Stress management

Bingi Rajeswari M.Sc Nursing NIMHANS

Definition
A state of affair which can disturb the normal physiological and psychological functioning of an individual. - Oxford dictionary. Arousal of mind and body in response to demands made upon them. - Schafer 2000

IMPORTANCE
The Importance of Stress Management for Nurses The health care industry is a stressful place to work. Nurses in particular face these stresses head on, since they are often responsible for the day-to-day care of patients and the families of patients. The hours in nursing can be long, and the work can be physically, mentally and emotionally exhausting. It is no wonder that nurses rank high among stressed-out employees.

Causes of stress at workplace

General Causes Of Stress At Work: Inadequate staffing. Long and/or unsociable hours Poor pay Poor promotion prospects Unnecessary procedures Uncertainty and insecurity

Specific Causes of Stress at Work

1. Lack of role clarity 6. Inadequate leadership

7. Conflicts with 2. Unrealistically high selfcolleagues expectations 3. Inability to influence 4. Lack of decision making 5. Poor communication 8. Inability to finish a job 9. Fighting unnecessary

VARIOUS STRESSORS
7 Major Nurse Related Stressors Dealing with death and dying Criticism by physicians Dealing with emotional needs of patients and their families Lack of staff support Workload Uncertainty of treatment plans Conflict with colleagues (Cox, Cox, and Griffiths, 1996)

Job stress & health Job stressors

Job Demands Workload Shift work Limited worker control Technology Client demographics (age, culture) Organizational Factors Role demands Management style Career security Interpersonal relations Change Physical Environment Space, noise, heat, cold, lighting, etc.

Individual factors Personality traits Motivation Talent Training

Acute stress

Chronic stress

Reactions: Physical Psychological Behavioral

Stressrelated Illness: Heart disease Depression Infections

Finances Family trauma Non-work stressors

Social support Coping skills Hardiness Buffer factors

OR Healthy worker

Adapted from NIOSH Publ. 87-111; 8 Vachon & Pakes; Maddi& Khoshaba

Work factors by occupation

Nursing: 17% fewer RNs in acute care hospitals in 2005 than 2000 (Reineck & Furino) Workload: pts. old, ill, obese. Paperwork, language. (Reineck & Furino) Each added pt/nurse 23% higher risk of burnout & 7% higher pt. mortality. (Aiken 2002) Inadequate/inexperienced staff & inadequate staff budget, agency RNs Shift work (nights), overtime, & pressure to reduce time on clock 12-hour vs. 8- or 10-hour shifts. Float/prn responsibilities Fast pace not meeting pt needs or own expectations, fear of errors Leadership/management style. Professional/mgt/pt/family conflict Lack of input in care, including moral distress/conflict Fishbowl environment in ICU settings Proximity to death and dying pts Threatening/difficult/demanding pts (especially psych) Lack of advancement options

Worker factors in stress

Personal traits
Age, partner/family status, race/ethnic, economic Personality Motivation
Gain knowledge, use technical skills, help or work with people Need to be needed to boost self-esteem is a risk for work overload and CF

Talents & training

Innate abilities that are advantageous in job Occupational training Experience

Non-work stressors
Current personal stressors Previous personal or job trauma or crisis

Buffer factors
Hardiness Coping style Social support

workplace stress
Job Demands (General) Workload Shift work Limited worker control Technology Client demographics (age, culture) Organizational Factors Role demands Management style Career security Interpersonal relations Change Physical Environment Space, noise, heat, cold, lighting Health care (Specific) Work overload, paperwork Shortage of staff Shifts/schedule issues, overtime Lack of control Patients older, sicker, and heavier Management style, culture Lack of supervisor & peer support Work not valued, low salary Lack of advancement options Fear of errors Conflict with coworkers, pts., staff Moral dilemmas, death, dying Risk of violence at work Work environment in disaster response Fishbowl in ICU Isolation (lab, dietician, SW, rural)

Coping with stress

Managing stress is all about taking charge of your thoughts, your emotions, your schedule, your environment, & The way you deal with problems.

steps to master stress

1. Claim it: everyone has stress. 2. Name it: everyones stressors are different. (TWERPS) 3. Reframe it: Look at your stress & stressors in a different way. Hardiness, coping. 4. Tame it: prepare, self-care, share, dare, be aware
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1. Claim it
Stress: present in all organisms Nonspecific response to any demand placed on the organism Impulse pushes us out of balance or equilibrium Stressors: factors that provoke stress response Stress responses Acute Fight-or-Flight Chronic stress. Healthy stress (Eustress)- adaptive Motivates growth & learning. Unhealthy stress (Distress):- maladaptive Can result from impossible demands. Biopsychosocial effects Job stress: Harmful responses that occur when requirements of the job do not match the capabilities, resources or needs of the worker. NIOSH 10% of total occupational disease claims are due to stress. Marine et al 2007 14

2. Name it: Your stressors: TWERPS Tasks, Time Worries Environment, Expectations, Events Roles, Responsibilities People (yourself, others, communication) Situations: all of the above put together
How much is in your control? How much is from outside circumstances?
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Effects of prolong stress Transition from eustress to distress

What happens to us when we experience intense stress over a prolonged period of time?

