The Stuart Stress Adaptation Model of Psychiatric Nursing Care

Gail W. Stuart

Much madness is Divinest Sense—To a discerning eye.

Emily Dickinson

Learning Objectives

1. Discuss the theoretical assumptions underlying the Stuart Stress Adaptation Model of psychiatric nursing care.

2. Describe dimensions of mental health and mental illness in the United States.

3. Analyze the biopsychosocial components of the Stuart Stress Adaptation Model of psychiatric nursing care.

4. Compare coping responses, nursing diagnoses, health problems, and medical diagnoses.

5. Evaluate nursing activities appropriate to the various stages of psychiatric treatment.

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Models provide a structure for thinking, observing, and interpreting what is seen. Nursing models can explain a person’s response to stress and the process and desired outcomes of nursing interventions. Psychiatric nurses enhance their practice by basing their actions on a model of psychiatric nursing care that is inclusive, holistic, and relevant to the needs of patients, families, groups, and communities.

This textbook is based on the Stuart Stress Adaptation Model of psychiatric nursing care, which integrates biological, psychological, sociocultural, legal, ethical, policy, and advocacy aspects of patient care into a unified framework for practice. It was developed by Gail Stuart as a synthesis of diverse bodies of knowledge from the perspective of psychiatric nursing and, equally important, as an application of this knowledge to clinical practice. This model is based on five theoretical assumptions.

Theoretical Assumptions

The first assumption of the Stuart Stress Adaptation Model is that nature is ordered as a social hierarchy from the simplest unit to the most complex (Figure 3-1). Each level of this hierarchy is an organized whole. Each level also is a part of all of the other levels, so nothing exists in isolation. Thus the individual is a part of the family, group, community, society, and the larger biosphere. Material and information flow across levels, and each level is influenced by all the others. The most basic level of nursing intervention is the individual. However, in working with the individual, the nurse also must consider how the individual relates to the whole.

The second assumption of the model is that nursing care is provided within a biological, psychological, sociocultural, legal, ethical, policy and advocacy context. Each of these aspects of care is described in detail in Chapters 5 through 9. The nurse must understand each of them in order to provide competent, holistic psychiatric nursing care. The theoretical basis for psychiatric nursing practice is derived from nursing science as well as from the behavioral, social, and biological sciences. The range of theories used by psychiatric nurses includes nursing, developmental psychology, neurobiology, pharmacology, psychopathology, learning, sociocultural, cognitive, behavioral, economic, organizational, political, legal, ethical, interpersonal, group, family, and milieu.

The third assumption of the model is that health/illness and adaptation/maladaptation are two distinct continuums:

• The health/illness continuum comes from a medical world view.

• The adaptation/maladaptation continuum comes from a nursing world view.

This means that a person with a medically diagnosed illness may be adapting well to it. An example is the adaptive coping responses used by some people who have chronic physical or psychiatric illnesses. In contrast, a person without a medically diagnosed illness may have many maladaptive coping responses. This can be seen in the adolescent whose problematic behaviors reflect poor coping responses to the many issues that must be resolved during adolescence. These two continuums thus reflect the complementary nature of the nursing and medical models of practice.

The fourth assumption is that the model includes prevention, treatment and recovery by describing four stages of psychiatric care: crisis, acute, health maintenance, and health promotion. For each stage of treatment the model suggests a treatment goal, a focus of the nursing assessment, the nature of nursing interventions, and the expected outcome of nursing care. Because it includes the full continuum of care, it can direct nursing practice in the hospital, community, and home settings.

The fifth assumption of the Stuart Stress Adaptation Model is that it is based on the use of the nursing process and the standards of care and professional performance for psychiatric nurses (Chapter 11). Psychiatric nursing care is provided through assessment, diagnosis, outcome identification, planning, implementation, and evaluation. Each step of the process is important, and the nurse assumes full responsibility for all nursing actions implemented and the enactment of a professional nursing role.

The assumptions of the Stuart Stress Adaptation Model are summarized in Box 3-1.

