and racing thoughts. Other signs include excessive worrying, restlessness, increased fatigue, difficulty concentrating, increased irritability, muscle tension, and sleep disturbances. Examples of subjective client information include somatic complaints, current relationship and work situations, and the client’s perceptions of current stressors and problems. The nurse may also consult family members and other individuals knowledgeable about the client (with the client’s permission), health records, and assessments conducted by other members of the mental health care team to fully understand the client’s unique situation.

Analysis

After conducting a comprehensive assessment, the nurse analyzes the client-related information to develop a statement of the client’s problem or health alteration. This may be referred to as the nursing diagnosis. To analyze actual or potential client concerns or health alterations, nurses use their clinical judgment skills. Analysis may include an actual description of the problem (e.g., loss of appetite) as well as an assessment of the client’s potential risk for developing additional health conditions. Nurses use the information obtained from this analysis to determine the client's plan of care.

Planning

Based on the assessment information, the nurse collaborates with the client, family, and members of the health care team to establish measurable short- and long-term goals (outcomes), which are then used to formulate the plan of care. The plan of care should take into account the client’s level of knowledge, available support systems, access to care, personal beliefs and health habits, and cultural and spiritual preferences. It includes the identified client problems that require priority and immediate attention, treatment goals, nursing actions needed to achieve the desired goals, and ways to evaluate goal achievement.

Examples of goals requiring immediate attention include the client staying with a friend or family member to reduce suicide potential, the client identifying at least two individuals who can be called if the client begins to have suicidal feelings, and the client identifying at least one goal for the future. Examples of long-term goals include the client implementing effective coping strategies to deal with stress and anxiety, the client identifying personal strengths, and the client using available resources and support systems. Approaches to assist clients in managing stress involve recognizing and altering harmful thought processes through techniques of mindfulness and cognitive modification. It's crucial for clients to acknowledge the value of social connections and to address issues in their interactions with others. Emphasize the practice of conscious eating and disrupting patterns of eating driven by emotions, instead of obsessing over calorie counts or specific nutritional intake. Highlight the significance of maintaining healthy sleep routines and enhancing levels of physical exercise for overall well-being.

Implementation

The next step in the nursing process focuses on implementing the nursing actions and interventions outlined in the plan of care and accurately documenting the client’s progress and response to treatment to ensure continuity of client care. Client outcomes or goals are achieved by accomplishing the nursing interventions detailed in the plan of care, which are designed to prevent, promote, maintain, and restore mental and physical client health. During the implementation phase, nurses may implement, coordinate, and delegate aspects of the plan of care.

Evaluation

Evaluation is an ongoing, iterative, and thorough assessment of the client’s health status and plan of care. This step is critical to determine whether the plan of care has been effective in improving the client’s condition and health status. The client’s status and the effectiveness of the plan of care need to be continuously evaluated and the plan of care modified as needed. When evaluating the plan of care, the nurse reviews all steps of the nursing process and assesses and reassesses the plan to determine whether the desired outcomes have been achieved.

Coping

Coping refers to the conscious and intentional thoughts and actions employed to handle stressful situations, both internally and externally. This concept is specifically about deliberate efforts to manage stress, unlike "defense mechanisms," which are automatic or instinctive reactions that also serve to lessen or endure stress. When faced with stress, the various methods an individual uses to contend with it are known as "coping styles." These styles represent enduring characteristics that shape how a person responds to stress, and they tend to be consistent over time and in different contexts. Coping is typically categorized into two types: reactive coping, which is the response that occurs after encountering a stressor, and proactive coping, which involves actions taken to prevent or mitigate future stress. People who are proactive tend to thrive in stable settings because they favor routine, exhibit inflexibility, and show less immediate response to stress. On the other hand, reactive individuals may perform better in environments that are more dynamic and changeable. Stressors and coping mechanisms vary across the lifespan and depend on an individual’s appraisal of the stressor, the amount and type of social support available to manage the stressor, the importance placed upon the stressor, the severity of the stressor, and the ability to cope effectively and in a healthy manner. A positive outcome is not necessarily associated with adequately managed stress.

Earlier in this lesson, the discussion of the TTSC suggested reasons why individuals might adopt either problem-focused or emotion-focused coping styles. A problem-focused approach involves dealing with the situation itself by trying to change it into something more palatable. In contrast, an emotion-focused approach requires altering our association with the situation to decrease the stress it may be causing. This can include either avoiding the situation or reframing its meaning. While this approach does not change the nature of the situation itself, it does change how the situation affects the individual. 

