Chapter 13 STRESS AND ADAPTATION
The art and science of nursing is based on the concept of holism. This concept is essential in understanding stress and its relationship to physical and mental health or ill-health. This is because stress and the way individuals adapt and cope is related to the interplay between environmental, cultural, spiritual, psychosocial and biological dimensions of each person. A basic concept of this chapter is therefore that each person is unique and the whole person a totality of body, mind and spirit.
DIMENSIONS OF STRESS AND STRESSORS
Stress is any emotional, physical, social, economic or other factor that requires a response or change. Stress can lead to a variety of psychological responses, the most common of which is anxiety. Anxiety can be defined as a feeling of apprehension, uneasiness, uncertainty or dread. The source of the anxiety may be real and easily identified or it may be a perceived threat and the person may not be able to identify the cause. Everyone experiences anxiety. It may be experienced on four different levels: mild, moderate, severe and panic level. It can be classified as normal, acute or chronic and has the potential to affect the person at a very deep level and to a point where self-esteem can be seriously eroded (Boyd 2007; Keltner et al 2006; Varcarolis 2006).
Stress can result in psychological and physiological effects, and prolonged stress can result in physical illness. This is because the immune system responds to a person’s internal and external environments and, when exposed to excessive stress, becomes damaged, reducing the body’s ability to combat infection and disease. Prolonged stress has been linked to many physical health problems, including migraine headaches, allergies, asthma, gastric ulceration and other disorders of the digestive tract. Scientists explain the physical manifestations of prolonged stress as being related to chemical, hormonal and cellular changes (deWit 2005; Rice 2000).
Stressors can also be classified as internal or external. Internal stressors arise from within the person. They include hunger, thirst, fatigue, fever and the effects of pregnancy or menopause. Internal stressors also include strong emotions such as embarrassment, shame or guilt. External stressors are those that originate outside a person and include environmental conditions such as exposure to overly high or low temperatures, overcrowding, noise and, of course, the traumatic effects of accidents or natural disasters such as fires, floods, hurricanes and earthquakes. External stressors also include issues such as peer group pressure, social isolation and the demands of study, family or work (deWit 2005; Watkins 2001).
A stressor may be perceived as positive, negative or a mixture of both. Many situations are both demanding and stressful, evoking mixed responses; a new job can be challenging and stressful but at the same time a positive and personally rewarding experience; the stress of a looming exam or competitive event can be very stressful but the stimulus also provides high levels of motivating energy that leads to positive outcomes (Varcarolis 2006; Stuart & Laraia 2004; Shives 2007).
Illness and hospitalisation are commonly significant stressors. Nurses frequently encounter a range of stress responses when providing care to clients. In fact, anxiety is the word most commonly used by clients to describe their emotional response to illness (Shives 2007). The nature and degree of stress a client experiences is an important component of wellbeing that is evaluated by the nurse as part of ongoing holistic nursing assessment. Some people adapt to hospitalisation, many cope successfully with illness, but others need help and support. The nurse in all areas of care, and particularly in mental health care, needs to facilitate exploration of the significance of particular stressors to each individual client.
ADAPTATION TO STRESS
PHYSIOLOGICAL ADAPTATION
The physiological response to acute stress is known as the fight-or-flight response. It begins when people are faced with a threat or stressful situation. When the body prepares to fight or flee, a number of changes occur. The autonomic nervous system and the neuroendocrine system combine to provide the body with the capacity to deal with the stressor. Hormones needed to adapt to the stress are secreted, muscles tense, the heart beats faster, the breathing and perspiration increase, the pupils dilate and blood sugar level increases. Once the cause of the stress is removed, homeostatic mechanisms involving the parasympathetic nervous system and decreased activity in the hypothalamus and pituitary gland return the body from its state of heightened readiness to relaxed mode (Keltner et al 2006). The fight-or-flight response is vital to defend against and tolerate danger. However, continued unresolved stress results in a chronic stress condition that impacts on the body and may produce any of a wide range of diseases and disorders. Box 13.1 indicates some of the health concerns that have been linked to stress. The body responds to stress in the same way regardless of the source of the stress and whether or not the stress is real or perceived.
Prolonged stress may also lower the threshold at which the body responds to threats, so that future stressors may trigger the physical stress response more easily. This can lead to a stress cycle whereby the person responds to relatively minor events with physical reactions and psychological fears beyond those congruent to the situation. Symptoms such as a rapid or pounding heart and rapid breathing start to become worrying, making the person even more anxious; this then reactivates the stress response, causing symptoms to become more severe. This can evolve into a cycle of stress, anxiety and more stress that ultimately causes increasingly severe or frequent episodes of high anxiety and, sometimes, negative thoughts and fears that can interfere with the person’s normal lifestyle, physical and mental health (Clinical Interest Box 13.1).
