SEMINAR ON

STRESS AND ADAPTATION

CRISIS AND ITS
INTERVENTION
 
PRESENTED BY:
V. PARASAKTHI,
M.SC (N) I ST YEAR,
CON-PIMS,
STRESS ADAPTATION
 INTRODUCTION

Modern world is full of hassles, deadlines, frustrations and demands. For many people
stress is so common place that it has become Way of life. Stress is not always bad, in small
doses, it can help you perform under pressure and motivate you to do your best. The word
stress is defined by the oxford dictionary as 'a state of affair involving demand on physical or
mental energy or circumstance which can disturb the normal physiological and psychological
functioning of an individual.
 
(Stress: it is your mind and body's response or reaction to a real or imagined threat,
event or change.)
 
 DEFINITION

Stress is the body's reaction to a change that requires a physical, mental or

emotional adjustment or response.

In medical parlance 'stress' is defined as a perturbation of the body's

homeostasis. This demand on mind-body occurs when it tries to cope with
incessant changes in life.
 

 
Stress as the nonspecific response of the body to any
demand. The nonspecific response is always the Same, it is
the degree of the response that changes.

Selye(1958)
 
 EUSTRESS AND POSITIVE

TYPES STRESS:

The Stress That Comes From Good

Sources:
MARRIAGE
BIRTH OF A BABY
WINNING THE LOTTERY.
DISTRESS OR
NEGATIVE Distress Or Negative Stress That Comes
From Bad Sources:
STRESS  DIFFICULT WORK
ENVIRONMENT
 OVERWHELMING
SIGHTS AND SOUNDS
 THREAT OF PERSONAL
INJURY
 • ACUTE STRESS
Other • EPISODIC ACUTE STRESS
classification of • CHRONIC STRESS
stress: • TRAUMATIC STRESS
Acute stress:
 Acute stress is the most common and most recognizable
form of stress, the kind of sudden jolt in which you know
exactly why You re stressed. Something scary but thrilling,
such as parachute jump. Along with obvious dangers and
threat, common causes of acute stress Include noise, isolation,
crowding, and hunger.
Normally your body rests when these types of stressful
events cease and your Life gets back to normal. Because the
effects are short-term, acute stress usually does not cause
severe or permanent damage to the body.
Episodic acute stress:

 Some people endure acute stress frequently, their lives are chaotic, out of
control, and they always seem to be facing multiple stressful situations. They are
always in a rush, always late, always taking too many projects, handling too
many demands.

People for whom stress is a while spike, these folks are experiencing episodic
acute stress.
Chronic stress:
The APA help center describes chronic stress as "unrelenting demand and
pressures for seemingly interminable periods of time .

 Chronic stress is the stress that wears you down day after day and year
after year, with no visible escape. It grinds a mental and physical health leading
to breakdown and even death.

Causes of chronic stress include:

 Poverty and financial worries
 Long-term unemployment
 Caring for a chronically-ill family member
 Living in an area besieged by war or violence
 Feeling trapped in unhealthy relationship or carrier
choices
 Bullying or harassment
 Perfection.
 STRESSORS

The physical, environmental and social causes

of the stress state are termed as stressors.
 TYPES OF STRESSORS

INTERNAL EXTERNAL
 Frustrations Environmental


 Conflicts Health

Financial
 problems
 Pressures Psychosocial
Workplace stress
Personal relationships
 
 PHYSIOLOGICAL ADAPTATION

Physiological adaptation to stress is the body's ability

To maintain a state of relative balance. This adaptive ability is a
dynamic form of equilibrium in the body's internal environment.

The internal environment constantly changes, And the body's

adaptive mechanisms continually function to adjust to these
changes and thus to maintain equilibrium, or homeostasis.
The body makes adjustments in heart rate, respiratory
Rate, blood pressure, temperature, fluid and electrolyte
Balances, hormone secretions, and level of
Consciousness-all directed at maintaining adaptation.
 MECHANISMS OF
PHYSIOLOGICAL ADAPTATION
Physiological mechanisms of adaptation function through
negative feedback, a process by which the Controlling
mechanism senses an abnormal state, such As lowered body
temperature, and makes an adaptive Response, such as initiating
shivering to generate body Heat.
Three of the major mechanisms used in adapting to A stressor
are controlled by the medulla oblongata, the Reticular formation,
and the pituitary gland.
MEDULLA OBLONGATA

The medulla oblongata control vital Functions necessary to

survival. These include heart rate, Blood pressure, and respiration.
Impulses traveling to from the medulla oblongata can increase or
decrease these vital functions.
RETICULAR FORMATION:
The reticular formation is a small Cluster of neurons in the
brainstem and spinal cord. It Also controls vital functions and
continuously monitors the Physiological status of the body through
connections with Sensory and motor tract.
 