Coping strategies are classified as adaptive if they help an individual manage stress in the short and long term, such as changing an unhealthy habit. Maladaptive coping behaviors reduce stress in the short term but often exacerbate the problem in the longer term, such as misusing drugs to cope.

coping strategies

Health Promotion and Healthy Coping Strategies

Health promotion is the art and science of helping individuals change their lifestyle to achieve optimal health. According to the National Institute of Health, health promotion focuses on interventions that support a healthy lifestyle. By practicing health promotion, people can be proactive and take control of their personal health, rather than having to respond to illness and disease. Nurses educate clients and families about the benefits of health-promoting behaviors and activities. Health promotion activities include interventions that mitigate or reduce stress-producing situations and increase resistance to stress. Several strategies and techniques are available to help individuals cope effectively with the stressors that life brings.

health promotion

Healthy Diet and Nutrition

A healthy diet can help offset the impact of stress by strengthening the immune system, lowering blood pressure, and supporting overall good health. According to Wurtman et al., consumption of complex carbohydrates stimulates the production of serotonin, a chemical that increases the sense of well-being, decreases stress, and stabilizes blood sugar levels. Good choices for complex carbohydrates include whole grains, oatmeal, lentils, and beans. Oranges are a good source of vitamin C, which can help lower stress hormone levels while strengthening the immune system. Consuming omega-3 fatty acids, which are found in fish, seafood, nuts, seeds, and plant oils, may provide protection against disorders such as heart disease, depression, and premenstrual syndrome. Drinking black tea may help individuals recover from stressful events more quickly. Seeds, nuts, and avocados are sources of healthy fats that help lower cholesterol levels, reduce inflammation, and protect against the effects of stress. The mechanical effects of munching raw vegetables such as celery or carrot sticks help reduce tension by releasing a clenched jaw. In addition, it is important to drink plenty of water. Keep a ready supply of water nearby for easy access, and drink two glasses of water upon waking. Finally, limit alcohol consumption. 

Exercise

One of the best stress-reducing strategies is to exercise and increase physical activity. Cardio (cardiovascular) exercise boosts oxygen circulation and spurs the body to produce feel-good chemicals called endorphins. Exercise programs such as Pilates, yoga, and tai chi are also effective in reducing stress. According to the American Heart Association, virtually any form of exercise can act as a stress reliever. Exercise increases overall health and sense of well-being while reducing stress. Regular movement and physical activity can increase energy, improve mood and self-confidence, and create a sense of relaxation. Exercise can also improve sleep, which is often disrupted by stress, depression, and anxiety. 

Time Management

Managing time well and staying organized can be a stress-reducing strategy. Time management techniques help reduce stress by identifying tasks and activities that require immediate attention versus tasks that can wait. Starting each day with a to-do list and prioritizing the list of tasks from high to low can help lower stress levels. Some lower-priority tasks may be rescheduled, delegated to someone else, or eliminated altogether. Managing multitasking and controlling the urge to immediately respond to every text, email message, or request helps alleviate stress.

Building Personal Resilience

Resilience is the ability to bounce back from life’s various challenges and to adapt well in the face of adversity, trauma, and stress. It can be fostered by practicing mindfulness activities. Mindfulness is the state of paying attention and being fully present and alert to your surroundings and environment. It means focusing attention in a purposeful way on the present moment, becoming aware of what is happening in the here-and-now, and being cognizant of your internal and external worlds without judgment.

Mindfulness Practice

1. Find a quiet place.

2. Sit in a comfortable position.

3. Take a deep breath through your nose with your eyes closed.

4. Open your mouth and exhale.

5. Focus on your breathing.

6. Refocus when your mind starts to wander.

7. Perform meditation for at least 10 minutes at 3 times per week.

Rest and Relaxation

Establishing a regular routine for getting adequate rest and sleep is essential to ensuring overall good health and reducing stress. Adequate sleep is necessary for the body to repair and restore itself and to release melatonin, an essential hormone for regulating sleep–wake cycles. Sleep quality can be enhanced by going to bed and rising at the same time each day; avoiding nicotine, caffeine, and alcohol before bedtime; unplugging from media devices; and keeping a comfortable, cool, and dark sleeping space.  

Guided imagery is a helpful technique to alleviate stress by using a combination of relaxation, visualization, and imagination. After assuming a relaxed and comfortable position, the individual focuses on a pleasurable image, experience, or event while practicing progressive relaxation. Progressive relaxation includes tensing and releasing each muscle group in the body, beginning with the head and moving to the toes.  

Progressive Relaxation

To practice progressive relaxation, begin by tensing and relaxing your facial muscles, then flow to your neck, arms, torso, abdomen, legs, and all the way down to your toes. Use a combination of deep breathing, stretching, and positive visualization. As you breathe deeply, stand on your tiptoes, extend your hands over your head, and reach with your fingers as far as you’re able toward the ceiling. As you are deep breathing and stretching, imagine a calm and peaceful scene and repeat a positive affirmation such as “Stress is leaving my body; my work as a nurse is very important; I am making a positive difference in the lives of my patients; what I do matters.” 

Complementary and Alternative Therapies

Complementary and alternative therapies refer to treatments such as aromatherapy, herbal medicine, acupuncture, massage, biofeedback, and meditation. An increasing number of clients are using complementary and integrative health products and therapies. In turn, nurses need to have a working knowledge of these therapies since they offer clients new avenues that may improve their overall health. 

Journaling

Keeping a personal journal of thoughts, feelings, and emotions can provide a meaningful and productive outlet for stress. Expressing gratitude is another way to reduce anxiety. When feeling stressed, anxious, or overwhelmed, an individual can reflect upon a person, experience, event, or thing for which they are grateful and record their reflections in a journal. Conveying gratitude may be one of the most effective strategies for achieving and maintaining a contented life.