5.4 Applying the Nursing Process to Promote Healthy Coping
This section will outline how nurses use the nursing process to recognize signs and symptoms of acute and chronic stress and promote healthy coping.[1]
Assessment (Recognizing Cues)
Nurses begin by assessing an individual’s response to the current situation, their level of stress, and their current strategies for managing stress and coping. The following factors are considered:
- Verbal and nonverbal signs and symptoms of acute or chronic stress
- Signs and symptoms of crisis
- Environmental stressors, including factors related to social determinants of health
- Signs of adaptive or maladaptive coping (see the “Maladaptive Coping Behaviors” chapter)
- Signs of violence (see the “Maladaptive Coping Behaviors” chapter.)
- Signs of abuse or neglect (see the “Maladaptive Coping Behaviors” chapter.)
- Use of defense mechanisms
- Support systems and family dynamics (see the “Family Dynamics” chapter)
- Signs of caregiver role strain and resources being utilized
Each of these factors is further discussed in the following subsections.
Signs and Symptoms of Stress and Crisis
Recall from the “Stress and Coping” section that nurses assess for signs and symptoms of acute and chronic stress. When assessing for signs and symptoms of stress, nurses also consider if clients are experiencing a crisis.
Crisis symptoms can manifest in various ways. Nurses should carefully monitor for signs such as escalating anxiety, denial, confusion or disordered thinking, anger and hostility, helplessness and withdrawal, hopelessness and depression, or verbalization of suicidal thoughts. When a nurse recognizes these signs in a client or one of their family members, it is important to carefully explore the symptoms exhibited, as well as the risk for self-harm or violence. If a client, family member, or visitor exhibits signs of crisis or verbal escalation, nurses follow agency policy to maintain a safe environment for the client, staff, and visitors. Review information about crisis and crisis intervention in the “Basic Concepts of Mental Health and Mental Illness” section and information about escalation and de-escalation in the “Workplace Violence” section of the “Maladaptive Coping Behaviors” chapter.
Environmental Stressors and Social Determinants of Health
Environmental stressors refer to aspects of a client’s surroundings that may increase mental or emotional strain, induce the stress response, and possibly impact their health care. Examples of environmental stressors include loud noise, extreme temperatures, and factors related to social determinants of health (SDOH). Examples of SDOH factors that may elicit the stress response include unemployment and job insecurity, unsafe working conditions, food insecurity, unsafe neighborhoods, inadequate access to affordable childcare services, and inadequate access to affordable health services.[2]
Adaptive and Maladaptive Coping
Nurses assess clients’ coping behaviors and determine if they are adaptive or maladaptive. An example of adapting to stress in a healthy way is when the client notices a problem and uses positive coping strategies like mediation or journaling. Review stress management and positive coping strategies in the “Stress and Coping” section of this chapter.
Conversely, clients may respond to stress in unhealthy ways referred to as maladaptive coping behaviors. Maladaptive coping may include responses such as aggressive behaviors, decreased social interaction, escapism, obsessive behaviors, self-injurious behaviors, substance misuse, or overeating. Aggressive behavior may include physical or emotional abuse of a child, older adult, or intimate partner. Read more about abuse, violence, and substance use disorders in the “Maladaptive Coping” chapter.
Defense Mechanisms
When clients experience stress, they may display reaction patterns called defense mechanisms that are used by individuals to protect themselves from anxiety that arises from stress and conflict. Excessive use of defense mechanisms is associated with specific mental health disorders. Nurses assess for the client’s use of defense mechanisms. See Table 5.4a for a description of common defense mechanisms.
Table 5.4a. Common Defense Mechanisms[3],[4],[5]
| Defense Mechanisms | Definitions | Examples |
|---|---|---|
| Avoidance | Staying away from people, places, or situations that are uncomfortable. | A client does not attend health care appointments because they do not want undesirable news about their health. |
| Conversion | Anxiety is converted into a physical symptom. | An individual scheduled to see their therapist to discuss a past sexual assault experiences a severe headache. |
| Denial | Unpleasant thoughts, feelings, wishes, or events are ignored or excluded from conscious awareness. | A client recently diagnosed with cancer states there was an error in diagnosis, and they don’t have cancer.
