Stress Overload: A New Diagnosis

Blackwell
Malden,
International
IJNT
©
1541-5147
73O riginal
2006Overload:
Stress Blackwell
Article
USA
Publishing
Journal
APublishing
of
IncNursing
New Ltd.
Terminologies and Classifications
Diagnosis

Margaret Lunney, PhD, RN

PURPOSE. To describe the phenomenon of stress Margaret Lunney, PhD, RN, is Professor and Graduate
Programs Coordinator of the College of Staten Island,
overload as a nursing diagnosis.
Department of Nursing, Staten Island, NY.
METHODS. A qualitative study using case study

method was conducted with nine adults experiencing
stress overload to fully describe the experience and
identify possible defining characteristics. Current
literature sources on stress and its related factors
were examined to support stress overload as a
nursing diagnosis for inclusion in the NANDA
International classification.
FINDINGS. Stress overload, defined as excessive
amounts and types of demands that require
action, is a human response that is experienced as
a problem and contributes to the development of
other problems. The proposed defining
characteristics are perceives situational stress as
excessive, expresses a feeling of tension or
pressure, expresses difficulty in functioning as
usual, expresses problems with decision-making,
demonstrates increased feelings of anger and
impatience, and reports negative effects from stress
such as physical symptoms or psychological distress.
PRACTICE IMPLICATIONS. Nursing interventions
such as active listening and decision-making
support are needed to help people reduce stress
levels. Studies are needed to further validate the
defining characteristics and related factors of this
new diagnosis.
T he stress experience exists in all human beings at
all ages in varying degrees (Holmes & Rahe, 1967;
Keil, 2004; Lazarus & Folkman, 1984; Motzer & Hertig,
2004; Power, 2004; Selye, 1956, 1974, 1976). Stress
occurs in relation to stressors that are positive (e.g.,
being in love) and negative (e.g., being in an abusive
relationship). Stress also contributes to positive and
negative effects (e.g., happiness or extreme discom-
fort). Stress stimulates individuals and groups to use
coping responses such as redefining the situation and
problem solving (Lazarus & Folkman). At times, how-
ever, the amounts and types of stressors are excessive,
and effective coping strategies are not adequate to
reduce the related risks of the stress response. Patterns
of excessive or high stress may lead to the fight-or-
flight response (Selye, 1956, 1974, 1976), psychological
and physical illnesses or symptoms (e.g., Cropley &
Steptoe, 2005; Hannigan, Edwards, & Burnard, 2004;
Holmes & Rahe; Lazarus & Folkman; Lloyd, Smith, &
Weinger, 2005; Motzer & Hertig; Neilsen et al., 2005),
extreme discomfort (Drew, Goodenough, Maurice,
Foreman, & Willis, 2005; Golden-Kreutz et al., 2005),
exacerbation of age-related declines in memory
(Vondras, Powless, Wheeler, & Snudden, 2005),
decreased quality of life (Golden-Kreutz et al.; Lustyk,
Widman, Paschane, & Ecker, 2004), and premature
mortality (Robinson, McBeth, & McFarlane, 2004). The
phrase stress overload can be used to describe excessive
stress because it refers to stress-related burden on
individuals or groups.
Although the stress experience is described in the
nursing literature as a phenomenon that may require
nursing interventions (e.g., Pender, Murtaugh, & Par-
sons, 2006), there are no nursing diagnoses pertaining
to the stress experience in the classification of nursing
diagnoses developed by NANDA International (2005).
Since there is no standardized label and definition for

International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006 165
Stress Overload: A New Diagnosis
the experience of stress in the NANDA classification,
nurses may use the diagnosis of ineffective coping in
clinical situations when stress overload is a more accu-
rate interpretation. When this occurs, it is akin to
“blaming the victim.” The purpose of this article is to
describe a qualitative study to validate the diagnosis
of stress overload, previously reported in an abstract
(Lunney & Myszak, 1997), and to use the findings from
this study and recent research and theoretical analyses
to propose a new nursing diagnosis for inclusion in the
NANDA International Diagnostic Classification (2005).
