Stress

Stress is a condition in which the person responds to change in the normal

balance state.

"The non-specific response of the body to any demand made upon it."

Hens selye

"Stress is like spice- in the right proportional it enhances the flavor of a dish. Too
little produces a bland, dull meal; too much may choke you."

Donald Tubesing

Stressor
Stressor is any event or stimulus that causes an individual to experience stress.
Stressors might be heat, cold, radiation, infectious organisms, trauma, pain etc.

Stressors are the situations that are experienced as a perceived threat to one's
wellbeing or position in life.

When a person faces stressor, responses are referred to as a coping mechanism.

Classification of stressor

Dr. Hans seleye further defines stressor as: "that which produces stress"
1. External stressors
The external stressors can be further divided into three types:

 Physical Stressors
The physical stressors are any physical demand made on the mind- body
to adapt. They include heat, cold ionizing radiation, chemicals, poisons,
toxins, fire, electricity, and trauma to any type.

 Biological stressors
The biological stressors are any biological demand made on the mind-
rickettsia, fungi, parasites, etc.
  Social stressors
The social stressors are any social demands made on the mind body to
adapt. Social stressors are of two types:

 The coercive social stressor:

Non- voluntary demands made upon the mind body to adapt. This
would include assault, murder, rape, theft, and any crime against and
individual and his property.

 The non- coercive social stressors:

Are voluntary demands made on the mind-body to adapt. They
include all voluntary contractual demand related to marriage,
personal relationship and financial loans etc.

2. Internal Stressors
The internal stressors are produced by maladoptation of the mind -body.
They are the results of errors of stressor adaptability ( the ability of the
mind-body to adapt stressor)
It originates inside the body such as fever, pregnancy, menopause, emotion
such as guilt.

CRISIS
It is a situational, developmental or social sources of stress. A person in crisis is
temporarily unable to cope with or adapt to the stressor by using methods of
problem solving .
Crisis is a situation that cannot be resolved by usual method of coping mechanism
as a result person become unable to function normally and requires interventions
to regain equilibrium.

CHARATERSTICS OF CRISIS
 Temporary state of disequilibrium precipitated by an events.
 Unexpected .
 Creates uncertainty.
 Self limiting- usually 4-6weeks.
 Seen as a threat to important goals.
 Crisis can promote growth and new behaviour.
 COPING
Coping is the cognitive and behavioural efforts to manage specific external and
internal demands. It may be described as dealing with problems and situations.
Three approaches to coping with stress are:
1. To alter the stressor
2. To adopt the stressor
3. To avoid the stressor
In coping with stress, people tends to use one of the three main coping strategies:

i. Appraisal focus strategies

Person modify the way they think, for e.g. employing denial, or distancing
oneself from the problem.

ii. Problem focused strategies

Finding out information on the disease, learning new skills to manage
their disease and rearranging their lives around the disease.

iii. Emotion focused strategies

It involves releasing pent-up emotions, distracing oneself, using systematic
relaxation procedure.

ADAPTATION
The word 'adapt' comes from latin word' adaptare' means adjust. Thus simply
meaning of adaptation is adjustment.
Adaptation is the ultimate goal of coping, whenever people encounter stress from
any sources, they attempt to adopt them.
If adaptation is successful, balanced is maintained or restored, if adaptation is
unsuccessful or person becomes unable to adopt, people become ill.
Adaptation:
 Is a life
 Permit forward movement Constant change and interaction
 Ego- personality structure
 Adjustment by using physical and psychological energy

Stress
Stress is any physiological and psychological tension that threats a person's total
equilibrium. In medical terms, stress is the distruption of homeostasis through
physical and psychological stimuli.
It is now accepted fact in the medical community that stress is one of the major
cause migraines, stroke, eczema, a weak immune system and many other disease.

Classification of stress
Richard Lazarus published in 1974 a model dividing stress into eustress and
distress.

1. Eustress
The prefix derives from the Greek 'eu' meaning either "well" or "good".
When attached to the word "stress" it literally means "good stress".

