presentation objectives Describe a crisis and its characteristics

presentation objectives ØDescribe a crisis and its characteristics, types of crises, and crisis intervention. ØAnalyze aspects of the nursing assessment related to crisis responses. ØPlan and implement nursing interventions for patients related to their crisis responses. ØDevelop a patient education plan to cope with crisis. ØEvaluate nursing care for patients related to their crisis responses. ØDescribe the settings in which crisis intervention may be practiced. ØDiscuss modalities of crisis intervention.

Definition of crisis: Stressful events, or crises, are a common part of life. They may be social, psychological, or biological in nature, and there is often little that a person can do to prevent them. As the largest group of health providers, nurses are in an excellent position to help promote healthy outcomes for people in times of crisis. Crisis = a sudden event in one’s life that disturbs homeostasis and during which usual coping mechanisms cannot resolve the problem

Crisis characteristics: ØA crisis is a disturbance caused by a stressful event or a perceived threat. The person’s usual way of coping becomes ineffective in dealing with the threat, causing anxiety. The threat or precipitating event, usually can be identified. ØTime limited: Generally lasting no more than six weeks. ØIt may have occurred weeks or days before the crisis, and it may or may not be linked in the individual’s mind to the crisis state the individual is experiencing. Precipitating events can be actual or perceived losses, threats of losses, or challenges.

Characteristics of a crisis: >>> Ø Crisis occurs in all individuals at one time or another and is not Ø Ø necessarily equated with psychopathology Crises are precipitated by specific identifiable events Crises are personal by nature; what may be considered a crisis situation by one individual may not be so for another Crises are acute, not chronic, and will be resolved in one way or another within a brief period A crisis situation contains the potential for psychological growth or deterioration

Crisis responses: After the precipitating event the person’s anxiety begins to rise, and three phases of a crisis response emerge: Ø In the first phase the anxiety activates the person’s usual methods of coping. If these do not bring relief, anxiety increases because coping mechanisms have failed. Ø In the second phase new coping mechanisms are tried or the threat is redefined so that old ones can work. Resolution of the problem can occur in this phase. However, if resolution does not occur, the person goes on to the last phase. Ø In the third phase the continuation of severe or panic levels of anxiety may lead to psychological disorganization.

Crisis responses >>> Successful resolution of the crisis is more likely if the person has a realistic view of the event, if situational supports are available to help solve the problem, and if effective coping mechanisms are present (Aguilera 1998). The phases of crisis and the impact of balancing factors are similar to the components of the Stuart stress adaptation model used in chapter 3. however by definition, crises are self-limiting. People in crisis are too upset to function as such a high level of anxiety indefinitely. The time used to resolve the crisis, whether it is a positive solution or a state of disorganization, may be 6 weeks or longer.

Crisis responses >>> It is also important to recognize that periods of intense conflict ultimately can result in increased growth. How the crisis is handled determines whether growth or disorganization will result. Growth comes from learning in new situations. People in crisis feel uncomfortable, often reach out for help, and accept help until they feel that their lives are back to normal. The fact that crises can lead to personal growth is important to remember when working with patients in crisis.

PHASES OF CRISIS SEVERE ANXIETY PERSONALITY DISORGANIZATION (CRISIS) TRIAL & ERROR SOLUTIONS STRESS ANXIETY USUAL COPING MECHANISMS INEFFECTIVE OR NEW PROBLEM- SOLVING SOLUTIONS AND SUPPORT ANXIETY PRE-CRISIS LEVEL OF FUNCTIONING

Types of crises: Maturational crises. Are developmental events requiring role changes. The nature and extent of the maturational crisis can be influenced by role models, interpersonal resources, and the response of others. Positive role models show the person how to act in the new role. Interpersonal resources encourage the trying out of new behaviors to achieve role changes. Other people’s acceptance of the new role is also important. The greater the resistance of others, the more stress the person faces in making the changes. Transitional periods during adolescence, parenthood, marriage, midlife, and retirement are the key times for the onset of maturational crises.