Burnout Compassion Fatigue Compassion Crisis Maladaptive stress response

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Burnout
M Meaning: Burnout is a progressive condition characterized by physical and emotional exhaustion involving the development of negative job attitudes and a loss of concern and a feeling for those with whom one works. Causes: Result of stress at both the individual level and the organizational level. stress associated with marital problems,financial strains or social pressure can influence and 18 compound job-related stress.

Symptoms: 1.Change in attitude(Stress is causing faulty perceptions- not the workers inherent nature). 2. Emotional exhaustion(easy fatigability). 3. Changes in self-image (one feels ineffective and inadequate, job satisfaction declines). 4. Education inflexibility(less tolerance for ambievity,less reliance on personal decision making)

 Burnout managers begin to promote job security and resist innovation by subordinates. They will either work harder but feel progressively less capable or will shorten job-related activities, but will not succeed in recharging .

 Example: A nurse has worked 18-hour shifts for

four days straight. She is exhausted and yearns to spend time with her family. She begins to dislike her job shortcuts because she doesn't feel as though she should put much more effort into her work since she's already done so much. A patient of hers needs hourly checkups to ensure fluid levels are adequate. Since she has been so preoccupied with her disgust for having to work such long hours, she forgets to check on her patient. All of sudden, there is a code called on her patient and he is rushed to emergency care due to her negligence.

Name it: Compassion Fatigue

Meaning: Compassion Fatigue has been described as the cost of caring" for others in emotional and physical pain. (Figley, 1982) It is characterized by deep physical and emotional exhaustion and a pronounced change in the helpers ability to feel empathy for their patients, their loved ones and their co-workers
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Compassion fatigue model

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 Compassion Fatigue can lead to very serious problems such as depression, anxiety and ssuicidal thoughts. Strategies and solutions; There are strategies and solutions both at the organizational & personal levels. Organizational Strategies First, by openly discussing and recognizing compassion fatigue in the workplace, helpers can normalise this problem for one another.

 They can also work towards developing a supportive work environment that will encourage proper debriefing, regular breaks, mental health days, peer support, assessing and changing workloads, improved access to further professional development and regular check-in times where staff can safely discuss the impact of the work on their personal and professional lives.

 Research has shown that working part time, or only seeing clients or patients part time and doing other activities the rest of the workday can be a very effective method to prevent compassion fatigue. Personal: Improved self-care is the cornerstone of compassion fatigue prevention. taking extra time out of their busy schedules to exercise, meditate or have a massage. On the personal front,

Danger! Compassion Crisis

It is a crisis when you experience or practice:
Repeated errors and omissions Drug or alcohol abuse Numb, robotic functioning Feeling suicidal, useless Abusing patients Blaming & criticizing other team members High absenteeism Tardiness Compassion Fatigue/Burnout are contagious to coworkers, family. It is not a sign of failure to realize you need a break, or a change! Consider transition to less stressful situation that uses your talents Treatment
CBT more effective than relaxation or multimodal intervention in stress reduction for all occupations (including non-health care) -van der Klink et al, 2001 CF/PTSD: trauma-focused cognitive behavioral therapy (CBT), exposure-memory/site, stress management, EMDR. Debriefing controversial, may harm.

Maladaptive stress response (Vachon & Pakes, 1984)

Physical: fatigue, headache, insomnia, abdominal pain, diffuse aches, frequent viral illness, increased sick days, weight and appetite change, lack of exercise. Psychological: depression, frustration, denial, anxiety, conflictladen dreams, over-identification with patients, anger, projecting blame onto others, awareness of own vulnerability, substance abuse, feeling robotic (unable to feel anything), unresolved grief for patients Social: Bringing job stress home, changed libido, fear of pregnancy, fear for family members health, no time for friends or no friends outside work, conflict between job and personal life. Occupational: Unrealistic expectations (science can cure everything, humans can be perfect), more & more time at work, feeling overwhelmed by job, inability to detach from job, overinvolvement with clients outside work, cynicism (insults, morbid jokes, dehumanizing attitude), role ambiguity (trouble defining one's duties and area of responsibility), decreased job satisfaction, role reversal with clients (they become your therapist).
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3. Reframe it: Hardiness A personal protective factor

Commitment: strive to stay involved
Engagement with job, effort to stay involved, even when times are rough Worker believes work deserves full attention & effort.

