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Original articles

Toward a System Theory of Stress, Resilience, and Reintegration

Etchin, Anna G. PhD, RN; Fonda, Jennifer R. PhD; McGlinchey, Regina E. PhD; Howard, Elizabeth P. PhD, RN, ACNP, ANP-BC, FAAN

Author Information
doi: 10.1097/ANS.0000000000000277
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Abstract

MILITARY to civilian reintegration is the return and adjustment of a veteran to his or her civilian families, communities, and workplace roles.1 Challenging reintegration affects a notable percentage (44%) of post-9/11 US veterans2 and has been linked to psychological, physical, and social morbidities.3–8 Furthermore, 25% to 56% report “some” to “extreme” difficulty with social functioning, productivity, community engagement, and self-care.9 These problems have implications for greater society as economic, human, productivity, and health care costs throughout reintegration are considerable in this cohort.10–13 The complexities of reintegration warrant comprehensive perspectives, which are limited.

Statement of Significance

What is known or assumed to be true about this topic:

Recent trends demonstrate a decrease in theory-driven research. The RAND Corporation, US Department of Defense Center of Excellence, and World Health Organization all suggest holistic theory–driven veteran reintegration research. Despite the complexity of reintegration, relevant theoretical frameworks lack holistic and comprehensive perspectives.

What this article adds:

A nursing conceptual model, Neuman's Systems Model, and a psychology theory, Transactional Model of Stress and Coping, were integrated to create the System Theory of Stress, Resilience, and Reintegration. Interdisciplinary theory integration may bolster research of and intervention development for complex phenomena.

From an ecological perspective, reintegration encompasses multilevel factors: individual, interpersonal, community, and societal.1 Organizations, such as the RAND Corporation, US Department of Defense Center of Excellence, and World Health Organization, suggest holistic models to investigate the complexities of military to civilian reintegration.14–16 For instance, the Total Force Fitness model integrates a mind-body holistic perspective, though it lacks interacting external and environmental factors. A holistic model specific to wounded US Air Force warriors incorporates services, health, housing instability, social functioning, and job/finance.14 Although lacking individual core characteristics that may also influence reintegration, the model encompasses mutually reciprocating concepts specific to reintegration. The transprofessional International Classification of Functioning, Disability, and Health surpassed these limitations and encompasses personal and contextual factors that influence functioning and disability.16 However, the principal outcomes are constricted to physiological functionality and disability. The aforementioned models all have value for holistic investigation but lack comprehensive relationships among concepts that may influence reintegration. In addition, no known metatheory has been associated with reintegration in the literature.

This article presents a System Theory of Stress, Resilience, and Reintegration among post-9/11 US veterans that is an integration of a nursing conceptual model, Neuman's Systems Model (NSM), with a psychology theory, Transactional Model of Stress and Coping (TMSC), within a metatheory of critical realism. Neuman's Systems Model was chosen as the conceptual model for its holistic underpinnings and TMSC for its focus on concepts relevant to reintegration. An overview of critical realism, NSM, and the TMSC are presented, followed by the proposed integrated theory with an application to research.

CONCEPTUAL AND THEORETICAL MODELS

Metatheory: Critical realism

Metatheories provide philosophical underpinnings to phenomena. Although scarcely cited in the literature, metatheories provide transparency for theory development and research methodologies and interpretations. For this article, critical realism was chosen for its holistic properties. It suggests that individual aspects of the whole act differently than when viewed as a whole and recognizes multiple realities17 and the independent contributions of characteristics within a phenomenon to be interrelated within nature and science.18 Within the current context, the reality of deployment and reintegration includes veterans' experiences, actions, and perceptions.

Conceptual model: NSM

In 1970, Betty Neuman developed the NSM to explain how system stability is maintained in response to stressors from the environment. A system is the dynamic, interactive composite of factors that are not simply reducible to their parts. Philosophical underpinnings embrace a holistic, multidimensional, and dynamic perspective of relationships within a reciprocal interaction worldview.19 Holistic underpinnings of NSM make it a suitable conceptual model for studying the complex nature of reintegration, though only 1 known military-related research study has utilized NSM in military-related research.20 The following presents key NSM elements relevant to reintegration that include client (ie, individual) system and interacting variables, environment, stressors, reconstitution, and lines of defense and resistance. These concepts are integral to NSM and applicable to the complex phenomenon of military to civilian reintegration.