Types of crises >>> Situational crises. Occur when a life event upsets an individual’s or group’s psychological equilibrium. Examples, loss of job, loss of a loved one, onset or worsening of a medical illness, divorce, school problems, and witnessing a crime. Situational crises can be accidental, uncommon, and unexpected events. For example, natural disasters, such as fires, tornadoes, earthquakes, or floods, which disrupts entire communities, are situational crises. Disasters, such as killings in the workplace or in schools, airplane crashes, suicide bombings, and acts of terrorism, also can precipitate situational crises. Individual variables such as psychological resilience, social support, and financial resources influence a survivor’s capacity to move through the phases.

CRISIS INTERVENTION BALANCING FACTORS Crisis- good outcome 1. Perception of event realistic 2. Situational support adequate 3. Coping mechanism adequate No crisis Crisis- development 1. Perception of event distorted 2. Situational support inadequate 3. Coping mechanisms inadequate Crisis

Crisis intervention: Crisis intervention is a brief, focused, and time-limited treatment strategy that has been shown to be effective in helping people adaptively cope with stressful events. Knowledge of crisis intervention techniques is an important clinical skill of all nurses, regardless of clinical setting or practice specialty. Is a short-term therapy focused on solving the immediate problem. It is usually limited to 6 weeks. The goal of crisis intervention is for the individual to return to a precrisis level of functioning. Often the person advances to a level of growth that is higher than the precrisis level because new ways of problem solving have been learned. It is important for the nurse to remember that culture strongly influences the crisis intervention process, including the communication and response style of the crisis worker. Cultural attitudes are deeply ingrained in the process of asking for, giving, and receiving help. They also affect the victimization experience, so it is essential to understand respect the sociocultural context of crisis care.

Specific cultural factors to be considered in crisis intervention include the following: Ø Migration and citizenship status Ø Gender and family roles Ø Religious belief systems Ø Child-rearing practices Ø Use of extended family and support systems Ø Housing and living conditions Ø Socioeconomic status

Crisis intervention >>> The age of the survivors is also important for the nurse to consider when providing crisis intervention. Responses to stressful events differ across the life span. Therefore age-appropriate interventions are most effective in helping survivors return to the previous level of functioning. For example, 4 -years-old children may best express themselves through play, whereas adolescents may best work through crisis issues in peer group discussions.

Assessment The first step of crisis intervention is assessment. At this time data about the nature of the crisis and its effect on the patient must be collected. From these data an intervention plan will be developed. People in crisis experience many symptoms, including those listed in Box 13 -2. some times these symptoms can cause further problems. Crises also can be complicated by old conflicts that resurface as a result of the current problem, making crisis resolution more difficult.

Box 13 -2 Behaviors commonly exhibited after a crisis: Anger Apathy Backaches Boredom Crying spells Diminished sexual drive Disbelief Fatigue Fear Flashbacks Forgetfulness Headaches Hopelessness helplessness Insomnia Irritability Nightmares Numbness Overeating or undereating Poor concentration Sadness School problems Self-doubt Shock Social withdrawal Substance abuse Suicidal thoughts Survivor guilt Work difficulties

Assessment >>> Although the crisis situation is the focus of the assessment, the nurse may identify more significant and long-standing problems. It is important therefore to identify which areas can be helped by crisis intervention and which problems must be referred to other sources for further treatment. During this phase the nurse begins to establish a positive working relationship with the patient. A number of balancing factors are important in the development and resolution of a crisis and should be assessed: Ø Precipitating event or stressor Ø Patient’s perception of the event or stressor Ø Nature and strength of the patient’s support systems and coping resources Ø Patient’s previous strengths and coping mechanisms

Precipitating event To help identify the precipitating event, the nurse should explore the patient’s needs, the events that threaten those needs, and the time at which symptoms appear. Four kinds of needs that have been identified are related to self-esteem, role mastery, dependency, and biological function. 1 - Self esteem is achieved when the person attains successful social role experience. 2 - Role mastery is achieved when the person attains work, sexual and family role successes. 3 - Dependency is achieved when a satisfying interdependent relationship with others is attained. 4 - Biological function is achieved when a person is safe and life is not threatened.

