The fourth defining attribute of stress is spiritual stress. Everything in the world is comprised of energy. Therefore, every thought or action affects not only each individual but the universe as well. Spiritual stress is composed of “negative thoughts produce negative energy and positive thoughts produce positive energy” (Engel, 2004, p. 5). As stated by Engel (2004) “Stress can cause a disconnection with one’s soul/sole purpose” (p. 4).
Within the nursing literature, many researchers have coined their own definitions of stress. The most common definition of stress is “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Engel, 2004, p. 4). Short term stress is effective for completing tasks. However, long term stress causes poor health, burnout, and even death.
Depending on the context, the definition of stress has several meanings unrelated to the critical attributes of its concept. However, clarifying the other definitions is important for this paper. Merriam-Webster Online Dictionary (n. d.) defines stress as:
1: constraining force or influence a: a force exerted when one body or body part presses on, pulls on, pushes against, or tends to compress or twist another body or body part; especially : the intensity of this mutual force commonly expressed in pounds per square inch b: the deformation caused in a body by such a force c: a physical, chemical, or emotional factor that causes bodily or mental tension and may be a factor in disease causation d: a state resulting from a stress; especially : one of bodily or mental tension resulting from factors that tend to alter an existent equilibrium e: strain, pressure <the environment is under stress to the point of collapse – Joseph Shoben> 2: emphasis, weight <lay stress on a point> 3: archaic: intense effort or exertion 4: intensity of utterance given to speech sound, syllable, or word producing relative loudness 5: a: relative force or prominence of sound in verse b: a syllable having relative force or prominence 6: accent.
Each of the definitions has different meanings and briefly describes varying aspects of the concept of stress. The concept of stress has been poorly defined in the nursing profession and the ultimate goal is to develop a working definition that can be used by nurses in the clinical setting. The explanation of the four critical attributes: physical, emotional, social and spiritual stress will assist in creating this statement.
Case Examples
Model case
A model case of a concept includes all its defining attributes and none of the others. The following case is an example of the concept of stress.
Nurse T arrives 10 minutes before her 12 hour day shift. She is exhausted because she worked a 12 hour shift the night before. After receiving report from the night nurse, Nurse T goes in to assess Patient A and Patient B. One hour later, Patient A cardiac arrests. The fatigued nurse calls the code and begins CPR. However, minimal staff arrives because they are short staffed that day. The patient dies after 50 minutes of resuscitation. Nurse T is very upset because this death was unexpected. This patient was supposed to be transferred to the floor later that day. The physician calls the family to explain the unfortunate event and the family comes to the hospital to see their loved one. The patient is young and Nurse T is having a hard time dealing with the death. However, Nurse T attempts to put her feelings aside and provide the angry and tearful family with support but, cannot do it. She is saddened by the fact this is her fourth patient that has died this month. A few colleagues asked Nurse T to go to dinner. However, she declined and after her long shift went home and drank 2 bottles of wine to forget about her day and help her sleep.
The model case example provides all the defining attributes for the concept of stress. Nurse T is experiencing fatigue from her rotating shifts. She is depressed about several of her patients dying during the month and as a result, turns to alcohol for comfort. Nurse T is also showing signs of disconnection with her friends by refusing their invitation to dinner and drinking alone at home.
Contrary case
A contrary case is constructed to reflect none of the defining attributes of stress. This allows the reader to see the opposite of the concept. Avant (2000) states “the opposite method can also be helpful” (p. 5).
Nurse K arrives 20 minutes prior to her shift. She feels refreshed because she has been off the previous three days. This intensive care has a scheduling rule nurses rotate on a two week or monthly basis depending on the nurse’s preference. Nurse K receives report from the night shift nurse and begins her day assessing her patients and attending grand rounds. Nurse K takes an hour lunch off the unit because there is adequate staff. At the end of the day, Nurse K reports her assessment to the oncoming RN. After work, she goes to dinner with friends and goes immediately home to get some sleep.
Nurse K is an example of a contrary case because it does not illustrate any of the defining attributes of stress. However, this case is highly unlikely in the nursing profession. Nurse K exemplifies the opposite of stress by stating she is well rested before coming to work, has power over her work schedule, is able to take a long lunch with friends, and does not exhibit maladaptive behaviors.
Borderline case
A borderline case is another example that reveals which factors are important to the concept and which are not (Avant, 2000, p.6). Several of the defining attributes are excluded deliberately.
The night shift charge nurse, John, makes the patients assignments for the day shift staff at six o’clock in the morning. At 6:15 a.m. he receives two sick calls for day shift which begins at seven o’clock. John calls the in house agency, but is unable to replace the two sick calls. At the last minute, one of the nurses who were scheduled committee work for the day was reassigned to do clinical nursing and a night shift nurse decided to stay 4 extra hours.
This example of a borderline case reveals a few defining attributes. The cut off time for sick calls is 5:00 a.m. However, John received two sick calls at 6:15 a.m. causing some emotional and physical stress. John called the in-house agency, but was not able to replace the two sick calls. His heart began to beat faster and he felt nervous because there was not a solution. After taking a look at the day shift roster, he realized he could pull the nurse doing committee work and have her take patients and one of the night shift staff decided to staff four extra hours. Although this resolution is temporary, it will resolve the problem.
Related case
In the example of a related case, the defining attributes are similar and occur in similar contexts. “It is through critical examination of the network of related concepts that the analyst can gain insight into which features of the study concept are essential and which are not” (Avant, 2000, p. 5).
Our country is under a great deal of stress concerning the environment. Recently there was an article in the newspaper about the increase pollution in the Chesapeake Bay’s waterways. A restaurant owner was caught dumping his sewage into the bay. This in turn has polluted the water and is killing the fish. It is estimated it will take millions to clean up what has been destroyed by the sewage. The people who live on the Chesapeake Bay and Maryland residents have decided to support the “Clean up the Chesapeake Bay” bill that was recently proposed in Congress.
