Question

Compare nursing interventions for crises, bereavement, and disasters. What are the similarities? What are the differences?

Answer 1

Crisis Characteristics

A 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. It 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.

Crisis Responses

After the precipitating event, the person’s anxiety begins to rise, and three phases of a crisis response emerge:

1. The anxiety activates the person’s usual methods of coping. If these do not bring relief, anxiety increases because coping mechanisms have failed.

2. 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.

3. The continuation of severe or panic levels of anxiety may lead to psychological disorganization.

In describing the phases of a crisis, it is important to consider the balancing factors shown in Figure 13-1. These include the individual’s perception of the event, situational supports, and coping mechanisms. 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

ctors are similar to the elements of the Stuart Stress Adaptation Model used in this textbook and described in Chapter 3. However crises are self-limiting. People in crisis are too upset to function at such a high level of anxiety indefinitely. The time needed to resolve the crisis, whether it is a positive solution or a state of disorganization, may be 6 weeks or longer.

It also is important to recognize that periods of intense conflict ultimately can result in increased growth. It is how the crisis is handled that 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.

Types of Crises

The two types of crises are maturational and situational. Sometimes these crises can occur simultaneously. For example, an adolescent who is having difficulty adjusting to a change in role and body image (maturational crisis) may at the same time undergo the stress related to the death of a parent (situational crisis).

Maturational Crises

Maturational crises are developmental events requiring role changes. Transitional periods during adolescence, parenthood, marriage, midlife, and retirement are key times for the onset of maturational crises. For example, successfully moving from early childhood to middle childhood requires the child to become socially involved with people outside the family. With the move from adolescence to adulthood, financial responsibility is expected. Both social and biological pressures to change can precipitate a crisis.

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. Some conflicts related to maturational crises are seen in the clinical examples that follow.

Disaster intervention

CHARACTERISTICS OF DISASTERS

• Intensity of the impact: Disasters that result in intense destruction within a short period of time are more likely to cause emotional distress among survivors than are disasters that spread their impact over a longer period of time.

• Impact ratio (i.e., the proportion of the community sustaining personal losses): When a disaster affects a significant proportion of a community’s population, few individuals may be available to provide material and emotional support to survivors.

• Potential for recurrence of other hazards: The real or perceived threat of recurrence of the disaster or of associated hazards can lead to anxiety and heightened stress among survivors.

• Cultural and symbolic aspects: Changes in survivors’ social and cultural lives and routine activities can be profoundly disturbing. Both natural and human-caused disasters can have symbolic implications.

• Extent and types of loss sustained by survivors: Property damage or loss, deaths of loved ones, injury, and job loss all affect emotional recovery.

Disaster responses usually occur in seven phases. These are described in Table 13-1. Individuals and communities progress through these phases at different rates depending on the type of disaster and the degree and nature of disaster exposure. This progression may not be sequential, because each person and each community is unique in the recovery process. Individual variables such as psychological resilience, social support, and financial resources influence a survivor’s capacity to move through the phases.

TABLE 13-1

PHASES OF DISASTER RESPONSE

PHASERESPONSE

Warning or threat phaseDisasters vary in the amount of warning communities receive before they occur from little or no warning to hours or even days of warning. When no warning is given, survivors may feel more vulnerable, unsafe, and fearful of future unpredicted tragedies.

Impact phaseThe impact period of a disaster can vary from the slow, low-threat build-up associated with some types of floods to the violent, dangerous, and destructive outcomes associated with tornadoes and explosions. The greater the scope, community destruction, and personal losses associated with the disaster, the greater the psychosocial effects.

Rescue or heroic phaseIn the immediate aftermath, survival, rescuing others, and promoting safety are priorities. For some, postimpact disorientation gives way to adrenaline-induced rescue behavior to save lives and protect property. Although activity level may be high, actual productivity is often low. Altruism is prominent among both survivors and emergency responders.

Remedy or honeymoon phaseDuring the week to months following a disaster, formal governmental and volunteer assistance may be readily available. Community bonding occurs as a result of sharing the catastrophic experience and the giving and receiving of community support. Survivors may experience a short-lived sense of optimism that the help they will receive will make them whole again. When disaster mental health workers are visible and perceived as helpful during this phase, they are more readily accepted and have a foundation from which to provide assistance in the difficult phases ahead.

Inventory phaseOver time, survivors begin to recognize the limits of available disaster assistance. They become physically exhausted because of enormous multiple demands, financial pressures, and the stress of relocation or living in a damaged home. The unrealistic optimism initially experienced can give way to discouragement and fatigue.

Disillusionment phaseAs disaster assistance agencies and volunteer groups begin to pull out, survivors may feel abandoned and resentful. The reality of losses and the limits and terms of the available assistance become apparent. Survivors calculate the gap between the assistance they have received and what they will require to regain their former living conditions and lifestyle. Stressors abound—family discord, financial losses, bureaucratic hassles, time constraints, home reconstruction, relocation, and lack of recreation or leisure time. Health problems and exacerbations of preexisting conditions emerge because of ongoing, unrelenting stress and fatigue.

Reconstruction or recovery phaseThe reconstruction of physical property and recovery of emotional well-being may continue for years following the disaster. Survivors have realized that they will need to solve the problems of rebuilding their own homes, businesses, and lives largely by themselves and gradually assume the responsibility for doing so. Survivors are faced with the need to readjust to and integrate new surroundings as they continue to grieve losses. Emotional resources within the family may be exhausted and social support from friends and family may be worn thin.When people come to see meaning, personal growth, and opportunity from their disaster experience despite their losses and pain, they are well on the road to recovery. Although disasters may cause profound life-changing losses,they also bring the opportunity to recognize personal strengths and toreexamine life priorities.