Stress: The Risk Factors, Physiological Implications, and the Techniques to Reduce it

INTRODUCTION

Stress is something that affects each person, but it is also unique to each individual. One event can be stressful for one person, but not elicit emotions for another. This, along with many other factors, makes stress a problematic word to describe. Stress can be defined as either a stimulus, such as a threatening situation, or a response. Someone who views stress as a stimulus believes that stress is an unpleasant event; however, someone who assumes that stress is a response would view stress as the physical, emotional, or mental strain or tension that accompanies a situation. While there is confusion behind the definition of stress, scientists and health professionals do agree “that stressors are the threatening stimuli that trigger coping adjustments in a person, and that stress is the process by which a person both appraises and responds to events that are judged to be challenging or threatening” (Straub 2019).

Hans Selye was the scientist that discovered the stress response in 1934. Selye was an endocrinologist that worked with ovary extract in hopes of identifying a new hormone. Selye set up an experiment in which he gave daily injections of the extract to laboratory rats and recorded changes in their behavior and health. After several months of the experiment, he discovered that the rats had developed bleeding ulcers, shrunken thymus glands, and enlarged adrenal glands. At first, Selye was excited because he believed he discovered the physiological effects that were the result of the ovary extract. However, he examined the situation more carefully and reworked the experiment with a control group that was given saline injections. He noticed that at the end of the new experiment, both the control rats and the rats that were given ovary extract had the same symptoms: bleeding ulcers, enlarged adrenal glands, and shrunken thymus glands. Selye discovered that this is because the rats were stressed out and experiencing the stress response. This led Selye to develop his general adaptation syndrome that is still implemented today

(Straub 2019). Selye’s discovery of the stress response and the general adaptation syndrome sparked new research efforts that explore the risk factors of stress, physiological implications of stress, stress-reducing techniques, and many more issues.

RISK FACTORS

Multiple risk factors contribute to a person’s susceptibility to stress like a predisposing genetic factor, certain personality traits, environmental factors, varying levels of general self-efficacy, a person’s socioeconomic status. Researchers from the University of Illinois at Urbana- Champaign examined how genetics and the environment affect the Big Five personality traits and perceived stress, both concurrently and longitudinally. They examined and used two different twin studies for their statistical analysis. Study 1 was from the National Longitudinal Study of Adolescent to Adult Health, and the second study was a twin study from the Midlife in the United States Survey. Study 1 showed that around 70% of the association found between the Big Five personality traits and perceived stress was because of genetic influences. The second study showed that genetic influences are related to the continuity in perceived stress, while nonshared environmental influences were associated with changes in perceived stress. The study goes on to state that “the genetic components in conscientiousness and neuroticism made substantial contributions to the genetic link between personality traits and perceived stress across both studies” (Lue et al. 2017). This study clearly shows that genetics, environment, and personality traits play a role in a person’s vulnerability to stress.

Similarly, another study published by the BMC investigated the effects of general self-efficacy, an individual’s belief in his or her ability to execute a specific task, on the effects of stress. This study was a cross-sectional survey that used over 800 nurses in China and investigated the relationship between general self-efficacy and stress while looking at job-related burnout. The study showed that stress was the most important factor when it comes to job-related burnout and that individuals who had low general self-efficacy and either the personality type of introversion or high neuroticism had stronger burnout when they faced stressful situations compared to counterparts. Most importantly, the study concluded that general self-efficacy moderates stress in burnout nurses who had the personality type of extroversion or neuroticism. The study proves that having general self-efficacy can affect how a person handles stress, along with providing further evidence that personality types do affect how predisposed a person is to stress (Yao et al. 2018).

Along the lines of the previously mentioned studies, an article published by the Journal of Urban Health explored how pregnancy and postpartum quality of life of adolescents and young mothers living in urban areas are affected by urban social stress and violence, both are which environmental factors. The study is a secondary data analysis of a previous prospective cohort study of almost 300 expectant young mothers that were recruited at OBGYN clinics. The results of the study state that higher urban social stress, due to factors like stressful life events, discrimination, family stress, and neighborhood problems, predicted lower mental and physical quality of life during pregnancy. This mental and physical degradation is a sign that the adolescences and young mothers are experiencing stressful events that could be due to the environmental factors that they live in (Willie et al. 2016).

