Expert Nurse & Company

Aim of Analysis

Many visits to primary care providers are a result of stress-related illnesses; it is estimated that

60% to 90% of visits may be related to stress. Strategies for health promotion and stress reduction are important for advanced practice nurses in primary care. Stress is associated with the development of mental disorders, increased incidence of stress-related illnesses, and decreased immunologic function (Robinson, 2003). The purpose of this paper is to explore the concept of stress. Stress is a part of almost everyone's existence. Our lives are crowded with stressors that produce threats to our well-being. As stress-related hormones are constantly secreted, the heart, blood vessels, and the body tissues may deteriorate. As a result, people may become more susceptible to diseases. Stress can increase the risk of becoming ill, make it more difficult to recover from illness, and reduce the ability to cope with future stress. Stress directly relates to the nursing concepts of person, environment and health.

Literature Review and Empirical Referents

A basic assumption in health and nursing is that stress plays a role in the etiology and progression of a broad range of physical diseases. However, evidence that stress contributes to the pathophysiology of human disease is thin, and where evidence exists,a small proportion of the variance is explained (Marsland, Cohen, Rabin & Manuck, 2001). There are two important classes of stressors: daily hassles (ex. sitting in traffic; waiting in a long line) and major life events (ex. death of a loved one; divorce).

Psychological models tend to classify sources of stress broadly, with more focus on understanding stress appraisals, central components of the stress process. This research allows for understanding individual differences in experiences of stress, and possible individual interventions. Social epidemiological models have generally considered the kinds of exposures that may contribute to a toxic environment. This research allows for understanding social differences in the experiences of stress, and allows an understanding of how the social environment may influence health for intervention at a macrosocial level (Krieger, 2000).

Nursing biopsychosocial models tend to focus on coping strategies that assist a person in dealing with stressors. Coping strategies are cognitive, emotional, and behavioral responses to stressors used to adapt to the environment or to change it. In nursing, the primary goals of stress management are: minimizing frequency of stressors; increasing resistance to stress; and avoiding physiologic arousal from stress. The aim is to promote parasympathetic stimulation to disease arousal. This can be seen when nursing interventions are used such as: guided imagery; deep breathing exercises; relaxation training; and meditation. In general, minimizing the frequency of stressors is the first line of defense. If that is not possible, then the next step is to strengthen family and individual coping resources (Robinson, 2003).

Stressful life events have a strong influence on physical symptoms of illness. Poor health behaviors (ex. Lack of physical exercise, smoking, and alcohol consumption) have been suggested as the link between psychosocial stress and physical health (Vitaliano, Zhang, & Scanlan, 2003). Higher stress scores among college students were related to lower levels of self-esteem and reduced perceptions of general health (Hudd et al, 2000). According to McEwen (1998), the effects of chronic stress on humans can be exacerbated by a rich diet and the use of tobacco and alcohol and may be reduced by moderate exercise. McEwen (1998) also states that individual sensitivity to stress is also determined by a person's general state of physical health and can lead to permanent overload. El-Sheikh, Harger, & Whitson (2001) examined the effect of marital conflict on children's emotional adjustment and physical health using a sample of seventy-five 8-to-12-year old, middle- to upper-middle-class children. They found that marital conflict, especially verbal conflict, increased child health problems. However, the negative effects of marital problems were balanced by the child's ability to regulate his or her physiological arousal.

A person's perception of stress was also found to influence the development of physical disease by causing negative emotional states (ex. Anxiety and depression) that in turn caused direct effects on biological patterns that influence disease risk (Cohen, Tyrrell, & Smith, 1993). Israel et al (2002) suggest that chronic stressors (i.e. family stress, financial vulnerability, physical environment, police stress, and safety stress) have an impact on depressive symptoms and general health. In this study, general health status was measured using a single-item self-report measure that asked participants whether their health was excellent, very good, good, fair, or poor. Since chronic stress has a direct association with general health, health care professionals should develop interventions and policies that focus on both reducing stressors and strengthening social support (Israel, Farquhar, Schulz, James, & Parker, 2002).

