Common themes in understanding what causes stress

Despite the difficulties in identifying individual stressors there are some common themes that can be identified as causing most people some stress. People need some stimuli to keep them active and motivated. However, the ability to deal with stress differs between individuals and at a certain point coping resources can fail and performance becomes impaired. There appears to be an optimum level of arousal in which eustress is associated with staying in this optimum range and distress occurs when the stress falls outside the range (Fig. 11.1).

Fig. 11.1 The Yerkes Dodson Law (based on Yerkes & Dodson 1908)

In this model, the arousal (heightened activity including cognitive, affective, physiological and behavioural changes) associated with stress produces the competitive edge; arousal speeds thought processes and quickens reaction. Indeed, when demands are made upon an individual, the increased arousal improves both physical and cognitive abilities in order to meet these demands. However, under- or overarousal is associated with a reduced ability to function effectively.

The role of the unconscious

Sigmund Freud (1856–1939) suggested that a person’s internal mental world was dominated by primitive, often socially and personally unacceptable, drives. In order to protect self-esteem and mental health these drives were kept out of awareness, in the part of the mind he called the unconscious. However, even though these unacceptable drives were unconscious they did continue to exert ‘pressure’ to come into conscious awareness and be acted upon.

In a similar way the memories of certain emotionally painful early experiences could also be kept out of awareness to defend the conscious mind from the associated pain. To manage the threat of unacceptable memories or impulses coming into consciousness, Freud suggested that people deploy a range of mental strategies he called defence mechanisms (Box 11.5 and Ch. 8). Defence mechanisms function by distorting a person’s view of reality, but even so, Freud considered them to have an important role in protecting a person from psychic pain. While defences can be functional and useful in protecting people from anxiety, Freud also recognized that this protection sometimes came at a very high cost to the individual.

More recent work has emphasized how certain events or experiences, e.g. the experience of illness, activate some of the more primitive unconscious fears that everyone has.

A seminal paper by Menzies-Lyth (1959) also identified a number of ways that organizational and social structures can evolve to support an individual’s defences. For nurses, these operate as depersonalization (a way of thinking about patients/clients that diminishes their basic humanity and identity). When a nurse relates to a patient/client as an individual the patient’s/client’s pain and distress can also be very distressing for the nurse to deal with. It is often suggested that nurses should avoid emotional involvement, which in a similar way diminishes or denies the nurse’s basic humanity. There is always some level of involvement for the nurse and finding appropriate ways of managing this can enhance the experiences and rewards of being a nurse. However, during periods of high work-related stress there is a tendency to reduce patient-related stress by minimizing the patient’s individual distinctiveness, so instead of using names the patient may be referred to by diagnosis or bed/room number.

There can also be a tendency to make moral judgements, that some patients/clients are more deserving of care than others. Patients/clients who engage in behaviours that are disapproved of may be excluded from good healthcare or treated badly. These groups include people who self-injure, smoke or those who do not cooperate with treatment. Because some types of behaviour would be seen as unethical or even abusive, it is only through using defences such as depersonalization, detachment and denial that nurses can continue to act professionally in ways that do not reflect their personal values.

One interesting example of this sort of defence may be found in the use of the obsolete term ‘psychosomatic’ to describe an illness. The assumption was that psychosomatic conditions were caused by, or aggravated by, stress and anxiety, i.e. ‘all in the mind’. Nurses invest a great deal of their self-esteem into their ability to help to treat illness. In addition to helping the patients/clients, this also helps to control the nurse’s own anxieties in the face of illness and death. A problem arises when, despite the nurse’s best efforts, patients/clients do not get better. This can be seen as a personal failure and a way of dealing with it is to blame the patient/client for the nurse’s lack of effectiveness – it is ‘all in their mind’ and therefore their responsibility.

Identifying stressors

An important function of the development of nursing knowledge is that it allows nurses to predict and manage potential problems that may arise. Nurses need to adopt a holistic approach in an assessment to identify stressors, which includes consideration of the following influences:

Stressors in healthcare rarely affect just the patient/client. They affect relatives, friends and of course nurses involved in their care. The way in which a person behaves in response to the stress will have a significant effect on their future. People often feel angry and irritable when stressed and if this results in aggressive behaviour, they might alienate the people that they rely upon for care and support, thus increasing future stress.