Furthermore, a study published in the Psychophysiological journal investigated the relationship between socioeconomic status and hemodynamic recovery from mental stress. The study included 200 men and women that were separated into higher, intermediate and lower socioeconomic status groups. The participants’ blood pressure and hemodynamic properties were measured throughout the study. The study states that blood pressure increased during two stressful behavior tasks through the increase in cardiac index and total peripheral resistance. After a 45-minute post-task recovery period, participants’ cardiac index fell below the baseline levels; however, peripheral resistance remained elevated. Interestingly, during the recovery period, peripheral resistance changes varied among individuals with various socioeconomic statuses. Specifically, there were higher levels of total peripheral resistance in reactive low-status participants. The study states that the results are consistent with the thought that disturbances of stress-related autonomic processes, like blood pressure, peripheral resistance, and cardiac index, are related to socioeconomic status, showing that a low socioeconomic status can be a risk factor for a person’s predisposition to stress (Steptoe et al. 2003). These four studies show that various factors play a role in how susceptible a person is to stress. If one or more of these factors lead a person to exhibit an abnormally large amount of stress, there are physiological implications that will affect that person.

PHYSIOLOGICAL IMPLICATIONS OF STRESS

Stress affects the body in a multitude of ways. For example, stress has adverse effects on cardiovascular disease, the metabolic syndrome, and sleep, while having varying effects on the immune system. A study published in the Stress and Health journal examined the connection between psychological stress and cardiovascular disease risk factors that include blood pressure, blood lipids, and obesity. The study showed that perceived stress significantly affects male’s diastolic blood pressure, total cholesterol, and the ratio of total cholesterol and high-density lipoprotein (HDL) cholesterol. Likewise, but not completely similar, psychological stress affected women’s low-density lipoprotein (LDL) cholesterol, total cholesterol/HDL ratio, body mass index, waist circumference, and waist-hip ratio. While the two genders have slightly different results, the study states that they both work together to prove that perceived stress is an independent factor that affects cardiovascular disease risk factors, even after controlling for other significant life-style related predictors (Sarkar and Mukhopadhyay 2008).

Likewise, a prospective study examined the relationship between work stres and the metabolic syndrome, a cluster of symptoms that include “abdominal obesity, atherogenic dyslipidemia (raised triglycerides, small low density lipoprotein particles, and low concentrations of high density lipoprotein cholesterol), high blood pressure, insulin resistance (with or without glucose intolerance) and prothrombotic and proinflammatory states)” (Chandola 2006). These clusters of symptoms that make up the metabolic syndrome increases a person risk of heart disease and type 2 diabetes. This study followed over 10,000 men and women from London. The study found a dose-response relationship that is independent of other related risk factors between exposure to work stress and the risk of metabolic syndrome. The study states that employees who have chronic work stress were twice as likely to have the metabolic syndrome than those who did not experience work stress. This study shows, once again, that stress is related to an increased risk of damaging health effects that can lead to diseases like heart disease and type 2 diabetes (Chandola 2006).

Furthermore, a systematic review examined the effects of stress on sleep through the use of polysomnographic measures, which records brain waves, oxygen levels in the brain, heart rate, and breathing. The study showed that experimental stresses resulted in a decrease in slow-wave sleep, REM sleep, and sleep efficiency, while stress was also shown to be associated with an increasing number of awakenings. The implication of this study is not just sleep itself, but also on memory. Both slow-wave sleep and REM sleep are associated with memory consolidation and learning. While the majority of the study was limited to experimental stressors, the effects of post-traumatic stress disorder (PTSD) were explored. The study states that are multiple reports that suggest that PTSD patients have an increased number of awakenings and a decrease in sleep efficiency, which is the percentage of time spent asleep while in bed. The study shows that whether a person has a psychological disorder like PTSD or not, stress is detrimental to their sleep (Kim and Dimsdale 2007).