PITUITARY GLAND:
 The pituitary gland, a small gland Attached to the hypothalamus, supplies
hormones that Control vital functions. The pituitary gland produces Hormones
necessary for adaptation to stress. In addition, The pituitary gland regulates the
secretion of thyroid gonadal And parathyroid hormones.

 Hormone secretion like other Homeostatic mechanisms is normally regulated,

by a Feedback mechanism that continuously monitors hormone Level in the
blood. When hormone levels drop, the pituitary Gland receives a message to
increase hormone secrection. When hormone levels rise, the pituitary gland
decreases Hormone production.
 MODELS OF STRESS

RESPONSE-BASED MODEL OF STRESS:

• Response based model is concerned with specifying The

particular response or pattern of responses that may Indicate a
stressor. Selye's model of stress (1976) is a .Response based model
that defines stress as a nonspecific.
•Response of the body to any demand made on it. Stress is
demonstrated by a specific physiological reaction the
General adaption syndrome. Thus the response of a Person
to stress is purely physiological and is never .Modified to
allow cognitive influences (Mcnett, 1989).
 ADAPATION MODEL

Four
 factors determine whether a situation is stressful (mechanic, 1962).
The ability to cope with stress, the first Factor, usually depends on the
person's experience with Similar stressors support systems, and overall
perception Of the stressor.
The second factor deals with the practices And norms of the person's peer-
group is the impact of the Social environment in assisting an individual to
adapt to a Stressor.
The last factor involves the resources that can be used To deal with the

stressor. The adaptation model is based on the understanding .
That people experience anxiety and increased stress when they are
unprepared to cope with stressful situations. Using this model and
appropriate interventions, nurses can help clients and families to
promote health in all human dimensions.
 STIMULUS-BASED MODEL:

The stimulus-based model focuses on the following Assumptions.

 
 Life change events are normal, and they require, the Same type and
duration of adjustment.
 People are passive recipients of stress, and their Perceptions of the
event are irrelevant.
 All people have a common threshold of stimulus, and
Illness results at any point after the threshold. As with the
response-based model, the stimulus-based Model does not
allow for individual differences in Perception and response to
stressors.

 Nurses may Experience difficulty when attempting to use this

model In stress management because of the lack of flexibility
For individual adaptation.
 TRANSACTION-BASED MODEL:

 The transaction-based model views the person and Environment in a dynamic,

reciprocal, interactive, Relationship. This model, developed by lazarus and
Folkman, views the stressor as an individual perceptual
 Response rooted in psychological and cognitive processes. Stress originates
from the relationship between the person And the environment. This model
focuses on stress-related Processes such as cognitive appraisal and coping.
THE STUART STRESS ADAPTATION MODEL:

PREDISPOSING FACTORS
Biological psychological sociocultural

PRECIPITATING STRESSORS
Nature Origin Timing Number

APPRAISAL OF STRESSOR
Affection physiological behavioral social

COPING RESOURCES
Personal abilities socialsupport material assests positivebeliefs

