STRESS MANAGEMENT

INTRODUCTION Right from the time of birth till the last breath drawn, an individual is invariably exposed to various stressful situations. The modern world which is said to be a world of achievement is also a world of stress and has been called the Age of Anxiety and Stress. The word stress was originally used by Selyle in 1956 to describe the pressure experienced by a person in response to life demands. These demands are referred to as stressors. Stress can be positive or negative. Perception plays a key role in interpreting how stressful situations are. DEFINITION STRESS According to Selye (1956), Stress is defined as the pressure experienced by a person in response to life demands. These demands are referred to as stressors and include a range of life events, physical factors (eg: cold, hunger, haemorrhage, pain), environmental conditions and personal thoughts. According to Selye (1976), Stress is a process of adjusting to or dealing with circumstances that disrupt or threaten to disrupt a persons physical or psychological functioning. Stress is tension, strain, or pressure from a situation that requires us to use, adapt, or develop new coping skills. STRESSOR Stressor is the stimuli proceeding or precipitating a change. It may be internal (fear, guilt) or external (trauma, peer pressure, etc). TYPES OF STRESS Distress: Stress due to an excess of adaptive demands placed upon us. The demands are so great that they lead to bodily and mental damage. eg: unexpected death of a loved one. Eustress: The optimal amount of stress, which helps to promote health and growth. eg: praise from an superior for hard working. TYPES OF STRESSORS Physiological stressors: a. Chemical agents b. Physical agents c. Infectious agent d. Nutrition imbalances e. Genetic or immune disorders Psychological stressors: a. Accidents can cause stress for the victim, the person who caused the accident and the families of both b. Stressful experiences of family members and friends

c. Fear of aggression or mutilation from others such as murder, rape, terrorist and attacks. d. Events that we see on T.V. such as war, earthquake, violence e. Developmental and life events f. Rapid changes in our world, including economic and political structures and technology SOURCES OF STRESS There are many sources of stress, these are broadly classified as: Internal stressors: they originate within a person eg: cancer, feeling of depression. External stressors: it originates outside the individual eg: moving to another city, death in a family. Developmental stressors: it occurs at predictable times throughout an individuals life. eg: child- beginning of school. Situational stressors: they are unpredictable and occur at any time during life. It may be positive or negative. eg: death of family member, marriage/ divorce. INDICATORS OF STRESS It may be physiological, psychological and cognitive: Physiological indicators: the physiological signs and symptoms of stress result from activation of sympathetic and neuro- endocrine systems of body. Pupils dilate to increase visual perception Sweat production increases Heart rate and cardiac output increases Skin is pallid due to peripheral blood vessel constriction Mouth may be dry Urine output decreases Blood sugar increases Psychologic indicators: the manifestations: of stress includes anxiety, fear, anger, depression and unconscious ego defense mechanism. Anxiety: state of mental uneasiness, apprehension, dread or feeling of helpless. It can be experienced at conscious, subconscious or unconscious level. Fear: It is an emotion/ feeling of apprehension aroused by impending or seeming danger, pain or threat. Depression: It is an extreme feeling of sadness, despair, lack of worth or emptiness. Unconscious ego defense mechanism: It is a psychologic adaptive mechanism developing as the personality attempts to defend itself and allay inner tensions.

 Cognitive indicators: Problem solving: the person assesses the situation or problem analyzes, chose alternatives, carries out selected alternatives and evaluates. Structuring: arrangement/ manipulation of a situation so that threatening events does not occur. Self control: assuming a manner and facial expression that conveys a sense of being in control or in change. Suppression: willfully putting a thought or feeling out of mind. Day dreaming: unfulfilled wishes and desires are imagined as fulfilled or a threatening experience is re worked or re played so that it ends differently from reality. STRESS CYCLE

An event occurs of neutral value or meaning After a period of rest, the individual is able to prepare for and meet a new threat or challenge

The individual appraises whether the event is a threat or a challenge

Fatigue follows the depletion of bio-chemicals from the exertion

Bio-chemicals are released to enhance the ability of ones mind and body to

The bio-chemicals are depleted through the exertion to meet the threat or challenge

The individual responds to the threat or challenge through fight or flight

THEORIES OF STRESS SELYES GENERAL THEORY OF STRESS During 1930s and 40s Selye performed the first extensive studies on stress responses. His famous treatise the physiology and pathology of stress describes his general theory of stress and influenced stress research throughout the world. Selye defined stress as a physiological phenomenon.

