Crisis and Grief: Practice Questions & Explanations

Kübler-Ross's five stages of grief (developed from observing dying patients in 'On Death and Dying,' 1969): (1) Denial — 'This can't be happening' — protects from initial shock; (2) Anger — 'Why me? It's not fair' — directed at self, others, healthcare team, God; (3) Bargaining — 'If only...' — attempts to negotiate, often with higher power; (4) Depression — 'What's the point?' — sadness, withdrawal, mourning the losses; (5) Acceptance — 'I'm ready for what comes' — peace, not necessarily happiness. Important points: (1) NOT linear — grieving people move between stages, revisit stages, or skip stages; (2) Individual experience — no 'right' way to grieve; (3) Cultural variation — different cultures express and process grief differently; (4) Time variable — there is no fixed timeline; complicated grief lasting >12 months is recognized as a clinical concern. Other grief models: (1) Bowlby's attachment-based grief stages; (2) Worden's tasks of mourning — accept reality, work through pain, adjust to environment without deceased, find ongoing connection while moving forward; (3) Dual process model — alternating between loss-oriented and restoration-oriented coping. Nursing interventions: (1) Therapeutic presence — be there, don't always fill silence; (2) Allow expression of all emotions — anger, fear, sadness are normal; (3) Avoid platitudes ('They're in a better place'); (4) Active listening; (5) Educate family about normal grief; (6) Refer to grief counseling, support groups, palliative care, chaplaincy as appropriate; (7) Recognize complicated grief — prolonged, intense, functional impairment. Anticipatory grief — grieving before the death — is common in terminal illness.

A crisis is a state of disequilibrium caused by a stressor that overwhelms the person's usual coping abilities. Types of crisis: (1) Maturational/developmental — normal life transitions (marriage, parenthood, retirement) that overwhelm; (2) Situational — unexpected events (illness, loss, accident, divorce); (3) Adventitious — disaster, violence, public catastrophe affecting communities. Crisis intervention principles: (1) Short-term focus — typical resolution within 4-6 weeks; if not resolved, evolves into chronic dysfunction; (2) Present-focused — address the immediate problem rather than deep psychological issues; (3) Problem-solving approach — concrete steps to manage the crisis; (4) Mobilize resources — family, friends, community, professional services; (5) Restore previous level of functioning — not aim for transformation; (6) Active and directive — crisis worker takes more active role than typical therapy; (7) Build on strengths — identify and use the person's existing coping abilities. Phases: (1) Pre-crisis — usual functioning; (2) Vulnerable — stressor occurs, usual coping fails; (3) Active crisis — high anxiety, disorganization; (4) Reorganization — new equilibrium achieved (better, same, or worse than pre-crisis). Crisis intervention steps: (1) Assess — what is the precipitating event? safety? supports? coping methods used? (2) Plan — concrete actions to address the crisis; (3) Intervene — implement the plan; (4) Evaluate — was the crisis resolved? at what level? Resources: crisis hotlines, mobile crisis teams, emergency rooms, crisis stabilization units, suicide prevention services (988 in US — Suicide and Crisis Lifeline). Nursing role: assessment, presence, support, resource referral.

CRISIS INTERVENTION is a short-term, active approach designed to help an individual in a crisis reach an acceptable level of functioning. A CRISIS is a temporary state of disequilibrium in which the person's usual coping mechanisms are insufficient for the situation. PHASES OF CRISIS INTERVENTION (Roberts' 7-Stage Model): ASSESS lethality/safety (FIRST); establish RAPPORT and RELATIONSHIP; identify major PROBLEMS; explore FEELINGS and emotions; explore previous COPING; RESTORE cognitive functioning/generate alternatives; implement ACTION PLAN. DIRECT LETHALITY ASSESSMENT: ask DIRECTLY about suicidal thoughts — 'Are you thinking about hurting yourself?' (asking directly does NOT increase risk; it is therapeutic); if yes: assess PLAN (do they have a specific plan?), MEANS (access to method), INTENT (do they intend to carry it out), TIMELINE; PROTECTIVE FACTORS: children, pets, religious beliefs, social support, reasons for living. IMMEDIATE SAFETY MEASURES based on assessment: if imminent risk: call emergency services (911); if client is seen in person: do not leave alone; ensure environmental safety; if telephone call: maintain contact, get location, call 911; RESOURCES: National Crisis Line 988 (Suicide and Crisis Lifeline); crisis text line; local mental health crisis centers; emergency room. CRISIS CHARACTERISTICS: usually time-limited (4-6 weeks); represents both DANGER and OPPORTUNITY (some clients emerge with better coping skills); acute, not chronic; the person is in pain, not pathological. POST-CRISIS: connect to longer-term mental health resources; follow-up; acknowledge strength in reaching out.

