Transcript Crisis intervention

presentation objectives
Describe a crisis and its characteristics, types of crises, and crisis
intervention.
Analyze aspects of the nursing assessment related to crisis
responses.
Plan and implement nursing interventions for patients related to their
crisis responses.
Develop a patient education plan to cope with crisis.
Evaluate nursing care for patients related to their crisis responses.
Describe the settings in which crisis intervention may be
practiced.
Discuss 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:
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.
Time limited: Generally lasting no more than six weeks.
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.
Characteristics of a crisis:
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 Crisis occurs in all individuals at one time or another and is
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not 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:
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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.
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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.
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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 and respect the sociocultural context of
crisis care.
Specific cultural factors to be considered in
crisis intervention include the following:
 Migration and citizenship status
 Gender and family roles
 Religious belief systems
 Child-rearing practices
 Use of extended family and support systems
 Housing and living conditions
 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:
 Precipitating event or stressor
 Patient’s perception of the event or stressor
 Nature and strength of the patient’s support
systems and coping resources
 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, the 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
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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
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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:
 Preventing clients in crisis from harming themselves or
others
 Administering medications
 Providing a supportive, therapeutic environment
CRISIS INTERVENTION
Planning and outcome identification
 1. Assist the client in setting realistic goals to return to
the pre-crisis level of functioning
 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
 Immediacy- Intervene as
 Assess the situation- let
soon as possible. Goal is to
reduce anxiety.
 Assume Control - via
providing the structure the
person needs, not be
overwhelming them
the person talk, watch for
nonverbal cues, be a guide
and avoid judgements and
putdowns
 Situation Management
 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:
 Has the expected outcome been achieved, and has patient
returned to the precrisis level of functioning?
 Have the needs of the patient that were threatened by the event
been met?
 Have the patient’s symptoms decreased or been resolved.
 Is the patient using constructive coping mechanisms?
 Does the patient need to be referral for additional treatment?
 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:
 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.
 Crisis intervention is a brief, active therapy with the goal of
returning the individual to a precrisis level of functioning