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Chapter: Medical Surgical Nursing: Homeostasis, Stress, and Adaptation

Psychological Responses to Stress

After the recognition of a stressor, an individual consciously or un-consciously reacts to manage the situation.



After the recognition of a stressor, an individual consciously or un-consciously reacts to manage the situation. This is called the medi-ating process. A theory developed by Lazarus (1991a) emphasizes cognitive appraisal and coping as important mediators of stress. Appraisal and coping are influenced by antecedent variables that include the internal and external resources of the person.

Appraisal of the Stressful Event

Cognitive appraisal (Lazarus, 1991a; Lazarus & Folkman, 1984) is a process by which an event is evaluated with respect to what is at stake (primary appraisal) and what might and can be done (sec-ondary appraisal). What individuals see as being at stake is influ-enced by their personal goals, commitments, or motivations. Important factors include how important or relevant the event is to them, whether the event conflicts with what they want or de-sire, and whether the situation threatens their own sense of strength and ego identity.


As an outcome of primary appraisal, the situation is identified as either nonstressful or stressful. If nonstressful, the situation is ir-relevant or benign (positive). A stressful situation may be one of three kinds: (1) one in which harm or loss has occurred; (2) one that is threatening, in that harm or loss is anticipated; and (3) one that is challenging, in that some opportunity or gain is anticipated.


Secondary appraisal is an evaluation of what might and can be done about this situation Actions include assigning blame to those responsible for a frustrating event, thinking about whether one can do something about the situation (coping potential), and determining future expectancy, or whether things are likely to change for better or worse (Lazarus, 1991a, 1991c). A compari-son of what is at stake and what can be done about it (a type of risk–benefit analysis) determines the degree of stress.


Reappraisal, a change of opinion based on new information, also occurs. The appraisal process is not necessarily sequential; pri-mary and secondary appraisal and reappraisal may occur simulta-neously. Information learned from an adaptational encounter can be stored, so that when a similar situation is encountered again the whole process does not need to be repeated.

The appraisal process contributes to the development of an emotion. Negative emotions such as fear and anger accompany harm/loss appraisals, and positive emotions accompany challenge. In addition to the subjective component or feeling that accompa-nies a particular emotion, each emotion also includes a tendency to act in a certain way. For example, an unexpected quiz in the classroom might be judged as threatening by unprepared students. They might feel fear, anger, and resentment and might express these emotions outwardly with hostile behavior or comments.


Lazarus (1991a) expanded his former ideas about stress, ap-praisal, and coping into a more complex model relating emotion to adaptation. He called this model a “cognitive-motivational-relational theory,” with the term relational “standing for a focus on negotiation with a physical and social world”. A theory of emotion was proposed as the bridge to connect psychology, physiology, and sociology: “More than any other arena of psy-chological thought, emotion is an integrative, organismic concept that subsumes psychological stress and coping within itself and unites motivation, cognition, and adaptation in a complex con-figuration”.

Coping With the Stressful Event

Coping, according to Lazarus, consists of the cognitive and be-havioral efforts made to manage the specific external or internal demands that tax a person’s resources and may be emotion-focused or problem-focused. Coping that is emotion focused seeks to make the person feel better by lessening the emotional distress felt. Problem-focused coping aims to make direct changes in the environment so that the situation can be managed more effec-tively. Both types of coping usually occur in a stressful situation. Even if the situation is viewed as challenging or beneficial, cop-ing efforts may be required to develop and sustain the chal-lenge—that is, to maintain the positive benefits of the challenge and to ward off any threats. In harmful or threatening situations, successful coping reduces or eliminates the source of stress and re-lieves the emotion it generated.


Appraisal and coping are affected by internal characteristics such as health, energy, personal belief systems, commitments or life goals, self-esteem, control, mastery, knowledge, problem-solving skills, and social skills. The characteristics that have been studied most often in nursing research are health-promoting lifestyles and hardiness. A health-promoting lifestyle buffers the effect of stressors. From a nursing practice standpoint, this out-come—buffering the effect of stressors—supports nursing’s goal of promoting health. In many circumstances, promoting a healthy lifestyle is more achievable than altering the stressors.


Hardiness is the name given to a general quality that comes from having rich, varied, and rewarding experiences. It is a per-sonality characteristic composed of control, commitment, and challenge. Hardy people perceive stressors as something they can change and therefore control. To them, potentially stressful situ-ations are interesting and meaningful; change and new situations are viewed as challenging opportunities for growth. Some posi-tive support has been found for hardiness as a significant variable that positively influences rehabilitation and overall improvement after an onset of an acute or chronic illness (Felton, 2000; Williams, 2000).


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