Characteristics
 It motivates, focuses energy
 It is short term
 It is perceived as within our coping abilities
 It feels exciting
 It improves performance
Example of Eustress
 Meeting a challenge
 coming in first or winning
 Getting a promotion
 Marriage
 Holidays
 Buying a new home
 Starting a new job
 Promotion

2. Distress
It is the most commonly- referred to type of stress, having negative
implications. The word distress has various meaning:
 Distress is a kind of suffering.
 In medicine, distress is stress caused by adverse events.

Characteristics
  It causes anxiety or concern
 It can be short or long term
 It is perceived as outside of our coping abilities
 it feels unpleasant
 it decreases performance
 It can lead to mental and physical problems

Examples

 Death of a spouse
 Divorce
 Losing contact with loved ones
 The death of a family member
 Separation from a spouse
 Money problem
 unemployment
 Conflict in interpersonal relationship

Others types of stress

1. Acute stress:
Effect are short- term, acute stress usually doesn't cause severe or
permanent damage to the body.
2. Episodic acute stress
People with episodic acute stress may find it so habitual that resist
changing their lifestyle until they suffer severe physical symptoms.

3. Chronic stress
Stress that wears you down day after day and year after year, with no
visible escape. Poverty, And financial worries, long term unemployment
etc. are the example of chronic stress.

4. Traumatic stress
 Severe stress reactions can result from a catastrophic event or intense
experience such as a natural disaster, sexual assault, life-threatening
accident, or participation in combat.

Causes of Stress

Physical factors:
Physical factors such as: poison, heat, cold, radiation, electricity, high low
atmospheric pressure, drugs etc , which may be injuries to health.

Psychological factors:
Psychological stress refers to all processes, whether origination in external
environment or within the person. Psychological factors first affect the brain and
central Nervous system. The cause and effects of psychological stress vary with
age. There are three major types of psychological stress that can produce disease
in people e.g. gastric and duodenal ulcer.

Chemical factors
Alteration in chemical factors such as: increase peptic ulcer

Socio- cultural factors

Environmental and social stressors can lead to developmental problems.
Potential stressors that could affect any age group, but that are especially stressful
for young people, include prolonged poverty, and physical handicap.
Children are vulnerable when relationship with parents and care givers are lost
through divorce, imprisonment or death or when parents have mental illness or
substance abuse disorder.

Ecological factors
Ecology is defined as the branch of biology dealing with mutual relationship
between organisms and their environment. For example, war can cause imbalance
to the environment. War and disease are closely linked. War may cause epidemic
disease e.g. cholera, plague etc.

Occupational factors
 Occupational factors can arise from job, some occupations are more stressful
than others. Stressful job changes can include promotions, transfer, downsizing,
changes in supervisiors and additional responsibilities. But response to the
pressure and problems of the job is depend upon individuals.

EFFECTS OF STRESS
Physical Effect: Nausea, palpitation, tachycardia, perspiration ,stomach problem,
restlessness, sleepiness, flushing urgency ,cold extremities , dry mouth increase in
bp etc.

Emotional Effect: Anxiety, anger, fear, crying, hopelessness, frustration, self- pity,
sad, negativism , burnout, irritability etc.

Cognitive Effect: Decrease concentration, misjudging, thought

block ,forgetfulness, confused insecure, daydreaming nervous, anxious etc.

Intellectual Effect: reduce ability to acquire knowledge and skill, ineffective

communication, inability to solve conflicts, decrease problem solving ability,
diminished attention decreased concentration, loss of interest, poor
judgement ,etc.

Behavioral Effect: isolated, silent, critical to others, alcoholic, smoker, over

eating, low personal hygiene etc.

Physiology of stress
The body has a preserving mechanism that automatically comes in times of stress
or danger. It may results from changes in the internal environment of the body.

During stress and crisis, nervous, endocrine, and immunological systems are most
commonly affected. These include CNS, ANS, adrenal gland, lymph glands that
affects all organ of the body.

If the body responds to stress, hypothalamus is stimulated, then sympathetic

nerves prepare the body for self-defense.
The reaction of this system is protective and involuntary response which
preserves health by major defense mechanisms. For example, external defense,
inflammatory response, immune system.

These systems work together to send impulses to the brain through the ganglia to
prepare the body for 'fight or flight'. The amount of energy released as well as
adaptation depends on intensity, duration and number of stressors.