Precipitating event >>> The nurse determines which needs are not being met by asking the patient to reflect on issues of self-image and self esteem, the areas of life that are considered a success, one’s relationships with others, and the degree of safety and security in life. The nurse looks for obstacles that might interfere with meeting the patient’s needs. What recent experiences have been upsetting? What areas of life have had changes? Coping patterns become ineffective and symptoms appear usually after the stressful incident. As the patient connects life events with the breakdown in coping mechanisms, an understanding of the precipitating event can emerge.

Perception of the event The patient’s perception or appraisal of the precipitating event is very important. Because most crises involve losses or threats of losses, theme of loss is a common one. In assessment the nurse looks for a recent event that may be connected to an underlying theme.

Support systems and coping resources The patient’s living situation and supports in the environment must be assessed. Does the patient lives alone or with family or friends? With whom the patient close, and who offers understanding and strength? Is there a supportive clergy member or friend? Assessing the patient’s coping resources is vital in determining whether hospitalization would be more appropriate than outpatient crisis therapy. If there is a high degree of suicidal or homicidal risk along with weak outside resources, hospitalization may be a safer and more effective treatment.

Coping mechanisms Next, the nurse assesses the patient’s strengths and previous coping mechanisms. How the patient handled other crises? How were anxieties relieved? Did the patient talk out problems? Did the patient leave the usual surroundings for a period of time to think things through from another perspectives? Was physical activity used to relieve tension? Did the patient find relief in crying? Besides exploring previous coping mechanisms, the nurse also should note the absence of other possible successful mechanisms.

Planning and implementation The next step of crisis intervention is planning. The previously collected data are analyzed, and specific interventions are proposed. Dynamics underlying the present crisis are formulated from the information about the precipitating event. Alternative solutions to the problem are explored, and steps for achieving the solutions are identified. The expected outcome of nursing care is that the patient will recover from the crisis event and return to a precrisis level of functioning.

CRISIS INTERVENTION Implementation Ø Ø Ø Assess for any suicidal/ homicidal thoughts or plans. Take initial steps to make the client feel safe and lower anxiety. Safety- intervene to prevent violence- suicide/ angry, aggressive client. Listen attentively and encourage the client to discuss the crisis situation. Facilitate the verbalization of thoughts and feelings. Creative and directive approach needed. Initially nurse may make phone calls (arrange baby-sitters, find shelters, contact social workers, etc. )

CRISIS INTERVENTION Con’t Ø Ø Ø Use problem solving approach. Identify needed social support (with patient’s input) and mobilize the most needed first. Identify and work to increase needed coping skills (problem solving, relaxation, assertiveness, job training, newborn care, self-esteem). Plan with patient interventions that are acceptable to both. Evaluate plan and instruct patient with alternative plan if needed.

Crisis intervention consists of: Ø Preventing clients in crisis from harming themselves or others Ø Administering medications Ø Providing a supportive, therapeutic environment

CRISIS INTERVENTION Planning and outcome identification Ø 1. Assist the client in setting realistic goals to return to the pre-crisis level of functioning Ø 2. Establish desired outcome criteria for the client using the problem solving approach.

Nursing intervention can take place on many levels using a variety of techniques. The four levels of crisis intervention: environmental manipulation, general support, generic approach, and individual approach, represent a hierarchy from the most basic to the most complex ( Sheilds, 1975 ) Each level includes the interventions of the previous level, and the progressive order indicates that the nurse needs additional knowledge and skill for implementing high-level interventions.

5 Stages of Successful Interventions Ø Immediacy- Intervene as soon as possible. Goal is to reduce anxiety. Ø Assume Control - via providing the structure the person needs, not be overwhelming them Ø Assess the situation- let the person talk, watch for nonverbal cues, be a guide and avoid judgements and putdowns Ø Situation Management Ø Post crisis intervention

Individual approach Generic approach General support Environmental manipulation

Level of crises intervention >>> Environmental manipulation It includes interventions that directly change the patient’s physical or interpersonal situation. These interventions provide situational support or remove stress. Important elements of this intervention are mobilizing the patients supporting social systems and serving as liaison between the patient and social support agencies. General support: Includes interventions that convey the feeling that the nurse is on the patient’s side and will be a helping person. The nurse uses warmth, acceptance, empathy, caring, and reassurance to provide this type of support.