Stress in biology is the non specific response of the body to any demand made upon it. It suffices to keep in mind that by stress the physician means the common results of exposure to the any stimulus. The bodily changes established when a person is exposed to nervous tension, physical injury, infection, cold, heat, x-rays or anything are also called stress. HOLMES AND RAHES MODEL RELATING LIFE CHANGES TO ILLNESS They studied on relationship between change and illness. Change is a form of stress requiring both psychological and physical adaptations. Adapting to change consumes energy beyond that needed to maintain a steady state of life. They developed the Social Readjustment Rating Scale, a ranking of major life change units. They explored the link between the amount of changes in a persons life and subsequent illness and discovered that the higher a persons life change score, the greater the likelihood that an illness will subsequently develop. LASARUSS THEORY OF STRESS AND COPING This theory emphasizes that cognitive appraisal is central in determining what is stressful and in coping with stress. He also pointed out that one of the major problems in defining stress is that, emotions have been treated as a cause of stress response rather than the effect of these responses. In the process of coping, the individual shapes as well as responds to a demand or stress. Coping may change the stressful experience and thus may influence what happens next. STRESS MODELS The adaptation of the concept of stress by the biological and behavioural sciences resulted in the formulation of a number of models to describe stress and its effects. They are, STIMULUS BASED MODELS: In this model, stress is defined as a stimulus, a life event or a set of circumstances that arouses physiologic or psychologic reactions may increase the individuals vulnerability to illness. In this model person is viewed as being constantly exposed to environmental stressors in their daily life, eg. the demand of work, family responsibilities, disablement or to more specific stressors such as smell or poor lighting. Here stress is a state that can generally be empirically observed, measured and evaluated and which can potentially be removed or altered to reduce the individual stress. PSYCHOSOMATIC MODEL: Stress is unique in the causation of diseases. It has not biological carrier such as germ or virus. Rather it is the result of how mind and body function or interact. It is psychosomatic in the true sense of word-psyche meaning mind and soma body. It is the disease created by the mind leading to different illness. Person may suppress the anger and eventually develop the mental dysfunction of depression. Emotional stress leads to physiological stress and results in psychosomatic illness.

 THE SYSTEM MODEL: Stress response is here defined as carrying six components. Environmental stimuli- Some environmental stimuli activate stress response as a direct consequence of their physical or biochemical properties. Eg. caffeine, nicotine, and extreme cold and heat. Cognitive-Affective domain- The individuals interpretation of the environment gives rise to most of the stress reactions. Neurological triggering mechanisms- The limbic system and the hypothalamic nuclei are the anatomical site for the integration of sensory cognitive, affective and visceral activity. It is the basis for a host of psychiatric and psycho physiological disorders. The physiological stress response axis- Stress response occurs sequentially along the neurological, neuro endocrine and endocrine axes and results in neural and hormonal activity directed at target organs. Coping- In this final phase of stress response, the individual attempts to reduce their level of arousal by manipulating the environment or making cognitive adjustment. Target organ effects- If coping are unsuccessful and arousal is either excessive or prolonged, the physiological process of stress response is likely to lead to target organ dysfunction or disease. TRANSACTION BASED MODEL: It is based on the works of Lazarus (1966) who states that stimulus theory and response theory do not consider individual differences. It encompasses a set of cognitive, affective and adaptive responses that arises out of person environment transactions. As the person and environment are inseparable, each affects and is affected by other. There are moderating factors such as ones copying behavior and cognitive appraisal. Effective preventive and health promotion strategies can be planned based on this model. RESPONSE BASED MODEL: In this model the word stress is used to describe the experience of a person who feels they are in a threatening or difficult situation. Stress is thus a persons response to threat as in the stimulus based model, is not necessarily inherent in the environment or situation. By using the response based model, it is possible to make sense of an individuals unique stress response and even of responses that might seem, within the stimulus based model, to be irrational, such as birds , spiders or flying. It consists of mainly 2 responses, 1) Local adaptation syndrome: It is a localized response of body to stress and it involves only specific body part (tissues, organs) instead of the whole body. It may be traumatic or pathologic. eg: inflammatory responses of a body part in response to a trauma or injury. It is a short term adaptive response which primarily is homeostatic. 2 most common stress responses that influence nursing care are reflex pain response and the inflammatory response

