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1
CrisisandDisaster
CHAPTER26
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Crisis“TheChinesewordforcrisisiswrittenbyjoiningtwo
ideogramstogether.ThesetwoideogramsmakeuptheChinesewordforcrisis.Whentheseideogramsare
presentedseparatelytheystandfortwodifferentideasorconcepts.Thefirstideogramsstandsfordangerandthe
secondideagrandstandsforopportunity.”(Russell,1979)
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Crisis
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Crisis intervention is what nurses and other health professionals do to assist those in crisis to cope. Interventions need to be broad, creative, and flexible.
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Crisis• Profound disruption of normal psychological homeostasis
• Astruggleforequilibriumandadaptation
• Results in inability to function as usual
• Presentsopportunityforpersonalgrowth
• Acuteandtime-limited
• Responsetoacrisisisanormalnotpathologiclifeexperience
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OutcomesofCrisis• Dependsupon
• Perceptionoftheeventbyindividual,family,community
• Adequatesituationalsupports
• Crisisintervention
• Adequatecopingmechanisms
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CrisisInterventionFoundations
� Crisisisself-limiting(4-6weeks)
� Goalofcrisisintervention:returntopre-crisisleveloffunctioning
� Duringacrisis,peoplearemoreopentonewproblemsolvingandcopingtechniques
� Focusontheimmediatecrisisonly
� Nursewillbeactive,evendirective
� Earlyinterventionincreaseschanceforgoodoutcomes
� Goalsshouldberealisticandmutual
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Theory
• ErichLindemann(1940s):ReportedCoconutGrovenightclubfireinBoston.
• GeraldCaplan(1964):Outlinedcrisisinterventionstrategies.
• JeffersonCenterforMentalHealth(JCMH)(1961):Reportresultedincrisiscenters.
• Aguilera/Messnick(1970):Providedframeworkfornursingcrisisassessmentandintervention.
• Roberts(2005):Seven-stagemodelofcrisisinterventionhelpsinacutesituationalcrisisandacutestressdisorder.
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(Continued)
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Roberts’s Seven-Stage Model of Crisis Intervention
Follow-up plan and
agreement
Develop and formulate an action plan
Generate and explore alternative
Deal with feelings and emotions (including active listening and validation)
Identify major problems (including the “last straw” or crisis precipitants)
Establish rapport and rapidly establish relationship
Plan and conduct crisis assessment (including lethality measures)
Crisis resolution
ClinicalPicture:TypesofCrisis
Threebasictypesofcrises:
(1)Maturational(2)Situational(3)Adventitious(disasters)
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Divorce
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TypesofCrisis• Maturational
• Newdevelopmentalstageisreached
• Oldcopingskillsnolongereffective
• Leadstoincreasedtensionandanxiety
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TypesofCrisis(Cont.)
• Situational
• Arisefromeventsthatare
• Extraordinary
• External
• Oftenunanticipated
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TypesofCrisis(Cont.)