Control: strive to influence outcomes

Worker perceives high degree of control in work role Exerts influence thru imagination, knowledge, skill, choice. We cant control what happens; we can control how we respond.

Challenge: view as opportunity, not obstacle

Change is the rule, not the exception React with openness, flexibility, innovation Transform and grow in response to change Dont seek to preserve & protect the status quo

Reframe it: Hardiness A personal protective factor

Transformational coping:
Put changes in perspective Realize youre not facing change alone Learn what change means for you: worst/best case How can I take advantage of change?
Learn from past success & failure Plan how to make best-case scenario happen

Social supportMaddi & Khoshaba

Work with others, dont alienate them Work toward constructive win-win solutions Believe that problems can strengthen relationships No matter what happens, dont burn bridges.

Reframe it: Effective Coping Strategies

Brief COPE Active coping Planning Positive reframing Acceptance Religion Using emotional support Using instrumental support Self-distraction Denial Venting Behavioral Disengagement Self-blame Humor (avoid ridicule, self-defeating) Blue: positive, Yellow negative Tan neutral

Think

Reframe it: a new view

Adopt a Hardy perspective Commonplace: Others have experienced same stressors. Manageability: The present is between the worst & best that could happen Improvability: Think how YOU can improve situation. Time: Estimate when stress will ease (e.g. short-term deadline stress) Unpredictability: Do what you can, the rest is out of your hands. Attitude: Turn lemons into lemonade; Attitude of Gratitude Cognitive behavioral therapy works to change thoughts, which in turn changes feelings & behaviors. Accentuate positive, reduce negative. Live in the present moment (Mindfulness) Adjust expectations. Serenity prayer: change what you can, accept what you cant. Humor: shifts perspective to less threatening. ? Mixed effects in coping with health care stress.

4. Tame it: TWERPs revisited

Tasks: Do, Delegate, or Drop. Time: Manage it & schedules.
Budget sleep and personal time!

Worries: Change what you can, Accept what you cant, Know the difference. Environment: Advocate positive change. Events: Discuss critical incidents; Counseling. Expectations: Change unrealistic to realistic. Roles: Control responsibilities, Delegate tasks. People: Assertiveness, Communication (with management & colleagues)

Tame it: Prepare, Self-care

Prepare for the expected and the unexpected. Self-care: Balance PIES
Balance: Clear line between work and life. Set limits!
Work:
Improve protocols, build teams & communicate. Maintain & upgrade skills. Network with others, followup with clients at home.

Life:
Make time (prioritize) for friends, family, hobbies. Relax, see nature, vacations, mental health days. Limit off-work time with clients.

Physical: Diet, exercise, sleep, preventive care Intellectual: Advanced education, change or add roles Emotional: Self-acceptance. Counseling, meds as needed (anxiety/depression). Positive outlook, ? humor. Spiritual: Morals, ethics, values, beliefs/religion, relax, meditate.

Tame it: Dare, Share, Be Aware

Dare to Dream, Decide, & Act
Meet with colleagues, research options Approach management with suggestions

Share burdens with others

Social support, support groups F2F & online, professional help

Be aware
Journaling helpful in coping with stress Ask others for feedback Monitor progress in personal wellness Stages of change model

Tame it: Self-care Alternative individual strategies & effectiveness

Music (A)patients preference Aromatherapy (lavender) (B)
Essential oils in massage or in oil burner (check natural health/New Age shops)

Yoga in healthy people (B) Relaxation techniques (B to C) many types

Autogenic training, breath therapy, guided relaxation, muscle relaxation techniques, Qi gong, self-hypnosis, visualization, biofeedback.

Massage, meditation, acupuncture, acupressure, guided imagery, therapeutic touch, other methods (C) A= strong, B= good, C= unclear evidence

Tame it: Relaxation (Natural Standard, 2007)

Goal: non-directed relaxation. 1) repetitive focus (on word, sound, prayer phrase, sensation, or muscular activity), 2) passive attitude towards intruding thoughts, and 3) return to the focus. Deep methods: autogenic, progressive muscle relaxation (PMR), meditation ("thoughtless awareness," differs from relaxation). Progressive relaxation: client taught how to relax by comparing relaxation with muscle tension. After months of practice, may evoke relaxation response within seconds. Brief methods: self-control relaxation, paced respiration, and deep breathing. Require less time, often a short form of a deep method. Applied relaxation: imagining relaxing situations, to induce muscular and mental relaxation. Other techniques: guided imagery, deep breathing/breathing control, passive muscle relaxation, refocusing. Instruction in hospitals, communities, books, audio/video, online

Tame it: Biofeedback

Biofeedback amplifies small physiological signals (i.e. muscle tension, brain waves) and displays them to client in real time. Client uses this information to learn to consciously change subconscious physiological functions (heartbeat, muscle tension, brain wave activity). (aapb.org)

Tame it: Types of biofeedback

EMG (forehead, upper back, other): For muscle tension backache or headache, neck pain, bruxism (grinding teeth). Temperature (sensor on finger): For Raynauds, migraine. Galvanic skin response (sweat): stress. EEG (brainwave or neurofeedback). Attention deficit, anxiety. Heart rate variability: the more variability, the better. IBS, asthma, non-cardiac chest pain.