Background
Stress overload is defined as excessive amounts
and types of demands that require action (Lunney &
Myszak, 1997) that are experienced as a problem and
contribute to the development of other problems. The
classic work of Holmes and Rahe (1967) in which
amounts and types of stressors are measured by add-
ing numbers assigned to stressors, such as divorce and
changing jobs, demonstrated that the numbers and
types of stressors that exist in people’s lives are predic-
tive of future illness, both psychological and physical.
The impetus for development of this new diagnosis
is (a) stress overload is a human response that differs
from all other diagnoses in the NANDA I taxonomy,
and (b) accuracy of nurses’ diagnoses of human
responses requires use of this concept. The concept of
stress overload had not been formally named before this
and is believed to be intuitively understandable. In
many literature sources on stress, stress overload is
implied, for example, terms like “stressed out” or
“high stress” are used (e.g., Boardman, 2004; Lim, Wil-
liams, & Hagan, 2005; Nielsen et al., 2005). After a
paper presentation on stress overload at a NANDA con-
ference (Lunney & Myszak, 1997), the diagnosis was
used by a researcher to partly describe the experience
of women in the postacute phase of battering (Carlson-
Catalano, 1998).
Inaccurate interpretations of the stress experience
contribute to harm to healthcare consumers, just as
166 International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006
low accuracy interpretations of other phenomena were
shown to be harmful (Lunney & Paradiso, 1995; Ryan,
2001). If nurses focus on other overlapping diagnoses,
such as ineffective coping or powerlessness, the interventions
may not be appropriate for stress overload. Interven-
tions for stress overload are specific to helping consumers
reduce the burden of stressors. Since nursing diagno-
sis labels guide the selection of interventions, it is
important that nurses recognize and identify stress
overload when it occurs. Using other diagnoses when
stress overload is the most accurate diagnosis probably
leads to inappropriate choices of nursing interventions
and subsequent failure to produce positive outcomes.
In order to advance knowledge of this diagnosis
and possible interventions, a qualitative study was
conducted to describe this experience from the per-
spective of people who were experiencing stress over-
load and an in-depth literature search was conducted
to support and expand knowledge of this diagnosis.
Study Methods
Design
The qualitative case study method described by
Mariano (1993) was used for this study. Structured
interviews were conducted using 10 questions to
obtain a description of the stress experience (Table 1).
The interviews took from 30 to 60 min and were audio-
taped and transcribed verbatim for a written record.
The methods described by Miles and Huberman
(1984) were incorporated in the study, including iden-
tification of themes or data reduction, data display,
and conclusion drawing and verification of the data.
The study was approved by the Hunter College Insti-
tutional Review Board. Each participant signed an
informed consent to participate.
Sample
The sample was nine persons who answered “Yes”
to the question, “Are you experiencing stress overload
Table 1. Structured Interview on Stress Overload
You have been asked to participate in this study because you answered Yes to the question: Are you experiencing stress
overload? Stress overload is defined as excessive numbers and types of demands that require action. This interview is to gather
more information about your experience. There are no right or wrong answers. The purpose is to describe the stress experience
from your own perspective.
1. On a scale of 1 to 10, what number would you give your experience of stress at this time?
2. Please describe the stress experience itself. What is it like? How is it affecting you now?
3. Can you elaborate on your description of this feeling of stress? Can you tell me more about the experience of stress?
4. Can you describe x (one or more aspects of the experience) any further?
5. How does this experience of stress compare to other times in your life? Is this the highest amount of stress you have ever had?
6. Is there anything else that you would like to tell me about your stress experience?
7. How would someone else, e.g., a nurse, know that you are experiencing stress overload?
8. Please describe the types of stressors that contribute to this feeling of stress, i.e., the events and occurrences that are
stressful to you.
9. Would a nurse be able to help you with your stress overload?
10. Would you like me to help you with methods to reduce your feeling of stress?

at this time?” and who, during the interview, rated
their stress level as at least 7 on a scale of 1–10. Four
persons lived in the community and had no identified
psychiatric illnesses and five persons were from a psy-
chiatric day care center with identified psychiatric
problems. The two different populations were selected
because stress overload may be expressed differently in
these populations. The nonpsychiatric community
population consisted of two men and two women, all
white, and were 30–45 years of age (mean = 38 years).
