CRISIS MANAGEMENT

Before you proceed …

1. Compare and contrast the differences among primary, secondary, and

tertiary intervention including appropriate intervention strategies;
2. Explain the potential crisis situations that patients may experience in hospital settings;
3. Provide concrete examples of interventions to minimize crisis situations; and,
4. List at least five resources in the community that could be used as referrals for a
patient in crisis.
Activities:
1. Critical Thinking exercises
2. Crisis Intervention Simulation

Let’s Begin v:◆◆:v◆:v

Activity:
1. What do you see or perceive in this image?

2. How many faces do you see?

 3. What happened to the feet of the elephant?

Terms to Remember
adventitious
crisis crisis
intervention
equilibrium
homeostasis
maturational
crisis mitigation
primary care
recovery
response
secondary care
situational
crisis tertiary
care

What is CRISIS?
It is a major disturbance caused by a stressful event or threat, disrupts this
homeostasis Normal coping mechanisms fail resulting in an inability to function as
usual
Equilibrium is replaced by disequilibrium
Factors:
 Perception
 Support
 Coping Mechanism

Perception of the Event:

Most important aspect associated with CRISIS – either realistic or distorted
Threat is based on a person’s unique perspective and coping abilities
People vary in absorption, processing, and usage of information from the environment

Situational Support
Includes all the people who are available that can be depended upon to help during
the time of a crisis

Coping Mechanisms
 Skills and mechanisms learned from variety of sources (e.g. cultural responses,
modeling behaviors from others, life opportunities) that may be used when faced with
stressful events and/or trauma

Types of CRISES

1. Maturational Crisis
Life changes that occur throughout the different lifespans
Changes may either be physical, cognitive, instinctual, and sexual
ACTIVITY: In each of the different changes that happen throughout the lifespan, give at
least 2 situations that you think might affect equilibrium.
a) Physical
i.
ii.
b) Cognitive
i.
ii.
c) Instinctual
i.
ii.
d) Sexual
i.
ii.

2. Situational Crisis
Arises from events that are extraordinary, external, and often unanticipated
ACTIVITY: Enumerate at least 2 events that may lead to situational crisis.
i.
ii.

3. Adventitious Crisis
Caused by events that are unplanned and may be accidental, caused by
nature, or human-made
It may be natural disaster, national disaster or crime of violence
ACTIVITY: Provide at least 2 situations of each kind of adventitious crisis
a) Natural Disaster
i.
ii.
b) National Disaster
i.
ii.
c) Crime of Violence
i.
 ii.

STOP AND REFLECT!!!

As it was mentioned earlier, crisis is associated to an unanticipated

event. Which do you think might be one of your crisis two years from
now?

CRISIS: Utilizing the Nursing Process

ASSESSMENT

CLINICAL VIGNETTE
Madison, a 25-year-old woman, is brought to the emergency department by police
after being beaten by her husband. Madison is seen by the medical personnel and
then interviewed by the psychiatric-mental health registered nurse working in the
emergency department. The nurse calmly introduces herself and tells Madison she
would like to talk with her. The nurse says, “It looks as if things are overwhelming.
Is that how you’re feeling?” Madison is slumped in the chair, her hands in her lap,
head hanging down, and has
tears in her eyes. She nods.

General Assessment:
Utilized an established crisis theory and sound knowledge based on the nursing
process Set realistic and meaningful goals with the patient and plan for possible
solutions

ALWAYS REMEMBER!
 A crisis is self-limiting and usually resolves within 4 to 6 weeks.
 At the resolution of a crisis, the patient will emerge at one of three different
functional levels:
o A higher level of functioning.
o The same level of functioning.
o A lower level of functioning.
 The goal of crisis intervention is to return the patient to at least the precrisis
level of functioning.
 The form of crisis resolution depends on the patient’s actions and
others’ interventions.
 During a crisis, people are often more receptive than usual to outside intervention.
With intervention, the patient can learn different adaptive means of problem solving to
correct inadequate solutions.
 The patient in a crisis situation is assumed to be mentally healthy, to have functioned
well in the past, and to be presently in a state of disequilibrium.
 Crisis intervention deals only with the patient’s present problem and resolution of
 the immediate crisis (e.g., the “here and now”).
 The nurse must be willing to take an active, even directive, role in intervention, which
is in direct contrast to conventional therapeutic intervention that stresses a more
passive and nondirective role.
 Early intervention probably increases the chances for a good prognosis.
 Encourage the patient to set realistic goals and plan a focused intervention with
the nurse.
Assessing Perception of Precipitating Events
The better the ability of the client to define the problem, the higher the identification of
solution
E.g.:
o What leads you to seek help now?
o Has anything upsetting happened to you within the past few days or weeks?
o Describe how you are feeling right now.
o How does this situation affect your life?
o How do you see this event affecting your future?
o What do you hope to get out of this treatment?
CLINICAL VIGNETTE
Nurse: “Madison, tell me what happened.”
Madison: “I can’t go home…, I am so afraid…, No one believes me…, I can’t go through it
again.”
Nurse: “Tell me what you can’t go through again.”
(Madison starts to cry, shaking with sobs. The nurse sits quietly for a moment and then
speaks.)
Nurse: “Tell me what is so terrible. Let’s look at it together.”