COPING MECHANISM

Constructive Destructive

CONTINUUM OF COPING RESPONSES

Adaptive responses Maladaptive Responses

NURSING DIAGNOSIS
DIMENSION OF ADAPTATION:
A. PHYSICAL DIMENSION
• Adaptive resources: local adaptation syndrome.
Eg: fever
 Unsuccessful outcome can result in death.
 Successful-outcome result in resolution.
B. DEVELOPMENTAL DIMENSION
• Adaptive resources: successful coping in the past Developmental
task/stages or successful adaptation to past stressors.
Eg: retirement
 Unsuccessful outcome can result in depression.
 Successful outcome result in alteration of role functions
To other meaningful activities.
C. EMOTIONAL DIMENSION:
• Adaptive responses are: psychological defense
Mechanisms, individual personality changes.
Eg of stressor: rape
 Unsuccessful outcome can result in irrational fear of men.
 Successful outcome can result in integration of traumatic memory.
D. INTELLECTUAL DIMENSION:
• Adaptive responses are: formal education. Ability to Solve problem,
communication skills, positive copingStrategies.
Eg: diagnosis of cancer
 Unsuccessful outcome can result in denial of cancer And foregoes
for treatment.
 successful outcome can result in using of an active Problem solving
approach to make decisions about Care.
E. SOCIAL DIMENSION:
• Adaptive responses are: social network provides Support, others may direct
person to needed resources.
Eg: alcoholism in a family member.
 Unsuccessful outcome can result in withdrawal from Family and other social
contacts.
 Successful outcome can result in active participation Of all the family members
in alcoholic anonymous Support groups.
F.SPIRITUAL DEVELOPMENT
• Adaptive responses are: prayer groups, support from Priest, rabbi and
minister.
Eg: ill family member feels that he has abandoned by god.
 Unsuccessful outcome can result in withdrawal from Church activities,
not mingling with church people.
 Successful outcome can result in seeking friends from The church,
becoming volunteers for in church activities.
STRESS AT WORK  SICKNESS ABSENCE
 HIGH STAFF TURNOVER
 POOR
COMMUNICATION
BETWEEN TEAMS
 LACKOF FEEDBACK ON
PERFORMANCE
 VALUE AND
CONTRIBUTION
STRESS AT WORK  TECHNOLOGICAL CHANGE
 LACK OF CLARITY OF ROLES
AND RESPONSIBILITIES
 DISSATISFACTION WITH
NON-MONETARY BENEFITS
 WORKING LONG HOURS
 UNCOMFORTABLE
WORKPLACE
 LACK OF TRAINING.
 
 STRESS EXPERIENCE AMONG
NURSING PERSONNEL

Everyday the nurse confronts stark suffering, grief and death as few
other people do. Many nursing tasks are mundane And unrewarding.
Many are, by normal standards, distasteful and disgusting. Others are
often degrading.
 1. Less Promotional
Opportunities
1)Frightening"
2. Harassment Of Nurses By
2)Working long hours Others
3)Poor working conditions
3. Lack Of Clarity Of Roles
4)Lengthy hours of duty And Responsibilities
and split duty.
4. 'Lack Of Feedback On
5)Less salary, allowances Performance
and other incentives.
5. Improper Supplies.
 HEALTH PROBLEMS LINKED TO
STRESS

Heart attack Substance abuse

Hypertension Ulcer
Stroke Irritable bowel syndrome
Cancer Memory loss
Diabetes Autoimmune disease (e.g. Lupus)
Depression Insomnia
Obesity Thyroid problems
Eating disorders Infertility.
MANIFESTATION OF STRESS:

 PHYSICAL STRESS
 MENTAL STRESS
 BEHAVIORAL STRESS
 
PHYSICAL STRESS SIGNS:
 Increased breathing
 Heart rate increase
 Muscles tighten
 Cold clammy hands
 Hands shake.
LONG-TERM PHYSICAL SIGNS
 Headache
 Immune system less efficient
 GI tract disorders
 Fatigue
 Sleeplessness
 Longer recovery from injury
 Endocrine system problems.
LONG-TERM PHYSICAL STRESS SYMPTOMS
 Insomnia
 Change in appetite
 Sexual disorders
 Aches and pains
 Frequent colds
 Feelings of intense and long-term tiredness
 Prone to illness.
Short-term physical stress symptoms
 Dry mouth
 Cool skin
 Cold hands and feet
 Increased sweating
 Rapid breathing
 Faster heart rate
 Tense muscles
 Feelings of nausea
 Butterflies in your stomach
 
MENTAL STRESS SIGNS:
 Mood swing
 Excitability or quick temper
 Inability to relax
 Anxiety
 Forgetfulness
 Depression
 Apathy
 Confusion.
BEHAVIORAL SIGNS OF STRESS:
 Eating more or less than usual
 Sleeping excessively or insufficiently
 Isolating themselves from other people
 Stalling or ignoring obligations
 Consuming alcoholic beverages, cigarettes, or dose drugs to
slow down
 Engaging in anxious habits such as pacing, nail biting,
chewing on lip, tapping, knee bouncing, etc.
 