Box 11.6 (see p. 282) considers a range of potential stressors that may impact on specific care situations.

Stress-related health problems

A general view of the effects of both stress and anxiety is that they evolved to influence physiology, cognition, affect and behaviour in order to increase the chances of surviving in difficult and dangerous environments. However, life has changed and the evolved mechanisms are less useful in dealing with the more complex and enduring stress associated with modern life. Stress depletes physical and mental resources while reducing control of behaviour.

Chronic stress in particular is strongly associated with a wide range of health problems because of physiological and psychological ‘wear and tear’ and inefficient use of energy. This may be associated with behavioural changes that increase other risks and reduce an individual’s ability to deal with new challenges.

In someone with a pre-existing vulnerability, exposure to increased stress may be the stimulus to trigger illness; it may then influence recovery and other health-related behaviours. Those with existing conditions may experience a worsening of symptoms, e.g. anginal pain (see Ch. 17) or increased frequency of migraine attacks.

Sociocultural, psychological and biological variables can combine to produce a range of disorders. The interaction between these factors is now widely accepted as the only way to make sense of body functioning. Increasingly, the immune system is becoming the focus for understanding the relationship between stress and illness; this area of study is called psychoneuroimmunology.

Avoidance

Avoidance commonly involves reducing exposure to stimuli that cause stress or anxiety, attempts to ignore the demands/threats or attempts to suppress the negative feelings. Avoidance is a very common reaction to threat when often the first reaction is to escape, thus avoiding further exposure. To ignore stressors people might engage in distracting tasks, use defence mechanisms (see pp. 280–281) or simply refuse to recognize the importance of the stimulus. People might try to induce positive feelings, e.g. by comfort eating, treating themselves or using stimulant (usually illegal) drugs, sedatives or alcohol.

People frequently resort to sedating drugs and alcohol to help manage the unpleasant feelings associated with stress and anxiety. They might attempt to ‘drown out’ overwhelming feelings associated with severe trauma, loss or threat by using a sufficiently high dose to induce insensibility.

Anxiolytic drugs, e.g. diazepam, can be used in similar ways during short episodes of intense anxiety or distress but, like alcohol, continued use over long periods is associated with a range of health and interpersonal problems.

Sedation does not address any of the causes or problems faced by people and while they might allow a person to cope with an acute and intense trauma they have no place in long-term management. Continued use is associated with a reduction in effective functioning and an increased risk of dependence.

Currently the role of medical intervention in responding to the normal effects of life events as illnesses to be treated is hotly debated; health staff seem motivated to attempt to remove all types of distress a person might experience. However, chronic stress and anxiety are strongly associated with problems that are considered to be diagnosable illness, depression being very common. Currently the main interventions are based on using antidepressant drugs, e.g. fluoxetine, as improving mood will improve coping.

Dealing with the stressor

The most direct approach to dealing with demands is to take action to meet those demands. This approach is often the most adaptive, particularly for low-level stressors when people can use problem-solving and evaluate the potential consequences of their actions. When the stress experienced is associated with very high levels of arousal, problem-solving is impaired and actions may not be well considered.

Among the most effective and easiest interventions nurses can use to reduce anxiety and stress is to provide useful and understandable information (see Chs 9, 23, 24). Patients/clients should know what to expect in relation to illness, recovery and specific interventions. This is important in allowing the person and their family to prepare themselves and recognize the difference between normal and abnormal sensations – without information every unusual sensation causes anxiety. Nurses may need to adapt information or ways of communicating, and seek help from family and carers when clients find it difficult to understand what is happening to them, e.g. a person with a learning disability or a person with dementia.

To deal successfully with a range of demands people learn and use a series of skills. When demands and expec-tations are predictable, learning useful skills can be structured and planned (Box 11.7).

When people feel confident in their abilities to control and meet demands, little stress is experienced and successful outcomes become more likely. People often experience positive feelings of achievement when they manage challenging situations and their beliefs about their coping abilities are enhanced. Assertion training by increasing skills in negotiation and relating to others may enhance this perception of control.

Explaining that anxiety is a normal response to many situations is also a useful way of giving people ‘permission’to talk about anxieties. Again the nurse must be imaginative in finding ways to help people with learning disabilities or dementia to express/communicate their anxieties.

