Stress, the so-called twentieth century disease, is blamed as a contributory factor in many of the problems that affect people in Western society today. Some of the most prevalent ailments and disorders in the UK, including coronary heart disease (CHD), hypertension, gastro-intestinal (GI) problems, and sexual difficulties, can all be related to the concept of "stress" (Sarafino, 1998; Patel, 1989). Conversely however, and contrary to popular belief, "taking all the available studies together, there is no good evidence that stress causes cancer" (Petticrew, 1999, p53).

This essay will address some of the issues surrounding stress, briefly asking what it is and looking at the pivotal role that nurses can play in its management.

 Problem Based Learning Trigger

In a fictional scenario, a young, 18 year old student attended his practice nurse following episodes of worsening indigestion, culminating in "coffee ground" vomiting – an indication of gastric haemorrhage.

"Robert Brown" lived with his mother and had recently started at University. He smoked 20 cigarettes a day and spent most of his time at the Students’ Union, where he also tended to eat, since his mother is rarely at home. Although he claimed to be coping with his course, he admitted that he was missing lectures due to his stomach problems.

It seemed fairly clear that Robert was suffering from a gastric ulcer, brought about by a combination of poor diet, smoking and a probable excessive alcohol intake, all of which could be attributed to stress caused by his home environment and the demands of his course.

There are several models for defining stress, but, at its most basic level, stress can be seen as excessive or chronic response to the "fight or flight" mechanism, otherwise called the "General Adaptation Syndrome" (Alexander, et al, 1994). This physiological model can be thought of as the sympathetic and hormonal reactions to a danger or "stressor", which release epinephrine (adrenaline) and nor-epinephrine (nor-adrenaline) into the bloodstream. The essential parts of the body (heart, muscle, blood-clotting mechanism, etc) are then prepared for fight or flight, and the input to less essential systems such as the immune system and the GI tract is reduced. (Patel, 1989).

On top of this, more modern models also consider stress as part of a state of dynamic flux between a person and their environment. They suggest that we are faced with stressors as part of our everyday activities of living and that stress, or the lack of it, is related to our appraisal, judgement and perception of control of the situation, and our consequent coping mechanisms. (Alexander, et al, 1994). A simple model can demonstrate this transactional relationship (See Appendix 1).

From this model, it can be argued that there is a certain amount of "good" stress, without which we would be unstimulated, become lethargic and lose our desire to succeed. However, when people talk about "stress", they are usually referring to the experience that the model calls "distress" and for the purposes of the essay these two terms will be considered synonymous..

It is also important to remember that stress, similar to pain, is a subjective experience and it can be difficult for the clinician to appreciate what a client feels he or she is going through. However, through appropriate communication, and the use of specific tools such as depression inventories, the nurse can begin to build up an empathic understanding.

Why should the nurse want to build such a therapeutic relationship? Nursing is regarded as being among the most stressful of occupations. Surely a nurse would be able to understand why a patient is stressed?

As has already been pointed out, though, stress is a very subjective experience. What may cause one person to consider himself under stress may not affect another person at all. So, some of the stressors a nurse faces are likely to be rather different to the stressors confronting a patient.

Unsocial working hours, night duty rotation, pay concerns, patient violence; the list seems endless. From the student nurse studying for an exam whilst trying to fit into a new ward, to the staff nurse struggling not to become emotionally involved with a dying patient, and the charge nurse working out the off-duty and trying to please everybody, nursing is full of stressors which are rarely found in other occupations to the same degree (Bailey & Clarke, 1989).

However, the experience of stress is almost universal, and so the nurse can, and should, be aware of these stressors, develop appropriate coping strategies, and be able to draw on these experiences in pursuit of the described empathic relationship.

Moreover, there are plenty of other general stressors that are common to the whole population!

"Stressor" is the term used to describe anything that causes stress. These can be broadly classified under "Daily Hassles" and "Life events".