 Reflex pain response: It is the response of central nervous system to pain. It is rapid, automatic and serves as a protective mechanism to prevent injury. eg: if you are about to step into a bath tub filled with dangerous hot water, skin senses the heat and immediately sends a message to the spinal cord. A message is then sent to motor nerve, which consciously realize that the water is too hot not safe. Inflammatory response: It is a local response to injury or infection. It helps to localize and prevent the spread of infection and promote wound healing. There are 3 phases: First phase: vasoconstriction occurs to control bleeding initially. Histamines are realized and capillary permeability increases resulting in increased blood flow to the area. Then the blood flow returns to normal but remain to help resist the infection. Second phase: exudates (made up of fluids, cells and inflammatory by products) are realized from the wound. The amount of exudates depends up on the site, severity of wound. Third phase: damaged cells are repaired by regeneration (replacement with identical cells) or formation of scar tissue. 2) General adaptation syndrome: It describes bodys general response to stress. It consists of 3 stages The alarm reaction: it is initiated when a person perceives a specific stressor, various defence mechanisms are activated. The autonomic nervous system initiates the flight or flight response preparing the body to either fight off the stressor or to run away from it. Resistance: the body attempts to adapt to stressor, after perceiving the threat. Vital signs and hormone levels return to normal. If the stress can be managed or confirmed to small area the body regains homeostasis. Exhaustion: it results when the adaptive mechanism are exhausted. Without defence against the stressor, the body either rest or mobilize its defence to return to normal or reach total exhaustion and die. STRESS ADAPTATION MODEL: The model was given by Gail Stuart so it is called Stuart stress adaptation model. It integrates biological, socio-cultural, psychological, environmental and legalethical aspects of patient care into a unified frame work for practice. The first assumption of Stuart stress adaptation model is the nature is ordered as a society hierarchy from the simplest unit to the most complex. Each level is a part next higher level, so nothing exists in isolation. Thus individual is a part of family, group, community, society and the large biosphere, through which material and information flows across various levels.

BIOSPHERE SOCIETY COMMUNITY GROUP FAMILY INDIVIDUAL BODY SYSTEM ORGAN TISSUE CELL Second assumption of the model is that nursing care is provided within a biological, psychological, socio-cultural, environmental and legal- ethical context. The nurse must understand each of them to provide holistic nursing care. Third assumption of the model is that health/ illness and adaptation / maladaptation are 2 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. In contrast a person without a medical illness may have adaptative coping resources. Fourth assumption is that the model includes the primary, secondary, and tertiary levels of prevention by describing four stages of psychiatric treatment: crisis, acute, maintenance and health promotion. For each stage of treatment, the model suggests a treatment goal, a focus of nursing assessment, nature of interventions and expected outcomes of nursing care. Fifth assumption is based on the use of nursing process and standards of care professional performance. Each step of the process is important and it is a local response to injury or infection. It helps to localize and prevent the spread of infection and promote wound healing.

TECHNIQUES OF STRESS MANAGEMENT Stress management involves controlling and reducing the tension that occurs in stressful situations by making emotional and physical changes. The degree of stress and the desire to make the changes will determine how much change takes place. Some of the techniques of stress management are: Laughter Adopting a humorous view towards life`s situations can take the edge off everyday stressors. Not being too serious or in a constant alert mode helps maintain the equanimity of mind and promote clear thinking. Being able to laugh stress away is the smartest way to ward off its effects. Benefits of laughter: Laughter lowers blood pressure and reduces hypertension. It provides good cardiac conditioning especially for those who are unable to perform physical exercise. Reduces stress hormones (studies shows, laughter induces reduction of at least four of neuroendocrine hormonesepinep hrine, cortisol, dopamine and growth hormone, associated with stress response). Boosts immune function by raising levels of infection-fighting T-cells, diseasefighting proteins called Gamma-interferon and disease-destroying antibodies called B-cells. Laughter triggers the release of endorphinsbody`s natural painkillers. Produces a general sense of well-being. AUTOGENIC TRAINING: It is a relaxation technique developed by the German psychiatrist Johannes Heinrich Schultz and first published in 1932. The technique involves the daily practice of sessions that last around 15 minutes, usually in the morning, at lunch time, and in the evening. During each session, the practitioner will repeat a set of visualizations that induce a state of relaxation. Each session can be practiced in a position chosen amongst a set of recommended postures (for eg: lying down, sitting meditation). The technique can be used to alleviate many stress-induced psychosomatic disorders. Eg of an autogenic training session are: Sit in the meditative posture and scan the body "my right arm is heavy" "my arms and legs are heavy and warm" (repeat 3 or more times) "my heartbeat is calm and regular" (repeat 3 times) "my forehead is cool" "my neck and shoulders are heavy" (repeat 3 times) "I am at peace" (repeat 3 times)