Imposing structure

In situations that involve multiple and complex stressors the ability to prioritize is important. This could involve making ‘to do’ lists, prioritizing demands in order of importance and managing the time available to deal with the demands. The principle here is a simple one: for life to be manageable, it needs to be managed (Box 11.8).

Controlling the emotion

Strategies are principally about changing appraisals about the situation. This could involve reassessing the importance of an event and reassessing personal ability to cope with the perceived demands. People may deliberately remind themselves of past successes in managing similar events or make positive statements about their coping abilities. Improving self-awareness helps people recognize the stressors that appear particularly import-ant to them and to recognize the effects of stress early, allowing them to address the situation before the feelings become overwhelming.

Most current research supports the view that it is people’s beliefs about the situation and their abilities to cope that control emotional reactions. Changing these beliefs can therefore alter the meaning of the situation and the responses to it. Unfortunately, the underpinning beliefs that inform the way in which people appraise threats or demands lead to habitual and automatic responses based on previous experience. Thus many people are basically unaware of why they feel like they do and as a consequence do not check the accuracy of their beliefs.

The cognitive therapies provide frameworks to help people understand these principles and techniques for re-evaluating belief systems. This involves helping individuals recognize that it is not the event that causes distress, but their beliefs about the event that lead to the emotional consequences. These beliefs then need to be made explicit and logically examined; examining the evidence for and against beliefs is the basis for disputing their validity. When individuals adopt these methods and use them continuously it is suggested that responses become more grounded in reality, rational and more likely to lead to effective management.

Ellis (1994), who developed a cognitive approach called Rational Emotive Therapy, suggests that people evaluate situations by using simple exclamatory statements about the event. Characteristically, they first make an evaluation of the event, which is sensible and rational, followed by an irrational statement about its meaning. It is the irrational statements which have little or no supporting evidence that cause the emotional reaction. Moreover, people tended to have generalized, irrational beliefs that add to stress interpretations (Box 11.9).

Table 11.3 outlines the sequence of events in creating distress and an example of ways in which people can challenge these beliefs and therefore change the feelings.

Table 11.3 Example of cognitive sequencing

People need to identify the beliefs that cause problems and then learn to challenge them. A useful strategy is to note the events/situations which cause stress and then try to identify why they are important. As in the example, this leads to a change from thinking the event controls the feelings to recognition that it is their own beliefs and appraisals that are important. Only then can they start to evaluate their beliefs by examining the evidence on which they are based.

Enhancing coping resources

A wide range of strategies can be used to enhance coping, including:

Complementary and alternative medicine (CAM) therapies

The role of CAM therapies in healthcare is discussed in more detail in Chapter 10. However, it is important to remember that some of these therapies are linked to particular faiths and will not be acceptable to all groups. There can also be ethical concerns about using methods that do not have an evidence base of research about safety and efficacy.

On the other hand, inducing relaxation is perhaps the one area in which many CAM therapies have shown considerable promise. Meditation, massage, reflexology, yoga and ti chi exercises can all be useful in helping a person manage the effects of stress. Massage techniquesare particularly useful in children and in individuals with sensory impairment; the fact that they may reduce pain might also reduce the impact of pain as a stressor.

Ability to tolerate stress

Despite the wish for a predictable controllable life, everyone is faced with periods of uncertainty and feelings of helplessness in dealing with the problems of living and indeed dying. There are techniques such as the AWARE technique that people can use to improve stress tolerance. The person is encouraged to:

The role of the nurse

The publication of Our Healthier Nation (DH 1998) marked a change in the philosophy of healthcare provided within the NHS. For the first time there was explicit policy direction for a service that previously had focused on treating illness to begin to focus on improving health and preventing illness. The broad and pervasive effects of stress on health, illness and recovery mean that stress management is a key theme in health promotion. Nurses in many diverse settings are often ideally placed to educate patients/clients about the nature and effects of stress. This in itself is a powerful intervention; people commonly misinterpret the effects of stress and anxiety as indicators of serious illness, increasing their anxiety still further.

Nurses can also offer advice or self-help materials to individuals in order to enhance coping skills. Holistic nursing assessment of the healthcare needs of both individuals and of specific groups should include the identification of stressors and current coping strategies used, thus allowing the nurse to offer pragmatic and practical actions that their patients/clients will find useful. The nurse in helping the patient/client to clarify the causes and effects of stress can identify the management strategies most likely to help.

