The importance of the stress concept has been increasing in behavioral and health sciences in the last six decades. Initially, stress was a term used in physics to describe how manmade structures can be designed to carry heavy loads and resist distortion by external focus (Eberhart & Hammen, 2009). The term stress was later adopted for usage in behavioral sciences to refer to any processes in the body that are facilitated by situations that put physical or psychological demands on an individual (Eberhart & Hammen, 2009).
Several theories have been formulated to link stressors and the resulting stress. These theories can be described under two broad categories based on the approach. The first group describes systemic stress based on physiology and psychobiology and the second group describes stress as a development within the field of cognitive psychology (Hammen, 2008).
Systemic stress description is best captured by Selye’s theory which was put forward by endocrinologist Hans Selye (Monroe & Reid, 2009). After conducting several experiments on animals Selye established that various stimuli such as heat and cold can elicit similar effects when intensely applied. According to Selye, stress can be identified as the syndrome that comes with all the nonspecifically induced changes in the biological system (Hammen, 2008).
In psychological terms, stress can be described best using the Lazarus Theory. According to the theory, stress results due to appraisal and coping; evaluation of the magnitude of various things that are happening for an individual’s well being and the individual’s effort to manage the specific demands (Eberhart & Hammen, 2009). Therefore psychological stress can be defined as the relationship with the environment that an individual appraises as significant for his or her well being and in which the environmental demands exceed the coping mechanisms (Monroe & Reid, 2009).
This paper seeks to appraise the stress concept by identifying two articles and three research papers that relate to stress and using them to: review the concept; identify the defining characteristics; create definitions based on the characteristics, and critique one instrument used in the research articles. The relevance of the stress concept for Advanced Practice Nursing will also be discussed and a summary of the findings given.
The stress concept was selected for analysis due to its rising importance in nursing and the larger medical field. The variability in the ability to cope with stress and the widespread damage it can cause makes it an important concept that calls for closer analysis.
Review of literature
According to Elser, Schwarz, & Alvarenga, there is recently established evidence linking psychiatric illness and mental stress to the development of cardiovascular disease (2008). There has been a lot of opposition to such findings in the past mainly due to a lack of consensus on what comprises stress and how it can be quantified (Elser, Schwarz, & Alvarenga, 2008). According to the researchers, an acute episode of mental stress can lead to the development of unusual heart rhythm and sudden death in a patient with already established heart disease (Elser, Schwarz, & Alvarenga, 2008).
Epidemiological studies that suggest a higher risk of myocardial infarction and death in patients with panic disorder have been cited in the article. In these patients, the sympathetic nervous system is activated during panic attacks precipitating a series of events that result in heart attack and death. According to Elser, Schwarz, & Alvarenga, chronic mental stress plays a role in the development of hypertension; psychologically described as agitated behavior (2008). The paper also cites studies that link the depressive disorder to the development of CHD.
The article concludes by identifying workplace experience as the major cause of stress in the contemporary world and suggests the implementation of measures to reverse this trend. This work provides a strong theoretical explanation of the relationship between stress and heart diseases but it does not provide sufficient data from empirical studies to support the claim. According to the article, the characteristics of stress include panic, agitation, hypertension and changes in heart rhythm.
Another article done by Khoozani & Hadzic utilizes an ontological framework to unify, analyze, combine and generate new knowledge on human stress (2010). The authors define the stress concept in psychology as “organisms adaptive physiological, cognitive and behavioral responses to challenging, harmful conditions” (Khoozani & Hadzic, 2008, p. 258). The authors however agree that there is no universally accepted definition of human stress.
The article cites the difficulty associated with the retrieval of specific information from the numerous independent and dispersed electronic journals (Eberhart & Hammen, 2009). Thus the generated human stress ontology (HSO) aims at presenting a “comprehensive, coherent and, and machine-readable knowledge model of human stress concepts and their relationships” (Khoozani & Hadzic, 2008, p. 261). The ontology characterizes human stress into five sub-anthologies: the causes; mediators, effects, treatments; and measurements (Khoozani & Hadzic, 2010).