There are two types of adaptations seen in stress

1. Local adaptation
2. General adaptation

Local Adaptation Syndrome

Local adaptation takes place within a single organ or specific area. It is the
method used to control the effects of physical stressor or stress locally,
where one organ or part of body reacts alone. e.g. inflammation
When the stressor cannot be handled locally, the whole body responds to
protect itself and ensures survival in the best way possible through the
general adaptation. The four characteristics of local Adaptation syndrome
are:

 the response is localized

 doesn't involve entire body system
 adaptive responses are short term
 assist in restoring homeostasis to the body

General Adaptation syndrome

In GAS, the general body response towards stressor augments bodily functions
that protect the organism from injury (physiological, physical and psychological)
and suppresses those functions non- essential to life.

It is the immediate physiological response of the body to stress. It involves several

body systems especially the autonomic nervous system and the endocrine
system. When stress comes, the pituitary gland initiates the GAS and the
hypothalamus secrets endorphins- it act on the mind like morphine and opioids
and they produce sense of well- being and reduce pain.

In this way GAS defines us against stress both by activating the neuron- endocrine
system and by providing endorphins that decrease our awareness of the pain.

Stages of General Adaptation Syndrome

1. Alarm reaction
2. Stage of resistance
3. Stage of exhaustion

1. Alarm reaction

The initial reaction to stress is alarm stage, which alters the bodily defenses. This
stage is an instantaneous, short term, life preserving, and total sympathetic
nervous system response. When a person consciously or unconsciously perceives
a stressor, feels helpless, insecure, or biologically uncomfortable. Selye divided
this stage in to two parts:

 Shock phase
 Counter shock phase
a) Shock phase
During shock phase, the stressor may be perceived consciously or
unconsciously by the person. This stage is known as "flight or fight"
reaction, in which autonomic nervous system reacts.
The anterior pituitary increases production of adrenocorticotropic hormone
that stimulates adrenal cortex to produce glucocorticoids (hydrocortisone)
and mineralocorticoids (aldestorone).
These catecholamine triggers increased sympathetic nervous system
activities, which stimulates production of epinephrine and nor- epinephrine
by the adrenal medulla and release at the adrenergic nerve endings. The
alarm reaction also stimulates the pituitary to release anti- diuretics
 hormone. This primary response is short lived lasting from one minute to
24 hours.

b.Counter shock phase

The second part of the alarm reaction is the counter shock phase, where the
changes produced in the body during the shock phase are reversed with the
intensification of stress opposite behaviors are observed. These are due to effect
of parasympathetic activity, because here is proximity between sympathetic and
parasympathetic nerve fibers. Thus a person is best mobilized to react during the
shock phase of the alarm reaction (the person is prepared to act, more alert and
able to adapt).

2. Stage of Resistance

The second stage of the GAS is the stage of resistance, where person starts to
adopt the stress through adopt the stress through adrenocortical response. In
other word, the body attempts to cope with the stressor and to limit the stressor?
stress to the smallest area of the body that can deal with it.

Because of adrenocortical response, tissue anabolism, antibody production,

secretion of hormone and changes in blood glucose and blood volume sustain the
body's fight for preservation, then body response eventually returns normal. If
stress occurs over a long period without adequate relief, the stage of resistance is
maintained, and the person becomes distresses and manifests objective and
subjective emotional, intellectual and physiological responses.

3. Stage of Exhaustion

In this stage, the adaptation that the body made during the second stage cannot
be maintained. This means that the ways used to cope with the stressor have
been exhausted. If the adaptation has not overcome the stressor, the effects may
spread to the entire body. At the end of this stage, the body may either rest and
return to normal, or death may be the ultimate consequence.
Stage of exhaustion occurs when the person is unable to continue to adapt to
internal and external environment demands. Because body can no longer
compensate for homeostatic imbalances, disease or death may result.

Manifestations of this stage are similar to those of the alarm stage. The end of
this stage depends on the adaptive energy resources, severity of the stressor and
external adaptive resources.