Of the five psychiatric patients, there are three women
and two men, four white, and one Hispanic, 25–61
years of age (mean = 37.5 years).
Procedures
The procedure for obtaining persons in the commu-
nity without identified psychiatric illness was to ask
nurses in the community for referrals to persons who
they believed were experiencing stress overload. Some
persons who were referred to the investigators were
not interviewed because they were not experiencing
stress overload at the time of the study. Interviews were
conducted in a quiet, private place where interruptions
would not be likely (e.g., in a participant’s kitchen
with no one else at home).
For the participants who were psychiatric patients
in a hospital day treatment center, only those patients
who were not primary patients of the co-investigator,
a clinical nurse specialist (CNS) in psychiatric nursing,
were asked to participate. This was done to avoid bias
by the CNS and to avoid putting inadvertent pressure
on patients to participate in the study. These were
patients whom the Medical Director and Director of
Nursing agreed could be interviewed for the study.
Only those who were judged as capable of giving
informed consent were asked to participate.
A scale of 1–10 was used, with 1 being “the least
stress you can imagine” and 10 being “the most stress
you can imagine.” If the volunteer participants did not
rate their stress as 7 or above, they were not enrolled
in the study. Initially, question no. 2 was “What are
the numbers and types of demands or stressors in
your life at this time?” The intention was to further
validate the diagnosis with the answer to this ques-
tion. But, in a pilot-test case, the participant became so
focused on the stressors that the investigator was
unable to get adequate information about the stress

International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006 167
Stress Overload: A New Diagnosis
experience. Thus, the question about numbers and
types of stressors was moved to no. 8.
The credibility of these data derived from three
strategies. First, the interviews were long enough to
describe the stress experience; that is, participants
indicated that they were finished describing the experi-
ence (Mariano, 1993). Second, the investigators were
skilled interviewers with broad bases of clinical experi-
ence in assessment of these populations. Third, the
dependability and confirmability of the study were
established by maintaining an audit trail and submit-
ting the findings to an external reviewer for confirma-
tion of data reduction. Transferability was established
by selecting persons for the sample who were
believed to be typical of persons who experience
stress overload.
Results
The participants described situations that represent
excessive amounts and types of demands that require
action. For example, in the nonpsychiatric group, one
male participant who was the major provider for his
family had serious physical health problems in which
the decisions he needed to make might mean a healthy
life or disability and even death. Also, he had just sold
his house which had been on the market for 3 years
and now had nowhere to live because, in the mean-
time, his other options for places to live were not
available. He had to find a place to live for a family of
seven within 4 weeks. He also had significant prob-
lems at work that were prompting him to look for
other jobs. He had many job offers, which meant
increased economic possibilities but also increased
economic risks. Decisional conflicts and an uncertain
future were significant stressors for this person. He
rated his stress as 9 on a scale of 10.
A female participant who described extensive
amounts and types of demands that required action
rated herself as an 8 on the 10-point scale, but
explained the rating of 8 as “I know it can always get
worse, so I refuse to see it as a 10, even though it
168 International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006
seems like it is a 10.” One person rated stress level as a
7, another as a 10, and all others as an 8 or 9.
The defining characteristics identified from this
sample are in Table 2. In both groups, two to three
people described feelings of “being paralyzed” or fro-
zen (e.g., just wanting to be alone, wanting to stay in
bed, not getting dressed to start the day). Problems
with decisions were prevalent. Concerns about future
complex decisions prevented present, simple decisions
from being made. Many persons described feelings of
being “on edge,” being “impatient” and “short tem-
pered” with people. This was described vividly by
psychiatric patients. Participants said that they
“couldn’t think as clearly as usual” and described a
feeling of “not being myself.” They also described not
acting as competent as usual and a wish that other
people would realize that this was not their usual self.