The causes of stress are classified into three categories concerning relativity (psychological or Biogenic), objectivity (objective or subjective), and duration (acute or chronic); human stress mediators are classified under psychological, Neurophysiologic and situational sub-groups; effects are subcategorized into stress-related disorders, Neurophysiological alterations, cognition alterations, emotion alterations, memory and learning alterations, attention alterations, and effects on interpersonal relationships; treatments for stress are grouped into those that fall under psychotherapy, pharmacotherapy, physiological techniques and alternative therapies; stress measurements include measurement of the stressors, measurement of the stress feelings, and measurement of the stress physiology (Khoozani & Hadzic, 2010).
The article, therefore, provides a framework that can be used to locate specific information concerning human stress. It includes leads to most of the electronically available data on human stress and does not align itself to specific characteristics of the stress concept.
The primary objective of the article was to come up with an ontological framework that can be used to optimize search engine retrieval of electronic information on human stress, and not characterization. A closer analysis of the article shows that stressful conditions can fall under different sub-categories of the same ontological classification and therefore create some ambiguity. Thus, there is a need for a universally accepted definition of the stress concept to guide the development of a proper ontological framework for not only search engine optimization but also classification and characterization of human stress (Eberhart & Hammen, 2009).
A study was carried out by Karademas, Karamvakalis and Zarogiannos in 2008 to determine the relationship of life stress with illness and coping mechanisms. The “purpose of the study was to examine the relationship between life stress, and the illness perceptions and coping aspects of the chronic illness experience” (Karademas, Karamvakalis, & Zarogiannos, 2008, p. 405).
The researchers identified stress as a major part of an individual’s life that influences nearly all aspects of functioning, including health and illness (Karademas, Karamvakalis, & Zarogiannos, 2008). The study cites available evidence that shows how stressful conditions play a role in the development of chronic diseases. The researcher’s main concern was to identify the particular association between stress that results from life context and the ways a patient experiences medical illness (Karademas, Karamvakalis, & Zarogiannos, 2008).
The first hypothesis was that “illness perceptions and coping strategies are associated with stress experienced by patients in other domains of their life” (Karademas, Karamvakalis, & Zarogiannos, 2008, p. 406). The second hypothesis was that “life stress is associated with the perceptions of illness and coping, even after the demographic variables and the restrictions caused by poor health are controlled, both of which are seen to have a major effect on the experience of illness” (Karademas, Karamvakalis, & Zarogiannos, 2008, p. 406).
The study was conducted on a total of 101 outpatients who visited a general hospital on scheduled appointments. The sample was composed of 38 males and 63 females both of whom had a mean age of 51.10 years (Karademas, Karamvakalis, & Zarogiannos, 2008). Patients of 70 years and above and those with communication difficulties were excluded from the study. Most of the sampled patients were suffering from cardiovascular disease (36.6%), 13% were suffering from chronic pain, 12% chronic respiratory problems, 10% from arthritis, 7% suffering from hormonal problems while 5% reported diabetes (Karademas, Karamvakalis, & Zarogiannos, 2008).
The researchers used questionnaires to investigate the different measures. Coping strategies were investigated by a specifically designed five-factor questionnaire. The five factors correspond to measures employed to cope with the problem and included information seeking, adherence to medical advice, palliative coping, wishful thinking and emotional reactions (Karademas, Karamvakalis, & Zarogiannos, 2008). The participants were required to respond concerning their illness.
Illness related perceptions were measured using the Brief Illness Perception Questionnaire based on the revised IPQ. The questionnaire has eight items and measures perceptions using a continuous scale beginning from 0 to 10. The scale consists of eight items that investigate the consequences, timeline, personal control, treatment control, identity, illness comprehensibility, concern and emotions (Karademas, Karamvakalis, & Zarogiannos, 2008). Life stress was measured using a scale based on the Life Stressors and Social Resources Inventory (Karademas, Karamvakalis, & Zarogiannos, 2008). The questionnaire used required participants to rate the degree of stress they had experienced in the recent past in seven domains. Illness-related restrictions were investigated using the EQ-5D measure that investigates the quality of life-based on health.
The results of the study were as follows: Regarding illness-related restrictions 34.7 reported problems with mobility, 7.9% had some problems with self-care, 32.7% had problems with usual care a 68% reported some severe pain (Karademas, Karamvakalis, & Zarogiannos, 2008).
According to this study, the stress in the broader life context is usually characterized by the development of several different diseases. The intensity of the stress involved depends on how a patient can strike a balance between illness perceptions and cope.
