The aim of this exercise is to encourage you to consider the theoretical models of stress and to give you a chance to apply these during your clinical education week. You will also have an opportunity to consider your coping strategies and evaluate how well you think they work for you. Below is an overview of the main models of stress. Read over this part and make sure that you understand these before you answer the questions which follow.
Stress Models Definition of Stress
Sarafino (1994) defined stress as being the condition which results when the interaction between the person and the environment leads the individual to perceive a discrepancy - whether real or not - between the demands of a situation and the resources of the person’s biological, psychological and social systems.
Stress is an umbrella term for an increasingly wide variety of conditions, responses and experiences.
Stressors - stressful stimuli
Stress response - the reaction to a stressor
Strain - this is the psychological response to stressors
The Stimulus Model
In this model, stress is considered to be external to the individual - a condition of the environment. Stress is considered to be a stimulus. Examples of this are environmental stress and life event stress.
1. Environmental stress- eg noisy workplace, difficult neighbours.
Limitation - doesn’t account for individual differences. Some people like a noisy environment for example.
2. Life event stress (Holmes and Rahe, 1967) - Some events are likely to be stressful for everyone. For example, death of a family member. Holmes and Rahe compiled a list of stressful events which they call life events. You will have an opportunity to measure your life event stress.
Limitation - events vary in amount of stressfulness for different people.
The Response Model
Relates stress to internal factors, reactions - stress responses
General Adaptation Syndrome - GAS, (Selye,1956)
Selye found, from studies on rats, that there was the same response no matter what the stressor.
1. The initial response is an alarm reaction - fight or flight - release of adrenaline.
Excitation of the hypothalamus leads to release of Corticotrophin Releasing Hormone (CRH). The anterior pituitary secretes adrenocorticotrophic hormone ACTH (sometimes called the stress hormone). The adrenal cortex becomes enlarged and hyperactive, secreting corticoids which supply energy for fight or flight. This can be useful in the short term.
2. Continued exposure to the stressor leads to the resistance stage. Here, initial signs of the alarm reaction diminish. The body continues to produce ACTH and corticoids.
3. Exhaustion - body systems now show signs of damage. The immune system becomes depressed leading to heart disease, high blood pressure, arthritis, colds and flu. These are known as diseases of adaptation.
Limitations 1. underestimates psychological factors such as emotions.
2. Specificity - People tend to act in their own specific way to stressors. Hypertensives respond by increasing blood pressure, people with stomach ulcers, increase gastric secretions.
Interactive Models of Stress
In these models stress is viewed as an interaction between the environment and the individual’s perception of it.
According to the Cognitive Appraisal Model by Folkman and Lazarus (1984) stress depends on the individual’s appraisal of:-
1. Primary Appraisal: How threatening is the event?
2. Secondary Appraisal: Can you cope with it?
If you don't find the event threatening then you won't find it stressful. If you do find an event threatening then you consider if you can cope. If you can cope then the event does not cause you stress, however if you can't cope then the event will be stressful for you.
The Frankenhauser Approach
This looks at the individual consequences of stress and considers control to be important.
Control:- Do you have control?
Do you want to have control?
Consequences:- Have you experienced this before?
What were the consequences?
Some people want to be in control and can find themselves to become more stressed when control is taken away from them. These individuals are said to have an internal locus of control. For example, a person who is admitted to hospital may feel unhappy if all control is removed from them and they are told what to wear, when to go to bed, what to eat etc. Giving patients control over some minor decisions about their care can be helpful in reducing their stress.
However, not everyone wants to have control. Some people like to trust in powerful others and believe that the hospital staff will make the right decisions for them. These people have an external locus of control. Forcing someone who has an external locus of control to make decisions can increase their stress.
Before completing the stress questionnaires, make sure that you have read and understood the preceding section on models of stress. See the Module Handbook for further reading.