After a while, Madison tells the nurse that her husband beats her regularly, and he becomes
particularly brutal when he drinks. The beatings have become much worse over time. Madison
states, “I’m afraid that he’ll eventually kill me.”

Assessing Situational Support

Determine available resources – emotional and/or material support – that may be used
as support system of the client
If unavailable resources, the nurses acts as a temporary support
person E.g.:
o Is there anyone—family or friends—you would like to have involved in your
care?
o Have you ever used a community agency for support?
o Do you have a religious affiliation?
o Are you active in a religious group?
CLINICAL VIGNETTE
Nurse: “Madison, what are your options? Do you have any family who can support you?”
Madison: “No. My family is in another state.”
Nurse: “How about friends?”
Madison: “I really don’t have any friends. My husband’s jealousy has made it impossible for
me to have friends. He finds fault with everyone.”
Nurse: “What about your co-workers?”
Madison: “My co-workers are nice, but I can’t tell them things like this.”

The nurse learns that Madison does well at her job. Madison explains that her job helps her
forget her problems for a little while. Getting good job reviews also has another reward: It
is the only time her husband says anything nice about her.
Assessing Coping Skills
Common positive coping mechanisms may be seeking out someone to talk to, writing
feelings in a journal, or engaging in other physical activity
Ineffective coping includes overeating, drinking, smoking, withdrawing, yelling, and
fighting
E.g.:
o What have you been doing to relieve the anxiety you have been feeling?
o What has helped in the past to relieve stress?
o Did you try it this time? If so, what was different?
o What helped you through difficult times in the past?
CLINICAL VIGNETTE
Nurse: “You’ve been through an emotionally painful time. Your anxiety is understandable.
What has helped you in the past to make you feel more calm?”
Madison: “I don’t know. Probably talking.”
Nurse: “Okay. While you’re here, we will talk for at least 30 minutes each day. In group
therapy, you will have the chance to share what you’ve been going through and also
hear about how others cope.”
Madison: “Thanks. I don’t want to be in an abusive marriage. I just don’t know where
to turn.”
Nurse: “I understand. We will work together to come up with a plan.”

Video#1: Virtual Simulation of Crisis Intervention

 Assessment Guidelines
CRISIS
1. Determine whether the patient is able to identify the precipitating event.
2. Assess the patient’s understanding of situational supports.
3. Identify the patient’s usual coping styles, and determine what coping
mechanisms may help the present situation.
4. Determine whether there are certain religious or cultural beliefs that
need to be considered in assessing and intervening in this patient’s
crisis.
5. Assess whether this situation is one in which the patient needs primary
intervention (education, environmental manipulation, or new coping skills),
secondary intervention (crisis intervention), or tertiary intervention
(rehabilitation).

DIAGNOSIS

Ineffective coping may be evidenced by inability to meet basic needs, inability to meet
role expectations, alteration in social participation, use of inappropriate defense
mechanisms, or impairment of usual patterns of communication
Anxiety related to a maturational, situational, or adventitious crisis is always present in
moderate, severe, and panic levels.