A study was carried out by Johanson, Youn & Woods to compare the stress levels of general hotel managers between 1998 and 2008. According to the researchers, existing research evidence shows that hospitality managers go through demands that make them experience higher stress levels that can affect their emotional health (Johanson, Youn, & Woods, 2010). Several studies have linked work related stress with reduced job satisfaction, lower organizational commitment, and increased turnover (Johanson, Youn, & Woods, 2010).
The purposes of the study were: to establish the current levels of stress among hotel managers in the US; to determine if the stress levels experienced currently are higher or lower than those experienced 10 to 20 years ago; to determine the most prevalent stressors today; and to determine if the stressors have changed over the past 20 years (Johanson, Youn, & Woods, 2010). The researchers hypothesized that currently, hotel managers experience more stress than they did 20 years ago and the stressors have also changed over the years.
A total of 407 randomly selected managers working in the US lodging industry were invited to take part in the study. Each of the managers was sent an enclosed SRRS to complete voluntarily. Up to 211 participants (52%) returned usable surveys to the researchers. The SRRS measurement instrument used assigns stress values to each of the 43 life events found on the scale. The values were established through repeated studies that established the link between life changes and illness (Monroe & Reid, 2009). One of the limitations of the SRRS tool is that it establishes the level of stress without taking into account the mitigation measures taken by the individual in question (Johanson, Youn, & Woods, 2010).
In a comparison of the 2008 results with those of a similar study carried out 10 years earlier, it was established that hotel managers experience more stress today. However, the results showed that the more frequently experienced stressors were family related rather than work-related. However, overall, the work related stress impacted more on an individual’s social life increases the chances of stress related illness.
A study was carried out by Uliaszek et.al to compare two competing theories of stress generation model of depression (stress causation vs. stress continuation) using interview based measures of episodic life stress, as well interpersonal and non-interpersonal chronic life stress ( 2012). The researchers cited evidence in other previous studies that showed a role played by chronic life stress in the onset of depression. Regarding the stress causation theory, “the characteristics of a depressed person are thought to play a causal role in generating stress over time” (Uliaszfek, et al., 2012, p. 5). Whereas the “stress continuation theory asserts that the prospective relationship between depression and stress is accounted for by the continuity of stress over time” (Uliaszek, et al., 2012, p. 5). Research on stress generation has shown that people who have gone through depression in the past will experience an elevated level of interpersonal life stress as compared to those who have never experienced depression.
The purpose of this study was to expand on the stress generation studies by assessing both interpersonal and non-interpersonal chronic life stress as well as the dependent episodic life stress (Uliaszek, et al., 2012).
The participants were drawn from the Youth Emotion Project and a total of 627 participants in their late adolescents have recruited for time one and two assessment. The participants were required to meet criteria to ascertain the presence of a clinically significant distress/impairment (Uliaszek, et al., 2012). Structured Clinical Interviews for the Diagnostic and Statistical Manual for Mental Disorders-IV (DSM)-IV (SCID) was used by the researchers to diagnose Axis I disorders, whereas life stress was evaluated using the Life stress interview (LSI) (Uliaszek, et al., 2012). Extraversion and neuroticism were used using a 9 point Likert scale ranging from extremely inaccurate to extremely accurate (Hammen, 2008).
The study was carried out after regular school hours whereby interviews were conducted followed by questionnaires on several occasions. Neuroticism was screened using the Eysenck Personality Questionnaire (Uliaszek, et al., 2012). The results of the study showed that there is evidence that interpersonal and non-interpersonal chronic life stress continuation in both depressive and anxiety disorders (Uliaszek, et al., 2012).
The literature reviewed indicates that the stress concept has varied characteristics that can be classified depending on the nature of the stressor and the effects that occur with varying degrees and magnitude of the resultant stress. Stress can be classified as short term or long term depending on the duration of a given stressful episode (Hammen, 2008). Stress can also be classified as dependent or independent depending on an individual’s ability to control it (Monroe & Reid, 2009). Independent stress results from events that are beyond an individual’s control while dependent stress occurs, at least in part, as a result of the individual’s actions (Karademas, Karamvakalis, & Zarogiannos, 2008).
