Stuart Stress Adaptation and Nola Pender's Model on Mental Nursing Care of Patients Schizophrenia: Case Study

Rohman Hikmat ^{1, †}, Iyus Yosep ^{2, †, *}, Efri Widianti ^{2, †}, Suryani Suryani ^{2, †}, Aat Sriati ^{2, †}, Icih Susanti ^{3, †}

1. Master Program of Nursing, Faculty of Nursing, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia

2. Department of Mental Health, Faculty of Nursing, Universitas Padjadjaran, Sumedang, Jawa Barat, Indonesia

3. Rumah Sakit Jiwa Cisarua, West Java Province

† These authors contributed equally to this work.

* Correspondence: Iyus Yosep

Academic Editor: Bart Ellenbroek

Received: July 20, 2024 | Accepted: October 07, 2024 | Published: October 12, 2024

OBM Neurobiology 2024, Volume 8, Issue 4, doi:10.21926/obm.neurobiol.2404249

Recommended citation: Hikmat R, Yosep I, Widianti E, Suryani S, Sriati A, Susanti I. Stuart Stress Adaptation and Nola Pender's Model on Mental Nursing Care of Patients Schizophrenia: Case Study. OBM Neurobiology 2024; 8(4): 249; doi:10.21926/obm.neurobiol.2404249.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Schizophrenia is a brain disorder characterized by chaotic thinking, delusions, delusions, violent behavior, and strange or catatonic behavior [1]. Prevalence of mental disorders worldwide According to World Health Organization data, there are 20 million people experiencing schizophrenia [2]. The prevalence of schizophrenia in Indonesian society in 2018 reached around 400,000 people/1.7 per 1,000 population [3]. As many as 70% of schizophrenia patients experience hallucinations, which are a psychotic disorder that can be characterized by significant disturbances in thoughts, perceptions, emotions, and behavior [4,5].

Violent behavior in schizophrenic patients is a severe and complex problem influenced by factors such as uncontrolled psychotic symptoms, substance or alcohol use, and past traumatic experiences [6]. The risk factors for violent behavior include individual factors such as a history of trauma, mental health disorders, and substance abuse [7]. Additionally, environmental factors like exposure to violence, peer influence, poverty, and social norms that support violence also play a role [8].

The impact of violent behavior can be very detrimental, not only for the individual who experiences the disorder but also for the people around him and society as a whole [9]. For individuals who experience mental disorders, violent behavior can cause social isolation, difficulty in maintaining healthy relationships, and serious legal problems. Loss of self-confidence and feelings of guilt are also often significant psychological impacts. For family and friends, the impact can include emotional stress, fear, and even physical or mental violence directed against them [10]. Violent behavior can lead to increased crime rates, insecurity, and feelings of discomfort in the neighborhood. The economic costs associated with health care, recovery, and the criminal justice system can also be very high [11].

The Stuart Stress Adaptation Model focuses on understanding the interaction between stressors and the patient's ability to cope, with an emphasis on biological, psychological, and social factors that influence psychiatric symptoms, such as psychosis and violent behavior [12]. This model enables nurses to identify stressors, assess adaptive responses, and implement interventions aimed at managing acute psychiatric symptoms, such as hallucinations or aggressive behavior [13]. In contrast, Nola Pender's Health Promotion Model centers on empowering individuals to engage in behaviors that promote health and well-being, emphasizing the role of self-efficacy and personal motivation in achieving long-term recovery [14]. By integrating health promotion principles, nurses can encourage patients to participate in activities that improve physical health, reduce stress, and foster social interaction, thus complementing psychiatric interventions [15].

The combination of Stuart Stress Adaptation and Nola Pender's model in psychiatric nursing care provides a holistic approach to schizophrenia patients by integrating psychiatric interventions and health promotion. This combinative approach is needed because the complexity of schizophrenia symptoms affects the patient's biological, psychological, and social aspects, so a more comprehensive method is required [16,17]. The integration of these two models allows nurses not only effectively to manage psychiatric symptoms through Stuart's techniques but also to encourage healthy behavior and long-term recovery through Pender's principles. Implementing this integrative strategy involves a thorough assessment and development of a plan of care that addresses the patient's physical and mental needs to increase their participation in activities that improve their quality of life [18].