In continuation, stress also has effects on the immune system; however, its effects are not as clear cut as its effects on cardiovascular disease, the metabolic syndrome, and sleep. Stress’s effect on the immune system is dependent upon what type of stress it is, either if it is acute or chronic. A meta-analysis of more than 300 empirical articles investigated the relationship between psychological stress and the immune system. The study states that acute stress was associated with an increase in the number of natural killer cells and large granular lymphocytes, both of which show an upregulation of natural immunity; however, acute stress is associated with a downregulation of some functions of specific immunity. Next, brief naturalist stressors, such as a participant being given an exam, showed to be associated with suppression of cellular immunity while having preservation of humoral immunity, both of which are divisions of the immune system. Finally, the study stated that chronic stressors were associated with the suppression of both the cellular and humoral immunity. While the study shows that the acute and brief naturalist stressors have mixed effects on the two divisions of the immune system, the study clearly shows that chronic stress has a detrimental effect on both divisions of the immune system, weakening a person’s ability to fight diseases (Segerstrom and Miller 2004).  These four studies show that stress is detrimental to people’s health and that scientist and health professionals need to find stress-reducing techniques.

STRESS-REDUCING TECHNIQUES

As mentioned previously, stress has negative effects on people’s health and there are predisposing factors that affect how likely were to experience it. Fortunately, health professionals and scientists have discovered multiple techniques that reduce stress in individuals. Examples of stress-reducing techniques include the implementation of social support, the use of mindfulness-based stress reduction therapy, the utilization of neurofeedback training, and the practice of diaphragmatic breathing techniques. A research team in Turkey investigated the relationship between social support and coping with stress in women who were being treated for breast cancer through the use of a descriptive and cross-sectional study with 100 women at a training and research hospital. The data was collected through an information form that covered sociodemographic and disease characteristics, the Scale of Ways of Coping with Stress, and the Multidimensional Scale of Perceived Social Support. The researchers discovered that people who were primary school graduates and who did not undergo surgery had a significantly lower ability to cope with stress. They also found a negative correlation between the women’s ability to cope with stress and age; however, they found a positive correlation between women’s ability to cope with stress and their perceived social support from their family, as well as the total score of perceived social support. This study clearly shows that if a person believes that they have social support, then they can cope with stress more effectively than someone who lacks social support. (Ozdemir and Arslan 2018).

In addition to this research, another study tested the effectiveness of mindfulness-based stress reduction (MBSR) on depression, anxiety, and psychological distress, which are associated with symptoms of stress, in people who are affected by different chronic somatic diseases. MBSR is a treatment for psychological distress, depressive symptoms, and anxiety that focuses on the practice of mindfulness, which is the skill to “non-judgmentally observe emotions, sensations, or cognitions” (Bohlmeijer et al. 2010). This study created a systematic review and meta-analysis of eight published, randomized controlled outcome studies that focused on MBSR. The meta-analysis showed that MBSR had a small effect on depression, .26, anxiety, .47, and psychological distress, .32; however, when lower quality studies were excluded, a .24 effect size on anxiety was found. Regardless of the decrease in correlation due to exclusions of some studies, the study did conclude that MBSR does have a small effect on depression, anxiety, and psychological distress in people who have chronic somatic diseases (Bohlmeijer et al. 2010).

Furthermore, a randomized controlled trial was produced to examine the effects of neurofeedback training on stress relief among financial employees. Neurofeedback training is a biofeedback technique that allows a person to modulate their brain rhythms. The thought behind neurofeedback training is if the person can detect changes through the use of electroencephalography (EEG), then they can recognize the brain patterns that are associated with stress and change their thought process to change the brain waves, therefore, reducing their stress. After a period of training on how to utilize the neurofeedback technique, the study stated that the participants were able to change certain brain patterns, proving the neurofeedback worked. This study proved that neurofeedback is an effective way to improve factors that contribute to work stress like work ethic, attention, memory, efficiency, and work execution (Liu and Cha 2018).