Stress concept can also be characterized as interpersonal or non-interpersonal. Interpersonal stress results due to difficulties with family, peers, or significant others while no interpersonal stress refers to stress for conditions that occur due to educational, occupational and health related stress (Khoozani & Hadzic, 2010). Stress as a concept is identified as a major part of an individual’s life that affects nearly all aspects of functioning and can be described in both biogenic and psychological terms (Karademas, Karamvakalis, & Zarogiannos, 2008). Many health problems such as heart diseases, pain and depression have been shown to directly result or exacerbate due to stress.
Definitions of the stress concept
There is no universally agreed upon definition of the stress concept. The reviewed articles and research papers only give contextual definitions that pertain to the specific area explored. However what is coming out in all the reviewed literature is that there must be a stressor that should be perceived to be averse and in control of the individual in question and there should be physiological, cognitive and behavioral responses (Khoozani & Hadzic, 2010). Therefore the stress concept can be defined as an individual’s adaptive physiological, cognitive and behavioral responses to an aversive condition (Khoozani & Hadzic, 2010, p. 258).
Instrument Critique & Application
The study carried out to compare stress levels among hotel general managers between 1998 and 2008 was measured using the Social Readjustment Rating Scale (SRRS) (Johanson, Youn, & Woods, 2010). The stress measurement instrument is administered in form of a questionnaire to determine the impact of up to 43 commonly known stressors such as marriage, occupation and death of a close relative among others (Hammen, 2008). Values are given to each stressor based on data from several research studies supporting the apparent connection between life events and the amount of stress it causes in a given population (Johanson, Youn, & Woods, 2010). The instrument is straightforward to use and is applied to both genders. The instrument has been “validated in Japanese, European, Latin American, and Malaysian populations” (Elser, Schwarz, & Alvarenga, 2008, p. 4).
Relevance of stress concept for Advanced Practice Nursing
The Advanced Practice Nurse (APN) is a health care provider who offers health in a variety of clinical settings. Just like any other worker, the APN is vulnerable to the stressful conditions that accompany occupational responsibilities. However, to the APN, the stress concept is of paramount importance as it has the potential to affect him/her and the client (patient) simultaneously (Monroe & Reid, 2009).
The APN working in psychiatric or clinical psychologists settings has the responsibility to control stress both themselves and in the patient (Eberhart & Hammen, 2009). In advanced practice nursing, the stress concept requires extremely good management techniques for best results.
Stress concept is of particular importance due to its commonness and the lack of personal control over a wide range of its causes, even when one is bestowed with the knowledge and the responsibility to control it in others.
The knowledge of sources of stress and specific stress management techniques is imperative for a practicing APN. Patient history is vital as individuals who have been diagnosed with mental disorders such as bipolar disorder and depression are much more vulnerable (Hammen, 2008). Social factors also play an important role in the vulnerability to stress. Health professionals such as APNs should screen patients for past predisposing factors, provide education on stress management and help patients in exploring the different ways they can overcome the stressful episodes (Monroe & Reid, 2009).
It’s important to note that people get stressed when it becomes apparent that they cannot control a harmful or bad situation. The knowledge of physiological and psychological mechanisms of stress build up is vital in the prevention of other complications that may occur due to stress. For instance, the body will physiologically react in a similar way to a variety of psychological and physical threats irrespective of their intensity or perceived importance (Hammen, 2008).
The importance of the stress concept in health and behavioral sciences has been growing steadily as more and more evidence is revealed on the extent of its influence on human life (Eberhart & Hammen, 2009). Many activities in life can cause stress buildup and this partly depends on individual perception. Several theories have been formulated to try and establish a connection between causal factors and the resulting stress and the effects. Stress has been extensively described in physiological and psychological terms but there is still no universally agreed-upon definition of the term.
Several studies have linked stressful conditions with the development of various diseases. There is probable evidence that mental stress plays a role in the development of cardiovascular diseases and other chronic illnesses (Elser, Schwarz, & Alvarenga, 2008). Information on the stress concept is widely dispersed in various independent databases and this calls for a need to develop an ontology that will optimize search engine retrieval of health related information. Stress can be classified as short term or long term, dependent or independent, and interpersonal or non-interpersonal. Stress is most commonly investigated using the SRRS measurement instrument (Monroe & Reid, 2009). The APN should look at stress as an important concept that calls for attention, especially regarding the detection and control of stress buildups both in self and patients.
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