Client system and interacting variables

The client, or individual, is the center of a system of mutually dependent variables influenced by one's internal and external characteristics and stressors.21 The basic components of the individual include survival and factors such as genetics, weaknesses, and/or strengths.22,23 Interacting variables (physiological, psychological, sociocultural, developmental, and spiritual) regarding the individual should be considered concurrently, as they lead to varying degrees of protection or invasion from stressors within the system.19

Environment

The environment encompasses all internal and external forces that affect the client. It includes the internal (where intrapersonal stressors exist), external (where interpersonal and extrapersonal stressors exist), and the created environment.22,23 The created environment reflects the dynamic, unconscious, and protective mechanism to maintain system stability.21

Stressors

Stressors occur within the individual and his or her system (intrapersonal), between or among individuals (interpersonal), or outside of the individual (extrapersonal).19 Harmful and neutral effects of stressors are intuitive; however, positive effects include increased resistance against future stressors as well as successful return to and maintenance of one's optimal level of overall wellness stability.

Reconstitution and lines of defense and resistance

Reconstitution is the adjustment and return to system stability following stressor reaction.19 The concept is minimally described or researched21,24 and is often discussed only with regard to the lines of resistance and defense, which are made up of the 5 interacting variables (physiological, psychological, sociocultural, developmental, and spiritual).19 The dynamic flexible line of defense moderates the reaction to environmental stressors in an attempt to prevent or minimize system reaction.25 It plays a protective role as a buffer against stressors that impact a person's usual level of wellness or the normal line of defense.25 Lines of resistance are stable, internal, and external factors that protect the individual's core and mediate reconstitution to normal wellness state following stressor invasion.25

Theoretical model: The TMSC

Theoretical models, guided by conceptual models, are directly testable19 and more commonly used in research. Lazarus and Folkman's TMSC26,27 contributed to the development and maturation of NSM. Lazarus and Folkman sought to better understand stress and coping in adults and to explain the environmental and internal stressors that influence individuals' well-being. The TMSC encompasses the person and environment within a mutually reciprocal, dynamic relationship in which an individual is the composite of himself or herself and his or her environment.28 The model, structured by stress and appraisal, coping, and adaptation, is described next.

Stress and appraisal

Stress, a stimulus or a response, is considered within the relationship of person and environment28 and is dependent on the dynamic perception and appraisal of one's meaning of the stress stimuli. Individuals react uniquely to stressors on the basis of stressor characteristics and one's coping ability and stressor perception. Stressful events occur in relation to context with other events and within the life cycle.28 Cognitive perception and appraisal are dependent upon the relationship between person and environment.26,29 Stressors, created by the internal and external environment, disrupt balance and affect one's well-being. With ineffective coping, stressors may lead to illness. Primary and secondary appraisal and coping are mediating processes.28 As such, researchers cannot predict performance and outcomes just by knowing the stressors.28

Primary appraisal is one's distinct initial perception of the significance of a stressor on one's well-being: benign, harmful, positive, negative, controllable, and so forth.28 Secondary appraisal is the action arm, including evaluation of stressor controllability and one's perceived coping resources and abilities that manage the reaction. Interpretations and reactions to comparable experiences are individualistic and related to individual coping mechanisms. Past experiences shape future appraisals and aid in development of coping skills for future similar encounters.28

Appraisal is based on individual characteristics: commitment and beliefs.28 Commitments are individual meanings one makes of events as harmful or beneficial. Beliefs are individual or group perceptual lenses and shape one's understanding of the meaning of an event. Of note, past experiences of harmful events, whether it be direct or indirect connections and experiences, shape future appraisals of similar experiences.28 These past experiences, whether harmful, beneficial, or neutral, aid in development of coping skills necessary for future encounters.28

Duration of a stressful event may erode one's psychological and physiological well-being.28 Furthermore, stressful events occur in relation to the individual's life, both in context with other events and within one's life cycle.28 Notably, timing of the event in relation to other events becomes crucial in understanding stressor reaction.

Coping

Coping, directed at secondary appraisal, is the actual cognitive and behavioral/emotional mechanism(s) and action(s), along with available psychological, social, and cultural resources,30 that mediate appraisal and result in stress reduction.27,28 Coping includes problem management and emotional regulation. Problem-focused coping strategies are more effective for dynamic stressors while emotion-focused strategies work best for static stressors.30 Of note, situations and stressors can be dynamic; thus, coping efforts also may change on the basis of time and context.28,30 Meaning-based coping efforts can prompt positive emotion, such as spirituality, positive reinterpretation of event, and so forth.30 Positive affect may function as a protective buffer against negative stress reactions.31 Coping resources, which can be beneficial and/or harmful, involve tools, problem-solving and social skills, social support, health, energy, positive beliefs, finances/material resources, or the ability to find necessary resources.28

Adaptation

Positive or negative adaptation, or the outcome of coping mechanisms and efforts, includes 3 potentially interacting outcomes: emotional well-being (including life satisfaction, morale), functional status (including health status, disease progression, vocational/social living), and somatic health.28,30 Short- and long-term adaptation is considered within the context of the environment and situation.