Feelings of “pressure,” “frustration,” and anger were
also described. Subjects described acting out on these
feelings and being sorry about it.
In response to the question “Would a nurse or
another person know that you were having these feel-
ings?” in quite a few instances, the participants said
“No. They would not know unless they asked me.”
One person said, “I hide it well.”
Some of the physical symptoms described were
headache, pain in the chest, neck, and behind the eyes,
being very tired, heart racing at times, stuttering, flut-
tering of the eyelids, muscle tension, and a feeling of
“being sick” or of “going to get sick.” There was evidence
that some NANDA I-approved diagnoses may coexist
with or be contributing factors to stress overload (e.g.,
anxiety, sleep pattern disturbance, fatigue, situational low
self-esteem, and decisional conflict). For example, a male
participant described that the stress overload itself leads
him to have less confidence in himself and he starts
having negative thinking about his abilities. In this
instance, stress overload coexists with situational low
self-esteem.
The premise that stress overload may not be associ-
ated with ineffective coping was substantiated by these
data. The participants described situations in which
Table 2. Stress Overload
Defining characteristics
Perceives situational stress as excessive, e.g.,
rates stress level as seven or above on a
10-point scale
Expresses a feeling of tension or pressure
Expresses difficulty in functioning as usual
and in ordinary ways
Expresses problems with decision making
Expresses or demonstrates increased feelings
of anger, impatience, or being short tempered
with others
Reports negative impact from stress such as
physical symptoms, psychological distress, or a
feeling of “being sick” or of “going to get sick.”
Definition: Excessive amounts and types of demands that require action (Choenarom et al., 2005; Golden-Kreutz et al., 2005; Lunney & Myszak,
1997; Motzer & Hertig, 2004; Selye, 1974)
use of the best coping strategies would not be effective
enough to reduce stress levels. One person in the
nonpsychiatric group described that “I must have very
effective coping skills just to survive.” The coping
skills of participants included skillful ways of mentally
and behaviorally blocking some stressors or demands
in order to proceed with one demand at a time.
The nursing intervention that subjects stated in
response to question no. 9 was listening. This was also
substantiated by the findings that the interview itself
helped participants to feel better. In response to the
question, Would a nurse be able to help you with
stress overload?, one person stated, “You can tell some
people in your life some things and other people in
your life other things, but rarely can you tell anyone
else in your life the full nature of your stress experi-
ences.” An intervention that was mentioned by one
person was “a nurse can ask questions for clarifica-
tion.” Examples of this are Can you wait to change
jobs? Do you think there might be a way to change
International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006
Literature sources
Bay et al., 2005; Boardman, 2004; Booth et al., 2005; Choenarom et al.,
2005; Cropley & Steptoe, 2005; Eby, 2004; Golden-Kreutz et al., 2005;
Goodman et al., 2005; Holmes & Rahe, 1967; Ilgen & Hutchinson, 2005;
Lim et al., 2005; Lunney & Myszak, 1997; Lustyk et al., 2004; Motzer
& Hertig, 2004; Nielsen et al., 2005
Ilgen & Hutchinson, 2005; Keil, 2004; Lunney & Myszak, 1997;
McNulty, 2005
Lunney & Myszak, 1997; McNulty, 2005; Ryan-Wenger et al., 2005
Lunney & Myszak, 1997; McNulty, 2005
Diong et al., 2005; Drew et al., 2005; Lunney & Myszak, 1997;
McNulty, 2005
Cropley & Steptoe, 2005; Golden-Kreutz et al., 2005; Keil, 2004; Krause,
2004; Lunney & Myszak, 1997; Maller et al., 2005; Ridner, 2004;
Ryan-Wenger et al., 2005
that? That same person expressed a concern that nurs-
ing interventions may not always be effective, “I
wouldn’t mind getting advice from a nurse, but a
nurse might oversimplify the situation and assume
that I had not already thought about obvious
solutions.”
The emphasis of this qualitative study was to
describe the stress experience. Even though question
no. 8 asked about the stressors that contributed to this
experience, there were inadequate data to describe the
contributing factors for the stress experiences of these
nine participants.