A wide range of health promotion activities can influence stress and coping indirectly – information about health and illness can increase the person’s sense of control. In a similar way, interventions designed to promote healthy living such as exercise advice contribute to ‘wellness’ and increase resistance to the adverse effects of stress.

Burnout

It is no surprise that some individuals working in high stress environments, particularly if combined with significant external stress and poor levels of support, can begin to feels powerless to contribute effectively at work. This failure of coping resources in the work environment is often referred to as burnout.

Many nurses start training with high hopes and expectations; indeed many people still consider it to be a vocation in which helping others becomes the person’s primary goal in life. While humanity should be thankful that such people exist, they often set themselves unrealistically high goals and expectations, dramatically increasing their risk of experiencing burnout.

There is no general definition of burnout but Maslach et al (1996) suggest that it is a syndrome characterized by:

Physical symptoms are common and are similar to anxiety:

Experienced over time, the negative effects on performance and relationships can increase the stress and burnout may become associated with more generalized anxiety and depression.

Burnout tends to develop and worsen over time. It commonly starts with feelings that initial expectations are not being met, disillusionment and disappointment. These vague feelings might lead to harder work to attempt to change the situation; if this fails the energy gives way to tiredness and irritability. It is at this point that the symptoms become more pronounced. An important feature of this insidious development is that, as the feelings of helplessness increase, awareness of the problems and their effects diminishes; individuals feel bad but fail to respond to the causes. Burnout can affect the individual, their relationships and the work environment in a range of ways (Box 11.12).

Managing work-related stress

However, while nursing is considered to be a stressful job, several important features of the work counter the negative effects of work-related stress. Nursing can be very rewarding work and if there are good supportive relationships nurses appear to tolerate and cope with potential stressors very well. The ability to discuss work pressures and develop new adaptive skills have been identified as protective so frequently in studies that providing mentorship and clinical supervision opportunities is considered central to good practice. Another important consideration is that an individual who identifies that they are stressed can use the problem-solving process of care planning to meet their own needs.

Schaufeli and Enzmann (1998) developed a matrix that provides a useful summary of the interventions that can be implemented to reduce stress-related problems caused through work (Table 11.4).

Table 11.4 Matrix of organizational stress management interventions

Managing traumatic stress

Symptoms persisting longer than 6 months are called post-traumatic stress disorder (PTSD), which may require more specialist help. Therapies are based on cognitive behavioural psychotherapy and some people benefit from antidepressant drugs. Even when the symptoms are severe, many people will recover with appropriate help.

Until very recently the individual was helped to review traumatic experiences in order to make sense of them in a process known as ‘critical incident debriefing’. Unfortunately, a critical fact was ignored, which is that the response to serious trauma is adaptive, it protects a person from being overwhelmed. Recent studies on formal debriefing have suggested that not only is there no evidence that it protects people from long-term problems but it also may increase risk (Bisson et al 2000).

The guiding principle in dealing with others who have experienced traumatic stress is to provide a safe, supportive environment with the opportunity to talk if required.

The best interventions appear to be in preparing people to deal with potential trauma. Individuals who understand what reactions can be expected, and how feelings of guilt and responsibility are common but usually inaccurate, are less likely to develop long-term problems. For example, training in the management of aggressive clients should not only address the skills involved, they also need to address the psychological effects of aggression on the nurse.

Body image

Body image is the mental representation people have of their body and physical appearance. The view of physical self is central to the person’s sense of identity, social value and self-esteem. Changes in body image, particularly if they involve loss of function, impaired ability to communicate or visible signs of illness and injury can be particularly traumatic. Where the change is likely to be temporary, individuals may simply detach from the situation, putting their life on ‘hold’ by adopting the sick rolekand making no attempt to adapt. This avoidance strategy can be highly adaptive in such situations. However, a change that is likely to be permanent often leads to grief-like reactions in which initial shock is followed by profound depression and feelings of anger. In these cases, adaptation can be difficult and delayed.