Effects of autogenic training: Autogenic Training restores the balance between the activity of the sympathetic (flight or fight) and the parasympathetic (rest and digest) branches of the autonomic nervous system. This has important health benefits, as the parasympathetic activity promotes digestion and bowel movements, lowers the blood pressure, slows the heart rate, and promotes the functions of the immune system. GETTING A HOBBY: Hobby is an activity or interest that is undertaken for pleasure or relaxation, typically done during one's leisure time.eg: collecting, games, outdoor recreation, gardening, performing the arts, reading, cooking and etc. MEDITATION: Meditation is a holistic discipline during which time the practitioner trains his or her mind in order to realize some benefit. Meditation is generally a subjective, personal experience and most often done without any external involvement, except perhaps prayer beads to count prayers. Meditation often involves invoking and cultivating a feeling or internal state, such as compassion, or attending to some focal point, etc. The term can refer to the process of reaching this state, as well as to the state itself. DEEP BREATHING: Diaphragmatic breathing, abdominal breathing, belly breathing, deep breathing or costal breathing is the act of breathing deep into one's lungs by flexing one's diaphragm rather than breathing shallowly by flexing one's rib cage. This deep breathing is marked by expansion of the abdomen rather than the chest when breathing. It is generally considered a healthier and fuller way to ingest oxygen and is often used as a therapy for hyperventilation and anxiety disorders. A common diaphragmatic breathing exercise is as follows: 1. Sit or lie comfortably, with loose garments. 2. Put one hand on your chest and one on your stomach. 3. Slowly inhale through your nose or through pursed lips (to slow down the intake of breath). 4. As you inhale, feel your stomach expand with your hand. 5. Slowly exhale through pursed lips to regulate the release of air. 6. Rest and repeat. Another diaphragmatic breathing exercise for raising oxygen levels in the blood and energy in the body is to take several negative breaths, immediately followed by an equal number of positive breaths. During negative breaths, one inhales, immediately exhales and then holds one's breathe for a short time. The emphasis is on keeping one's lungs empty. Negative breaths reduce the amount of oxygen in one's blood.

 During positive breaths, one inhales, holds one's breath, and then exhales. The emphasis is in keeping one's lungs full of air. Positive breaths increase the oxygen in one's blood. Although not always taught, continuing to breathe into the chest at the same time can provide an ever more "fulfilling" exercise. The goal is to have the entire torso move in & out when breathing, as if one is surrounded by an expanding and contracting inner tube. YOGA NIDRA Yoga-nidra may be rendered in English as "yoga sleep". It is a sleep-like state that occurs with some practitioners of meditation, details of which have been handed down by guru-to-disciple transmission (parampara) within the Indian religions. These aspects may include relaxation and guided visualization techniques as well as the psychology of dream, sleep and yoga. Yoga-nidra should not be confused with hypnotic states, known as "yoga tandra". The practice of yoga relaxation has been found to reduce tension and anxiety. The autonomic symptoms of high anxiety such as headache, giddiness, chest pain, palpitations, sweating, abdominal pain respond well. NOOTROPICS Nootropics also referred to as smart drugs, memory enhancers, and cognitive enhancers, are drugs, supplements, nutraceuticals, and functional foods that are purported to improve mental functions such as cognition, memory, intelligence, motivation, attention, and concentration. Nootropics are thought to work by altering the availability of the brain's supply of neurochemicals (neurotransmitters, enzymes, and hormones), by improving the brain's oxygen supply, or by stimulating nerve growth. However the efficacy of nootropic substances, in most cases, has not been conclusively determined. RELAXATION TECHNIQUES: Relaxation technique (also known as relaxation training) is any method, process, procedure, or activity that helps a person to relax; to attain a state of increased calmness; or otherwise reduce levels of anxiety, stress or anger. Relaxation techniques are often employed as one element of a wider stress management program and can decrease muscle tension, lower the blood pressure and slow heart and breath rates, among other health benefits. FRACTIONAL RELAXATION: Fractional relaxation is a method of releasing muscular tension in one small part of the body at a time, such as relaxing one finger, then relaxing another, then adding another... Then the whole hand is relaxed, followed by the forearm, and then the upper arm... The other arm is relaxed next, starting with a finger... Then the legs (each starting with a toe)... and so on, including all body parts (including all the parts of the head) until the entire body is relaxed. The fractional relaxation approach is often used in preparation for trance induction and hypnosis, but is very useful as a relaxation technique by itself. The theory behind this tension release method is that it is easier to relax a fraction of the body than it is to relax the whole body all at once.

