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Levon Ter-Bagdasarian is a psychiatric assessment clinician at Las Encinas Hospital in Pasadena, Calif. He conducts crisis evaluations, does psychiatric clinical assessments, determines level of psychiatric care needed, and makes recommendations for further management and referrals.
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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.6
| Case Study: Part 1 Karen, a 36-year-old registered nurse, was working the night shift in the emergency department. It was a quiet night, so she and the other nurses were sitting in the break room when a call came in that 3 of the staff nurses from the intensive care unit, carpooling on their way home from work, had been struck head on by a drunk driver. The injured nurses were transported back to their own hospital; 1 nurse had head trauma, 1 had multiple extremity fractures, and 1 had blunt chest trauma. Despite nearly 8 hours of resuscitative measures and surgical intervention, all 3 nurses died of their injuries. The driver of the other car, who had a fractured pelvis and femur, was transported to the same hospital. He underwent surgery and was admitted to the intensive care unit. He was expected to survive his injuries. That day a critical incident stress management team was called in to provide debriefing for the staff and other employees of the intensive care unit and emergency department.
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Critical 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.
Acute Stress
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.9
Critical Incident Stress
A 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.12
The 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.10
An 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, panic, major depression, dysthymia, alcoholism, somatoform disorders, and personality disorders. If these sequelae go untreated, they and their attendant pain and suffering can persist until death.
Acute Stress Disorder
The most common psychiatric problem after a traumatic event is acute stress disorder. The main diagnostic features of acute stress disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition13 are described in Table 1
. These features generally occur within the first month after the traumatic event and can last from 2 days to 4 weeks. The types of stressors or traumatic events that may lead to development of the disorder are presented in Table 2. In general, the signs and symptoms of acute stress disorder experienced by a person during or after the traumatic event are a subjective sense of numbing, or absence of emotional responsiveness; a reduction in awareness of his or her surroundings (derealization); a feeling of detachment or estrangement from himself or herself (depersonalization); and blocking of traumatic events from his or her memory (dissociative amnesia).
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The differences between CIS and acute stress disorder are important. First, acute stress disorder is explicitly defined,13 whereas CIS has no standardized definition. Second, persons experiencing CIS vary in both the number and the severity of their signs and symptoms of stress. These ambiguities make a structured study of responses to CIS somewhat difficult.12
Overview of CISM
CISM is a comprehensive program involving an entire organization. The ultimate purpose is to maintain or restore personnel to their usual state of health by mitigating the extreme effects of traumatic stress. CISM, simply put, accelerates the normal recovery of formerly healthy people who are experiencing painful reactions in response to abnormal events. The interventions of CISM are implemented during precrisis, acute crisis, and postcrisis phases. CISM includes the need for follow-up and, if possible, provides a sense of psychological closure after the crisis. CISM, provided by persons trained in the techniques and not directly involved in the incident, can be applied to individuals, small functional groups, large groups, families, organizations, and even communities. Thus, in CISM, critical incidents are viewed from a holistic and encompassing perspective.16,17
CISM must be differentiated from psychoanalysis or counseling and from crisis intervention. Crisis intervention has a long and rich history as a therapeutic technique for individuals. CISM is not meant to take the place of crisis intervention; rather, as an integrative modality, CISM focuses on the larger picture of crisis and the immediacy of the critical incident, with immediate resolution of sequelae.
A CISM program has 7 major components (Table 4). An overall plan is put into place before a disastrous event occurs.16,17 Precrisis preparation includes providing (1) basic information on stress management education, stress resistance, and relaxation and (2) crisis mitigation training for both individuals and organizations. Stress inoculation training is a technique based on the premise that individuals can affect their ability to deal with stress by modifying their beliefs and self-statements about their performance in stressful events by activating appropriate coping resources. The technique might enable persons to deal with a future situation more effectively by reducing the overall stress response and by providing an understanding that the stress reaction is a normal physiological reaction. Stress inoculation training has 3 phases: cognitive preparation, skills acquisition and rehearsal, and application and practice of coping techniques.18
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CISD is a structured group discussion usually held 1 to 10 days after the crisis. It is designed to mitigate acute signs and symptoms, assess the need for follow-up, and if possible, provide a sense of psychological closure after the crisis. Crisis intervention includes counseling or psychological support throughout the full spectrum of the crisis to allow each person to return to the level of functioning he or she experienced before the crisis. Appropriate questions to ask at this time might include those listed in Table 5.
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Overview of CISD
CISD, one of the components of CISM, is a peer-driven, therapist-guided, structured group intervention designed to mitigate the effects of the overwhelming event and accelerate the recovery of personnel.6 CISD can have a beneficial effect on healthcare workers who participate in the debriefings.20–22 The intervention originally was developed as a short-term, group, preventive mental health intervention for traumatized law enforcement and emergency services personnel. CISD has since been used in a variety of personnel and crisis situations, and its structure and process have been modified.23 Clearly, CISD requires a well-trained and organized response team and the acceptance, participation and support of the organization’s management at all levels. CISD is more than just the job of the well-trained team; it is also the job of those people who offer the leadership and education for CISD activities within an organization.
