Understanding internal and external stressors in the Erickson, Tomlin, and Swain framework

Let’s unpack a idea that often goes unseen in busy wards, clinics, and home visits: stress isn’t just what bubbles up from inside a person or what storms in from the outside alone. In the framework developed by Erickson, Tomlin, and Swain, stressors are a two-way street. They’re both internal and external, and together they shape how health feels and how care should be guided.

What the framework really says about stress

Think of stress as a ripple, not a single droplet. A patient’s health is rarely influenced by one thing in isolation. Inside the person—how they feel, think, and physically respond—meets the world around them—people, places, and systems. When nursing theory talks about internal stressors, it’s pointing to the things that arise from within: emotions like fear, sadness, or anger; thoughts and beliefs about illness or treatment; coping styles; and physiological states such as pain, fatigue, sleep disruption, or chronic conditions. External stressors are the stuff that comes from the outside: the emotional climate of a home, financial strain, crowded living conditions, confusing or unsupportive health systems, or even the hospital environment with noise, unfamiliar routines, and limited privacy.

Let me explain with a simple picture. Imagine a patient with newly diagnosed diabetes. The internal stressors might include worry about managing blood sugar, fear of needles, and beliefs about whether they’ll be able to follow a meal plan. The external stressors could be a busy work schedule, a lack of reliable access to fresh foods, and the support—or lack of support—from family. Together, these factors don’t just add up; they interact. The fear might be worse because finances are tight, or the plan feels overwhelming because the patient doesn’t have a quiet space at home to focus on self-care. That interplay helps explain why two people with the same diagnosis can experience entirely different paths.

Inside vs outside: concrete examples

Internal stressors (inside the person)

• Emotions and mood: anxiety, sadness, embarrassment about illness.

• Thoughts and beliefs: doubts about treatment, fatalistic views, or confidence in self-management.

• Physiological states: pain, fatigue, sleep disturbances, hormonal shifts.

• Coping patterns: whether someone tends to withdraw, confront issues, or seek social support.

External stressors (outside influences)

• Family dynamics: a caregiving burden, conflicting opinions about treatment, or a lack of encouragement.

• Financial pressures: costs of care, transportation, time off work.

• Environmental factors: living in crowded housing, exposure to allergens, or unsafe neighborhoods.

• Health system factors: appointment availability, communication gaps, and the clarity of instructions.

The magic (and the challenge) lies in how these sets of stressors weave together

Here’s the thing: internal and external stressors don’t operate in silos. They influence each other in real time. You see a patient stiffen up before a blood draw (internal stress), and you realize the room is too warm, the clock is ticking loudly, and the nurse’s back is turned to the window for privacy (external stress). The result can be a stronger physiological stress response—more pain, higher heart rate, more tension—exactly at the moment when calm, clear communication could help.

This is where the holistic view becomes more than a nice idea. It’s a practical compass for care. When nurses and other caregivers acknowledge both sides, they’re better equipped to tailor interventions that touch the whole person, not just the symptom cluster.

Why this matters for patient-centered care

If you’ve ever watched a patient’s shoulders drop after a kind, honest conversation, you’ve seen the value. Recognizing internal stressors invites us to ask questions like: “What worries you most about this diagnosis?” or “What helps you feel steadier when you’re overwhelmed?” Recognizing external stressors nudges us to map practical supports: “Is transportation a barrier to appointments? Do you have a family member who can assist with meals? Could we connect you with social work for financial counseling or community resources?”

Together, these insights guide a more effective plan:

• Assessment that really listens: open-ended questions, reflective listening, and plain-language explanations.

• Tailored interventions: symptom management for internal stressors (pain control, sleep hygiene, coping strategies) combined with changes in the environment or supports to reduce external stressors (quiet space for care, clearer instructions, flexible scheduling, or social services involvement).

• Collaboration: coordinating with social workers, family members, or community programs to shore up supports.

A quick mental model you can carry

Think of internal stressors as the “inside weather” and external stressors as the “outside weather.” The patient’s overall experience is the weather forecast you’re trying to understand and improve. If the forecast shows storms (high stress) on both sides, your job is to pick interventions that dampen the storm where you can—offer soothing explanations, simplify treatment plans, arrange support services, adjust the environment, or advocate for resources. The goal isn’t to erase stress entirely (that’s not always possible) but to reduce its intensity and protect the patient’s well-being.

Practical takeaways you can apply

• Ask and listen: “What’s most stressful for you right now?” and “What helps you feel more in control?” These questions bring internal stories to light while also hinting at external pressures you can address.

• Map stressors together: a quick two-column note in patient records can help. Column A is internal stressors; Column B is external. You’ll often find links—like how poor sleep (internal) is worsened by a noisy ward (external).

• Coordinate care beyond the bedside: involve social work for financial or housing concerns, dietitians for food access, and community organizations for transportation.

• Modify the environment when possible: ensure privacy, reduce unnecessary noise, provide clear signage, and simplify instructions. Small changes can lower external stress and make internal stress easier to manage.

• Empower with information: clear explanations and practical demonstrations (how to monitor glucose, how to use a inhaler, what side effects to expect) reduce uncertainty, which is a big internal stressor.

• Use consistent, compassionate communication: validate feelings, acknowledge effort, and share realistic expectations. A patient who feels heard often copes better, even when challenges remain.

A few real-world tangents you’ll appreciate

• Sometimes, a patient’s stress isn’t about disease at all. Or it’s about the idea of losing independence. In those moments, honoring autonomy—offering choices, inviting preferences, and letting patients steer parts of their care—can deflate a lot of fear.

• Think about families, too. Caregivers carry stress that’s just as real. When you include them in conversations, you cut the knot of confusion and build a sturdier support system around the patient.

• Technology isn’t just about devices. It can either ease the load or add to it. Telehealth options, remote monitoring, or simple mobile reminders can soften external pressures and help patients feel more capable.

A gentle caution about over-simplification

None of this is about blaming the patient or the system. It’s about recognizing complexity and choosing actions that honor that complexity. Some days the internal stressors feel heavy; some days the external ones loom larger. The beauty of Erickson, Tomlin, and Swain’s ideas is that they offer a humane lens—one that helps us see the person behind the diagnosis and the world they’re navigating.

If you’re ever tempted to shortcut the moment, pause and remember this: stress is multi-layered and personal. Two patients might look alike on paper, yet their inner weather and outer climate could be entirely different. The more attuned you are to this, the more you can shape care that feels respectful, practical, and genuinely helpful.

Bringing it together with care that’s both thoughtful and effective

In a field that moves fast, it’s easy to focus on the “this” and forget the “that”—the person and their lived experience. Erikson, Tomlin, and Swain remind us that health isn’t just a physical state; it’s a dynamic blend of inner feelings and outer circumstances. When you attend to both, you’re not just treating a disease. You’re smoothing the path toward better well-being, one patient at a time.

So, what does this mean for your daily work or study? It means staying curious about the person in front of you. It means asking about stressors with kindness, listening for what really matters, and weaving supports into a plan that respects both the mind and the environment. It’s a flexible, human-centered approach that recognizes that health is lived, not just listed in a chart.

And in the end, isn’t that what good nursing is all about? Seeing the whole person, not just the illness, and using that understanding to help people move forward with a little more confidence, a little more peace, and a lot more resilience.