For most individuals, blood pressure tends to be highest during work hours, and blood pressure tends to be higher on a workday than a day away from work. Work stress is associated with long-term risk of hypertension, according to a 20-year follow-up study of originally normotensive and stage 1 hypertensive adults. During this study, psychosocial stress was measured as the volume of air traffic in the air space of each controller, recorded every 20 minutes for 5 hours during 5 typical workdays. Blood pressure and behavioral indicators were measured at the end of 75 observation periods. A telephone interview was conducted 20 years later and 16.5% of the 218 subjects were defined as having a history of hypertension. The researchers found that the increase in systolic blood pressure for each individual plane in the controller's airspace was a significant prediction of long-term hypertension (Ming, Aldler, & Kessler, 2004).

Women who have experienced domestic violence are likely to experience increased stress. An Australian study suggests that domestic violence is associated with a wide range of physical illnesses. Allergies of breathing problems,pain and fatigue, bowel problems, vaginal discharge, and eyesight and hearing problems were associated with women who have experienced the stress of domestic violence. Self-reported diagnoses of low iron, asthma, bronchitis or emphysema, cervical cancer, and other major illness were also associated with participants who have been victims of domestic violence. This highlights the importance for advanced practice nurses to take a detailed social history from women so that counseling can be implemented with medical treatment of symptoms (Loxton, Schofield, Hussain, & Mishra, 2006).

Essential Attributes, Antecedents, Consequences

Attributes

Hans Selye (1974), a physiologist, defines stress as the nonspecific response of the body to any demand made on it. Stress is a bodily reaction that can occur in response to either internal, cognitive stimuli or external, environmental stimuli. It consists of bodily responses- increased heart rate and blood pressure, “butterflies” in your stomach, dry mouth, and rapid breathing. Selye's (1974) definition of stress states that anything placing a demand on the body can cause stress. Almost all external stimuli can cause stress; some of that stress is pleasant and beneficial. Exercise is a beneficial stressor because it increases the efficiency of the cardiovascular system. The total absence of stress would mean the total absence of external stimulation, which would eventually lead to death (Selye, 1974). An inordinate amount of stress will exceed the body's ability to cope and may lead to moderate or serious illness.

Stress is the response to events that threaten or challenge us. The first stage is the person's assessment of an event to determine whether its implications are positive, negative, or neutral. The second stage is the person's assessment of whether their coping abilities and resources are adequate to overcome the harm, threat, or challenge posed by the potential stressor (Feldman, 2003).

General principles help predict when an event will be considered stressful. Taylor (1991) suggests the following:

• Events and circumstances that produce negative emotions are more likely to lead to stress than events that are positive.

• Situations that are uncontrollable or unpredictable are more likely to produce stress than those that can be controlled and predicted.

• Events and circumstances that are ambiguous and confusing produce more stress than those that are unambiguous and clear.

• People who must accomplish simultaneously many tasks that strain their capabilities are more likely to experience stress than those who have fewer things to do.

Antecedents

Although stress is pervasive in our lives, some things cause more stress than others. The major causes of stress include life changes, chronic stress, hassles, frustration and conflicts. Divorce, child abuse, spouse abuse, alcoholism, and money problems can place severe stress on all members of a family. People may experience stress associated with keeping or changing jobs, with job performance, or with interactions with co-workers. Certain job characteristics can cause stress such as: no health insurance, physically demanding work, or dangerous environment exposure. Low socioeconomic status and perceived discrimination are also antecedents of stress. Another source of stress is conflict. The longer any conflict exists or the more important the decision, the more stress a person will experience. In addition, self-confidence, decisiveness, sociability, practical mindedness, original thinking, conformity, and leadership are all predictors of perceived stress. Personal relationships and emotional stability are also predictors of perceived stress (Sivberg, 1998).

Loss is the primary stressor for the older adult. Loss of a close family member, loss of a spouse, and retirement are considered negative life events. Normal age-related changes such as decreased visual acuity and decreased ability to perform activities of daily living, may intensify the person's reaction to stressors, further compromising the immune system (Robinson, 2003).