Discussion
The findings from this qualitative study indicate
that stress overload is a viable diagnosis and the defini-
tion is appropriate. Identification and treatment of this
diagnosis is important because continued high stress
is associated with development of physical and
169
Stress Overload: A New Diagnosis
psychological illnesses (Booth, Beaver, Kitchner, O’Neill,
& Farrell, 2005; Harwood, Locking-Cusolito, Spittal,
Wilson, & White, 2005; Holmes & Rahe, 1967; Lim et al.,
2005; Lloyd, Smith, & Weinger, 2005; Ridner, 2004;
Selye, 1974; Sepa, Wahlberg, Vaarala, Frodi, & Lud-
vigsson, 2005; Stewart, Cianfrani, & Walker, 2005). For
example, in a review of the links between stress and
diabetes, Lloyd et al. explained the direct and indirect
relationships between stress and metabolic control in
diabetes, with possible negative effects on both the
autonomic and neuroendocrine systems, and interfer-
ence with the person’s self-management of the disease.
Cropley and Steptoe (2005) found that significantly
more physical symptoms, e.g., wheezing and sore
throat, were reported by individuals in a chronically
high-stress group (n = 57) compared to individuals in
a chronically low stress group (n = 43) (F(2) = 9.5;
p < .001). In a survey of 401 HIV-positive persons in
the state of Alabama, high scores on a general stress
scale were negatively associated with mental health
status (Stewart et al.). In a prospective 8-year follow-
up study, in which psychological distress and pain
had been measured at the beginning of the study, a
postal questionnaire returned by 4,501 adults, ages
18–75 (65% response rate) showed that individuals in
both the high and intermediate groups of psychologi-
cal distress had increased risks of mortality when com-
pared with those in the low distress group (Robinson
et al., 2004).
The defining characteristics generated by this quali-
tative study are supported by the literature. Numerous
studies show that the first defining characteristic, per-
ceives situational stress as excessive, can be present in
children and adults at all levels of health and illness
(Al-Hassan, & Sagr, 2002; Booth et al., 2005; Choenarom,
Williams, & Hagerty, 2005; Cropley & Steptoe, 2005;
Drew et al., 2005; Eby, 2004; Golden-Kreutz et al., 2005;
Goodman, McEwen, Dolan, Schafer-Kalkhoff, & Adler,
2005; Harwood et al., 2005; Hung, 2005; Ilgen, &
Hutchinson, 2005; Kanner, Coyne, Schaefer, & Lazarus,
1981; Lim, Williams, & Hagan, 2005; Neilsen et al.,
2005; Ryan-Wenger, Sharrer, & Campbell, 2005;
170 International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006
Scollan-Koliopoulos, 2005; Sepa et al., 2005; Stewart
et al., 2005). For example, in a study of stress and stressors
of 84 patients recovering from myocardial infarctions,
it was found that most of the patients experienced
moderate stress and 20% experienced high stress.
More than half of a sample of 70 women treated for
gynecologic cancer, ages 24–83 years, reported four or
more concerns perceived as a burden at the time of
diagnosis and 6 months afterwards, with high rates of
anxiety and depression (Booth et al.). In a comparison
of two groups of low income women, abused (n = 50)
and not abused (n = 57), abused women had significantly
higher stress levels, as measured by identification of
difficult life circumstances and stressful life events, than
not-abused women (t = 4.78; p < .05) and higher rates
of physical health problems (t = 2.60; p < .05). In two
studies of children aged 7–12 years old, Ryan-Wenger
et al. identified 54 mutually exclusive stressors that
contribute to high stress levels in children, including
community violence, threat of war, and availability of
drugs. These and other studies imply that high levels
of stress occur in some people and not others, thus
supporting the need to identify those at risk and to
conduct careful assessments and diagnoses.