Finally, the breathing practice that is known as diaphragmatic breathing has been proven to help reduce stress. Diaphragmatic breathing is the process through which a person focuses on contracting the diaphragm and expanding the belly in order to breathe deeper and control their respiration rate, which is believed to reduce stress. In a study published by the frontiers of Psychology, researchers set up a randomized controlled trial to explore the effects of diaphragmatic breathing. Forty participants were either assigned to be in the breathing intervention group, which were trained over 20 sessions on how to practice diaphragmatic breathing, or the control group. The results showed that there was a significant relationship between diaphragmatic breathing and cortisol levels, the hormone that is associated with stress. The participants that were trained in diaphragmatic breathing technique had significantly lower cortisol levels after their training session, showing that diaphragmatic breathing is effective in reducing levels of cortisol (Ma et al. 2017). These four studies show that while stress is detrimental to a person’s health, there are ways to reduce the stress levels a person has.

CONCLUSION

While defining stress is a difficult task for scientists to agree upon, scientists can agree that stress has specific risk factors, physiological implications, and ways to be reduced. Stress risk factors include genetics, personality types, environment, socioeconomic status, and general self-efficacy. If one or more of these risk factors leads a person to have a detrimental amount of stress, the person can have harmful physiological implications like an increased risk of cardiovascular disease and the metabolic syndrome, while also suffering from the effects of a lower immune system and lack of quality sleep. While people may be predisposed to stress and feel the harmful effects of stress, there are proven ways to reduce this stress. Studies have shown that social support, MBSR, neurofeedback, and diaphragmatic breathing all can help reduce perceived levels of stress. With stress being such a universal concern and having wide-spread health implications, more research is needed to determine how to prevent it and treat it even better.

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Reducing the incidences of malnutrition that often occurs during admission to hospital has been a priority within the nursing care profession for many years. There have been various explanations for this such as lack of staff, patients not able or are unwilling to admit they require assistance, poor use of assessment tools and care pathways. A key factor in the prevalence of patients presenting with malnourishment is the disturbances patient’s endure during mealtimes, such as ward rounds, non urgent medical interventions, housekeeping activities and visitors. This essay will explore the incidences of malnutrition, and those who are most at risk and the changes that have been made to reduce such incidences.

Change management should be regarded as an ongoing process, which requires good communication, planning, positive leadership and cooperation. This essay will endeavor to explore the change management processes, leadership and team management skills used in the implementation of protected mealtimes. It will explore the negative aspects and problems encountered when implementing a change and the ongoing management skills required to maintain such changes.