Consequences

Stress, whether from psychological or physiological causes, causes the body to undergo several major and minor physiological changes. The most significant changes are controlled by the autonomic nervous system. These changes are particularly important because they can lower the body's resistance to disease. Under normal, everyday low stress conditions, the parasympathetic part of the autonomic nervous system tends to lower heart rate and blood pressure while increasing muscle movements in the stomach and intestines. This allows the body to conserve energy, absorb nutrients, and maintain normal functioning. Under stressful conditions, the sympathetic part of the autonomic nervous system takes control. It increases heart rate, blood pressure, respiration, and muscle tension, decreases the movement of the stomach muscles, constricts the blood vessels, and releases hormones such as epinephrine and cortisol. These hormones in turn release fats into the bloodstream for energy. The constant wear and tear caused by the physiological arousal that occurs as the body tries to fight off stress produces negative effects. Headaches, backaches, skin rashes, indigestion, chronic fatigue, and even the common cold can be related to stress. Ulcers, asthma, and high blood pressure can be related to stress (Feldman, 2003; Robinson, 2003).

The Acute Stress Disorder Scale (ASDS) was developed to provide a self-report measure of acute stress reactions. It demonstrates internal consistency, convergent validity, and test-retest reliability. According to this scale, psychological consequences of stress can be measured by factors such as: emotional numbness; feeling in a daze; things seem unreal; feeling different; intrusive memories; nightmares; sense of re-experiencing; difficulty sleeping; feeling irritable; difficulty concentrating; feeling more alert to danger; feeling jumpy and physiological reactivity (Bryant, Moulds, & Guthrie, 2000).

Model Case

This “related” case was cited above in the review of literature. This case is related to the concept of stress because domestic violence is considered to be an antecedent of stress; history of domestic violence is one measure of stress. Women who have experienced domestic violence are likely to experience increased stress. Loxton et al (2006) designed a study to assess the association between physical health and lifetime experience of stress from domestic violence. The study participants were a large sample of Australian middle-aged (45 to 50 years old) women who were randomly recruited in 1996 from the general population. Surveys were mailed to collect self-report data on health and related variables. Of the middle-aged women who were randomly selected, 14,100 agreed to participate and the response rate was 53.3%. Health behavior variables included: smoking; alcohol use; body mass index; and physical activity. Physical health variables included the following: menopause status; recent physical symptoms (allergies & breathing problems, indigestion, pain & fatigue, urinary problems, bowel problems, vaginal discharge, menstrual symptoms, skin problems); and diagnoses (diabetes, heart disease, hypertension, stroke, low iron, asthma, bronchitis or emphysema, osteoporosis, breast, cervical, lung, bowel, skin cancer) (Loxton et al, 2006).

Statistical analysis was performed using univariate odds ratios (ORs). Smoking and binge drinking were associated with increased odds of ever having experienced domestic violence. This can certainly have a negative impact on a woman's physical health status. Also, pain & fatigue, hypertension, and bowel problems were associated with having ever experienced domestic violence. The survey only used a single-item, self-report measure of being in a violent relationship so the question could have been interpreted in different ways. And it is not known when the violence took place, and what type of abuse was experienced. However, domestic violence was associated with a wide range of negative health behaviors and symptoms. The participants who have experienced domestic violence are likely to experience increased stress. Past research confirms the fact that psychological stress can have a direct impact on physical health status (Loxton et al, 2006).

Implications for Nursing

According to the Betty Neuman Health Care Systems Model, “the internal and external environments are a source of stressors that have different potentials to disturb the normal line of defense and disrupt the system...The system's model is based on an individual's relationship to stress, reaction to it, and reconstitution factors that are dynamic in nature...Basically, nursing focuses on the occurrence of stressors, the organism's response to them, and the state of the organism” (Chinn & Kramer, 2004, pp.229-230). A person's coping mechanisms, perception of an event, and situational supports influence their individual equilibrium. The advanced practice nurse should display unconditional acceptance and active listening, and should connect the person to a social network. Social support and self-disclosure reduce stress. Physical conditioning and psychological conditioning reduces stress, therefore, nurses should promote exercise, adequate sleep, and good nutrition. In addition, nurses can improve a client's self-esteem by giving positive verbalization and identifying positive personal aspects. Nursing interventions also include the following: assessing the client's perceptions of the environment and health status; advising the client to develop goal alternatives & support positive coping behaviors; providing opportunities for the person to express fear and concern; encouraging the client to ask questions and gather information about the unknown; promoting an increased sense of control by offering choices and alternatives whenever possible; acknowledging and permitting anger & setting limits on expression of anger to discourage destructive behavior; helping the person identify strengths, stressors, inappropriate behavior, and personal needs; exploring the person's desire for spiritual or psychological counseling; and identifying factors that inhibit the patient's ability to cope (Robinson, 2003).