Literature support for each of the defining charac-
teristics—expresses a feeling of tension or pressure,
expresses difficulty in functioning as usual and in ordi-
nary ways, expresses problems with decision making,
and expresses or demonstrates increased feelings of
anger, impatience, or being short tempered with
others—is present but comparatively weak. This is
because the purpose of most studies is to demonstrate
the relationships between stress and other variables,
with little or no attention to identification of the signs
and symptoms of high stress. Support for the defining
characteristic, expresses a feeling of tension or pres-
sure, was noted, however, in a concept analysis of
coping and stress. Keil (2004) concluded that “perhaps
stress lies somewhere ambiguously between [pressure
and tension]” (p. 662). Additionally, in a study of the
effects of high- and low-stress conditions with experi-
mental tasks (N = 62), scores on both a 1–10 stress
scale and a tool to measure tension were significantly
higher under high-stress conditions compared to
low-stress conditions (F(1,57) = 9.13; p < .01) (Ilgen &
Hutchinson, 2005). This study examined the responses
of two groups of men and women between 21–35
years of age, with no evidence of psychiatric illnesses,
and with a history of major depressive disorders.
Those with a history of major depression were more
susceptible to the experimental high-stress conditions
and tended to “give up” in the face of the challenge.
Using an index of anxiety, McNulty (2005) found that
a high percentage of deployed naval personnel (N = 1,
195 from three aircraft carriers) felt extremely tense
(40%) or very tense (28%) in the predeployment phase
and these percentages remained comparable in the
mid-deployment and postdeployment phases. In a
longitudinal study of work stress factors with 2,270
employees from 20 different companies, a positive
association of perceived work stress and mental strain
was demonstrated, with correlations ranging from .20
to .40, of various work–stress factors and mental strain
for both men and women (Rydstedt, Devereux, &
Furnham, 2004).
Support for the defining characteristic, expresses
difficulty in functioning as usual and in ordinary ways,
is evident in McNulty’s (2005) study of navy personnel,
in which large percentages reported being extremely
confused (62%) or very confused (24%). These percent-
ages remained comparable in the mid- and post-
deployment phases. In a review of stressors that affect
school-age children, Ryan-Wenger et al. (2005) suggested
that withdrawing was a symptom of childhood stress,
implying difficulty in functioning in usual ways.
Support for the defining characteristic, expresses
problems with decision making, is also evident in
McNulty’s (2005) study with 57% reporting that they
were extremely indecisive and 26% reporting that they
were very indecisive in the predeployment phase,
with percentages remaining comparable in the mid-
and postdeployment phases.
Support for expresses or demonstrates increased
feelings of anger, impatience, or being short tempered
International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006
with others was demonstrated by Drew et al. (2005),
who defined stress as frustration and irritability; 39%
of the participants (56 bereaved parents) demonstrated
at least moderate stress. McNulty (2005) showed that
4% of male participants (n = 923) and 3% of female
participants (n = 259) reported anger and abuse.
Female personnel, in general, also voiced fears regard-
ing their overall and gender-related safety, implying
anger among male personnel. Diong et al. (2005),
using structural equation modeling of data from 248
policemen, supported their theoretical model of anger
and stress as co-occurring and contributing to psycho-
logical distress and higher frequencies of being sick.
The remaining defining characteristic, reports nega-
tive impact from stress such as physical symptoms,
psychological distress, or a feeling of “being sick” or
of “going to get sick,” is supported by two concept
analyses and many studies (Cropley & Steptoe, 2005;
Golden-Kreutz et al., 2005; Keil, 2004; Krause, 2004;
Ridner, 2004; Ryan-Wenger et al., 2005; Sepa et al.,
2005). Both Keil’s and Ridner’s concept analyses state
that stress contributes to development of physical and
psychological symptoms and distress. Ryan-Wenger
et al., an experienced researcher of stress and coping
in children, advised parents that events may be judged
as too stressful for children if they complain of psy-
chosomatic conditions such as headache and stomach
ache. In a study of older adults and stress in relation to
highly valued roles, Krause concluded “the stressors
in highly valued roles affect health primarily by erod-
ing an older person’s sense of meaning in life” (p. S287).