For many patients admitted to hospital, in particular the elderly, malnutrition is a common occurrence. It is the nurse’s fundamental duty of care to provide patients with the highest of care possible, a major requirement for any human being to survive and live a healthy life is the intake of a healthy nutritious diet, be that by conventional methods or artificial measures suitable for the patient’s state of health at that time (Royal College of Nursing 2007). Studies into hospital malnutrition show that as many as four out of ten elderly patients admitted to hospital are already malnourished and as a result of a hospital admission as many as six out of ten elderly patients, become malnourished, their situation worsens and their illness very often escalates (Age Concern 2006; BAPEN 2007). The NHS Improvement Plan (2004) set standards to deal with the increasing incidences of malnutrition within hospital settings; it has become apparent that these examples of good practice recommendations have not been implemented in every hospital in the country, as incidences of malnutrition continue to exist. Davidson and Scholefield (2005) reports that inadequate nutrition can lead to longer hospital stays, impairs the recovery of patients and increases financial costs; several hospitals have indeed planned and implemented changes to reduce such incidences but on the whole have had limited success. The authors found that constant interruptions from drug, rounds, clinical activities and lack of nursing staff being on the ward at mealtimes (due to lunch breaks coinciding with mealtimes) all accounted for patients being provided with very little or on occasion no nutritional intake at any given mealtime. Savage and Scott (2005) does agree with this statement to some extent but argues that it is all to easy to blame nursing staff alone, it is the responsibility of each individual NHS trust to implement managerial changes and policies and ensure that they are monitored, evaluated and improved to provide the best care possible for each patient. Mamhidir et al (2007) argues that since the implementation of protected mealtimes in some hospitals there is substantial evidence to suggest that patients, particularly the elderly benefit immensely; patients gained weight, healing time reduced, were discharged earlier and mealtime experiences were a more pleasant experience for patients as well as nursing staff. Mooney (2008) argues that there is evidence to suggest even after hospital trusts have been presented with unarguable evidence that malnutrition is a major problem and a catalyst for longer hospital stays, only 43 percent of those trusts have not yet provided evidence that they have implemented schemes in order to reduce hunger and malnutrition. The Hospital Caterers Association (2004) further comment that mealtimes should not primarily focus on the provision of nutrition, it also makes way for social interaction between patients and carers, they further comment that in general the quality of the food provided is not the issue, the inability of the patient to be able to feed themselves is far more the worrying issue. Council of Europe (2003) comment that hospitals should be designed to be patient centred, ensuring that the delivery of nutrition is flexible and all deliverance of care is set within a framework; all staff should work together in partnership to ensure that incidences of poor nutrition are dealt with. Repetitive reports of malnourishment is evidence enough to suggest that current practices are no longer working, change is a necessary force to ensure incidences are reduced. It is the responsibility of the leader to ensure this is tackled (Age Concern 2006).

Change Management can be described as the process of developing a planned approach to change within an organisation. The objective should be to maximise the collective benefits for all stakeholders involved in the change and minimise the risk of failure implementing the change. Change involves assessment, planning and evaluation; changes in which people are nursed should always be focused on the benefits patients will receive if change is implemented (National Institute of Health and Clinical Excellence, 2007). Welford (2006) writes that there are many theories which explore the need for change; the goal should be the provision of the highest quality of care, each individual involved in the delivery of such care should work together, be committed and supportive of each other during times of change. Change within a team which leads to new practices and ideas affects each individual differently; it can be a very daunting task for some and for others it is embraced to allow for personal development and the sharing of knowledge (Murphy 2006). There are many theories which uses steps or phases that can evaluate if a change is needed and if the changes that are implemented work. For the purpose of this essay the author refers to a popular theory developed by Lewin in the 1950’s which requires three stages to implement effective change the acceptance and participation of all those involved in the area requiring change. The first phase, commonly referred to as the ‘unfreezing’ stage of this theory requires the participants to acknowledge the need for change; evidence should be provided to encourage new thinking and beliefs about current practices. Hallpike (2008) writes that there is evidence to suggest that teams can be divided into groups who have their own individual opinion on certain regimes, practices and care deliverance. This can be said for the provision of nutrition to patients. In this particular study the author reports that some team members did not think there was a problem with the current provision, some were not convinced that changes would be made and others did not have faith in a holistic approach across the team. In this situation it is the responsibility of the team leader to persuade all the team members that the need for change is necessary in order to provide the best service possible, that the whole team work towards a common goal. Welford (2006) discusses the second phase of Lewin’s theory; describing this stage as the moving stage, allowing individuals to voice their own ideas, experiment with different regimes, it allows time for reflection, to discuss positive or negative findings. Past practices may have seen some team leaders adopt the belief that employees were seen to work better when the leader provided strict job descriptions and a clear plan of what was expected of them; their opinions and ideas were not of value to the overall success of a team. Major (2002) argues that for a leader to adopt such thinking will only lead to flaws and a feeling of negativity within a team; the leader should adopt good communication skills and openness to allow for effective team building, positive group dynamics, all working efficiently and productively. Dennis and Morgan (2008) suggests that although change is the responsibility of the service provider, input from the service user is without doubt a valuable tool in assessing if a change is working for the greater good. Feedback, regardless of being positive or negative ascertains if the change has been a positive one. If the new change has a detrimental affect to the service user then the change has been a negative one, this requires a return to the freezing stage to allow the team to make further changes to increase the benefits to the service user. The authors’ further comment that managers should be seen as advocates for the service user; it should be the responsibility of the manager to challenge team members over poor practice, poor attitudes and resistance to change for the better. Conflict within a team leads to unrest, a disbelief that change is for the greater good leading to a dysfunctional team. The third phase of Lewin’s theory can be commonly referred to as the ‘refreezing’ stage, where new ideas and behaviours become a new or common practice. Pearce (2007) argues that to name this phase as such denotes that the change remains static, leaders should continuously strive to make changes for the better, communication across the whole team allows for individual’s points of view to be exposed and discussed; feedback on how a new change is working is necessary in order to achieve the highest levels of quality care.