 STRESS MANAGEMENT

How to manage stress-

ABCs of stress management:
 Awareness
 Belief
 Commitment
 DIET:
 
 STRESS MANAGEMENT:
 Stress diary
 Job analysis
 Performance planning
 Imagery
 Physical relaxation technique
 Experienced. As one becomes aware of stressors, they can be
omitted, avoided or accepted.
 Rational thinking and positive thinking
 Anger management
 Building self-confidence
 Acupuncture.
PHYSICAL HEALTH MANAGEMENT:
 Take a deep breath!
 Stand-up straight!
 Go to bed early
 Relax
 Take a break
 Eat properly
 Exercise.
MENTAL HEALTH MANAGEMENT:
 Realistic expectations
 Reframe your thoughts
 Laugh
 Social support
 Massage
 
 Music Therapy:
 Meditation
 Yoga
 Acupuncture
 Biofeedback
 Guided Imagery
 Sound Therapy
 
 NURSING DIAGNOSES FOR
STRESS:

1)Anxiety related to:

 Change in health status
 Maturational or situational crisis
 Altered growth and development related to
 Separation from significant others
 Situational crisis (e.g., unplanned pregnancy)
2)Caregiver role strain related to:
 Adjustment to medical diagnosis
 Adjustment to decreased level of physical function
3)Fatigue related to:
 Overwhelming psychological demands
 Excessive role demands
4)Hopelessness related to:
 Long-term stress
 Lost belief in value
5)Risk for injury related to:
 Impaired problem-solving abilities
CRISIS AND ITS
INTERVENTION
 INTRODUCTION

Stress full situation are part of everyday life. Any stress full situation can
precipitate crisis. Crisis intervention requires problem-solving skills that are
often diminished by the level of anxiety. Therefore assistance is required to
solve the problem and preserve the self-esteem. Priority of crisis
intervention/counseling is to increase stabilization. Crises are temporary, no
longer than a month, although the effects may become long-lasting.
 
 DEFINITION

Crisis is a sudden event in one's life that disturbs homeostasis, during which the
individual's usual coping mechanisms cannot resolve the problem.

_Lagerquist
A crisis is self-limited and can last from a few hours to
weeks. It is characterized by an initial phase in which
anxiety and tension rise, followed by a phase in which
problem-solving mechanisms are set in motion.
_Kaplan and saddock
 CHARACTERISTICS OF CRISIS
 

Crisis occurs in all individuals at one time or another and is 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.
Crisis is 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.
 PHASES IN THE DEVELOPMENT
OF A CRISIS

Individuals progress through this in response to a precipitating stressor and that

culminate in the state of acute crisis.
PHASE:I
 The individual is exposed to a precipitating stressor.
 Anxiety increases and the previous problem-solving techniques are used.
PHASE:II
 When the previous problem-solving techniques do not relieve the
stressor, anxiety increases further.
 The individual begins to feel great deal of discomfort at this point.
 Coping techniques that have worked in the past are attempted.
 When they are not successful, that will create feeling of
helplessness.
 Feeling of confusion and disorganization prevails.
 
PHASE:III
 All possible sources-both internal and external are called onto solve the
problems and relieve the discomfort.
 The individual may try to ok at the problem from different perspectives.
 New problem-solving techniques may be used.
 If effective, the individual will come out of the stressful situation.
PHASE:IV
 If resolution does not occur, the tension mounts beyond the
threshold and individual reaches to a breaking point.
 Anxiety will reach to a panic level.
 Cognitive functions get disordered.
 Behavior may reflect presence of psychotic thinking.
 
  
TYPES OF CRISIS

Dispositional crises
Maturational/developmental crises
Crises reflecting psychopathology
Crisis resulting from traumatic stress
Crises of anticipated life transitions
Psychiatric emergencies.
Crisis intervention
CRISIS CONTINUUM
 CRISIS CONTINUUM

1) POTENTIAL CRISIS STATE

Whenever any acute problem or serious threat occurs ,Individuals will
become tense and employs emergency Problem solving methods to resolve
crisis, but it is Ineffective.
2) PRE-CRISIS STATE
When person has high probability of exposure to Stressful events,
in an adequate support, lack of coping Abilities, poor history of
handling stress will be more Upset and enter into a state of
disequilibrium.