System Theory of Stress, Resilience, and Reintegration

A Conceptual-Theoretical-Empirical model19 was created (Figure 1) using relevant concepts integrated from the NSM and the TMSC. This model guided the study of interdependent risk factors and needs among a sample of postdeployed, post-9/11 US veterans. Exemplar empirical measures from a research study (A. G. Etchin, J. R. Fonda, E. P. Howard, C. Fortier, W. Milberg, K. Pounds, R. E. McGlinchey, unpublished data, 2019), along with their conceptual (NSM) and theoretical (TMSC) concepts, can be found in the Table. These instruments measured concepts congruent with the NSM and the TMSC in the Conceptual-Theoretical-Empirical, which was relevant for hypothesis testing but lacked deeper theoretical relationships. They were chosen as an example, though others could be interchangeable. The Conceptual-Theoretical-Empirical model was used as a guide for conceptual congruency between the NSM and the TMSC.

Figure 1
Figure 1:
Conceptual-Theoretical-Empirical (C-T-E) model. NSM indicates Neuman's Systems Model; TMSC, Transactional Model of Stress and Coping.
Table
Table:
Exemplars of Instrument Tools and Associated Theory/Model Concepts

Concepts from NSM and TMSC were concatenated into the System Theory of Stress, Resilience, and Reintegration (Figure 2), considered within a perspective of critical realism, in which concepts are considered concurrently with regard to the context of one's life and reality (perceptions, experiences, and actions). Stressors, environment, and person were derived from NSM and primary and secondary appraisal, coping, and adaptation from TMSC. Known and hypothesized relationships among concepts, based on theory and the literature, were integrated into the diagram. This integrated theory captures a system of interrelated concepts within a perspective of the environment, context, and person. More specifically, past and current stress influences one's resilience and reactions to stress. Past stressor events, such as childhood trauma, influence one's perception of the stressor effect on his or her overall well-being and his or her ability to cope with the stress. Resilience resources, such as family support, contribute to one's ability to cope with stressors and their overall resilience. Coping, a concept from the TMSC, is congruent with the newly developed theory concept of resilience. Stress and resilience then influence reintegration outcomes.

Figure 2
Figure 2:
System Theory of Stress, Resilience, and Reintegration.

Application to research

Integration of the NSM and the TMSC provides a model that is testable and explicit, while contributing hypothesized relationships missing from each individual theory. The proposed integrated model was used for a research study focused on complex issues that impacted post-9/11 US veterans throughout their military to civilian reintegration period (A. G. Etchin, J. R. Fonda, E. P. Howard, C. Fortier, W. Milberg, K. Pounds, R. E. McGlinchey, unpublished data, 2019). In keeping with systems logic, integration of these models was appropriate to study the multifaceted, interdependent, and often concurrent nature of deployment-related stressors, resilience, and reintegration. Reality was considered from a critical realism perspective: events and personal perceptions/experiences are considered together within a reciprocal system of the person, environment, and context. With regard to critical realism, investigation included participant experiences (including their perceptions of experiences), underlying motifs that led to the actual events, and methods used to measure these aspects of reality.

Stress

Reintegration outcomes may be influenced by various past and present stressors and stressor reactions, which should be viewed holistically. For instance, a recent study by Jennings et al37 found that combat experiences were not enough to explain deployment characteristics. Instead, a compilation of deployment and personal demands, along with personal and interpersonal resources, could be stressful and/or supportive. Lifetime personal demands have also been investigated, revealing important avenues for research and interventions. Research suggests that early life stress can predict aspects of adult psychopathology,38 resilience,39 and coping strategies.28 In the presence of chronic stress, positive and/or negative emotion-based coping may occur.31