OUTCOMES IDENTIFICATION

Signs & Symptoms Nursing Outcomes

Diagnosis
Inability to meet basic needs, IneffectiveModifies lifestyle as needed, uses
decreased use of social support, Coping effective coping strategies, reports
inadequate problem solving, inability decrease in physical symptoms of
to attend to information, isolation stress, reports decrease in
negative
feelings
Denial, exaggerated startle response, Post-trauma Exhibits non-labile mood, impulse
flashbacks, horror, hypervigilance, Syndrome control; reports adequate sleep,
intrusive thoughts and dreams, panic exhibits concentration, tends to ADLs,
attacks, feeling numb, substance shows interest in surroundings
misuse, confusion, incoherence
Minimizes symptoms, delays seeking Ineffective Recognizes reality of health situation,
care, displays inappropriate affect, Denial maintains relationships, copes with
makes dismissive comments when health situation, makes decisions
speaking of distressing events about health, reports sense of life
being worth living
Overwhelmed, depressed, states has Risk for Remains free from harm, expresses
nothing in life worthwhile, self- Suicide feelings of self-worth, verbalizes sense
hatred, feelings of being ineffectual, of personal identity, expresses
sees limited alternatives, feels meaning in life, sets goals, believes
strange, perceives a lack of control that actions impact outcomes
 Difficulty with interpersonal Social Expresses a sense of belonging, effects
relationships, isolated, has few or no Isolation meaningful relationships
social supports
Changes in family relationships and Compromise Manages family problems, expresses
functioning, difficulty performing d Family feelings openly among family
family caregiver role coping members, respite for caregiver, sense
of control for caregiver
Caregiver
Role Strain

PLANNING

Plan and intervene verity of crisis-intervention modalities

o disaster nursing
o mobile crisis units
o group work
o health education and crisis prevention
o victim outreach programs
o telephone hotlines
CLINICAL VIGNETTE
In a group meeting with the nurse and a social worker, Madison announces that she has made
a decision to leave her husband and not return home. Madison, the nurse, and the social
worker establish goals:
• Madison will return to her precrisis state within 2 weeks.
• Madison will find a safe environment.
• Madison will identify at least two outside supports within 24 hours.

IMPLEMENTATION

Focus: present problem

Initial goals: (1) patient safety and (2) anxiety reduction
Active role: provision of competent crisis-intervention skills and showing genuine interest
and support
Keep in mind: provide autonomy and independence

Levels of Care
1. Primary Care
 Promotes mental health and reduces mental illness
 The nurse can:
o Work with a patient to recognize potential problems by evaluating
the patient’s experience of stressful life events.
o Teach the patient specific coping skills, such as decision making,
problem solving, assertiveness skills, meditation, and relaxation skills.
o Assist the patient in evaluating the timing or reduction of life changes to
decrease the negative effects of stress as much as possible. This may
involve
 working with a patient to plan environmental changes, make important
interpersonal decisions, and rethink changes in occupational roles.

2. Secondary Care
 Establishes intervention during an acute crisis
 Primary focus is to ensure the safety of the patient
 Goals are explored, interventions are planned
 Occurs in hospital units, emergency departments, clinics, or mental health centers,
usually during daytime hours

3. Tertiary Care
 Provides support for those who have experienced a severe crisis and are now
recovering from a disabling mental state
 Goals: (1) facilitate optimal levels of functioning and (2) prevent further emotional
disruptions

Critical Incident Stress Debriefing (CISD)

This is an example of a tertiary intervention directed toward a group that has
experienced a crisis
Consists of a seven-phase group meeting that offers individuals the opportunity to share
their thoughts and feelings in a safe and controlled environment
Uses:
a) to debrief staff on an inpatient unit following a patient suicide or an incident
of violence
b) to debrief crisis hotline volunteers
c) to debrief schoolchildren and school personnel after multiple school shootings
d) to debrief rescue and health care workers who have responded to a natural
disaster or a terrorist attack
Phases:
a) Introductory phase—Meeting purpose is explained; an overview of the debriefing
process is provided; confidentiality is ensured; guidelines are explained; team
members are identified; and questions are answered.
b) Fact phase—Participants discuss the facts of the incident; participants
introduce themselves, tell their involvement in the incident, and describe the
event from their perspective.
c) Thought phase—Participants discuss their first thoughts of the incident.
d) Reaction phase—Participants talk about the worst thing about the incident
— what they would like to forget, what was most painful.
e) Symptom phase—Participants describe their cognitive, physical, emotional, or
behavioral experiences at the incident scene and describe any symptoms they
felt following the initial experience.
 f) Teaching phase—The normality of the expressed symptoms is
acknowledged and affirmed; anticipatory guidance is offered regarding future
symptoms; the group is involved in stress-management techniques.
g) Reentry phase—Participants review material discussed, introduce new topics,
ask questions, and discuss how they would like to bring closure to the
debriefing. Debriefing team members answer questions, inform, and reassure;
provide written material; provide information on referral sources; and summarize
the debriefing with encouragement, support, and appreciation.
CLINICAL VIGNETTE
After talking with the nurse and the social worker, Madison seems open to going to a safe
house for battered women. She also agrees to talk to a counselor at a mental health facility.
The nurse sets up an appointment at which she, Madison, and the counselor will meet.