Results of the author's study of mental disorder patients at a mental hospital in West Java. There are patients at risk of violent behavior at the time of assessment. The patient speaks firmly and has a sharp gaze. The client said he was angry with his family, which did not respect him as a wife and part of the family. Psychiatric nurses play a crucial role in treating patients with violent behavior quickly and appropriately. Psychiatric nursing is an interpersonal process aimed at improving and maintaining patient behavior that contributes to integrated functioning [19]. Based on the explanation above, the author is interested in writing scientific work about the combination of Stuart Stress Adaptation and Nola Pender's models in mental nursing care for schizophrenia patients.

2. Case Report

Mrs. N is a 38-year-old woman with an elementary school education and marital status. She has been hospitalized since May 30, 2024, with a medical diagnosis of paranoid schizophrenia. The patient who acts as the main person in charge is Mrs. N, a housewife who lives with her child at the same address. When the assessment was carried out on June 3, 2024, the patient looked anxious and angry, had sharp eyes, and spoke loudly. Previously, the patient had threatened to harm her husband and brought a machete to hack family members. Identification of the leading nursing problem is the risk of violent behavior.

Predisposing factors include biological aspects, where there is no family history of a similar disease, as well as psychological, which include childhood experiences that tend to be passive and several events that were not resisted, such as being bullied at school and sabotaging assignments at boarding school. Socioculturally, the patient had an elementary school education, worked odd jobs, and had problems with residents. Economic conditions are also a predisposing factor, considering that her husband suffered a stroke four years ago, so the patient became the backbone of the family. Precipitating factors that trigger violent behavior include feeling disrespected by the husband and the husband's family, which results in the client getting angry and threatening him with a machete. In assessing the stressor, the client expressed a desire to go home and apologize to her husband and husband's family, as well as realizing emotional problems that were difficult to control. Family perceptions also support recovery, hoping clients can recover and control their emotions.

Client coping and resources show that clients rely on spiritual beliefs to overcome problems and keep issues to themselves without telling others. The client shows a strong ego identity and believes she has played a good role as a wife and housewife, even though her husband and husband's family do not appreciate her. Individual factors such as understanding of mental disorders and perceptions of the benefits of mental health interventions indicate that clients are aware of their illness and believe that talking to a health professional can help manage their emotions. Barriers to relating to others include often getting angry if offensive words are said.

Mrs. N has a nursing problem, namely the risk of violent behavior, showing physical examination results within normal limits with blood pressure 130/80 mmHg, pulse 90 bpm, body temperature 36.5°C, and breathing 20 times per minute. To overcome her paranoid symptoms and aggressive behavior, Mrs. N was given pharmacological therapy in the form of Risperidone at a dose of 2 mg per day and Valproate at a dose of 500 mg per day. Additionally, Lorazepam 1 mg is given as needed to treat anxiety or agitation. This therapy is equipped with a psychosocial approach, which includes stress management education, adaptive coping strategies, psychosocial support, and individual and family counseling.

The interventions carried out include therapeutic communication by maintaining a safe environment, discussion about the causes of violent behavior, and collaboration in treatment. Clients are trained to relax, speak well, and participate in religious activities according to their beliefs. Evaluation shows that the client understands his illness better and is able to control his emotions well, although intervention still needs to be continued to ensure the continuation of positive results. Implementation and evaluation also show good progress in understanding and managing clients' emotions, with support from collaborative interventions and specialist therapies such as forgiveness therapy, logotherapy, and psychoeducation for families.

Stuart's Stress Adaptation Model was used to assess how psychosocial stressors and living conditions affected her mental state. The model focuses on identifying predisposing factors such as psychological background and socioeconomic conditions, as well as triggering factors that contribute to his aggressive behavior. The assessment includes analyzing past experiences, current situations, and emotional reactions that may influence the risk of violence. The Nola Pender Health Promotion Model was used to evaluate Mrs. N's resources and coping mechanisms and to design interventions supporting health promotion and preventing violent behavior. Pender's model assisted in assessing the patient's understanding of mental health, perceptions of interventions, and ability to implement adaptive coping strategies.

Stuart's Stress Adaptation Model was conducted with interventions focusing on stress management and therapeutic techniques. Relaxation techniques as well as stress management strategies were applied to help Mrs. N cope with her emotions and reduce her violent behavioral tendencies. Therapeutic communication was also used to create a safe environment, discuss the causes of violent behavior, and assist Mrs. N in managing and adjusting to the stressors she faced. In addition, psychoeducational approaches were integrated to provide education on stress management and adaptive coping strategies, supporting Mrs. N in developing the necessary skills to cope more effectively with stress.