Frequently GAS responses triggers disease:

 Adrenocortical hypertrophy
 Thymolymphatic atrophy
 Elevate blood glucose
 Ulceration of GI tract

Fig: Pictorial presentation of GAS

Techniques of stress management
There are variety of ways of coping with stress. Some techniques of time
management may help a person to control stress. In the face of high demands,
effective stress management involves learning to set limits and to say "No" to
some demands that other make. Following technique should be done:

1. Autogenic training
Autogenic training is a relaxation technique developed by the German
psychiatrist Johannes Heinrich Schultz and first published in 1932. The
sessions that lasts around 25 minutes, usually in the morning, at launch
time, and in the evening. Each session can be practiced in a position chosen
amongst a set of recommended postures (for example, lying down sitting
like a rag doll). The technique can be used to alleviate many stress -
induced psychosomatic disorders.

2. Progressive relaxation

Progressive muscle relaxation can be practiced while lying on back or sitting in a

chair with head supported. Each muscle or muscle group is tensed for five
seconds and then relaxed for twenty seconds .This procedure is repeated at least
once. At first only partial relaxation may occur, but after practice the whole body
can relax within a few minutes. This technique has been effective in the treatment
of muscular tension, anxiety, insomnia, depression, fatigue, muscle spasm, neck
and back pain, high blood pressure etc.

3. Meditation

Meditation is a mind-body practice in complementary and alternative medicine

(CMA). There are many types of meditation, most of the originated in ancient
religious and spiritual traditions. Meditation helps learn to focus attention. This
practice is believed to result in a state of greater calmness and physical relaxation,
and psychological balance. Practicing meditation can change how a person relates
to the flow of emotion and thoughts.
General methods of dealing with stress
1. Identify the possible causes of stress.
2. Develop good rapport with other.
3. Teaching healthy ADLs; Exercise, sleep and Nutrition
4. Encourage use of support systems
5. A special place in home to relax, a special time for doing certain pleasurable
activities or a person in confidence and friendly.
6. Do one things at a time
7. Assume more positive attitudes toward irritating and frustrating situations
or events.
8. Determine to enjoy selected stressors as a challenge :e.g examination
9. Accept love and support from others
10.Set a time of relaxation each day
11.Talk about the feelings with friends and counselors
12.Dealing with stressful situations: The Four A's
 Change the situation
 Avoid the stressor
 Alter the stressor
 Change your reaction:
 Adapt to the stressor
 Accept the stressor

Burn out
Burn out is defined as psychological exhaustion and diminished efficiency
resulting from overwork or prolonged exposure to stress. Burn out is also known
as work place stress.

According to Ellis and Nweis (1994) " Burnout syndrome is a physical, emotional
and social exhaustion due to change in the role of care provider. It can be happen
to anybody but mainly to the professional person."
" It is a syndrome of emotional exhaustion, depersonalization of others and
perceptions of reduced personal accomplishment resulting from intense
involvement with people in a care- giving environment."(Angilera, 1998)

Burnout doesn't happen overnight and its difficult to fight once person in the
middle of it, its important to recognized the early signs of burnout and head of it.

Causes of Burnout

1. Setting unrealistic goals or having them imposed upon the person.

2. Being expected to be too many things too many people.
3. Working under rules that seem unreasonably coercive.
4. Boredom from doing work that never change or doesn't challenge.
5. Feeling trapped for economic reasons by a job that fits any of scenarios
above.

Stages of Burnout Syndrome

a) Enthusiasm:

The person has high desire, hope, interest and expectation towards job and works
hard. Person feels job is everything in his life.

b) Stagnation

In this stage, hope and interests are reduced, but the person carries job
continuously. One looses one strength as well as previous energetic interest and
hope.

c) Frustration

Person feels hopelessness, helplessness, withdrawn from others, inactive easily

outburst to others.

d) Apathy

At last, he or she comes to boredom and may leave the job.

 Degree of Burnout syndrome
1) First degree (mild)
For short periods, the person can troubled by irritability, fatigue, worry and
frustration. It remains only a few days. With well treatment, it heals quickly.
2) Second degree (moderate)
(Few weeks), feeling tired. It Involves more pain and takes longer time to
heal.
 Sense of failure
 Negative feeling
 May become easily upset and cry often
 May be constantly angry with self, coworkers, or friends and family
 No pleasure at work
 Feeling of guilty
 Sense of inadequacy
 Sense of powerlessness

3) Third degree(Severe)
Severe negative feeling, than involve the whole body which may lead to
develop ulcer, chronic back pain, migraine headache etc. Healing process is
and difficult to mobilize individual support system, may use alcohol, drug
etc.

