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Stress: Wilson Concept Analysis

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The concept of stress has been researched for many years. Stress research has can be traced to two theorists which have different approaches to the field of stress research. Hans Selye based his theory of systemic stress on physiology and psychobiology. Richard S. Lazarus bases his theory of psychological stress on cognitive psychology. Lazarus defines psychological stress as a relationship with the environment that the person appraises as significant for his or her well being and in which the demands tax or exceed available coping resources (Lazarus and Folkman, 1984). Selye defines this stress as a state manifested by a syndrome which consists of all the nonspecifically induced changes in a biologic system (Selye, 1976).

Selye observed that patients suffered physical symptoms not caused directly by their disease or by their medical condition (Berczi, 2004). This physiological response is known as the general adaptation syndrome. The general adaptation syndrome has three stages alarm reaction, resistance, and exhasution. The alarm reaction comprises an initial shock phase which exhibits autonomic excitability, an increased adrenaline discharge, and gastro-intestinal ulcerations; and subsequent counter shock phase which marks the initial operation of defensive processes and is characterized by increased adrenocortical activity.

During this stage the body mobilizes itself to fight or to flee from a threatening stimulus. The second stage which is resistance takes place if the noxious stimulation continues. In this stage the symptoms of the alarm reaction disappear which indicates the organism’s adaptation to the stressor. As resistance to the noxious stimulation increases, resistance to other kinds of stressors decreases at the same time. In which the body mobilizes its resources to achieve equilibrium despite the continued presence of the stressor. The final stage is exhaustion in which symptoms of the first stage reappear, but resistance is no longer possible.

There are many sources of stress. Stress can be a result of physical, psychological, and social stressors. Stressors are the stimulus that throws the body’s equilibrium out of balance. Stressors can be both internal and external. External stressors include adverse physical conditions such as pain or hot or cold temperatures or stressful psychological environments such as poor working conditions or abusive relationships. Internal stressors include physical infections, inflammation or psychological stressors. An example of an internal psychological stressor is intense worry about a harmful event that may or may not occur. Psychological and social stressors are more subjective than physical stress. Stressors in the work setting predispose individuals to stress reactions, physiological responses, and psychological responses (Shirey, 2004).

Isolating Questions of Concept and Answers

How does stress affect nurses: physically, emotionally, psychologically, and socially? Stress is not only prevelant in patients but is rising among healthcare providers. Emegency Room staff and patients, because of the nature of the practice environment, may experience more stressful situations than other areas of healthcare (Revicki, et al, 1997).

From the beginning of time, those who care for the ill have given more than physical comfort to their patients. Every day, registered nurses give a great deal of themselves emotionally in the process of providing care to their patients. The emotional cost of giving is inevitably borne by the giver who may be unprepared to combat the changes that occur when burnout reaches the stage of compassion fatigue or stress. The difference between burnout and compassion fatigue is that burnout produces emotional withdrawal and diminished empathy, whereas those with compassion fatigue try to continue to give of themselves and feel as though they have failed at their profession (Fisher, 2002). Physical, emotional and spiritual exhaustion develops. Compassion fatigue and stress can be distinguished from burnout in that caregiver symptoms often parallel those of the patient population served.

Many nurses suffer from mild symptoms of stress such as headaches, insomnia, muscle strain, and anxiety. Nurses lead complicated lives. As well as being workers, they are parents, partners, siblings and members of larger communities. Stresses nurses face that are associated with our profession are extended work hours, giving intense emotional support in the face of patients’ suffering, having little power and control in physician-controlled work environments, and dealing daily with pain, loss, and traumatic illness events (Fisher, 2002). Nurses are now also faced with added stress due to nursing shortages and having to care more patients at one time.

Can stress be reduced? A step in reducing stress is recognizing that stress exists (Losee, 1998). Communication is vital in reducing stress. One must allow another to acknowledge stress exists and talk about it. One must be proactive in reducing stress. By expressing stress exists help can then be initiated. Active awareness of the signs of detrimental stress is necessary for recognizing and rectifying problems that may exist at present or arise in the future. Exercise, eating a balanced diet, getting plenty of sleep and spending quality time with friends and family are necessary ingredients for managing stress (Siviter, 2004). We can start by setting work and personal priorities to become firmly grounded. We need to learn how to say no, and stop trying to be all things to all people.

Time management gives you control over your decisions, so practice time management by finding a system that is easy and convenient to use. Be realistic about your time commitments, and stay flexible and adaptable, knowing you have the option to re-establish your priorities. You need to have realistic expectations of yourself and others, and remember that nobody is perfect. Change is inevitable, so learn how to accept and adapt to it. You can try to resist change and maintain the status quo, or avoid it all together, but this leads to passive resistance. Instead, learn to accept what you cannot change (Brewer, 1995).