Furthermore, the Nola Pender Health Promotion Model was applied through education and counseling interventions. Education on stress management, as well as individual and family counseling, were conducted to support Mrs. N's understanding and acceptance of her illness, as well as motivate her to participate in the recovery process actively. In addition, participation in religious activities was encouraged as part of a holistic approach to improve Mrs. N's mental health and well-being, reinforcing the social and emotional support she received.

The results of this study indicate that the use of nursing interventions that integrate Stuart's Stress Adaptation Model and Nola Pender's Health Promotion Model effectively reduces symptoms of violent behavior in schizophrenia patients. By applying Stuart's Stress Adaptation Model, specifically through forgiveness therapy and logotherapy techniques, patients show significant reductions in violent behavior. Forgiveness therapy helps patients process and resolve deep feelings of anger and frustration. At the same time, logotherapy facilitates finding meaning in their experiences, which positively impacts managing emotions and reducing aggressive behavior. On the other hand, through a psychoeducational approach, Nola Pender's Health Promotion Model focuses on increasing patients' understanding of their illness and developing effective coping strategies. This psychoeducation not only strengthens patients' motivation to be active in the recovery process but also increases their ability to manage stress and emotions.

3. Discussion

3.1 Assessment

According to Erikson's theory of development, the client is 38 years old and in the adult stage. This stage, known as generativity, marks a period in which individuals often assume many responsibilities, including economic stability and healthy social interactions. However, if this achievement is disrupted, individuals are vulnerable to experiencing dependency in terms of work and finances, which in turn can trigger maladaptive behavior. Previous research shows that schizophrenia patients aged 25-40 years tend to exhibit higher levels of physically aggressive behavior compared to the same-age population who do not suffer from mental disorders [20]. Other research also shows that incidents of violent behavior occur more frequently in young adult schizophrenia patients [21]. The adult age range is vulnerable to mental disorders and violent behavior because they are facing great pressure in their lives, which includes heavy responsibilities and high levels of stress.

The client and her husband not working is a condition that can affect their mental well-being. Unemployed individuals have a higher risk of experiencing mental disorders. Poverty conditions also have the potential to exacerbate this situation, which is often linked to insecurity, lack of education, inadequate housing, and nutritional problems [22]. This increases the likelihood of mental disorders due to stress associated with difficult daily life.

The wife's role as the backbone of the family, who also cares for her sick husband, is often closely related to the family's economic conditions. When a wife has to take on significant financial responsibilities because her husband cannot work due to illness, this creates a substantial additional burden. Poverty or economic hardship can exacerbate this situation, as lack of access to adequate economic resources often results in the inability to meet basic needs such as health care, adequate housing, and education [23]. This can cause financial pressure, additional stress, as well as social feelings such as shame or inferiority which can increase the risk of mental disorders such as depression or anxiety in the wife [24].

Stuart's Stress Adaptation Model Stuart's Stress Adaptation Model identifies that individuals adapt to stress through two main mechanisms: coping and social support. In this case study, she faced financial problems and family conflict, which can interfere with healthy coping. Previous research shows that individuals with mental disorders, especially schizophrenia, often exhibit more aggressive behavior when faced with severe stress [25]. Previous studies have found that schizophrenia patients who experience high stress are more likely to exhibit violent behavior, especially when the stressors are related to significant economic and social factors [26].

Nola Pender's model emphasizes the role of individual motivation and knowledge in adopting healthy behaviors. Mrs. N demonstrated a strong desire to recover from her condition despite facing severe economic and social challenges. Previous research suggests that individuals' motivation and understanding of their health problems are critical factors in the success of health promotion interventions [27]. Motivation and knowledge of health problems are essential components of nursing assessment [28]. Stuart's Stress Adaptation Model provides tools for managing stress and emotions, while Nola Pender's Health Promotion Model emphasizes the importance of motivation and support in recovery.