BOX 3-1 ASSUMPTIONS OF THE STUART STRESS ADAPTATION MODEL

• Views nature as ordered on a social hierarchy

• Assumes a holistic biopsychosocial approach to psychiatric nursing practice

• Regards adaptation/maladaptation as distinct from health/illness

• Addresses prevention, treatment, and recovery in psychiatric care

• Identifies the four stages of care—crisis, acute, health maintenance, and health promotion—in nursing activities

• Can be used across health care settings and throughout the continuum of care

• Is based on standards of psychiatric nursing care and professional performance

Describing Mental Health and Illness

The standards of mental health are less clear than those of mental illness. It is dangerous to assume that an unusual lifestyle is a sign of illness or abnormality. This can be avoided if one thinks of health/illness and conformity/deviance as separate concepts. Combining them creates four patterns: the healthy conformist, the healthy deviant, the unhealthy conformist, and the unhealthy deviant (Figure 3-2). Psychiatric nurses must carefully consider the meaning of an individual’s behavior and its context, because it reflects an adaptation to issues in the individual’s life and one’s social and cultural environment.

A person should not be assessed against some vague or ideal notion of mental health. Each person should be seen in both a group and an individual context. The issue is not how well someone fits an arbitrary sociocultural standard, but rather what is reasonable for a particular person in their life situation. Is there continuity or discontinuity with the past? Does the person adapt to changing needs throughout the life cycle?

Defining Mental Health

Mental health is a state of well-being associated with happiness, contentment, satisfaction, achievement, optimism, or hope. However these terms are difficult to define, and their meanings change as they relate to a particular person and life situation. Some suggest that mental health is not a simple concept or a single aspect of behavior. Instead, mental health involves a number of criteria that exist on a continuum. Although no one reaches the ideal in all the criteria, most people can approach the optimum.

Critical Reasoning

Do you think that a person with diabetes that is controlled with medication can still be regarded as healthy? How does this compare with a person who has schizophrenia that is controlled with medication?

Criteria of Mental Health.

The following six criteria are indicators of mental health:

1. Positive attitudes toward self

2. Growth, self-actualization and resilience

3. Integration

4. Autonomy

5. Reality perception

6. Environmental mastery

Positive attitudes toward self include an acceptance of oneself and self-awareness. A person must have some objectivity about the self and realistic aspirations that necessarily change with age. A healthy person also must have a sense of identity, wholeness, belongingness, security, and meaningfulness.

Growth, self-actualization and resilience mean that the individual seeks new experiences to more fully explore aspects of oneself. Maslow (1958) and Rogers (1961) developed theories on the realization of the human potential. Maslow describes the concept of self-actualization, and Rogers emphasizes the fully functioning person. Both theories focus on the entire range of human adjustment. They describe a self as always seeking new growth, development, and challenges. These theories focus on the total person and whether the person has the following characteristics:

• Is in touch with one’s self and able to use the available resources

• Has access to personal feelings and can integrate them with thoughts and behaviors

• Can interact freely and openly with the environment

• Can share with other people and grow from such experiences

This criterion includes the concept of resilience, which is the ability to achieve, retain, or regain a level of physical or emotional health after a tragedy, trauma, adversity or significant stressor. It is the idea that some people “bounce back” after a problem, and proposes that humans must weather periods of stress and change throughout life. Successfully weathering each period of disruption and reintegration leaves the person better able to deal with the next life change (Wagnild and Collins, 2009; Resnick and Inguito, 2011).

Integration is a balance between what is expressed and what is repressed, between outer and inner conflicts. It includes the regulation of emotional responses and a unified philosophy of life. This criterion can be measured by the person’s ability to withstand stress and cope with anxiety. A strong but not rigid ego allows the person to handle change and grow as a result of it.

Autonomy involves self-determination, a balance between dependence and independence, and acceptance of the consequences of one’s actions. It implies that the person is self-responsible for decisions, actions, thoughts, and feelings. As a result the person can respect autonomy and freedom in others.

Reality perception is the individual’s ability to test assumptions about the world and to change perceptions based on new information. This criterion includes empathy, social sensitivity, and a respect for the feelings and attitudes of others.

Environmental mastery allows a mentally healthy person to feel success in an approved role in society. The person can deal effectively with the world, work out personal problems, and obtain satisfaction from life. The person should be able to cope with loneliness, aggression, and frustration without being overwhelmed. The mentally healthy person can respond to others, love and be loved, build new friendships and have satisfactory social group involvement.