Model Case

A nurse is feeling stressed and overwhelmed with her assignment for the day. The nurse has multiple patients with high acuity. Due to staffing issues and the nursing shortage she cannot rely on her coworkers for support because they too are experiencing similar stress. The nurse is required to do more while providing quality and safe patient care with less staff and support. Social support is the help and support gained through interacting with others counteracts the adverse effects of stress. The typical nurse patient ratio in the Emergency Department is 4:1. On this day due to the critical staffing shortage on her unit the nurses are responsible for 6 patients. Two patients may not seem to one who works in other areas of healthcare like a heavy patient load. Those who work in critical care areas can understand and empathize with a nurse required to care for such a heavy patient load. Due to the effects of stress that this nurse is facing the patient is placed at risk. The nurse is experiencing many signs and symptoms of stress such as headache, loss of concentration, memory loss, muscular and joint pain just to name a few. Research shows that there are many negative effects of stress.

These effects are heart disease, stroke, and susceptibility of infections, immune disorders, cancer, gastrointestinal problems, eating problems, diabetes, pain, sleep disturbances, sexual and reproductive dysfunction, memory, concentration, and learning (Brewer, 1995). Research with humans experiencing uncontrollable stress shows that such stress results in deterioration in their cognitive processes, resulting in diminished problem-solving abilities (Seligman,1972). Despite her need to increase her productivity to compensate for the increased patient load the nurse is less effective making many mistakes including medication errors. Downshifting is the process in which, as stress level increases, our intellectual, emotional, and interpersonal functioning becomes more primitive and therefore, less effective (Hart, 1983). We also seem less able to engage in complex intellectual tasks, those requiring creativity and the ability to engage in open-ended thinking and questioning. The nurse is exhibiting defensive and aggressive behaviors as a result of her increased stress level. People are more likely to respond in an aggressive, territorial, paranoid manner when stressed (Linsky, 1995).

Contrary Case

A nurse is working a twelve hour shift in a busy hospital. There are 4 sick calls for the upcoming shift. The charge nurse is able to replace the sick calls with the exception of one. The nurse volunteers to work overtime until a replacement is found. The nurse creates physical and emotional stress by working overtime. Research indicates that risks of making an error were significantly increased when work shifts were longer than 12 hours, when nurses worked overtime, or when they worked more than 40 hours per week (Rogers, 2004). Mandatory overtime has historically been used to provide nursing staff in a facility when nursing staffs is not available for work on upcoming shifts. This method of staffing is dangerous for both patients and nurses. In 2001 the American Nurses Association passed the Safe Nursing and Patient Care Act of 2001. This bill was designed to strictly limit the use of mandatory overtime for nurses. According to the 2004 Mandatory Overtime Legislative Report ANA is pursuing the enactment of federal legislation to prohibit mandatory overtime.

Related Case

A nurse is caring for a patient that is expressing the need for empathy. The nurse is nonchalant in her responses to her patients and lacks empathy. She feels she lacks personal accomplishment. Chronic stressors on the job, physical and mental exhaustion, and a sense of little accomplishment add up to burnout. Employees with burnout feel tired all the time, often show symptoms of depression, and frequently feel trapped in the job and cynical about it (Fisher, 2002). Personal characteristics can contribute to burnout are if one takes their work more seriously than necessary or are in jobs requiring involvement with others who do not obtain satisfaction from this involvement. Examples are jobs in which workers must make decisions that affect others, must keep others busy and happy and, most notably, are responsible for others’ lives are particularly stressful.

Different aspects of the job may be considered stressful depending on culture. Culture can help determine what constitutes a stressor, and when and how to ask for assistance in coping with stressors. Culture plays a role in helping people experience a sense of control over stressors. Crowding is an example of a culturally defined stressor. In different cultures, different levels of the number of people in a given space produce the perception of crowding (Linsky, 1995). Culture also plays a role in defining the choices of coping strategies, as well as in the use of social support. Japanese-American men who were closely tied to the Japanese culture were 5 times less likely to have heart disease than those least involved in Japanese culture, after controlling for diet, smoking, and other risk factors (Linsky, 1995). The researchers proposed that this difference arose because of the cultural and social cohesiveness found in Japanese culture protects against heart disease.

There is evidence that many women in Western cultures experience more stress than men. As women have entered the workforce, a number of studies have focused on the effects of their multiple roles employee, wife, mother, and daughter. Women and men appear to have different biological responses to stressors (Linsky, 1995). Men produce more cortisol when hassled than do women. Husbands and wives also differ in the benefits and stressors accrued in marriage. Women experience more stress and negative health effects from marital conflicts. Women also experience more happiness from their marital relationships. Linsky states that parental work stress is associated with higher levels of parent-child conflict. Children are also negatively affected by work stress not only.

Stress can be a result of physical, psychological, and social stressors. Stressors in the work setting predispose individuals to stress reactions, physiological responses, and psychological responses. Many factors are associated with stress that is faced by nurses. Patient care can be compromised as a negative effect of stress. Stress cannot be reduced until one is aware that it exists. Due to the high incidence of stress there is an abundance of research on reduction methods.


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