Daily hassles have been described as the little stressors which we all face day to day. They range from sleeping in and having to rush to work, to, say, arguments with a spouse or an inconsiderate flatmate. The Hassles Scale, developed by Richard Lazarus and his colleagues (see Sarafino, 1998), can help give an idea of the stressors facing a person and, in future, try and avoid them or reduce their impact. Daily hassles will vary from person to person, but would probably average out in the longer term. In order to understand differences, therefore, it is imperative to look more at recent major events in a person’s life and the coping strategies employed.

Life event type stressors give an indication of a person’s predisposition to stress and are probably the major differences between one person and another. A person who has recently lost a spouse is more likely to feel unable to cope with the death of a friend than someone who has not lost a spouse, or has been widowed for many years. This is where the widely-used Social Readjustment Rating Scale (Holmes & Rahe, 1967) and similar tools can be used.

Although Holmes and Rahe’s study was initiated to look at the correlation between stressful life events and illness, it is now widely accepted that stress, due to its physiological effects on the immune, GI and circulatory systems can be a major cause of physical disease. The Scale, therefore, can also now be seen as a predicator for the build-up of stress. The initial study had a list of 43 major life events and arbitrarily gave marriage an index value of 500. Participants then had to score the other events relative to this value. From this data, the final Social Readjustment Rating Scale was derived on a scale of 1 to 100 "Life Change Units" (LCU’s), with marriage at an index of 50 (See Appendix 2).

Adding up the LCU score for a person over a period of time, usually six months, can give an indication of the stress that someone is under and hence the likelihood of succumbing to stress-related illness.

Personality has also played a part in understanding different people’s reaction to stress, with type-A, competitive, personality types at a higher risk of becoming stressed than the more relaxed, type-B, personality. However, recently, this approach to understanding stress has become less popular with experts. Some research even suggests that it is stress that causes the type-A pattern of behaviour, rather than the other way around (Sarafino, 1998). At most, the belief is that the only differences lie more in how these different personalities cope with stressors.

Some people may cope by employing a simple breathing exercise; others may reach instinctively for a cigarette or put the kettle on for a strong cup of coffee; still others may react with anger or violence. Consequently, it can be seen that the coping mechanisms can be divided broadly under two "grades" – good and bad. While "bad" coping strategies are more obvious and more likely to lead to recognition of stress, certain "good" strategies may hide "anger-in" coping methods, leading to an internalisation of the stress, which may go unnoticed until it is too late and the person has had a heart attack.

It is often the practice nurse who first recognises symptoms of stress in a client, whether they are attending a routine clinic, or seeing them for hypertension management. For example, anger-in coping methods must be recognised as such, and not confused with genuine relaxation techniques. Over-use of relaxation methods must also be watched for as, again, the client may be denying an underlying cause instead of trying to deal with it.

However, recognising and diagnosing stress is only the beginning. The nurse is involved in all levels of stress management from the monitoring of drug taking in chronic cases to the promotion of good coping strategies.

While drug therapy plays a very important part in stress management, the majority of cases seen, particularly in Primary Health Care, will be readily treated without the need for drugs such as the tricyclics and lithium. In chronic cases, and in the mental health ward, for example, if stress has led to clinical depression, nursing care may well involve administration of such medicines, but the effects of relaxation and other non-pharmaceutical therapies cannot be over-emphasised.

Relaxation is the primary method of reducing stress levels. There are many methods of doing so, and it can be confusing trying to work out which are appropriate for an individual. With stress being such a subjective topic, it is important that the client-centred approach of health promotion (Ewles & Simnett, 1999) is used and any treatment regime be tailored for, and in conjunction with, the client.

Primarily, the clinician may use a cognitive approach with the client. The nurse’s communication skills, built upon since joining the profession, are very useful in helping the client identify negative beliefs, and use problem-solving techniques to turn them into more positive thoughts and increasing the effectiveness of the coping strategies decided upon. (Ellis, et al, 1997; Stein-Parbury, 1993)

The commonest methods of relaxation involve little in the way of external articles. These include breathing exercises and simple imagery techniques, which can be performed quickly and even on the spot (Payne, 1995a). The nurse should be able to spend time with the client to demonstrate and practise the various methods employed. Even simpler methods of reducing stress, such as proper time management to avoid rushing and ensuring a reasonable amount of personal space, can all be part of this discussion between nurse and client.