3) IMMEDIATE CRISIS STATE

As tensions continue to build, they mobilize all internal
And external resources to restore the equilibrium.
4) INTERMEDIATE CRISIS STATE
The problem may be re-evaluated and attacked from a New angle or the
problem may be distorted and viewed as unsolvable.

5)ADVANCED CRISIS STATE

Persons who have continued to draw all inner Resources, have continued
failing in attempts to resolve .The problems, emotional pressures
continue to build And people become completely disorganized or
Immobilized owing to serve anxiety or depression State.
6) FULL CRISIS STATE
Person, who has failed in all attempts to solve the Problems, believes
that all resources have been used Feels more stress.
 
 CRISIS INTERVENTION

Crisis intervention refers to the methods used to offer immediate,

short-term help to individuals who experience and Produces
emotional, mental, physical, and behavioral distress or problems.
 
 PURPOSE

 To reduce the intensity of an individual's emotional, mental, physical and

behavioral reactions to a crisis.
 To help individuals return to their level of functioning before the crisis.
 To assist the individual in recovering from the crisis and to prevent serious
long-term problems from developing.
 
GOALS OF CRISIS INTERVENTION
 INDICATION FOR CRISIS
INTERVENTION

 Abstinence  Severe depression

 Pediatric  Severe anxiety
 Geriatric
 Marital conflicts
 Adolescent-maturational crisis
 Suicidal thought
 People who attempted suicide
 Psychosomatic patients  Illicit drug abuse
 Violent behavior  Traumatic events or traumatic
 Accident victims experiences
 Family crisis  Intra group staff issues
 High risk families eg ill members recent deaths  Client management issue
 SETTINGS FOR CRISIS
INTERVENTION
 Hospitals- outpatient unit, inwards emergency room Settings
 Mental health care centers
 Community setting
1. Stress
2. Home visit
3. Outreach centers
 Telephonic counseling and hotline
1. Information calls
 Suicide prevention and crisis intervention centers.
 Schools, offices, private practice
CONTINUUM OF CRISIS
RESPONSES
 
CONTINUUM OF CRISIS RESPONSES

Adaptive Responses Maladaptive Responses

Growth Precrisis functioning Disorganization

 TECHNIQUES OF CRISIS
INTERVENTION

1.CATHARSIS
 The release of feelings that takes place as the patient
 Talks about emotionally charged areas.
 For eg: tell me about how you have been feeling since
You last your job.
2.CLARIFICATION
 Encouraging the patient to express more clearly the Relationship
between certain events.
 For eg: I have noticed that after you have an argument
With your husband you become sick and cannot leave your bed.

3.SUGGESTION
 Influencing a person to accept an idea or belief, Particularly the
belief that the nurse can help and that the Person will in time feel
better.
 For eg: many other people have found it helpful to talk About this
and I think you will, too.
4.REINFORCEMENT OF BEHAVIOR
Giving the patient the positive responses to adaptive behavior.
For eg: that is the first time you were able to defend
Yourself with your boss and it went very well. I am so
Pleased that you were able to do it.

5.SUPPORT OF DEFENSE
 Encouraging the use of healthy, adaptive defenses and Discouraging
those that are unhealthy or maladaptive.
 For eg: going for a bicycle ride when you were so angry Was very helpful
because when you retumed you and your Wife were able to talk things
through.
6.RAISING SELF-ESTEEM
Helping the patient regain feeling of self- worth.
For eg: you are a very strong person to be able to manage The
family all this time. I think you will be able to handle .This situation,
too.

7.Exploration Of Solution
Examining Alternative Ways Of Solving The Immediate Problem.
For Eg: You Seem To Know Many People In The Computer Field.
Could You Contact Some Of Them To See Whether They Might
Know Of Available Jobs?
8.EVALUATION
The last phase of crisis intervention is evaluation, when the nurse and
patient evaluate whether the intervention Resulted in a positive resolution
of the crisis. Specific Questions the nurse might ask include the following:
 Has the expected outcome been achieved and has The patient returned to
the pre crisis 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?
 Does the patient have adequate support systems and Coping resources
on which to rely?
 