Expressing sexuality

Expressing sexuality is linked to gender identity, attractiveness, fertility and sexual functioning and gives a person a sense of value and self-esteem. Changes caused by trauma or illness that impact on these areas appear to have emotional effects much more pronounced than would be expected from just functional loss. The presence of visible lesions, stoma formation or loss of body parts, e.g. female breast, or sudden weight changes are all particularly difficult to cope with. Loss of sexual functioning, factors affecting sexual performance, e.g. erectile dysfunction, and infertility may reduce self-efficacy and increase stress and depression.

Coping with illness

Illness can often highlight major differences in the demands made by the situation and the resources a person has available to deal with them. Coping often involves ongoing appraisals and reappraisals of a situation in which individuals may attempt to alter the problem or their emotional responses to the problem.

Attempting to alter the problem is problem-focused coping and depends on the person believing that the problem is controllable or changeable. Ideally, actions should be based on analysis of the situation and planning solutions before the problem is dealt with. However, often actions are based on attempts to confront situations assertively which may involve actions based on anger, thus increasing risk.

Emotion-focused coping strategies that aim to control the emotion are frequently used when the person believes that they cannot change the stressor, either because they believe that they lack the resources/skills or the situation is insoluble, e.g. bereavement (see Ch. 12). Coping can involve attempts to avoid exposure to the stressors or suppressing its effects with alcohol or drugs. Alternatively, a person may seek social support or alter their appraisals of the situation by attempting to reduce its importance.

Social support provides emotional support through empathy, understanding, caring, etc., supporting self-esteem and offering practical help or information. People differ in their needs for social support; for those who like to cope alone, social support can be detrimental.

Helping patients/clients and carers to cope – role of the nurse

The nurse is an important resource which patients/clients and carers often rely upon to reduce the demands made upon them and enhance their coping resources. In serious acute situations where life-saving treatments are required this might be difficult; however, in the longer term, enhancing and supporting the patient’s/client’s coping skills becomes more relevant.

Although dealing with distressed individuals can be emotionally draining, the nurse needs to maintain an aspect of calm and helpful concern. Nurses can help the patient/client or carer focus on the important issues, provide useful though often limited information, help the person to identify what immediate actions are needed and offer practical help as in acute stress attention and memory may be impaired.

Nurses should anticipate the potential for stress and anxiety in their patients/clients and plan actions to prevent or minimize the more damaging effects. It is import-ant to recognize that many of the anxieties a patient/client may have are realistic and so prevention may be difficult. As there is also the problem that anxiety and stress often interfere with logical thinking and memory, interventions are best made before feelings become too strong, ideally before the stressful event. Patients/clients and their carers, with appropriate and timely help from the nurse, may cope much more effectively.

Patients/clients/carers may also be reluctant to discuss anxieties so as to avoid embarrassment; again the nurse can prevent problems by introducing such subjects into conversation. The effective use of nursing models to inform assessment and interventions should mean that a wide range of issues are specifically addressed, even when they may not appear to be related to the presenting problem. Using a structured approach gives the person ‘permission’ to talk about difficult subjects.

There are important mediators of stress and anxiety that the nurse must consider in planning care. Cognitively, both stress and anxiety reflect feelings of vulnerability. There is a perception that demands/threats will overwhelm a person’s ability to cope.

Stress and vulnerable individuals

Children, some people with learning disabilities and other vulnerable people, who do not understand stressful events and have limited coping resources, will be particularly vulnerable and are more likely to respond differently to life events.

The effects of long-term stress on a child’s development have been well documented and have been associated with a wide range of problems in adult life. Gunnar (2004) argues that long-term stress affects emotional areas of the brain. This can alter the child’s future ability to deal with stress-related events.

In common with adults, stress in childhood may relate to issues other than illness, such as bullying (see pp. 294–295) or examination pressures. Children’s behaviour may change, e.g. becoming withdrawn, tearful, depressed, headaches, etc. Children are affected by stress within the family such as that caused by abusive relationships and domestic violence (see Further reading suggestions, e.g. DH 2000).

Children have limited experience of dealing with demands and limited coping strategies, thus anxiety is a common and frequent experience for children. Young children in particular may also have a very limited ability to communicate their distress to adults. So to understand stress in children it is important to consider the age, the developmental stage and their communication skills.

Children are skilled at judging the emotional state of their parents/carers and can become distressed in response to their parents’/carers’ anxiety. This is important for a child who is admitted to hospital, as they have an increased level of stress caused by the reason for the admission and the environment.