Social Readjustment Rating Scale (Holmes and Rahe, 1967) Rank Life event Mean value
1 Death of spouse 100
2 Divorce 73
3 Marital separation 65
4 Jail term 63
5 Death of close family member 63
5 Personal injury or illness 53
7 Marriage 50
8 Fired at work 47
9 Marital reconciliation 45
10 Retirement 45
11 Change in health of family member 44
12 Pregnancy 40
13 Sex difficulties 39
14 Gain of new family member 39
15 Business readjustment 39
16 Change in financial state 38
17 Death of close friend 37
18 Change to different line of work 36
19 Change in number of arguments with spouse 35
20 Mortgage over $10,000 31
21 Foreclosure of mortgage or loan 30
22 Change in responsibilities at work 29
23 Son or daughter leaving home 29
24 Trouble with in-laws 29
25 Outstanding personal achievement 28
26 Wife begins or stops work 26
27 Begin or end school 26
28 Change in living conditions 25
29 Revision of personal habits 24
30 Trouble with boss 23
31 Change in work hours or conditions 20
32 Change in residence 20
33 Change in schools 20
34 Change in recreation 19
35 Change in church activities 19
36 Change in social activities 18
37 Mortgage or loan less than $10,000 17
38 Change in sleeping habits 16
39 Change in number of family get-togethers 15
40 Change in eating habits 15
41 Vacation 13
42 Christmas 12
43 Minor violations of the law 11
Measure your personal stress score with the Social Readjustment Rating Scale by ticking the events that have occurred to you in the last year and add up the mean values. Write your score in here:-
300+ major life stress
According to Holmes and Rahe, the higher the number you end up with, the more chance you have of developing an illness.
Identify some of the major problems associated with this scale.
There are also a number of problems with this method of measuring stress, what are they?
Complete the Professional Life Stress Scale then add up your score using the scoring key provided.
PROFESSIONAL LIFE STRESS SCALE (Please tick as appropriate)
Two people who know you well are discussing you.
Which of the following statements would they be most likely to use?
(a) X is very together. Nothing much seems to bother him/her.
(b) X is great, But you have to be careful what you say to him/her at times.
(c) Something always seems to be going wrong with X's life.
(d) I find X very moody and unpredictable.
(e) The less I see of X the better!
2. Are any of the following common features of your life:
* Feeling you can seldom do anything right YES/NO
* Feelings of being hounded or trapped or cornered YES/NO
* Indigestion YES/NO
* Poor appetite YES/NO
* Difficulty in getting to sleep at night YES/NO
* Dizzy spells or palpitations YES/NO
* Sweating without exertion or high air temperature YES/NO
* Panic feelings when in crowds or in confined spaces YES/NO
* Tiredness and lack of energy YES/NO
* Feelings of hopelessness (what's the use of anything?) YES/NO
* Faintness or nausea sensations without any physical cause YES/NO
* Extreme irritation over small things YES/NO
* Inability to unwind in the evenings YES/NO
* Waking regularly at night or early in the YES/NO
* Difficulty in making decisions YES/NO
* Inability to stop thinking about problems or the day's events YES/NO
* Tearfulness YES/NO
* Convictions that you just cannot cope YES/NO
* Lack of enthusiasm even for cherished interests YES/NO
* Reluctance to meet new people and attempt new experiences YES/NO
* Inability to say 'no' when asked to do something YES/NO
* Having more responsibility than you can handle. YES/NO
3. Are you more or less optimistic than you used to be (or about the same)? MORE/LESS/SAME
4. Do you enjoy watching sport? YES/NO
5. Can you get up late at weekends if you want to without feeling guilty? YES/NO
6. Within reasonable professional and personal limits, can you speak your mind to A/B/C
a) your boss? b) your colleagues? c) members of your family? (Circle all that apply)
7. Who usually seems to be responsible for making the important decisions A/B
in your life: a) yourself? b) someone else?
8. When criticised by superiors at work, are you usually: A/B/C
a) mildly upset? b) moderately upset? c) very upset?
9. Do you finish the working day feeling satisfied with what you have achieved: A/B/C
a ) often? b) sometimes? c) only occasionally?
10. Do you feel most of the time, that you have unsettled conflicts with colleagues? YES/NO
11. Does the amount of work you have to do exceed the amount of time available: A/B/C
a) mostly? b) sometimes? c) hardly ever?
12. Have you a clear picture of what is expected of you professionally: A/B/C
a) mostly? b) sometimes? c) hardly ever?
13. Would you say that generally you have enough time to spend on yourself? YES/NO
14. If you want to discuss your problems with someone, can you usually YES/NO
find a sympathetic ear?