Other examples include denial of a financial problem, an addiction, or a partner’s infidelity. |
| Dissociation | A feeling of being disconnected from a stressful or traumatic event or feeling that the event is not really happening. | A person experiencing physical abuse may feel as if they are floating above their body observing the situation. |
| Displacement | Unconscious transfer of emotions or reaction from an original object to a less-threatening target to discharge tension. | An individual who is angry with their partner kicks the family dog. An angry child breaks a toy or yells at a sibling instead of attacking their father. A frustrated employee criticizes their spouse instead of their boss. |
| Intellectualization | Excessive thinking or overanalyzing to avoid feelings. | When unpleasant emotions begin to arise, a client starts explaining the situation and solving the problem rather than feeling emotions. |
| Introjection (Identification) | Unconsciously incorporating the attitudes, values, and qualities of another person’s personality. | A client talks and acts like one of the nurses they admire. |
| Minimization | Presenting events as trivial or unimportant. | A client who drinks to excess says, “I don’t drink that much.” |
| Projection | A client attributes their individual positive or negative characteristics, affects, and impulses to another person or group. | A person conflicted over expressing anger changes “I hate him” to “He hates me.” |
| Rationalization | Logical reasons are given to justify unacceptable behavior to defend against feelings of guilt, maintain self-respect, and protect oneself from criticism. | A client who is overextended on several credit cards rationalizes it is okay to buy more clothes to be in style when spending money that was set aside to pay for the monthly rent and utilities. A student caught cheating on a test rationalizes, “Everybody cheats.” |
| Reaction Formation | A client denies unacceptable or threatening impulses and consciously replaces them with an opposite, acceptable impulse. | A client who hates their mother writes in their journal that their mom is a wonderful mother. |
| Regression | A return to a prior, lower state of cognitive, emotional, or behavioral functioning when threatened with overwhelming external problems or internal conflicts. | A child who was toilet trained reverts to wetting their pants after their parents’ divorce. |
| Repression | Painful experiences and unacceptable impulses are unconsciously excluded from consciousness. | A victim of incest indicates they have always hated their brother (the molester) but cannot remember why. |
| Splitting | Objects provoking anxiety and ambivalence are viewed as either all good or all bad. | A client tells the nurse they are the most wonderful person in the world, but after the nurse enforces the unit rules with them, the client tells the nurse they are the worst person they have ever met. |
| Suppression | A conscious effort to keep disturbing thoughts and experiences out of mind or to control and inhibit the expression of unacceptable impulses and feelings. Suppression is similar to repression, but it is a conscious process. | An individual has an impulse to tell their boss what they think about them and their unacceptable behavior, but the impulse is suppressed because of the need to keep the job. |
Support Systems, Family Dynamics, and Caregiver Role Strain
Nurses assess the client’s current social support system, which may include family members, significant others, or friends. As discussed in the “Stress and Coping” section, supportive relationships are considered a healthy coping strategy. While assessing the client’s support system, nurses assess family dynamics for signs of dysfunction that can affect the client’s stress level and coping.
Read more about healthy and unhealthy family dynamics in the “Family Dynamics” section of the “Family Dynamics” chapter.
If a family member or significant other provides regular care for a client with a chronic mental illness, the nurse also assesses for excessive caregiving burden and their need for additional support. Signs of excessive caregiving burden include examples such as fatigue, frequent illness, headache, poor appetite, unintended weight change, emotional lability, impatience, and suicidal ideation, as well as maladaptive coping behaviors like substance misuse and aggressive behaviors.[6]
If signs of excessive caregiving burden are present, nurses provide information about available community resources. Community resources available for clients with chronic mental illness or disability may include child or adult day care, respite care, or residential facilities.
Read more about excessive caregiving burden in the “Psychosocial Effect of Illness on Client and Family Health” section of the “Family Dynamics” chapter.
Documentation
After completing a comprehensive assessment regarding a client’s signs and symptoms of stress and their coping behaviors, nurses document their assessment findings in the client’s medical record.
Diagnosis (Analyzing Cues)
NANDA nursing diagnoses related to stress and coping are described in Table 5.4b with definitions and defining characteristics.
Table 5.4b. NANDA Nursing Diagnoses Related to Stress and Coping[7]
| Nursing Diagnosis | Definition | Selected Defining Characteristics |
|---|---|---|
| Maladaptive Coping | Counterproductive and/or behavioral efforts to manage a stressful or unpleasant situation. |
|
| Readiness for Enhanced Coping | A pattern of cognitive and/or behavioral efforts to manage a stressful or unpleasant situation, which can be strengthened. |
|
Outcome Identification (Generate Solutions)
A broad nursing goal for clients experiencing stress is to promote the use of adaptive coping strategies.