Taking up a relaxing hobby, such as art or a musical instrument can also be recommended. The community nurse, in particular, should have an accumulation of "Healthy Alliances" to draw upon in order to recommend an evening class or social group.

Physical relaxation techniques include chiropractice, the Alexander technique of posture, deep muscle relaxation, and similar approaches (Payne, 1995b). While the nurse may not know the specifics of them (although more and more people are learning them through self-teaching books) they should, again, know where the client can access practitioners and classes.

Many nurses are putting themselves through training in various complementary therapies, most of which promote relaxation. While the healing properties of some, such as reflexology, may be uncertain, their relaxation qualities are well-documented (Lynn, 1996; Lockett, 1992). Aromatherapy, acupuncture and yoga are also used successfully in the management of stress symptoms (Stress UK, 1999). Tai’chi, a non-contact martial art which promotes relaxation, may also be useful.

Other martial arts, such as Tae-Kwon-Do, can also be recommended, because, as well as the relaxation techniques taught, exercise is another popular method of reducing stress symptoms (Alexander, et al, 1994). Aerobic exercise, such as swimming or cycling, as well as having many health benefits, is believed to utilise the excess epinephrine (adrenaline) produced by the physiological stress response. Simply taking the dog for a walk in the evening can be just as beneficial.

Overall, the best idea is to promote as relaxed a lifestyle as possible, whether this is through the uptake of exercise and relaxation techniques or just having an established "time out" provision. However, in some cases, it is conceivable that a client may require to take early retirement if their work is proving very stressful, or another, major, lifestyle change is essential. In cases such as these, the nurse who has been following the case from the beginning may be needed for counselling.

The nurse is also involved in a lot more than just the basic health promotion and consequences of relaxing lifestyle changes.

In order to prevent further complications, or, as in the example of Robert Brown, minimise the effects of complications already present, further health promotion is required. In particular, with Robert’s case, management of his gastric ulcer is important.

The effects of the increased sympathetic input, which slows down gut motility, and his bad diet, have primarily caused the ulcer. Hence, in Robert’s case, as well as the main concern of relaxation promotion, his diet must also be addressed. He eats at the Students’ Union, which probably means he eats a lot of fatty foods (such as burgers and chips) as well as sweets and quick snacks. Even small steps, such as switching to low calorie drinks, or preferably milk, and having baked potatoes or pasta instead of chips, will show an improvement in his symptoms.

Other stress symptoms that must be addressed by the nurse and his colleagues in the Primary Health Care team include hypertension and the onset of CHD and other vascular problems.

In this respect, stopping smoking is arguably the best thing Robert, or anyone, can do in reducing the symptoms of stress. Although a cigarette seems to be relaxing in the short term, the long term effects of tobacco on blood pressure and the heart are now well known (Shuttleworth, 1996). Helping a client with stress to stop smoking is very important and knowledge on the nurse’s part of campaigns and resources such as the Smokeline is invaluable.

In fact, reducing a client’s reliance on any drug or habit, from caffeine and binge eating, to alcohol, tobacco and illegal substances, is important. These all demonstrate examples of "bad" coping strategies and do not address the real issues, which cognitive therapies and proper relaxation can. It could be argued that helping a person stop smoking or reduce their alcohol intake will help them to focus on the more positive aspects of their efforts to manage their stress.

Stress is no longer the taboo subject it once was, and it is now accepted that it causes physiological, as well as psychological changes. As the primary factor in many heart attacks and bowel disease, it is not being melodramatic to suggest that stress is a killer and its management is of utmost concern.