Tame it: Biofeedback in action

Tame it: Biofeedback efficacy in stress-related disorders

Efficacious (Fourth level evidence):
Anxiety Attention Deficit Disorder Headache- Adult Hypertension Temporomandibular Disorders

Probably efficacious (Third level evidence):

Alcoholism/Substance Abuse Arthritis Chronic Pain Insomnia Source: aapb.org quotation from Yucha C. & Gilbert C. (2004). Evidence-Based Practice in Biofeedback and Neurofeedback. More info: aapb.org, bcia.org.

Tame it: Share Therapy, e-therapy

Traditional counseling
Cognitive behavioral therapy CBT/exposure/EMDR for traumatic stress

Coaching -- personal or professional E-therapy Barak et al.:

Online therapy, via email, website programs etc. can be as effective as traditional therapy for anxiety & stress. No studies cited specific to work stress. http://www.metanoia.org/imhs/ How to find a therapist online, cautions etc. Older info. Ismho.org, onlineclinics.com

Tame it: Share Face-to-Face (F2F) & Online Groups

Present in F2F & online:
Sense of community Empathy Information & advice exchange Self-disclosure Shared experiences Catharsis Learning from peers and mentors Helper role Advocacy

Unique online:
Anonymity:
Filters nonverbal cues Hides disturbing personal characteristics Encourages prompt intimacy/deception

Writing is therapeutic Lurkers: 75-95% of members lurk, yet learn & identify with group Response is delayed (except in chats)

Tame it: Share Benefits & Risks of Online Groups

Convenient access Decreased isolation Increased perceived social support Easier discussion of sensitive & controversial topics (sexuality, ethics, atypical lifestyle, suicide, end of life) Practical help received Ability to help others Misinformation Delayed treatment Alternative medicine focus Meeting severely affected peers Strong emotions, arguments Privacy/Identity Concerns Stalking Deception

Healthy systems
Team problems, Team solutions

similar to shipmates preparing for a storm. Just as

shipmates understand that the ship must be made with solid materials and fortified with necessary provisions, so does the NICU crew rely on structure, interdependent relationships, harmony and leadership in their preparation.
Reddick, Catlin & Jellinek, Crisis within Crisis: Recommendations for Defining, Preventing, and Coping with Stressors in the NICU, J. Clinical Ethics, Fall 2001.

What do healthy systems look like?

Structure: High level of function and effectiveness.
Multidisciplinary team Mutual respect, cross-training, awareness of others roles. Flexible schedules, with staff input. Adequate staffing with independent, empowered staff. Education, training & development: for tasks, leadership, & coping with stress

Relationships: Communication
All team members feel valued: Everyones opinions count. Communication flows both ways: workers to administration. Discussions after deaths, adverse outcomes, difficult clients Critical incident debriefing controversial for emergency workers Outside the hospital Reunions, classes, support groups Contact with community resources (visiting nurse, home health, hospice, community pharmacists)

What do healthy systems look like?

Harmony: Workers have input into decisions, workload, work flow. Error response seeks system improvement, not scapegoat Leadership: Management listens and responds to employees, Management encourages risk-taking, trying new processes. Policies dont handcuff employees to protocols, & allow independent, innovative action. Mentoring Employee assistance programs (not enough by itself) Consultants, organizational changes Psychological training on attitude, communication & job stress relieve stress. (Marine et al. 2007) Support and advice given by nurse managers or quality care coordinators decrease Depersonalization on Burnout Inventory. (Marine et al. 2007)

Healthy systems: Harmony in tough times

Discussions for deaths, errors, stressful cases, moral dilemmas
Team case review (doctors & others)
Focus on learning and improvement Kudos for good care

Informal and formal discussions with peers Sharing memories & feelings with families
Verbal and written: discharge, death, later Tears & appropriate touch can be professional

Attend funerals for client death

Healthy systems:
Forgiveness

Perhaps the single most useful piece of knowledge

isthat more is unknown than can ever be known. ...A part of wisdom isthat ignorance should be accepted and forgivenThe forgiveness of families, colleagues, and--most of all--ourselves becomes the cushion against crises and the guiding spirit to coping in a sea of chaos. Reddick, Catlin & Jellinek, Crisis within
Crisis: Recommendations for Defining, Preventing, and Coping with Stressors in the NICU, J. Clinical Ethics, Fall 2001.