Children attempt to make sense of illness and to cope by using much more basic defence strategies, such as regression and repression (see pp. 280–281). Nurses assessing stress and anxiety in children often find that behaviour is a better indicator of a child’s distress than their verbal reports (Box 11.14, p. 294). Children commonly become uncooperative. These behaviours may lead to reduced social support or anger in their carers and so can be seen as maladaptive and damaging. Teenagers in particular can be especially difficult by refusing help and by engaging in high-risk behaviours, which include:

Table 11.5(see p. 294) outlines some age-related techniques that nurses, parents or other carers might use to reduce the child’s distress.

Table 11.5 Reducing distress in children (Adapted from Huband & Trigg 2000)

Children with long-term health problems, e.g. diabetes, when faced with the increased stress associated with the major transition into adolescence, may also start to neglect their condition and increase their health risks.

For nurses working with people with learning disabilities there may be problems in both recognizing and helping to manage stress in their clients. Depending on the nature of the disability the person may have restricted understanding of situations and limited communication skills. In addition, damage to the central nervous system may lead to a reduced tolerance to environmental stimulation, overwhelming their ability to cope. Alternatively, they may become insensitive to stressors, leading to disinhibition and risk taking.

For those with reduced tolerance to environmental stimuli one approach to reducing distress is the use of Snoezelen. This multisensory stimulation technique utilizes lights, tactile surfaces, music and sometimes essential oils (see Ch. 10) to provide an environment that is soothing and relaxing (Box 11.15). Moreover, the client’sfamily can be involved in sessions in order to increase their understanding of the client’s feelings, abilities, etc. and enhance family relationships.

Many older people with learning disabilities evaluate their sense of value and their abilities by comparison with people of their own age. This can lead to problems with self-concept and an acute sensitivity to perceived criticism. For some clients the frustrations associated with these social comparisons and their perceived lack of ability may be expressed in low self-esteem, dependency, self-destructive behaviours or difficult behaviours towards their carers. All of these features are associated with reduced ability to deal with potential stressors; the behaviours used in coping often increase stress in both carers and client.

There is still considerable stigma associated with learning disabilities, which can lead to exclusion, rejection and prejudice. Even when prejudice is not present there can be a general insensitivity to the needs of people with a learning disability, which can add considerably to the stress they experience.

Bullying is a stressor commonly identified in children, people with a learning disability and in other vulnerable adults who are considered different in some way (physically, culturally, intellectually), especially if they are seen as less able or weak (Box 11.16).

Chronic illness and disability

An acquired disability often means that the client’s social roles change and the pressures placed upon the family and carers increase. Throughout there is a need to adapt to many new situations that affect not only health and functioning but also roles and self-concept. Initially, adaptation is resisted but at some point the patient/client must learn to accept the changes and work towards the best outcomes. Patients/clients who fail to make these mental changes often become depressed and possibly self-destructive.

Assessment requires a measure/tool that is inclusive, identifies normal functioning and establishes a baseline from which to evaluate the effect of care at a later date. The assessment also needs to address the needs of the patient’s family, as providing long-term care can have profound effects on family and carers. Long-term interventions include many specialist services and collaborative multiprofessional working (see Ch. 3). However it is good practice for a specifically named person to act as care coordinator and to engage the patient and family in all aspects of care.

Models in rehabilitation

It is particularly important in long-term care that the guiding model is person-centred, holistic and allows for multiagency collaboration with patients/clients and their carers. The underpinning processes involved in care planning are outlined in Box 11.17 (see Ch. 14).

An example of using a structured approach is in the development of a Wellness Recovery Action Plan (WRAP). The WRAP was developed by Copeland (1997) as a structured system that enables the active monitoring of distressing symptoms in people with long-term mental health problems. However, many of the principles are applicable to most care situations. The development of a WRAP culminates in a plan that aims to modify or eliminate the most distressing symptoms the patient/client identifies. There are five pivotal principles that need consideration when developing a WRAP:

The development of a WRAP is dependent on framing what is wanted and needed by the patient/client. Patients/clients, although frequently anxious, do know what they can and cannot do and in developing the plan the patient/client can begin to recognize the collaborative nature of the nurse–patient relationship. In time, and with help from the nurse, the patient/client becomes the expert in their illness or disability.