Level of crises intervention >>> Generic approach The generic approach is designed to reach high-risk individuals and large groups as quickly as possible. It applies a specific method to all people faced with a similar type of crisis. Individual approach is a type of crisis intervention similar to the diagnosis and treatment of a specific problem in a specific patient. This type of crisis intervention can be effective with all types of crises. And its also helpful when symptoms include homicidal and suicidal.

Interventions are aimed at facilitating cognitive and emotional processing of the traumatic event and at improving coping. Five core interventions to assist survivors of acute stress are as follows ( Osterman and Chemtob 1999 ): * Restore psychological safety. * Provide information. * Correct misattributions. * Restore and support effective coping. * Ensure social support.

Techniques The nurse should be creative and flexible, trying many different techniques. These should be active, focused, and explorative techniques that can facilitate achieving the targeted interventions. Some of these include catharsis, clarification, suggestion, reinforcement of behavior, support of defenses, raising self-esteem, and exploration of solutions. The crisis worker must take an active directive role and maintain flexibility of approach. If more complex problems are identified that are not suitable for crisis intervention, the patient should be referred for further treatment.

Evaluation The last phase of crisis intervention is evaluation, when the nurse and patient evaluate whether the intervention resulted in a positive resolution of crisis. Specific questions the nurse might ask include the following: Ø Has the expected outcome been achieved, and has patient returned to the precrisis level of functioning? Ø Have the needs of the patient that were threatened by the event been met? Ø Have the patient’s symptoms decreased or been resolved. Ø Is the patient using constructive coping mechanisms? Ø Does the patient need to be referral for additional treatment? Ø Does the patient have adequate support system and coping recourses on which to rely?

Settings for crisis intervention Nurses work in many settings in which they see people in crisis. Hospitalization are often stressful for patients and their families and are precipitating causes of crises. Emergency room and critical care settings also are flooded with crisis cases. People who attempt suicide, psychosomatic patients, survivors of sudden cardiac arrest, and crime and accident victims are all possible candidates for crisis interventions. Community and home health nurses work with patients in their own environments and can often spot and intervene in family crises. Crisis intervention can be implemented in any setting and should be competency skill of all nurses, regardless of specialty area.

Modalities of crisis intervention Mobile crisis programs Mobile crisis teams provide front-line interdisciplinary crisis intervention to individuals, families, and communities. Group work Crisis groups follow the same steps that individual intervention follows. The nurse and group help the patient solve the problem and reinforce the patient’s new problem-solving behavior.

Telephone contacts Crisis intervention is sometimes practiced by telephone or internet communication rather than through face-to-face contacts. When individuals in crisis use the telephone or internet, its usually at the peak of their distress. Nurses working for these types of hotlines or those who answer emergency telephone calls or electronic mail may find themselves practicing crisis intervention without having visual cues to relay on. Disaster response As part of the community, nurses are called on when situational crises strike the community. Floods, earthquakes, airplane crashes, fires, nuclear accidents, and other natural or unnatural disasters precipitate large number of crises. Experts in the field of disaster response suggest that organized plans for crisis response be developed and practiced during nondisaster times.

Health education Although health education can take place during the entire crisis intervention process, it is emphasized during the evaluation phase. At this time the patient’s anxiety has decreased, so better use can be made of cognitive abilities. The nurse and patient summarize the course of the crisis, and the intervention is to teach the patient how to avoid other similar crises.

Summary: Ø A crisis is a disturbance resulting from a perceived threat that challenges the person's usual coping mechanisms. Crises are a time of increased vulnerability, but they can also stimulate growth. There are two types of crises: maturational and situational. Ø Crisis intervention is a brief, active therapy with the goal of returning the individual to a precrisis level of functioning