In the related case example, the Maryland and Chesapeake Bay residents are angry that fish and the bay are contaminated with sewage. The residents are becoming ill after swimming in the bay and feel more obligated to pay higher taxes to clean the bay. Sometimes the concept of anxiety is used as a synonym for stress. Individuals who experience anxiety are considered to have increased levels of stress in their lives.
Illegitimate case
An illegitimate case reveals other qualities of the concept, but do not relate to the concept analysis case. The following scenario is an example of an illegitimate case.
Mrs. Taylor is the first grade teacher at the local elementary school. Currently, the children are learning how to pronounce words by using flashcards. Mrs. Taylor shows the class the flash card Cinderella and puts the phonetic stress on “sin” when she pronounces the word to her students.
This illegitimate case shows the concept of stress out of the normal context in this paper. Merriam Webster (n. d.) defines stress as “a syllable having relative force or prominence”. Mrs. Taylor places great emphasis on each syllable when she pronounces it to the class. This example allows another angle to look at the concept of stress.
Proposition for Stress
Definitional propositions relate to and provide descriptions of a specific concept (Tomey and Alligood, 2002, p. 52). A definitional proposition of the concept of stress is: Stress is a natural, individualized feeling that can cause positive and/or negative effects to a nurse’s physical, emotional, social, and spiritual well being. Tomey and Alligood (2002) stated “Relational statements assert relationships between the properties of two or more concepts or variables” (p. 52). An example of a relational statement using the concept of stress would be: Nurses experience stress working rotating shifts and have difficulty falling to sleep; therefore, they rely on alcohol and over the counter sleep aides and/or narcotics to help them rest. Another example would be: Inadequate staffing and increase patient work loads precipitates stress in nurses and despite the dangerous research about cigarettes, nurses’ smoke to cope with the stress.
Antecedents and Consequences
The next step in Walker and Avant’s method of concept is antecedents and consequences. “Antecedents are those events or incidents that must occur prior to the occurrence of the concept…Consequences are those events or incidents that occur as a result of the occurrence of the concept (Glaister, 2001, p. 66).
There are many antecedents of stress and clinical nursing such as: “death and dying, conflicts with colleagues and physicians, inadequate job preparation and lack of support in their work, ethical and moral issues” (O’Reilly, 1993), rapid changes in technology, belligerent and confused patients, demanding families, increase responsibilities at home, shift work, and legal issues. This disruption can affect nurses physically, emotionally, socially, and/or spiritually. Individuals were designed to cope with short-term stress with minimal affects to the body and mind. However, if stress continues on a long-term basis, nurses experience ‘burnout’, increase fatigue and tension, maladaptive behaviors such as: smoking, alcohol abuse, narcotic abuse, and over eating (Kowalski, 2001). According to Kowalski (2001) “these four maladaptive reactions are also the most common negative responses to stress and cause further stress and avalanching consequences”.
Clinical examples of stress used in practice
The Stress Pathway consists of four steps. According to Dr. Posen (n. d.) “First, an event or situation occurs which we perceive through our five senses. We then immediately process the information intellectually, forming an interpretation or judgment about what happened. We give meaning to the event - which forms our "reality." In the final step, our bodies respond to the interpretation with a stress reaction. This happens so fast that the situation itself appears to cause the stress reaction. But, if you tease dissect it, you see these intermediate steps. We react not to the situation, but to our thoughts about the situation”. Understanding this pathway allows a better understanding of the advantages and disadvantages in the clinical setting. During a critical situation i.e. respiratory arrest, the nurse interprets his/her thoughts about the event causing a release of stress hormones. “These chemical substances trigger a series of responses that gives the body extra energy: blood sugar levels rise, the heartbeat speeds up and blood pressure increases” (Stress-Symptoms, treatment, and prevention, n. d.). This release benefits the nurse and gives his/her fuel to respond quickly and appropriately to the serious situation. A drawback to stress in the clinical setting would be some nurses don’t handle their stress in a calm and collective manner. Nurses handle stress in an individualized manner and become angry or scared in critical situations causing them to make vital errors.
Empirical Referents
The empirical referents are the last step in the Walker and Avant concept analysis model. “Empirical referents are classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself” (Glaister, 2001,
p.67). Stress is an individualized concept and the attributes of stress cannot be measured, but can be measured empirically. In a research study conducted in Wales, a 120-item self report measure called “Pressure Management Indicator (PMI) was developed by Williams and Cooper from the Occupational Stress Indicator in order to address shortcomings in some scales of the Occupational Stress Indicator to measure the areas of stress nurses faced in a community hospital” (Cottrell, 2000). Another test that was developed to measure stress was the Hari’s Stress Inventory. This test was a five point scale with 140 items questions to measure stress (Hari’s Stress Inventory, n. d.). Few written test exist to measure stress. These tests are subjective reports from individuals and are helpful in understanding and measuring stress. Informal ways to measure stress are observation of body language, behaviors, moods, posture, and facial expressions, but can be biased by the data collector.
Conclusion
The nursing profession is rapidly changing as a result of stress related issues. The impact of stress is different from one individual to the next. The various types of emotional, physical, social, and spiritual responses that a person has to stress are set in motion by stress hormones. This paper revealed important issues nurses face on a daily basis and the effects of the stress on these nurses. If they are able to manage tension effectively, it can be very beneficial in getting daily tasks done in the clinical setting. Conversely, research has shown stress is more of a disadvantage to nurses. With increasing problems in the profession, there are a larger number of nurses leaving the occupation. As a result, many ‘burnt out’ nurses continue to practice in an increasingly stress laden environment.
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