ABC OF STRESS MANAGEMENT Always take time for yourself at least 30 min/ day. Be aware of your own stress meter; know when to step back and cool down. Concentrate on controlling your own situation, without controlling everybody else. Daily exercise will burn off the stress chemicals. Eat lots of fresh fruit, veggies, bread and water; give your body the best for it to perform at its best. Forgive others, do not hold grudges and be tolerant; not everyone is capable as you. Gain perspective on things, how important is the issue? Hugs, kisses and laughter; have fun and dont be afraid to share your feelings with others. Identify stressors and plan to deal with them better next time. Judge your own performance realistically; dont set goals out of your own reach. Keep a positive attitude, your outlook will influence outcomes and the way others treat you. Limit alcohol, drugs and other stimulants, they affect your perception and behavior. Manage money well, seek advice and save at least 10% of what you earn. No is a word you need to learn to use without feeling guilty. Outdoor activities by yourself, or with friends and families, can be a great way to relax. Play your favorite music rather than watching TV. Quit smoking; it is stressing your body daily, not to mention killing you too. Relationships; nurture and enjoy them, learn to listen more and talk less. Sleep well, with firm mattress and supportive pillow; dont over heat yourself and allow plenty of ventilation. Treat yourself once a week with a massage, dinner out and the movies. Understand things from the other person point of view. Verify information from the source before exploding. Worry less, it really doesnt get things completed better or quicker. Xpress ; make a regular retreat to your favorite space, make holidays part of your yearly plan and budget. Yearly goal setting; plan what you want to achieve based on your priorities in your career, relationships etc Zest for life; each day is a gift, smile and be thankful that youre the part of the bigger picture.

CONCLUSION Stress is an universal phenomenon which provides a way of understanding person as a being who responds in totality (mind, body and spirit) to a variety of changes that take place in daily life. Stress and anxiety are basic to life, no matter how wealthy, powerful; good working and happy you might be mild stress can be stimulating, motivating and sometimes even desirable. JOURNAL ABSTRACT Dr. Sailaxmi Gandhi, Dr. Lalitha K; Perceived stress in nurses working with psychiatric patients; Nightingale Nursing Times; October 2008; Volume 4; Issue 7; PN- 19-22. The statement of the problem- Effectiveness of stress management programme on selected variables of nurses working on a psychiatric hospital. The researchers used DCL stress scale which was administered randomly to 60 nurses working in psychiatric wards of a hospital in Bangalore using Tippets Random number table. The perceived score indicated that some degree of stress was being perceived by nurses. Findings- Considering the potentially detrimental effects of stress, there is a need to understand mental health nurses experience of stress, so that where possible it can be avoided and it is unavoidable, strategies can be devised to help nurses to cope with it more effectively. Neelakshi. G; Stress management through self management; Nightingale nursing Times; May 2006; Volume 2; Issue 2; PN-9-12. A study was conducted on stress management through Yogic philosophy of deep relaxation, yogic plan to de-stress, self management and mind matching. It was concluded that Yoga can help women cope with the challenges of infertility. The best combination of yoga, meditation, and relaxation is based on preferences of the patient and her belief system, opinions, and willingness to participate. BIBLIOGRAPHY www.ccghe.jhmi.edu/assets/ccghe/documents/s2-group_dynamics.

 Use open-ended questions to start discussions. Encourage all members to ask questions. Respond with a positive comment or summary each time a member makes a contribution. Give your full attention to each person's contribution. Refrain from negative comments about member's contributions. Don't take sides, instead summarize opinion differences. State that issues can be viewed from different perspectives. Seek equal input from all members. ACTIVELY LISTEN to all members. Focus discussion on the purpose of the group. Check perceptions of the group. Convey the meaning of what a team member has said so that all members can understand. Clarify statements. Sort out the confusing and conflicting. Restate and summarize major ideas and feelings. Summarize points of opinion differences among team members. Encourage open expression of member's feelings and thoughts. Avoid frequent questioning. Too many questions at one time are annoying. Confirm members' ideas, emphasize the facts and encourage further discussion. CAUSES OF STRESS AT WORK These are typical causes of stress at work:

bullying or harassment, by anyone, not necessarily a person's manager feeling powerless and uninvolved in determining one's own responsibilities continuous unreasonable performance demands lack of effective communication and conflict resolution lack of job security long working hours excessive time away from home and family office politics and conflict among staff a feeling that one's reward reward is not commensurate with one's responsibility working hours, responsibilities and pressures disrupting life-balance (diet, exercise, sleep and rest, play, family-time, etc)