CLINICAL INTEREST BOX 13.1 The stressor–anxiety stress cycle
A range of anxiety disorders such as panic disorder, acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) has been linked to this stress cycle. Recurrent and prolonged stress causes a range of effects on mood, cognition and behaviour in addition to physical responses. Overwhelming stress or distress can seriously interfere with mental wellbeing and can cause the person to lose contact with what is real or not real. This may manifest with a range of effects, including disorganised and/or delusional thoughts and hallucinations.
INDICATORS OF STRESS
Stress is not easily measured but the nurse can assess and evaluate clients’ subjective stress by exploring their feelings. Objective indicators may be observed in a variety of physiological, psychological, cognitive and behavioural responses. Examples of some common effects are outlined in Box 13.2. and Table 13.1.
TABLE 13.1 Common psychological, cognitive and behavioural effects of stress
| Psychological | Cognitive | Behavioural |
|---|---|---|
| Sadness | Confusion | Unable to sleep |
| Depression | Forgetfulness | Under- or over-eating |
| Labile mood | Inability to concentrate | Talking rapidly/loudly |
| Irritability | Decision making is difficult | Stammering |
| Quick to anger | Comprehension impaired | Inability to sit still |
| Finger tapping | ||
| Constant pulling at hair | ||
| Constant pumping of leg up and down | ||
| Inability to control tears |
Illness and hospitalisation and frightening medical procedures may mean that clients feel they have little control. Many people adapt successfully to the reality of what is happening to them and are able to remain optimistic and cheerful. However, individuals respond differently to the experience of illness, and high levels of anxiety and frustration at being ill or feeling neglected mean that clients may respond with irritability. This may manifest as constant complaints and criticisms or even displays of anger towards people around them, including nurses. Anxiety may also result in clients becoming withdrawn. Some may become passive and dependent on others and behave in an immature way. Some clients may become introspective and self-absorbed, showing no interest in anything other than themselves and their illness. Nurses who understand these behaviours as ways of attempting to cope with stress and anxiety continue to respond with empathy and are therefore able to promote a relationship of trust with the client. An example of a nursing diagnosis for an anxious client might be, ‘Anxiety related to verbalised “fear of hospitals”, as evidenced by changes in vital signs, discomfort due to diaphoresis (sweating) and client’s inability to sit still, pacing and wringing hands’. A trusting relationship and effective communication skills (Chapter 29) facilitate the client being able to talk about and deal with fears and other feelings and ultimately to adapt more positively to their situation.
STRESS ADAPTATION MODELS
SELYE’S STRESS ADAPTATION MODEL
In 1950 Hans Selye published a now renowned work called The Stress of Life. In a later edition he defined stress as the wear and tear on the body (Selye 1976). Selye links the wear and tear on the body to chemical changes that instigate a process of adaptation.
Stage of resistance
If this stage of the GAS continues for a prolonged period of time without periods of relaxation and rest to counterbalance the stress response, sufferers become prone to fatigue, concentration lapses, irritability and lethargy. Significantly, continued release of excessive amounts of the steroid cortisol, stimulated during prolonged stress, leads to suppression of the immune response. Reduced immunity makes the body more susceptible to health problems ranging from the common cold and other infections to disorders such as headaches, gastritis, a range of intestinal disorders and cancer (Keltner et al 2006; Herlihy & Maebius 2002).
Stage of exhaustion
Selye (1974) defined two particular concepts of stress; distress and eustress. Distress is described as the negative outcome that drains energy and gives rise to feelings of anxiety, confusion and depression, and creates an inner sense of helplessness and hopelessness. Mental illness is closely associated with human distress. Watkins (2001) links difficulty in adapting and coping with overwhelming distress to the distress behaviours and feelings associated with poor mental health, for example, defensive or self-harming behaviour, despair, helplessness, anger, guilt and self-loathing. Eustress is described as the converse effect that gives rise to positive outcomes — motivating energy, feelings of happiness and an inner sense of peace and hope.
Psychosocial changes
Although Selye did not elaborate on the psychosocial effects of stressors, psychosocial changes have been aligned with the GAS model (Table 13.2).
TABLE 13.2 Stress adaptation syndrome
| Stage | Physical response | Psychosocial changes |
|---|---|---|
Noradrenaline and adrenaline are released, causing vasoconstriction, increased blood pressure and increased rate and force of cardiac contractions  Stay updated, free articles. Join our Telegram channel
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