EVALUATION

If the intervention has been successful, the patient’s level of anxiety and ability
to function should be at pre-crisis levels
Patient chooses to follow up on additional areas of concern and is referred to other
agencies for more long-term work
To prepare a patient for further treatment

Modalities of Crisis Intervention

1. 23-hour crisis stabilization

Goal: Quick de-escalation of crisis situations and avoid unnecessary and costly
hospitalizations
Provision of specific referral for OPD

2. Short-term crisis residential services

Provision of continuous 24-hour observation and supervision for people who do
not require inpatient services
Goal: Elimination or reduction of acute symptoms of psychiatric disorders
Provision of community-based resources and safe environment for care and recovery

3. 24/7 crisis hotlines

Provision of immediate response during
crisis No insurance needed
Easy linking to community services

4. Warm lines
Designed to prevent escalation of distress
Provided by trained consumers – people who have experience using mental health
services.
5. Mobile crisis service
Provide acute crisis stabilization and psychiatric assessment services to people within
their own homes and in other sites outside of traditional clinical settings
Goal: Provide a rapid response, resolve crisis situations, and prevent hospitalizations

6. Peer crisis services

Provided by people who have had experience with living with a psychiatric disorder
Provide calm environment, support, and links to psychiatric services
Intended for >24hrs but may continue to several days

7. Psychiatric advance directive plan

Proactive method of addressing a crisis situation before it occurs
Developed by the consumer to be used in crisis situations where the consumer is
unable to make decision
Includes: (1) treatment of choice, (2) treatment facilities and providers, (3)
designated support person

SUMMARY:
• Crises can lead to personality disorganization but also offer opportunities for emotional growth.
• There are three types of crises: maturational, situational, and adventitious.
• Crises are usually resolved within 4 to 6 weeks.
• Crisis intervention therapy is short term, from 1 to 6 weeks, and focuses on the present
problem only.
• Resolution of a crisis takes three forms: a patient emerges at a higher level, at the
precrisis level, or at a lower level of functioning.
• Social support and intervention can promote successful resolution.
• Nurses take an active and directive approach with the patient in crisis.
• Whenever possible, the patient is an active participant in setting goals and planning
possible solutions.
• Crisis intervention is usually aimed at the mentally healthy patient who generally is
functioning well but is temporarily overwhelmed and unable to function.
• The crisis model can be adapted to meet the needs of patients in crisis who have long-term
and persistent mental problems.
• Specific qualities in the nurse that can facilitate effective intervention are a caring
attitude, flexibility in planning care, an ability to listen, and an active approach.
• The basic goals of crisis intervention are to reduce the individual’s anxiety level and to
support the effort to return to the patient’s precrisis level of functioning.
CRITICAL Thinking

Give what is being asked. Explain each item comprehensively. If answers were taken from
articles or journals, please cite according and don’t forget to include your bibliographic entries
using the APA format. Please be reminded to include proper punctuation and the use of
subject- verb agreement.

Situation: Currently a third-year nursing student of MCNP, Jomar voices concerns to his class
adviser regarding his father’s (43 years old) termination from work. For years long, his father
has been drinking heavily, and Jomar seems to cope with the situation difficultly. Because of his
father’s heavy drinking and the increasing stress in his family, Jomar expressed that he wanted
to leave the school for good. His mother is currently experiencing neuromuscular disorder and
thinks Jomar should stop studying and should be taking care of her.

1. Enumerate and discuss the different crises present in the situation based from the
different viewpoints of each family member.
2. Identify the areas of assessment and what questions to be included to evaluate
the individual’s needs and the needs of the family as a unit?
3. Provide tentative goals that is fitted for this family.
4. Identify appropriate agencies in your local areas that you think will be helpful for each
client and for the family as a whole.
5. Device an effective discharge plan for this family. Include the set-up of follow-up visits,
cooperation of family members, and type of service to be provided.