15. Are you reasonably on course towards achieving your major objectives in life? YES/NO
16. Are you bored at work: a) often? b) sometimes? c) very rarely? A/B/C
17. Do you look forward to going into work:
a) most days? b) some days? c) hardly ever? A/B/C
18. Do you feel adequately valued for your abilities and commitment at work? YES/NO
19. Do you feel adequately rewarded (in terms of status and promotion) for your
abilities and commitment at work? YES/NO
20. Do you feel your superiors: a) actively hinder you in your work? A/B
b) actively help you in your work?
21. If ten years ago you had been able to see yourself professionally as you A/B/C
are now, would you have seen yourself as: a) exceeding your expectations?
b) fulfilling your expectations? c) falling short of your expectations?
22. If you had to rate how much you like yourself on a scale from 5 (most like) ( )
to 1 (least like), what would your rating be?
KEY FOR PROFESSIONAL LIFE STRESS SCALE
1 a) 0, b) 1, c) 2, d) 3, e) 4
2. Score 1. for each yes response
3. Score 0 for more optimistic, 1 for about the same, 2 for less optimistic
4. Score 0 for yes, 1 for no.
5. Score 0 for yes, 1 for no.
6. Score 0 for each circled, 1 for each left uncircled.
7. Score 0 for yourself, 1 for someone else.
8. Score 2 for very upset, 1 for moderately upset, 0 mildly upset.
11. Score 2 for mostly, 1 for sometimes, 0 for only hardly ever.
12. Score 0 for mostly, 1 for sometimes, 2 for hardly.
13. Score 0 for yes, 1 for no.
14. Score 0 for yes1 for no.
15. Score 0 for yes, 1 for no.
16. Score 2 for often, 1 for sometimes, 0 for very rarely.
17. Score 0 for most days, 1 for some days, 2 for hardly ever.
18. Score 0 for yes, 1 for no.
19. Score 0 for yes, 1 for no
20. Score 1 for a), 0 for b).
21. Score 0 for exceeding your expectations, 1 for fulfilling your expectations, 2 for falling short of your expectations.
22. Score 0 for 5, 1 for 4 and so on down to 4 for 1.
6) Write your score in here.
7) Compare your score to the rating scale below:
0 - 15 Stress is not a problem in your life
16 - 30 This is a moderate range of stress for a busy professional person. It is nevertheless well worth looking at how it can reasonably be reduced.
31 - 45 Stress is clearly a problem, and the need for remedial action is apparent. The longer you work under this level of stress, the harder it often is to do something about it. There is a strong case for looking carefully at your professional life.
46 - 60 At these levels, stress is a major problem, and something must be done.
Please note scores on stress scales must be interpreted cautiously. There are so many variables which lie outside the scope of these scales, but which influence the way in which we perceive and handle our stress, that two people with the same scores may experience themselves as under quite different levels of strain. Nevertheless, taken as no more than a guide, these scales can give us some useful information.
8) Discuss if this is a better method for measuring stress.
9) Consider your experiences during your clinical education week. Have you felt particularly stressed during this week? If so, try to identify the stressors and stress reactions and record them here.
Do you think your patients showed signs of stress? What were the main stressors for your patients?
Coping Strategies Coping describes the range of responses for dealing with everyday hassles and stressors as well as the demands and threats of illness and related treatment.
According to Folkman et al (1986) coping can be divided into two classes.
a) Changing the situation that is creating the problem - problem-focused coping Confrontative coping is facing up to the problem and fighting for what you want, possibly expressing anger to the person who caused the problem.
Planful problem-solving is making a plan of action and following it.
b) Managing the distress - emotion focused coping Distancing - I carried on as if nothing had happened
Self-controlling - I tried to keep my feelings to myself
Seeking social support - I told my friends
Accepting responsibility - I criticised myself and promised to work harder
11) From the coping strategies outlined above, can you identify which kind of strategy or strategies you used (if any)?
12) What coping strategies do you think your patients may have used?
13) How useful were these coping strategies for you?
14) Which strategies do you think would be the most useful if you experienced similar stresses in the future?
Hopefully, you will have found these exercises helpful and you will have reflected on your experiences and can identify what events caused you and your patients to suffer stress. You should also have identified possible coping strategies which may be helpful for the future. It may be useful to read over your responses to these questions before you go out on your next clinical placement. You may find that the events which cause you stress in future placements will change as you progress through the course. Something simple like answering the phone can cause major stress for some people when they are in their first placement!