Sepa et al. found that the psychological stress of par-
ents also affects the physical heath of infants, showing
a positive association of high parenting stress and the
production of diabetes-related autoimmunity in 1-year-
old infants (χ2(1) = 11.133, p < .001). In a prospective
study of 162 participants, Cropley and Steptoe found
that the chronically high-stressed group reported sig-
nificantly more physical symptoms than the chroni-
cally low-stressed group (F(2) = 9.5; p < .001), with no
significant differences between males and female
participants. In a study of 562 women, aged 25–74,
171
Stress Overload: A New Diagnosis

Table 3. Contributing Factors to Stress Overload Identified from Literature Sources

Related factors Literature sources

Burden of worry related to life events or concerns Booth et al., 2005; Carlson-Catalano, 1998; Golden-Kreutz et al., 2005;
Holmes & Rahe, 1967; Hung, 2005; Kanner et al., 1981; Selye, 1974
Illness or symptoms of illness Al-Hassan & Sagr, 2002; Carlson-Catalano, 1998; Davidson et al., 2004;
Harwood et al., 2005; Holmes & Rahe, 1967; Ilgen & Hutchinson, 2005;
Ridner, 2004; Ryan-Wenger et al., 2005; Selye, 1974; Taxis et al., 2004
Social factors, e.g., interpersonal relationships, Al-Hassan & Sagr, 2002; Boardman, 2004; Carlson-Catalano, 1998;
community, family, friends, and/or health Choenarom et al., 2005; Harwood et al., 2005; Holmes & Rahe, 1967;
providers Krause, 2004; Power, 2004; Ryan-Wenger et al., 2005; So & Chan, 2004
Low educational level or lack of knowledge Al Hassan & Sagr, 2002; Booth et al., 2005; Harwood et al., 2005
Poverty Al-Hassan & Sagr, 2002; Eby, 2004; Goodman et al., 2005;
Harwood et al., 2005
Severe emotional responses, e.g., grief, powerlessness, Drew et al., 2005; Golden-Kreutz et al., 2005; Hung, 2005; Power, 2004;
change in body image or self esteem Ridner, 2005; Ryan-Wenger et al., 2005; So & Chan, 2004
Inadequate social support Bay et al., 2005; Booth et al., 2005; Choenarom et al., 2005; Cropley,
2005; Hung, 2005; Ryan-Wenger et al., 2005
Environmental threats, demands, or lack of resources, Hannigan et al., 2004; Harwood et al., 2005; Scollan-Koliopoulos, 2005;
for example, community, family or school violence, Sepa et al., 2005; Stewart et al., 2005
threat of war, excessive demands of others (e.g., for
children, excessive homework or over-organized
sports and play)

Mallers, Almeida, and Neupert (2005) determined that
women in the young and middle-age groups with
high stress reported more physical health symptoms
than older women. They suggested that environmental
stressors, including interpersonal relationships, may
have more negative effects than biologic stressors. This
association of older age women with lower stress was
also reported in other studies (Janz et al., 2004).
According to the stress literature, which is much
more extensive than the articles cited in this paper, the
stressors that contribute to stress overload are many and
varied (Table 3). Some stressors can be mitigated, e.g.,
acculturative stress may be mitigated by using the
intervention of “culture brokerage,” while other stres-
sors are less controllable (e.g., race and socioeconomic
status or deployment to war zone). In structured inter-
views of 101 Hispanic clinic patients, Thoman and
Suris (2004) found that acculturative stress was a
predictor of psychological distress. A study of social
disadvantage and adolescent stress found that stress
was higher among African American students, those
from lower socioeconomic status families, and those
with lower perceived socioeconomic status (Goodman,
et al., 2005). McNulty (2005) found that deployment to
a war zone was associated with extreme individual
and family stress and suggested that interventions
were needed for these service personnel and their
families.
Stress overload occurs when stressors become a bur-
den for an individual or group. This diagnosis does
not refer to single time-limited stressors such as the
stress of test-taking (Sarid, Anson, Yaari, & Margalith,
2004). Stress overload can occur with one intense,
repeated stressor (e.g., family violence) (Carlson-
Catalano, 1998), or with multiple coexisting stressors
(e.g., relationships with spouses and friends, housing,
money, work, legal difficulties) (Cropley & Steptoe,
2005).

