Stress

By: Tina Moore

Introduction

It is debatable whether caring for the critically ill is more stressful than other areas of nursing. Nurses working in critical care units are exposed to different types of stressors, e.g. life-sustaining treatment, complex decision-making, continuous crisis atmosphere and complex technology. Stress is a subjective phenomenon and is dependent upon multiple variables – e.g. the nurse’s level of competence and experience, the severity of the patient’s illness, past experiences, perceptions of the situation, and the complexity of decision-making. Considering these variables, any clinical environment has the potential to be stressful.

There are various definitions of stress, each containing many meanings, which makes them confusing and ill-defined. Nevertheless, they all have a common attribute – the relationship between environmental influences and the individual.

Stress is a constant state of tension to which an individual is subjected whilst being incapable of controlling or finding adequate responses to it (Goldhill and Worthington, 1999). Stress can be viewed as a response to perceived demand, and is therefore a situation that is created when an individual is faced with any stimulus that causes disequilibrium in homeostatic functioning (Hudak et al., 1998). This function is dependent upon the individual’s ability to perceive and appraise the situation. Consequently, any situation can activate stress.

There is a tendency to concentrate on the negative components of stress and, where possible, to attempt to avoid stress-provoking situations. Stress can and does act as a motivator. This can be seen in individuals who work in critical care environments for significant periods of time, and in those who thrive on some degree of stress. A certain amount of stress is considered to be desirable for adaptation to occur. Problems arise when coping mechanisms fail and stress becomes counterproductive. Initial signs include lack of concentration, anxiety and insomnia.

This chapter aims to identify some of the sources of stress from both patient and nurse perspectives.

Stressors

The inability to cope with excess demand will possibly lead to prolonged stress and abnormal responses (physical and/or psychological), affecting the quality of life and performance. Stressors may be:

n Biological (injury or illness)

n Psychosocial (interpersonal conflicts, poor communication)

n Environmental (unfamiliarity with the surroundings, technology).

Stressors can be harmful, threatening or indeed challenging. Individuals’ ability to cope will be different depending upon their perception and appraisal, and the supportive mechanisms in place, as well as their own health status. The more uncontrollable an event seems, the more likely it is to be perceived as stressful.

Coping strategies can be problem-focused and/or emotion-focused (Lookin‑land, 1995). Problem-focused strategies are directed towards alerting the stressor, and involve identification of the problem and the generation of ideas to solve it.

Emotion-focused strategies involve developing and regulating the accompany­ing distressful emotions. Strategies may involve distancing, escape avoidance, self- control, positive appraisal and acceptance of responsibility (Lookinland, 1995). Patients may view similar situations in different ways, resulting in different con­sequences for long-term adjustment.

Models of stress

There are various models of stress. Stimulus-based models relate to the relation­ship between the external causes of stress and the individuals who are exposed to it. These models may be useful in identifying external stressors, such as noise or poor air quality, but they fail to identify the individual’s responses to the stres­sor(s).

Probably the most well-known model is Selye’s (1956) General Adaptation Syndrome (GAS), an example of a response-based model involving physiological responses to stress. It recognises the individual’s ability to respond and adapt to the environment. This is demonstrated in three progressive phases:

1 The alarm state – the body mobilises to confront the threat (‘fight and flight’)

2 Resistance, or adaptation – physical and nervous energy is used up; coping mechanisms vary

3 Exhaustion and death – response to stress is initially appropriate and useful in aiding coping; responses in the long term will be detrimental.

Sumber: Tina Moore & Philip Woodrow (2004). High Dependency Nursing Care Observation, Intervention and Support. London: Routledge