INITIAL SUICIDE RISK ASSESSMENT is the first priority because it determines the immediate safety response. ELEMENTS OF ASSESSMENT: IDEATION: Passive ('I wish I were dead') vs. active ('I am planning to kill myself'); PLAN: Specificity of plan (vague vs. specific date, method, location); METHOD: Availability and lethality (firearms are highest lethality, most impulsive methods); INTENT: Level of commitment and desire to act; PROTECTIVE FACTORS: Reasons to live (family, pets, religious beliefs, future plans); PRIOR ATTEMPTS: History of attempts is the strongest predictor of future attempt; SAFETY ENVIRONMENT: Are there firearms in the home? PN ROLE vs RN ROLE: RN leads initial crisis assessment; psychiatry or psychology consults for formal evaluation; the RN does not defer assessment while waiting for psychiatry. IMMEDIATE SAFETY MEASURES: Remove or secure potentially lethal items; constant supervision (1:1 for highest risk); communicate level of risk clearly to team.

SAFETY DURING PHYSICAL RESTRAINT: RESTRAINT RISKS: POSITIONAL ASPHYXIA: If face-down (prone) restraint is used, chest compression restricts breathing; risk of death; EXCITED DELIRIUM: State of extreme agitation with high sympathetic drive; risk of sudden cardiac death during or after restraint; MONITORING DURING RESTRAINT: Airway — ensure unobstructed airway at all times; respiratory status — observe chest rise, SpO2 if possible; level of consciousness; CRITICAL: The period immediately after restraint is a high-risk time — the individual may become suddenly unresponsive after fighting against restraint stops (cardiovascular collapse); BEST PRACTICE: Avoid prone restraint; allow the individual to be in a position that permits adequate breathing; at least one staff member monitors vital signs and consciousness throughout; DEBRIEF: After the event: assess for injuries to client and staff; document; psychological debrief for staff; determine if there were missed early warning signs; LEAST RESTRICTIVE: Physical restraint is the most restrictive option and should be followed immediately by verbal de-escalation attempts once the immediate danger is controlled.

ACUTE STRESS / TRAUMA RESPONSE — CRISIS INTERVENTION: In the acute phase after trauma, the priorities are SAFETY, STABILIZATION, and SUPPORT — not deep emotional processing. APPROPRIATE INTERVENTIONS: Ensure physical safety and basic needs; provide a calm, safe environment; allow the client to express feelings AT THEIR OWN PACE; validate their experience and normalize their reactions ('what you're feeling is a normal response to an abnormal event'); offer presence and support; AVOID: Forcing the client to recount details (re-traumatizing); pushing premature emotional processing; minimizing ('you're lucky'); telling them to 'forget it' (invalidating); ACUTE STRESS reactions (intrusive memories, hypervigilance, dissociation) are normal in the immediate aftermath; if symptoms persist beyond a month, it may develop into PTSD; PSYCHOLOGICAL FIRST AID principles: safety, calm, connectedness, self-efficacy, hope; REFERRAL: Trauma-informed counseling for ongoing support; nursing role: provide safety and support, validate, avoid re-traumatization, connect to resources.

INTIMATE PARTNER VIOLENCE (IPV) ASSESSMENT: PRIVACY AND SAFETY: Always interview the client ALONE — never assess for abuse with the partner present (the abuser may control the narrative, intimidate, or the client may fear retaliation); ensure a private, safe setting; APPROACH: Direct but nonjudgmental questions ('Do you feel safe at home?' 'Has anyone hurt you or threatened you?'); convey support and belief; assess for safety and immediate danger; NURSING RESPONSIBILITIES: Provide a safe environment; document objectively (specific injuries, client's words in quotes, photos with consent); know mandatory reporting requirements (varies by state — IPV reporting differs from child/elder abuse which are typically mandatory); provide resources (hotlines, shelters, safety planning); RESPECT AUTONOMY: A competent adult may choose not to leave — respect their decisions while ensuring they have resources and a safety plan; do not pressure or judge; SAFETY PLANNING: Help the client develop a plan (important documents, emergency bag, code word, safe place); DANGER: Leaving is the most dangerous time — support without forcing; nursing role: assess privately, support nonjudgmentally, document, provide resources, respect autonomy, ensure safety.

PSYCHOLOGICAL FIRST AID (PFA): An evidence-informed approach for helping people in the immediate aftermath of disaster or trauma. PRIMARY GOALS: Reduce initial distress; meet immediate practical needs (safety, food, shelter, information); foster adaptive coping and resilience; connect people with support and resources; promote a sense of safety, calm, connectedness, self-efficacy, and hope; PFA PRINCIPLES: Provide comfort and practical support; do NOT force people to talk about or 'process' the event (premature debriefing can be harmful); listen if they want to share; respect culture and individual coping; protect from further harm; reunite with loved ones; provide accurate information; NOT PFA: Formal psychotherapy; mandatory critical incident debriefing (no longer recommended — can interfere with natural recovery); diagnosing; pathologizing normal stress reactions; TRIAGE: Identify those needing higher-level care while supporting the majority who will recover with basic support; nursing role: provide practical and emotional support, ensure safety and basic needs, foster coping, connect to resources, avoid forcing trauma processing.