• Adventitious
• Unplannedandaccidental
• Naturaldisaster
• Nationaldisaster
• Crimeofviolence
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TextQuestion
Ms.T.,asinglemotheroffour,comestothecrisiscenter24hoursafteranapartmentfireinwhichallthefamily’shouseholdgoodsandclothingwerelost.Ms.T.hasnofamilyinthearea.Hereffortstomobilizeassistancehavebeendisorganized,andsheisstillwithoutshelter.Sheisdistraughtandconfused.Thenurseassessesthesituationaswhichofthefollowingtypesofcrisis?A. MaturationalcrisisB. SituationalcrisisC. AdventitiouscrisisD. Evidenceofaninadequatepersonality
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Caplan’sFourPhasesofCrisis:Phase1Conflictorproblem
$�Self-conceptthreatened
$Increasedanxiety
$Useofproblem-solvingtechniquesanddefense
mechanisms$
Resolveconflictorproblem$
Reduceanxiety
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Caplan’sFourPhasesofCrisis:Phase2Problem-solvingtechniquesanddefensemechanismsfail
$Threatpersists
$Anxietyincreases
$Feelingsofextremediscomfortproduced
$Functioningdisorganized
$Trial-and-errorattempttosolveproblem
andrestorenormalbalance
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Caplan’sFourPhasesofCrisis:Phase3Trial-and-errorattemptsfail
$ Anxietycanescalatetosevere
andpaniclevels$
Automaticreliefbehaviorsmobilized(i.e.,withdrawalandflight)
$ Someformofresolutionmaybemade
(i.e.,compromisingneedsorredefiningsituation)
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Caplan’sFourPhasesofCrisis:Phase4Problemnotsolved
andcopingskillsineffective$
Overwhelminganxiety$
Possibleseriouspersonalitydisorganization,depression,confusion,violenceagainstothers,orsuicidalbehavior
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ApplicationoftheNursingProcess• Assessment
• Firstassessforsuicidalorhomicidalideationsorgestures• Generalassessment• Assessmentofperceptionofprecipitatingevent• Assessmentofsituationalsupports• Assessmentofpersonalcopingskills• Selfassessment
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NursingProcess(Cont.)
• Diagnosis(Table25-2)• Riskforsuicide• Ineffectivecoping
• Outcomesidentification(Table25-3)• Implementation
• Basiclevel• Patientsafety• Anxietyreduction
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CrisisIntervention:ThreeLevelsofNursingCare
• PrimaryCare
• Promotesmentalhealthandreducesmentalillnesstodecreasetheincidenceofcrisis
• SecondaryCare• Establishesinterventiontopreventprolongedanxietyfromdiminishingpersonaleffectivenessandpersonalityorganization
• TertiaryCare• Providessupportforthosewhohaveexperiencedaseverecrisisandarenowrecoveringfromadisablingmentalstate
• Rehabilitationcenters,shelteredworkshops,dayhospitals,outpatientclinics
• Socialandcommunityfacilitiesthatprovidestructuredenvironmentsthatcanhelppreventproblemsituations
Evaluation:Crisis
• Anevaluationforapersonincrisisisusuallyperformed4to8weeksaftertheinitialinterview.
• Appropriatequestionstoaskareasfollows:• Isthepatientsafe?• Hasthepatientdevelopedmoreadaptivewaystocopewithstress
andanxiety?• Doesthepatienthaveastrongerexistingsupportsystem?• Hasthepatientmaintainedanoptimalleveloffunctioning?• Hasthepatientreturnedtothepre-crisisleveloffunctioning?
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ClassActivity
Defineanddiscussthefollowing:• Terrorism• Masscasualtyincidents(MCIs)• Disasterresponse• TheNationalIncidentManagementSystem(NIMS)
• Triage
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Disasters• Disastermanagementcontinuum
• Preparedness
• Mitigation
• Response
• Recovery
• Evaluation
CriticalIncidentStressDebriefing
Criticalincidentstressdebriefing(CISD)isatertiaryinterventiondirectedtowardagroupthathasexperiencedacrisis.
CISDisusedtodebrief:• Staffmembersonaninpatientunitafterthesuicideofapatient
• Staffmembersafterincidentsofpatientviolence• Crisishotlinevolunteers• Schoolchildrenandschoolpersonnelaftershootingshaveoccurredinaschool
• Rescueandhealthcareworkerswhohaverespondedtoanaturaldisasterorterroristattack
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CriticalIncidentStressDebriefing(CISD)
• Sevenphases• Introductoryphase• Factphase
• Thoughtphase• Reactionphase
• Symptomphase
• Teachingphase
• Re-entryphase
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AudienceResponseQuestions1. Whichtermismostapplicabletocrisis?
A. Self-limitingB. BoundariesC. AmnesiaD. Chronic
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AudienceResponseQuestions2. Acategory5hurricanedestroyshomesandbusinessesina
community.Howwouldthiscrisisbeclassified?
A. DisequilibriumB. AdventitiousC. MaturationalD. Situational