From the first recognition of stress symptoms, the nurse, whether in primary, secondary or tertiary care, is fully involved. The vast majority of his involvement will be in health education and promotion – advocating a relaxing lifestyle, helping with smoking cessation programmes, encouraging a healthy diet and so on. He will also be involved in the management of symptoms; angina, hypertension, irritable bowel syndrome, peptic ulcers, myocardial infarction are all side effects of stress which the nurse is likely to see on a very regular basis.

Although the role of the whole multiprofessional team should not go unmentioned, the nurse’s role in every level of stress management is a crucial one.

• ALEXANDER, M.F., FAWCETT, J.N., RUNCIMAN, P.J., (eds.), (1994). Nursing Practice: Hospital and Home – the adult. Edinburgh: Churchill Livingstone. pp 575-596.
• BAILEY, R., CLARKE, M., (1989). Stress and Coping in Nursing. London: Chapman and Hall.
• ELLIS, A., GORDON, J., NEENAN, M., PALMER, S., (1997). Stress Counselling. London: Cassell.
• EWLES, L., SIMNETT, I., (1999). Promoting Health: a practical guide (4^th ed.). Edinburgh: Baillière Tindall.
• GORHAM, C., HATT, M., (1998). Stressed Eric’s Guide to Stress Management. London: BBC Worldwide Ltd.
• HOLMES, T.H., RAHE, R.H., (1967). ‘The Social Readjustment Rating Scale’. Journal of Psychosomatic Research. 11(2), pp 213-218.
• LOCKETT, J., (1992). ‘Reflexology – a nursing tool?’. Australian Nurses Journal. 22(1), pp 14-15.
• LYNN, J., (1996). ‘Using complementary therapies: reflexology’. Professional Nurse. 11(5), pp 321-322.
• PATEL, C., (1989). The Complete Guide to Stress Management. London: Vermilion (Random House).
• PAYNE, R., (1995a). ‘How to use instant relaxation methods’. Nursing Standard. 10(12-14), pp 23-25.
• PAYNE, R., (1995b). Relaxation Techniques: a practical handbook for the health care professional. Edinburgh: Churchill Livingstone.
• PETTICREW, M., (1999). ‘Cancer-stress link: the truth’. Nursing Times. 95(9), pp 52-53.
• SARAFINO, E.P., (1998). Health Psychology: biopsychosocial interactions. (3^rd ed.). New York: John Wiley & Sons, Inc.
• SHUTTLEWORTH, A.L., (1996). ‘Coronary heart disease’. Professional Nurse. 11(6), pp 386-390.
• STEIN-PARBURY, J., (1993). Patient and Person: developing interpersonal skills in nursing. Melbourne: Churchill Livingstone.
• STRESS UK. ‘For all those interested in personal and occupational stress management’. Stress UK. http://www.stress.org.uk (23^rd March 1999)

• CHANGING TIMES. ‘The Changing Times way to stress relief’. Stress. http://www.less-stress.com/. (23^rd March 1999)
• CONDUIT, E., (1995). The Body under Stress: developing skills for keeping healthy. Hove: Lawrence Erlbaum Associates Ltd.
• EBRAHIM, S., SMITH, G.D., (1998). ‘Lowering Blood Pressure: a systematic review of sustained effects of non-pharmacological interventions’. Journal of Public Health Medicine. 20(4), pp 441-448.
• KILTY, J., BOND, M., (1991). Practical Methods of Dealing with Stress (2^nd ed.). Guildford: University of Surrey.
• KIRSTA, A., (1986). The Book of Stress Survival: how to relax and live positively. London: Thorsons.
• LAZARUS, R.S., LAZARUS, B.N., (1994). Passion and Reason: making sense of our emotions. New York: Oxford University Press.
• MCCLELLAND, N., (1995). ‘Look back in anger’. Nursing Times. 91(6), pp 59-61.
• SUNDAY TIMES, THE. ‘Stress Manager’. InfoTIMES. http://www.sunday-times.co.uk/news/ pages/resources/stress_manager1.n.html?1786082. (23^rd March 1999).