Leadership styles become a key issue when developing, implementing and upholding change. Motivation of staff also plays a key role in the acceptance of change; leaders should demonstrate that they are a good role model, adopt a friendly attitude towards team members, accepting of criticism and be willing to provide positive feedback, when the team endeavour to believe in and implement the change (Darlington 2006). Corkindale (2009) argues that leaders need balance their role within a team to ensure that they do not become too over familiar with individual team members, as this may lead to team members relying too heavily on the leader to make all the decisions and authority may be compromised.

Murphy (2006) writes that leaders need to adopt a style of leadership that suits the workforce; a laissez-faire approach can be seen as the leader not taking into account individual team member’s ideas, work ethics and commitment seriously, it can lead to a team feeling devalued and unorganised. The National Institute for Mental Health (2007) further suggests that leaders who show their commitment, by working alongside their colleagues, adopting and maintaining the changes themselves demonstrates a leader who is at the forefront in the deliverance of quality care. They further suggest that each leader will bring their own set of ethics, life experiences and education to a team, will often adopt their own style of leadership that may be a mixture of several styles moulded to suit the team and the area of practice they are employed to manage. Opportunities for team members to voice their opinions and concerns are invaluable; they are after all the main implementers of the change and will have be the first to recognise if the change has gained positive or negative results. The change can only work if leaders allow for reflection, discussion and adaptation of the change to suit each individual involved in the change process. A change that is difficult to implement or maintain will end in failure, this leads a team adopting negative feelings and a resistance to change in the future.

Goleman (2000) suggests that to adopt an authoritarian approach, can at times be a positive approach to leadership especially if some team members resist change or there is a need to produce quick results. Goffee and Jones (2000) disagree with this statement and suggest that a good leader is someone who other people want to follow without bullying, threats or the fear of reprisals; they lead by communicating effectively and adopt a style of leadership that allows the team to understand what is expected of them.

RCN (2007) writes that the only way malnourishment can be identified and managed effectively is with effective use of recognised screening tools.Perry (2009) argues that in many cases nursing staff are given the means and tools to assess a patient, but many are inadequately trained to understand the findings of the assessment or are unwilling to involve other health professionals in the care of the patient. A multidisciplinary approach to tackle such problems should be used. Protected mealtimes have been proven to be useful to not only the patient but to the whole care team, it allows for assessment in areas such as speech and language, mental health issues and other physical problems which can affect the nutritional intake of individuals. South Staffordshire Primary Care Trust (2009) reports that protected mealtimes affects and involves all staff within in the organisation from physiotherapists, domestic staff, maintenance staff through to outside professionals such as social workers. It involves all areas of clinical practice where patients require nutritional intake, not only for patients who are unable to feed themselves but for those patients who require and deserve a quiet, interruption free period to eat, drink and relax.

To maintain and monitor the change process and may require several attempts before the target is reached. takes time and may not always be successful first time. National Patient Safety Agency (2008) states that many clinical staff referred to the implementation of protected mealtimes as a hindrance to their daily routine, but once the benefits for patients as well as the staff members were explained they became more compliant and understanding for the need to change.