In the context of the Nola Pender Health Promotion Model, the results of the assessment show that the patient shows hope of recovering from his condition and has a good understanding of his health problem. This is consistent with Pender's theory, which emphasizes the importance of individual motivation and knowledge in adopting healthy behavior. Although patients face significant economic challenges, such as poverty and social problems with neighbors due to a tendency to be irritable, the desire to recover is an important indicator in implementing health promotion strategies [29]. The client also experiences problems with his family, who use words that hurt the client, so a psychoeducational approach to the family is needed to form a supportive system in the patient's recovery process [30].

3.2 Interventions

Based on Stuart's Stress Adaptation Model, forgiveness therapy and logotherapy were the two main approaches applied. Forgiveness therapy aims to help Mrs. N let go of anger and resentment that may have exacerbated her aggressive behavior, focusing on the process of forgiving oneself and others as a way to reduce emotional stress. Logotherapy, developed by Viktor Frankl, focuses on the search for meaning in life and can help Mrs. N find purpose or meaning behind her suffering, which is important for reducing feelings of hopelessness and improving emotional well-being. Previous study shows that forgiveness therapy is effective in reducing anxiety and aggression in patients with mental disorders. In contrast, logotherapy has been shown to improve emotional resilience and quality of life in various patient groups [31].

The intervention based on the Nola Pender Health Promotion Model focused on psychoeducation, which aimed to increase Mrs. N's knowledge and awareness of her mental health condition as well as effective stress management strategies. Psychoeducation included information about schizophrenia disorder, stress management techniques, and ways to cope with negative emotions. Pender's model emphasizes the importance of individual motivation and understanding in adopting healthy behaviors, and psychoeducation can strengthen Mrs. N's motivation to engage in recovery actively. Previous research showed that effective psychoeducation can improve patients' understanding of their illness and facilitate positive behavior change [32]. Factors influencing the outcome of psychoeducation include the patient's level of education, family support, and personal desire for recovery [33].

The combination of interventions based on Stuart's Stress Adaptation Model and Nola Pender's Health Promotion Model ensured a comprehensive approach to addressing violent behavior and improving Mrs. N's mental well-being. Integrating forgiveness therapy and logotherapy to address the emotional aspects and meaning of life, along with psychoeducation, strengthens understanding and engagement in the recovery process [34]. This strategy created a holistic and in-depth approach in accordance with research findings supporting the importance of integrating multiple methods in managing mental disorders [15].

Logotherapy has shown significant results in reducing violent behavior in schizophrenia patients. Logotherapy focuses on the search for meaning in life, which helps patients find purpose and value in their lives, even when faced with challenging conditions [35]. The success of logotherapy is seen in its ability to change the patient's focus from the suffering and symptoms they experience to a search for more profound and positive meaning. The mechanism involves three main principles: freedom of will, will to meaning, and meaning of life [36].

Schizophrenia patients who underwent logotherapy sessions experienced a significant reduction in aggressive behavior compared to a control group who received standard therapy. This research shows that logotherapy is not only effective in reducing violence but also improving overall emotional well-being. This is in line with previous research, which showed a decrease in the level of violence in schizophrenia patients after applying logotherapy but with a smaller effect scale [37]. A comparison of these two studies indicates that while logotherapy consistently shows positive effects, results may vary depending on the intensity and duration of therapy and individual patient factors [38].

Forgiveness therapy has shown significant results in reducing violent behavior in schizophrenia patients. This therapy focuses on helping patients let go of resentment and hatred, often the source of emotional tension and aggression [39]. Forgiveness therapy, in freeing patients from heavy emotional burdens, can worsen schizophrenia symptoms and trigger aggressive behavior. The mechanism involves several steps, including identifying emotional wounds, understanding the impact of holding a grudge, and actively choosing to forgive [40]. This process allows patients to let go of negative feelings and replace them with empathy, compassion, and understanding.

Schizophrenia patients can be a burden on themselves and their families. Maladaptive behavioral problems in patients also increase family stress levels [41]. Family intervention in the form of family psychoeducation is needed to manage family stress and burden. Family psychoeducation can improve patient symptoms and social functioning, overcome family burdens, and provide family coping strategies. Family psychoeducation can improve patient care experiences and quality of life and reduce stress for family members [39].

Family psychoeducation plays a vital role in forming an environment that supports the recovery process of schizophrenia patients. Through psychoeducation, family members can understand schizophrenia in more depth, including the symptoms and impact on the individual experiencing it, thereby reducing stigma and misunderstanding [42]. In addition, psychoeducation helps families manage the stress that arises from the challenges of caring for a patient by learning effective stress management techniques. Communication skills taught through psychoeducation also enable better patient interactions, reduce conflict, and increase emotional support [43].