Nurses establish specific expected outcomes based on a client’s circumstances and specific needs that are measurable actions for the client that are responsive to nursing interventions. Expected outcome statements should contain five components that are easily remembered using the “SMART” mnemonic:
- Specific
- Measurable
- Attainable/Action oriented
- Relevant/Realistic
- Time frame
Examples of SMART outcomes related to stress management and promoting healthy coping are as follows:
- The client will identify two stressors that can be modified or eliminated by the end of the week.
- The client will identify three preferred emotional coping strategies to implement by the end of the week.
Interventions (Take Action)
Nurses plan and implement nursing actions categorized as Coping Enhancement to “facilitate a client’s cognitive and behavioral efforts to manage perceived stressors that interfere with meeting life demands and roles.”[8] See selected interventions from Nursing Interventions Classification (NIC) for this category in the following box.
Selected NIC Coping Enhancement Interventions[9]
- Establish a safe environment:
- Use a calm, reassuring approach
- Reduce stimuli in the environment that could be misinterpreted as threatening
- Provide an atmosphere of acceptance
- Assessments:
- Seek to understand the client’s perspective of a stressful situation
- Assess and respect the client’s spiritual/cultural values and beliefs
- Assess the effect of the client’s life situation on roles and relationships
- Assess the client’s decision-making ability
- Assess the client’s need/desire for social support
- Assess the client’s risk for symptoms of crisis and intentions for inflicting self-harm. If present, immediately modify the environment for safety before leaving the room and then notify the provider.
- Actions:
- Encourage the client to verbalize feelings, perceptions, and fears
- Instruct the client on the use of stress management and relaxation techniques as needed
- Encourage the identification of the client’s specific life values
- Explore the client’s previous successful methods of dealing with life problems and encourage the client to identify their own strengths and abilities
- Assist the client in identifying appropriate short-term and long-term goals
- Assist the client in identifying available resources to meet the established goals
- Assist the client in breaking down complex goals into small, manageable steps
- Encourage social and community activities
- Encourage family involvement, if appropriate
- Encourage the use of spiritual resources, if desired (Review spirituality and spiritual care by nurses in the “Spirituality” chapter of Open RN Nursing Fundamentals, 2e.)
- Encourage the initiation and maintenance of relationships with other individuals who have common interests and goals or have successfully undergone the same experience
- Assist the client in solving problems in a constructive manner
- Discourage decision-making when the client is under severe stress
- Foster constructive outlets for anger and hostility
- Encourage the client to evaluate their own behavior
- Encourage an attitude of realistic hope as a way of dealing with feelings of helplessness
Evaluation (Evaluate Outcomes)
Nurses evaluate the effectiveness of interventions and determine if outcome criteria were met by the established timelines. If they were partially met, or not met, the nurse modifies the nursing care plan by performing additional assessments, modifying expected outcomes, revising planned interventions, and collaborating with the interdisciplinary health care team.
- Ernstmeyer, K., & Christman, E. (Eds.). (2022). Nursing: Mental Health and Community Concepts. Access for free at https://wtcs.pressbooks.pub/nursingmhcc/ ↵
- World Health Organization. (n.d.) Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health ↵
- American Psychological Association. (2018). Stressor. https://dictionary.apa.org/stressor ↵
- Sissons, C. (2020). Defense mechanisms in psychology: What are they? MedicalNewsToday. https://www.medicalnewstoday.com/articles/defense-mechanisms ↵
- Bailey, R. (2023). Defense mechanisms. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK559106/ ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). Nursing diagnoses: Definitions & classification, 2024-2026. Thieme. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). Nursing diagnoses: Definitions & classification, 2024-2026. Thieme. ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classifications (NIC) (8th ed.). Elsevier. ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classifications (NIC) (8th ed.). Elsevier. ↵
Aspects of a client’s surroundings that may increase mental or emotional strain, induce the stress response, and possibly impact their health care.
An ineffective response to stressors, such as avoidance of the stressful condition, withdrawal from a stressful environment, disengagement from stressful relationships, aggression, or misuse of alcohol or other substances.
Reaction patterns that are used by individuals to protect themselves from anxiety that arises from stress and conflict.