Future research can be geared toward the development of measures of stress, and the evaluation of this concept in a wide range of populations. The development of screening instruments that facilitate the identification of people who will develop stress can have significant implications for managing various clients. When designing future interventions to combat stress and reduce risks to health, a multidisciplinary approach including behavioral, psychological, physiological, and pharmacological approaches may be more effective in bringing about long-term alleviation of stress than would interventions focusing on a single-discipline approach. The documented risk to physical health strongly points to the need to assess and treat stress to prevent or at least reduce possible damage to health. The assessment of stress by advanced practice nurses can be introduced as part of the overall risk assessment during the physical exam. It is important to develop frameworks that are better able to characterize the psychological, social, and biological features of stress, so researchers can more effectively study the relationship between stress and illness.

References

Bryant, R., Moulds,, M., Guthrie, R. (2000). Acute Stress Disorder Scale: A Self-Report Measure of Acute Stress Disorder. Psychological Assessment, 12(1), 61-68.

Chinn, P., & Kramer, M. (2004). Integrated Knowledge Development in Nursing. St. Louis, MO: Mosby

Cohen, S., Tyrell, D., & Smith, A. (1993). Negative life events, perceived stress, negative affect, and susceptibility to the common cold. Journal of Personality & Social Psychology, 64, 131-140

El-Sheikh, M., Harger, J., & Whitson, S. (2001). Exposure to interparental conflict & children's adjustment and physical health: The moderating role of vagal tone. Child Development, 72, 1617-1636

Feldman, R. (2003). Development Across The Lifespan. Upper Saddle River, NJ: Prentice Hall

Israel, B., Farquhar, S., Schulz, A., James, S., Parker, E. (2002). The Relationship Between Social Support, Stress, and Health Among Women on Detroit's East Side. Health Education and Behavior, 29(3), 342-360

Krieger, N. (2000). Discrimination and health. In L.F. Berman & I. Kawachi (Eds.), Social Epidemiology (pp.36-75). New York, NY: Oxford University Press.

Loxton, D., Schofield, M., Hussain, R., Mishra, G. (2006). History of Domestic Violence and Physical Health in Midlife. Violence Against Women, 12(8), 715-731

Marsland, A., Cohen, S., Rabin, B., & Manuck, S. (2001). Association between stress, trait, negative affect, acute immune reactivity, and antibody response to hepatitis B injection in healthy young adults. Health Psychology, 20, 4-11

McEwen, B. (1998). Protective and damaging effects of stress mediators. New England Journal of Medicine, 338, 171-179

Ming, E., Adler, G., Kessler, R. (2004). Cardiovascular reactivity to work stress predicts subsequent onset of hypertension: The air traffic controller health change study. Psychosomatic Medicine, 66, 459-465.

Robinson, D. (2003). Stress Management. In P.S. Kidd, D.L. Robinson, & C.P. Kish (Eds.), Family Nurse Practitioner Certification Review (pp.816-819). Philadelphia, PA: Lippincott Williams & Wilkins

Selye, H. (1974). Stress without distress. New York, NY: Signet

Sivberg, B. (1998). Self-Perception and Value System as Possible Predictors of Stress. Nursing Ethics, 5, 103-121

Taylor, S. (1991). Health Psychology. New York, NY: McGraw-Hill.

Vitaliano, P., Zhang, J., & Scanlan, J. (2003). Is caregiving hazardous to one's physical health? A meta-analysis. Psychological Bulletin, 129, 946-972.