Early Identification and Management of Critical Incident Stress

Abstract

The cumulative cost of treating acute stress is staggering. Stress and its related comorbid diseases are responsible for a large proportion of disability worldwide, and it is estimated that these factors will cost organizations more than $150 billion in lower productivity, absenteeism, and disability in the next 2 decades.1 Amazingly, within the work setting, nearly half of all employee turnover is due to job stress.2 Between 1980 and 1990, the number of stress disability claims made by workers in California alone increased by more than 800%. Finally, in 2000, it was estimated that the cost for treating acute stress was possibly the highest per capita cost of any psychological condition.3 Stress can also lead to physical, psychological, and behavioral difficulties.4 Three stress-related disorders in particular, chronic pain, hypertension, and headache, account for approximately 54% of all job-related absenteeism. Furthermore, stress in an acute or a critical care nurse can have a direct effect on patients’ outcomes, such as patients’ falling or medication errors.Stress related to a critical incident can adversely affect individuals and their capacity to respond adaptively at work or at home.5 Both pre-hospital and healthcare workers involved in disaster response are particularly susceptible to a variety of stress-related psychological and physical sequelae6 (see Case Study). Unexpected events or critical incidents have an emotional impact that overwhelms a person’s usual coping skills and causes significant distress in otherwise healthy people. Often, nurses in acute and critical care have only relatively informal resources for coping with the extremes of sadness and grief they might experience after traumatic events.7 Thus, stress management programs can provide myriad benefits to both staff and employers.6Critical incident stress management (CISM) is an intervention method used in relation to sudden unexpected critical events. Critical incident stress debriefing (CISD), a component of CISM, offers a safe, nonthreatening environment in which individuals can express their emotions. Little information on this intervention method is available for acute and critical care nurses. In this article, we provide an overview of critical incident stress (CIS), discuss CISD as a method to reduce the impact of a critical event, and present implications for use of CISD by and for advanced practice nurses in acute and critical care.Stress plays an important role in the physical and psychological state of human beings and is characterized as the nonspecific response of an organism to any demand placed upon it.8 However, in highly stressful situations, when demands become too extreme, stress often produces a heightened state of physical, cognitive, behavioral, and emotional arousal. Traumatic events can pose particularly significant psychological and physiological threats, challenging a person’s perceptions of control over his or her environment and life outcomes.9A critical incident can be described as any sudden unexpected event that has an emotional impact sufficient to overwhelm the usual effective coping skills of an individual or a group and that causes significant psychological distress in usually healthy persons. Factors that can influence a person’s response to an extraordinary situation include a history of psychological impairment, personal values, the manner in which the threat is perceived or the personal meaning of the event for the participant, attitudes, existence of warning or lack of preparation time, and the ability to create some personal distance from the event. When a critical incident occurs, the aftershocks of trauma can occur in 2 dimensions: (1) each participant’s individual internal process of realizing the repercussions and (2) the circles of influence radiating from ground zero at the most affected victim, to groups of people such as victims’ and survivors’ family members, friends, neighbors, and coworkers, and then to the community at large, creating a cumulative “ripple” effect.10,11 The immediate impact of a critical incident can cause victims and survivors to be exposed to what may be considered inconceivable violence and unimaginable loss. For each person, this impact can carve unique roadways in the heart, mind, and memory. The typical reactions to the event can change over time. A person may initially be energized by the event in order to face the immediate challenges necessary to cope or perform necessary work functions and then later become depressed.CIS refers to a broad range of responses that occur after a stressful experience. Conceptually, it consists of 4 major types of signs and symptoms: cognitive, physical, emotional or affective, and behavioral. The cognitive problems associated with CIS include confusion, poor concentration, and memory lapses. The physical effects include fatigue, insomnia, gastrointestinal problems, muscle tension, and heightened autonomic activity. The emotional or affective effects may include anxiety, depression, guilt, anger, and denial. Finally, the behavioral manifestations can include social withdrawal, listlessness, substance abuse, and aggressive behaviors.12The frequency with which healthcare workers are exposed to critical incidents is obvious. For healthcare workers, primarily nurses, a critical incident has 4 components: the event, each worker’s reaction to the event, each worker’s performance, and the meaning each worker gives to the event. One or more of these components can trigger the cognitive, affective, physical, and/or behavioral changes in the worker.10An incident involving particularly gruesome injuries to a patient’s body or the death or serious injury of a fellow healthcare worker may lead to CIS and has been implicated in the eventual development of acute stress disorder, posttraumatic stress disorder, generalized anxiety disorder,...