CISD is based on the principles of rapid outreach and intervention; a focus on the present, the "here and now"; and the mobilization of existing internal and external resources. Debriefing is thought to enable victims of psychological trauma to cognitively and emotionally process the experience. Provided 1 to 10 days after a critical incident, debriefing takes about 2 to 3 hours and is thought to reduce the opportunity for maladaptive and disruptive cognitive and behavioral patterns to become established.24 CISD is almost always followed by individual sessions for participants who require them.
| Case Study: Part 2 During the critical incident stress debriefing session, Karen and her coworkers were given information about the purpose of the session and an opportunity to verbalize their knowledge about the facts related to the incident. They were encouraged to discuss their initial thoughts ("Life is unfair . . . " "This could have happened to me. . . ."); their feelings ("I feel sad about . . . " "I feel guilty that we were unable to save their lives. . . ."); and their cognitive, emotional, and physical reactions to the critical incident. Then the participants were asked to speak about their relationships with their deceased coworkers and the deceased coworkers’ families. Toward the end of the debriefing session, Karen and her coworkers received information about maladaptive coping mechanisms and constructive cognitive and behavioral patterns that would help relieve many of the anxieties they were experiencing and, for those requesting it, were given referrals for further counseling.
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The main goals of CISD are as follows24:
Finally, CISD ensures follow-up and referral for professional assistance when necessary.24
CISD has 7 phases25:
Another widely accepted model25 outlines the areas to explore in psychological debriefing of workers and helpers after disasters/traumatic events:
Implications for Advanced Practice Nurses
Advanced practice nurses in acute and critical care are educated to assume leadership roles in the healthcare environment. In addition, they have been educated in advanced communication techniques and organizational behavior and structure. Development of and participation in CISM teams and other interventions to lessen the initial impact of major stressful events that affect persons in the work environment are reasonable outcomes of that education.
Recommended interventions to accelerate the physical and emotional healing of nurses from critical incidents include the use of CISM and personal stress management strategies such as relaxation exercises, meditation, physical exercise, and group and humor therapy.26 One of the main advantages of CISM is its structured approach; the problem of stress is addressed in a proactive way by making education the starting point. If acute and critical care nurses can recognize and acknowledge stress and its causes, then they will be better able to prevent accumulative pressures and lessen the impact of critical incidents.27
Advanced practice nurses process information related to the stress experience of individuals, the individuals’ ability to successfully cope given the magnitude of the critical incident, and the effectiveness of the coping behaviors and make sound clinical judgments about the need for CISD. The ability to help persons examine and evaluate a critical incident and cope effectively is related to an ability to do a complete assessment for intrusive thoughts, avoidance reactions, and physical signs and symptoms.
Other interventions include an appraisal and reorientation of the work environment to promote communication, collaboration, empowerment, and accountability for improved nursing care and patients’ outcomes. One way to achieve this end is to train colleagues who volunteer to participate in a CISM program and who have participated in an extensive training program as a peer counselor. Because no one understands better than acute and critical care nurses themselves what acute and critical care nurses do, these peer counselors are ideal advocates and are valued and trusted members of the CISM team.
Research and education should be focused on the factors that promote and prevent acute, chronic, and posttraumatic stress in acute and critical care nurses after a critical incident. A comprehensive approach, using groups such as CISM teams and mental health professionals to work toward these goals, is a beginning.24
Summary
Everyone experiences stress. That stress may be related to work (internal), community (external), or family; it may be cumulative or related to a particular critical incident. The cost related to treating acute stress is staggering, both to individuals and to organizations. Critical care nurses are well educated in the physiological responses to the stress of acute illness. Recognizing the emotional impact of stress and the techniques to manage it in themselves and in those with whom they work is equally as important. CISD is widely advocated as an intervention after critical incidents. Although debriefing in and of itself is effective, a single-session semi-structured crisis intervention will not prevent posttraumatic stress; thus, the use of CISD as part of a comprehensive multifaceted approach to the management of acute stress related to a critical incident is recommended.
References
This article has been cited by other articles:
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  L. A. P. Watson Informing Critical Care Patients of a Loved One's Death Crit. Care Nurse, June 1, 2008; 28(3): 52 - 63. [Full Text] [PDF]
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 S. Lorin, J. Heffner, and S. Carson Attitudes and Perceptions of Internal Medicine Residents Regarding Pulmonary and Critical Care Subspecialty Training Chest, February 1, 2005; 127(2): 630 - 636. [Abstract] [Full Text] [PDF]
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