 ROLE OF THE NURSE

 ASSESSMENT
 PLANNING OF THERAPEUTIC INTERVENTION
 INTERVENTIONS
 EVALUATION
ASSESSMENT
 Ask The Individual To Describe The Event That Precipitated The Crisis.

Determine When It Occurred.

 Assess The Individual's Physical And The Mental Status.
 Determine If The Individual Has Experience This Stressor Before .If So
What Method Of Coping Was Used ?Have These Methods Been Tried
This Time?
 Assess Suicide And Homicide Potential Plan And Means.
 Assess The Adequacy Of Support Systems.
 Assess The Individuals Perception Of Personal Strengths And Limitations.
 Assess The Individual Use Of Substances.
PLANNING OF THERAPEUTIC INTERVENTION

• In planning the intervention, the type of crisis, as well as the individual's

strengths and available resources for support, are taken into consideration.
• Goals are established for crisis resolutions and a return to, or increase in,
the precrisis level of functioning.
INTERVENTIONS

 Use reality : orientation approach the focus of the problem is

on the here and now.
 Remine with the individual who is experiencing panic anxiety.
 Discourage lengthy explanation or rationalization of the
situation, promote an admosphere for verbalization of true
feeling.
 NURSING DIAGNOSIS

 Anxiety
 Ineffective coping
 Inability to carryout routine activity
 Impaired social interaction
 Risk for suicide
 SUMMARY

By The End Of Class We Have Seen About Stress Types What Are
The Health Problem Linked to Stress , Stress In Nursing Personal,
Stress Management .Crisis ,Types , Techniques ,Nursing Diagnosis
.
 JOURNAL ABSTRACT

Stress and Coping Strategies of Students in a Medical Faculty in Malaysia

 Abstract
 Background:
 Stress may affect students’ health and their academic performance. Coping
strategies are specific efforts that individuals employ to manage stress. This
study aimed to assess the perception of stress among medical students and their
coping strategies.
Method:
A cross-sectional study was conducted among 376 medical and medical sciences undergraduates in
Management and Science University in Malaysia. Stress was assessed by a global rating of stress. Sources
of stress were assessed using a 17-item questionnaire. The validated Brief COPE inventory was used to
assess coping strategies.

Results:
The majority of respondents were females (64.4%), aged 21 years or older (63.0%), and were Malays
(68.9%). Forty-six percent felt stress. The most common stressor was worries of the future (71.0%),
followed by financial difficulties (68.6%). Significant predictors of stress were smoking (OR = 2.9, 95%
CI 1.3–6.8, P = 0.009), worries of the future (OR = 2.1, 95% CI 1.3–3.4, P = 0.005), self-blame (OR =
1.3, 95% CI 1.1–1.5, P = 0.001), lack of emotional support (OR = 0.8, 95% CI 0.7–0.9, P = 0.017), and
lack of acceptance (OR = 0.8, 95% CI 0.6–0.9, P = 0.010). Students used active coping, religious coping
reframing, planning, and acceptance to cope with stress.
Conclusion:
Stressors reported by the students were mainly
financial and academic issues. Students adopted active
coping strategies rather than avoidance. Students
should receive consultation on how to manage and
cope with stress.
 BIBLIOGRAPHY

Bookreference:
1)Shebeer.P Basheer,A Concise Text Book Of Advanced Nursing Practice,I St
Edition,Emmess Medical Publishers, Bangalore, 2012, Pg No:625-638.
2)Navdeepkaur Brar Hc Rawat, Text Book Of Advanced Nursing Practice ,Ist Edition,
Jaypee Brothers publication Pg No:865-883.
3)Sreevani, Textbook Of Mental Health Psychiatric Nursing,3rd Edition , Jaypee
Brothers Publication Pg No -292 -295.
4)Gail W. Stuart , Michele T.Laraia , Text Bookof Principles And Practice Psychiartric
Nursing 7th Edition,Ph No-75, 115.
 
Net Reference:

1)https://www.medical NewstodayCom./Articles/7624#Prevention
 
2)https://www.pitt.edu/~super4/39011-40001/39311.ppt
 
3)https://nursekey.com/stress-and-adaptation/
 
4)https://us.sagepub.com/sites/default/files/upm
assets/14229_book_item_14229.pdf

5) http://www.mjms.usm.my/default.asp