172 International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006
 The interventions suggested by the nine partici-
pants in this qualitative study that are covered by
labels in the Nursing Interventions Classification
(NIC) (Dochterman & Bulechek, 2004) are “active
listening,” “presence,” “decision-making support,” and
“values clarification.” By listening, nurses can help
persons with stress overload to make sense of the experi-
ence and come to a fuller understanding. Nurses
may be more helpful than family or friends because
they are not involved in the specific demands being
made on patients. Providing “presence” for a period
of time (e.g., 15–60 min) may enable persons with
stress overload to feel supported. With the interven-
tion of “decision-making support,” nurses can help
persons with stress overload to prioritize decisions,
separating what may seem like overwhelming
tasks to smaller subgroups of tasks. With the
intervention of “values clarification” nurses can
help persons with this diagnosis to decide the best
courses of action to reduce stress (Dochterman &
Bulechek).
Implications
The implications for these findings relate to nursing
assessment, diagnosis, and interventions, and patient
outcomes. With assessment, nurses should be mindful
that this diagnosis represents a subjective experience
of individuals and groups, a feeling of burden. The
best way to obtain valid and reliable information from
patients about their experiences is to develop nurse–
patient partnerships, in which patients trust nurses
enough to share intense experiences. To assess this
response, nurses should ask questions such as (a) Are
you experiencing stress overload? and (b) On a scale of
1–10, how would you rate this experience? Recently, a
1–5 scale (1 = not at all stressful, 5 = extremely stress-
ful) was successfully used (Eby, 2004; Lim et al., 2005),
so a 5-point scale is also an option. Assessment should
also include asking how the person feels and how the
stress affects their daily routines. Through working in
partnership with patients, nurses can validate the
International Journal of Nursing Terminologies and Classifications Volume 17, No. 4, October-December, 2006
diagnosis and decide with patients the interventions
that would help to reduce stress.
The interventions that can be offered to patients are
those identified through this study and others
suggested by literature sources. Additional nursing
interventions that should be considered are “environ-
mental management,” “energy management,” “social
support enhancement” (Dochterman & Bulechek,
2004), and stress reduction. In circumstances in which
environmental factors are contributing factors, e.g., for
patients in critical care units (So & Chan, 2004), “envi-
ronmental management” may reduce the amounts
and types of stressors. The NIC intervention of
“energy management” may help persons with this
diagnosis to prevent fatigue. “Social support enhance-
ment” helps to mediate the effects of high stress
(Choenarom et al., 2005; Cropley & Steptoe, 2005;
Krause, 2004). An intervention that is not in the NIC
and should be developed is stress reduction, defined
as helping an individual or group to reduce the
amounts and types of stressors that demand action.
When the diagnosis of stress overload is available for
nurses’ use through the NANDA I taxonomy, the
most appropriate nursing interventions can be identi-
fied through additional research.
The Nursing Outcomes Classification outcome that
directly relates to this diagnosis is Stress Level, with a
score of 1 for Severe (i.e., Stress Level), 2 for Substan-
tial, 3 for Moderate, 4 for Mild, and 5 for None. Nurses
and patients, working in partnership, identify the
overall baseline score using scores on the indicators,
e.g., headache, diminished attention to detail, and in-
ability to concentrate on tasks. With the diagnosis of
stress overload, most likely the baseline score on stress
level will be 1 or 2. If nurses can help patients move even
one level on the outcome scale, patients will probably
feel some relief from the symptoms of stress overload.
Conclusions
The diagnosis of stress overload can be used as
needed by nurses in clinical settings now that it is a
173
Stress Overload: A New Diagnosis
part of the NANDA I Taxonomy. Inclusion in the
taxonomy is expected to stimulate further research to
validate the defining characteristics and related factors,
as well as to identify the most appropriate nursing
interventions for various populations. This diagnosis
is relevant for community and acute care settings, and
for people of all age groups.
Author contact: lunney@mail.csi.cuny.edu
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