The case study results showed that the patient experienced significant psychological distress due to complex social problems. According to the Stuart Stress Adaptation Model, issues such as minimal social support from the family in facing daily challenges are significantly related to the family's additional role as the family's backbone due to the husband's illness and limited economic conditions [44]. A lack of social support and a tendency to keep feelings to yourself can lead to a buildup of unresolved emotional stress, which in turn can contribute to the onset of mental disorders such as depression or anxiety [12].

Forgiveness therapy intervention is part of the cognitive behavioral therapy approach, designed to help patients forgive themselves and others regarding psychological stressors originating from social and economic problems. Forgiveness therapy aims to strengthen adaptive coping with internal conflict, increase positive self-perception, and improve the patient's overall psychological well-being [45]. In addition, logotherapy as an additional intervention focuses on finding meaning in the patient's life experiences, including facing the dual role of supporting the family and a partner caring for a sick husband [46].

Psychoeducational interventions for families are essential in building an effective support system during the patient's recovery process. The case study results show that families play a crucial role in providing emotional and practical support to patients, especially considering challenging economic conditions and social problems with neighbors that can affect the patient's mental health. Psychoeducation aims to increase the family's understanding of the patient's health condition, reduce stigmatization, and strengthen open communication between family members [43]. Efforts to increase their knowledge about the best way to support the patient's recovery process, it is hoped that families can provide a more supportive environment and encourage the implementation of positive health behavior in the household [47]. This is in accordance with Pender's principles, which emphasize the importance of a supportive physical, social, and psychological environment in achieving optimal health goals [30,48].

The integration of Stuart's Stress Adaptation Model and Nola Pender's Health Promotion Model offers a significant contribution to clinical practice in managing schizophrenia cases with violent behavior. One of the key innovations is the application of forgiveness therapy and logotherapy, which have not been widely explored in previous literature to address violent behavior in schizophrenia patients. Forgiveness therapy, which focuses on forgiving self and others, and logotherapy, which aims to help patients find meaning in their lives, have effectively alleviated aggression and improved emotional well-being [49]. Previous studies have shown that this approach can reduce the frequency of violent behavior and enhance the quality of life of patients with severe mental disorders. In addition, psychoeducation as part of the Nola Pender Health Promotion Model, is vital in improving patients' understanding of their condition and effective stress management strategies. This supports research that underscores the importance of individual knowledge and motivation in the recovery process [50].

4. Conclusions

In this case study, Mrs. N, a 38-year-old woman with paranoid schizophrenia, showed a risk of violent behavior due to her biological background with no family history, difficult childhood experiences, and socio-economic pressure after her husband had a stroke. Her violent behavior was triggered by feelings of disrespect from her husband's family. Interventions include pharmacological therapy with Risperidone, Valproate, and Lorazepam, as well as discussions about violent behavior. Forgiveness therapy and logotherapy are used to overcome trauma and form positive meaning. After the intervention, the symptoms of violence decreased, and the recovery process continued with family psychoeducation to create a supportive environment. This holistic approach emphasizes the importance of violence risk management and socio-psychosocial support in the care of patients with paranoid schizophrenia.

The nursing implications of this case study emphasize the importance of a holistic approach in caring for patients with paranoid schizophrenia, including violence risk management, the use of pharmacological and psychosocial therapies such as forgiveness therapy and logotherapy, as well as family psychoeducation to create a supportive environment. Recommendations for further research include analysis of the effectiveness of forgiveness therapy and logotherapy in managing psychotic symptoms and improving clients' quality of life, as well as research on the effectiveness of family psychoeducation in accelerating the recovery process in clients with mental disorders.

Acknowledgments

All authors thank you to Universitas Padjadjaran who has facilitating us to make this study.

Author Contributions

Rohman Hikmat, Iyus Yosep, Efri Widianti: Conceptualization, writing – original draft, formal analysis, writing – review and editing. Suryani Suryani, Aat Sriati: Software, writing – review and editing. Icih Susanti: Methodology, writing – review and editing.

Funding

This research has not external funding.

Competing Interests

The authors have declared that no competing interests exist.