Learning Objectives
By the end of this section, you will be able to:
- Define the appraisal of a stressful event
- Explain how one may cope with a stressful event
- Discuss the effects stress has on one’s psychological, behavioral, and cognitive functions
Nurses must recognize the psychological response to stress to better assess, evaluate, and create a care plan to help the patient. Using the clinical judgment measurement model, the nurse can assist the patient who is experiencing a stressful event achieve optimal outcomes.
Appraisal of Stressful Event
Psychological stress is the neurological response to experiencing a stressor or event, and the distress that results when the stress exceeds one’s ability to adapt and cope. An important factor in appraising a stressful event is the mental and emotional interpretation of the event. Although the work of Hans Selye outlines a predicated response to stress, more modern research reveals there is still much variation due to differences among people’s interpretation of stress.
Evaluating a stressful event first requires asking the person what they find stressful about the event. How someone perceives reality becomes their reality, which may be very different from that of another person. Their cognitive appraisal of the stress matters, even if it appears unreasonable or illogical to another person. Lazarus and Folkman added to the contemporary view of stress and coping with their transactional theory (Lazarus & Folkman, 1984). The ability to adapt to a stress is called coping, and is contingent upon the person’s view of the level of threat, resources available, and ability to overcome the stress. If there is a match between the threat level and the perceived ability to overcome or address the threat, coping can be effective.
Coping with a Stressful Event
Coping is on a continuum from poor management to successful and effective management of a stress. The concepts of stress and coping apply to individuals, families, and communities. Coping abilities become part of the stressful experience and can either decrease or worsen the stress. Although humans have great ability to cope, there can be a limitation to what a person can cope with. One stressful event may become a mere nuisance, but when grouped together or in a string of stressful events, however, such a situation may lead to a person’s inability to cope effectively. For example, an acute illness such as a cold or pneumonia may become a bother to a person but is very manageable. If that simple event is coupled with inability to pay for medical care, lack of resources to travel to the doctor, and income lost due to missing work, it can become quite difficult and unmanageable. Nurses need to be aware of additional stressors in a patient’s life beyond the present chief complaint or reason they are hospitalized, because it is rarely associated with a single event.
Coping may be adaptive or maladaptive (Centre for Studies on Human Stress, n.d.). Adaptive coping is the ability to navigate and manage a stressful event in socially acceptable ways and with positive outcomes. For example, seeking medical attention or psychiatric counseling demonstrates a thoughtful and responsible behavior to address a problem. Maladaptive behaviors do decrease stress but generally produce negative outcomes and may add problems to the situation. An example is someone who drinks alcohol or takes illicit drugs to cope with a poor marriage or loss of a job. The maladaptive behavior does not solve the problem—often it only masks it and can cause additional distress. Even if maladaptive behaviors sound illogical, people still use them because they can decrease initial distress, such as smoking or taking sedatives to numb emotions and problems.
Effects of Stress
Effects of stress can be neutral, positive, or negative. Stress has been shown to initiate and encourage growth, but it can also stunt growth and disable a person. The difference is in the amount, type, and interpretation of that stress, and the person’s access to resources. In the role of a nurse, physical and psychological effects of stress must be assessed. The physical examination can help the nurse identify physical and emotional effects of stress, as outlined earlier.
Normal physiological processes are activated by stress and, if coping is intact and resources are available, the stressor becomes neutral. Navigating traffic on your way to work or school can be a neutral stressor. If, however, your car is unreliable, traffic is heavy, and you are late to class, the same stressor of traffic can become negative and cause distress. The same stressful event of navigating traffic could become a positive experience if the ride is shared with someone engaging and the conversations in the car are enjoyable.
The effects or consequences of stress affect all body systems (Abdulkaleq et al., 2018). It is within the scope of the nurse to evaluate the physical and emotional effects of stress.
Psychological Stress
In the medical profession, nurses focus on physical stressors that cause illness or injury; however, psychological and emotional stressors may be more common among the public. According to the results of an American Psychological Association 2022 survey of people in the United States, the most common causes of stress included the future of America (63%), finances (62%), work (61%), politics (57%), violence and crime (51%), and negative racial climate (62%) (American Psychological Association 2022). Worry and stress about life is part of our human daily experience. Psychological signs and symptoms of stress include the following:
- anger and irritability
- anxiety
- depression
- disinterest
- dizziness
- loneliness
- loss of concentration and memory recall
- restlessness
- tension
- sense of dread
- sexual problems
- withdrawnness
- worriedness
Variations in stress and coping are seen across the lifespan for all age groups as their cognitive, physical, and emotional resilience change. Inquiring about the person’s interpretation of a stressful event is helpful in identifying where they are emotional and mentally. Taking the time to assess and question a patient about their biggest concern may even reveal their truest concern. For example, a person who is brought to the emergency department after a house fire would be expected to be concerned about their physical belongings and devastation to their home, but when questioned, the biggest concern for the patient may be the safety of their pet cat and not the physical belongings. Efforts could then be made with social services or the fire department to locate the pet.