Sign and symptoms of Burnout

Burnout develop when a person's expectation of a situation and reality of the
situation clash on. It also results from hopelessness and helplessness that people
feel when they try to achieve the unachievable goal. The signs of burnout tends to
be more mental than physical. The can include:

Early stage

 Cannot recognize self as burn out due to overwork.

 Have a high expectation for themselves.
  Start blame to self rather than the working situation.
 Guilt feeling may later erupt in self destructive way.

Late Stage

 Decrease productivity and quality of job performance.

 Frequent mistakes and poor judgments.
 Forgetfulness
 Reduce interest, attention, creativity, absenteeism
 Lethargy

Burnout in Nursing
Burnout is most common in the workplace. But there is difference between a bad
workday or two and job burnout. We may be working with burnout if:

 Every day on the job is a bad one.

 Caring about work like a total waste of energy.
 Nothing appears to make a difference in a workplace full of bullying,
clueless or ungrateful, supervisors, colleagues, and clients.

Workplace burnout is not the same as workplace stress. When you're stressed
you care too much, but when you're burned out, you don't see any hope of
improvement. You don't want to get to that point.

Factors Causing Burnout in Nursing

Nursing is a tough profession. The job of a nurses is physically, and emotionally

demanding. Nurses are at high risk for experiencing burnout. The possible causes
are as follows:

 high workload
 Shortage of manpower
 mismatch of job with description
  high expectation
 improper facility and working situation
 no place for personal, professional, and emotional development
 no provision for promotion and higher education
 misuse of manpower, ego, and no right person in right place
 lack of proper monitoring evaluation system
 low paid salary

Preventing job Burnout in Nursing

The most effective way to head off job burnout is to quit doing what you're doing
and do something else, whether that means changing jobs or changing careers.
But if that isn't an option for you, there are still things you can improve your
situation, or at least your state of mind.

1) Clarify your job description

Ask your supervisor for an updated description of your job duties and
responsibilities. You may then be able to point out that some of the things you're
expected to do are not part of your job description and gain a little leverage by
showing that you've been putting in work over and above the parameters of your
job.

2) Request a transfer

If your workplace is large enough, you might be able to escape a toxic

environment by transferring to another department. Talk to your supervisor a
request from another supervisor.

3) Ask for new duties

If you're been doing the exact same work for a long time , ask to try something
new; a different grade level, a different machine, a different patient.
 4) Take time off

If burnout seems inevitable, take a complete break from work. Go on vacation,

ask for a temporary leave- of - absence- anything to remove yourself from the
situation. Use the time away to recharge yourself from the situation. Use the time
away to recharge yourself and take prospective.

5) Develop interpersonal skills

 Development of social professional support system.
 Use sense of humor.
 Make separation between work and home situation
 Maintain personal/ physical health
 Maintain IPR, professional counseling, self help measures, identify the
cause.

More strategies for preventing in Burnout

A) Educate yourself
Learn as much about the care receiver's illness and about how to be a
caregiver as you can. The more you know, The more effective you'll , and
the better you'll feel about your effort.
B) Join a support Group
Find support group. You'll feel better knowing that other people are in
the same situation, and their knowledge can be invaluable, especially if
they are dealing with the same illness or job.
C) Know your limits
Be realistic about how much of your time and yourself you can give, set
limit and communicate those limit to doctors, family members, and
other people involved.
D) Accept your feelings
You might be angry towards the care receiver because your care isn't
appreciated; because you feel trapped in the position of caregiver:
because someone you care about is ill. And then you might feel guilty
 for being angry. As long as you don't compromise the well- being of the
care receiver, allow yourself to feel what you feel.

E) Confide in others
Talk to people about you feel; don't keep your emotions bottled up. This
is where the support group comes in, but trusted friends and family
members can help too. You may also benefit from seeing a therapist or
counselor.

Dealing with burnout: the "three" R approach

Recognize: Watch for warning signs of burnout

Reverse: Undo the damage by managing stress and seeking support

Resilience: Build your resilience to stress by taking care of your physical and
emotional health.