Resilience

Integrating Lazarus and Folkman's concept of coping and NSM's concepts of the lines of resistance and flexible lines of defense, resilience may function as a dynamic buffer that mediates reactions to stressors.40–42 Resilience includes the beliefs, actions, and abilities that promote coping or adaptation to challenging conditions.40,43 It can be innate, learned, or acquired.44 As a protective and adaptive resistance against stressors, resilience may mediate reintegration success following deployment-related stressors,21,28 though the exact mechanisms are feebly understood. Furthermore, promoting positive reactions (ie, personal growth, coping skills) to chronic stress may prevent or reduce the severity of chronic stress disorders.31

Notably, resilience includes resources that strengthen one's ability to reintegrate successfully. Common resources in the literature include social support (ie, friends, society, family),45–47 relational support (ie, significant others),48,49 and personal characteristics (ie, self-esteem, the ability to make meaning of experiences).43,47 Research suggests that coping is integral for and during reintegration1; thus, it should stand that resilience is a vital component for positive reintegration outcomes.

Reintegration

Neuman's concept of system stability in reconstitution can be perceived as reintegration, which is also congruent with Lazarus and Folkman's concept of adaptation. The literature often utilizes reintegration, resilience, adaptation, and coping synonymously as actions and/or outcomes. Multifaceted factors influence successful reintegration. These may be intrapersonal, such as mental health problems. Interpersonal factors may include military unit structure or family and other social supports. Resource availability or environmental factors represent extrapersonal influences. Despite the complex nature, most studies focus on domains of reintegration, such as family,50 occupational,51 or personal functioning.52 Domain-specific investigations limit the multidimensional knowledge of reintegration. From the NSM perspective of holism, the whole (ie, reintegration) is made up of its parts (ie, various domains) that should be studied concurrently.

DISCUSSION

The System Theory of Stress, Resilience, and Reintegration is a holistic, comprehensive, systems-based model that can guide treatment plans and interventions for veterans as they reintegrate back into civilian society. Applying the model in research has methodological challenges. As coping is a dynamic process with complex mechanisms, operationalization requires a multidimensional approach.28 Similarly, investigation of multiple stressor events and resilience patterns in the same person may better attempt to understand one's future resilience style. Investigation of lifetime stress and coping mechanisms may provide better insights regarding coping and adaptation trajectories. Notably, coping and adaptation, or resilience and reintegration, can be considered as the same concept that can create a confounding event when attempting to investigate separately; thus, they should be conceptualized clearly. Another challenge to consider is that affect and coping have a reciprocal relationship; thus, the causation pathway is based directly upon the research question.31

This integrated theory has fundamental application in clinical practice, education, and policy. Nurses and interdisciplinary teams can apply this theory to ensure comprehensive assessments of veterans reintegrating to civilian society, which could then aid in treatment plan development and implementation. For individuals expecting to work with veterans (ie, health care personnel, educators, etc), understanding this theory could promote awareness of factors that may influence veterans' outcomes. Improved assessments, treatment plans, interventions, and awareness of reintegration and influencing factors could benefit policy makers and stakeholders. As reintegration is complex and difficult to target in siloed treatment, allocating funds to bolster veterans' resilience and mitigate effects of past and current stressors may in turn improve reintegration outcomes. As such, health care costs for reintegration-related problems could be drastically reduced. Future research should further investigate individual resilience experiences and characteristics as well as how persons maintain positive affect despite chronic and/or severe stress.

CONCLUSIONS

Nursing knowledge will continue to evolve through use of sound theory, though trends between 1985 and 2010 demonstrate decreases in theory-based nursing research,53 reversing trends of previous century. Similarly, metatheories are often lacking in nursing research literature.54 Although theory integration across disciplines is controversial, interdisciplinary health care systems and teams will benefit from collaboration, particularly to further advance understanding of complex phenomena. In fact, a White Paper from the Office of the Chairman of the Joint Chiefs of Staff55 advocates for holistic collaboration as a necessary component for promoting successful reintegration.

The System Theory of Stress, Resilience, and Reintegration has implications for veterans and caregivers. RAND, along with other corporations and organizations, recognizes the complexity of reintegration and identifies a significant need for a holistic model.14 Veterans with and without diagnosable impairments following military service will reintegrate. Thus, understanding key components that may influence reintegration outcomes is instrumental in designing personalized, transdiagnostic treatment plans. The model also may guide policies to develop and support clinical practice guidelines, currently nonexistent for reintegration. The theory may be applicable for research in other populations, such as civilian adults, teenagers, children, individuals who are institutionalized, and underserved communities that experience traumatic situations. Further research is needed to test this theory among veterans and other aforementioned populations in order to better design treatments and interventions.

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Keywords:

nursing research; nursing theory; theory integration; veterans

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