Link to Learning
Watch this video about stress as a psychological process from the Psychology Concepts series.
Behavioral Responses to Stress
Cognitive behavior therapy considers the very real triangular relationship among thoughts, emotions, and behaviors. Thoughts about stressful events create emotions, which, in turn, are the catalyst for behavior. When negative thoughts exist, negative emotions are stirred, including anger, depression, loneliness, and hopelessness, which can lead to maladaptive behaviors. For example, a nursing student experiences an external stressor of failing an exam, which could lead to thoughts of feeling dumb and worthless, which can lead to self-loathing or anger, which could lead to destructive behaviors such as excessive alcohol intake to drown out the negative thoughts or social withdrawal. Negative behaviors can be traced back to negative thoughts and emotions. Challenging negative thoughts is at the core of CBT. When someone is under stress and behaving in ways unlike their usual self, it is generally negative thoughts and emotions about the stressor that create the maladaptive behavior. Negative coping responses include the following:
- aggressive behavior
- chewing one’s fingernails
- criticizing oneself (negative self-talk)
- eating too much or too little
- excessive alcohol intake
- illicit drug use
- reckless driving
- self-mutilation (e.g., cutting oneself, pulling hair)
- sleeping excessively
- smoking or chewing tobacco.
- violence toward self or others
- withdrawal from friends or family
Behaviors that are threats to someone’s health can reveal the person is under stress. These behaviors include
- arguing
- avoiding tasks
- changes in appetite
- difficulty completing work or tasks
- excessive drug use
- irrational behavior
- irritability
- lack of self-care
- nervous behaviors (e.g., fidgeting, nail biting, pacing)
- not attending school or work as usual
- outbursts of emotions (e.g., anger, crying
- tardiness
Positive behaviors can also be traced back to positive thoughts and emotions. A nurse can help the patient explore their thoughts about the stressor to identify their reality or falsehood. Ideally, nurses can help the patient see positive sides of a stressor, without being overly optimistic. Strategies to deal with stress in a positive manner are discussed later in this chapter.
Cognitive Effects of Stress
Humans are often more deeply rooted in feeling than in thought, and they tend to be more emotional than logical beings. Stress can make it all the more difficult to think clearly and rationally about a problem. Even when a person is able to rationally determine that a stressor is not one that should, logically, be a source of stress, it does not mean that they will cease to be stressed out about it. Like physical and psychological stresses, the effect of stress on cognitive abilities can be neutral, positive, or negative. An example of positive effects of stress on cognition is the stress nursing students feel when learning new content or with exam deadlines and clinical duties. The positive stress of learning and meeting high expectations can help someone get organized and feel energized as they push themselves to attain higher achievements and abilities. Unfortunately, stress can also create a negative impact on cognition when the stress level is too high and irrational and cloudy thinking results.
High stress levels can have a negative effect on the brain’s ability to process information, rationalize it, and make decisions based on it. For example, a patient who has recently been diagnosed with a terminal illness must make decisions about their care as well as consider the needs of their loved ones after their ensuing death. Nurses need to be able to recognize the stress that patients and their family members will be under during a hospitalization. Everyone involved in a patient’s care is asked to take in and process a lot of new information and often need to make important decisions about life and death. It can be useful to give patients and family members written materials that give them clear information to guide discussions and decisions. In times of stress, the ability to mentally process is often lacking or lagging. It’s ironic, but when the sympathetic nervous system is activated during the first alarm stage of stress, cognition can get a lot sharper. However when stress becomes chronic, cognition starts to decline. Nurses also need to think about the importance of compassion and patience during these critical and challenging times.
Nursing is stressful, too, and one way to help nurses maintain clear cognition when providing quality patient care is following the Quality and Safety Education for Nurses (QSEN) competencies.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Patient-Centered Care
Definition: Providing responsive care that respects individual patient preferences, needs, and values and uses those factors for clinical decision-making
Knowledge: Recognizing and appreciating the diverse factors that influence a patient’s experience of stress, including cultural, socioeconomic, and environmental factors
Skill: The nurse will
- assess and evaluate physical manifestations of stress in clients.
- educate clients about positive adaptive behaviors for stress adaptation.
- recognize the individuality of a patient’s stress response.
- use effective communication techniques to establish rapport and trust with patients.
- use active listening skills to understand the patient’s unique stressors and concerns.
- collaborate with the patient to develop personalized stress management plans tailored to their individual needs and preferences.
- provide empathetic support and encouragement to empower patients to cope with stressors effectively.
- continuously reassess and adjust interventions based on the patient’s response and evolving needs throughout their health care journey.