TAN Issue: July/August 1999: Features: STRESS! It's everywhere! And it can be managed!

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by Susan Trossman, RN

Stress

Registered nurse DeeDee Bloch knows what stresses her out: Having to say "no" to a colleague who asks for help.

As a staff nurse on her Minneapolis-area hospital's "flying squad," Bloch pinch-hits whenever and wherever her expertise as an RN is needed -- be it performing conscious sedation in the CT room or helping a nurse on another unit with a difficult cath.

Her services are in such demand that she has to turn down requests. "When I say 'no,' I can hear the frustration in my colleagues' voices," Bloch said. "I have to decide who needs help the most."

Bloch is not alone

"These days, everyone is being asked to do more with less," said stress management expert JoAnne Herman, PhD, RN, CSME. "Nurses who work in hospitals and clinics typically are bombarded with more work than they can legitimately do. They're working in a heightened state of responsiveness in which they're very alert and vigilant. Nurses often maintain that state throughout their shift without taking a break in the action."

A break is crucial to good health, because with a heightened state of responsiveness comes an increased heart rate and blood pressure, said Herman, a South Carolina Nurses Association member.

The world around us

Stress is so ubiquitous that it made the June 14 cover of Newsweek -- represented graphically by a bright orange-and-yellow human figure seemingly ablaze in flight-or-fight hormones.

"All of us experience stress Ð that's part of being alive," Herman said. "What Americans are not good at is letting go of the heightened state of excitement that accompanies the stress response and returning to a relaxed state."

For many people, Herman said, remaining in a stressed state has become a habit. And for nurses, the world is fraught with stress-producing events.

A nurse for 25 years, the Rev. Ben Evans, MSC, MSN, RN, CS, ACRN, had little difficulty coming up with a list of on-the-job stressors. No nursing specialty is immune.

"In the ICU, the hours are long, and the work is physically taxing. Nurses must be hyper-vigilant -- continuously watching their patients for subtle changes and interpreting the different beeps of machines," said Evans, a New Jersey State Nurses Association member and clinical coordinator of the New Jersey AIDS Education and Training Center.

"Hospice nurses have to cope with working variable hours and being on call," Evans said. "Also, part of their work involves phone triage, which can be very stressful because they often have to make critical decisions based on information provided by family members who may be very emotional."

Many nurses face the ongoing stress of working in a health care system that is in almost a constant state of redesign -- a system with changing staffing configurations, increasingly complex documentation requirements and reams of red tape, according to Evans.

"A corporate mindset has crept into nursing. Now nurses have more projects and are taking work home," he said. "It's amazing that nurses cope with all of this and keep coming to work."

Home is where the work is

Like other working Americans, when nurses go home at the end of their day, it's generally not to kick back and relax. Many have children and older parents to care for -- which means they are part of the "sandwich generation."

"The number of nurses who also are caregivers (for older family members) has never been looked at," said New York State Nurses Association member Mary Shelkey, PhD(c), RN, an expert on caregiving. "But the demographics of nurses and the demographics of caregivers, especially for gender and age, are very similar."

The National Family Caregivers Association (NFCA) reports that there are 25 million households involved in caregiving, Shelkey said. Eighty-two percent of the caregivers are females. Further, a recent article in The Gerontologist identified 46 as the mean age for caregivers of persons with dementia, and 42 for caregivers of persons without dementia.

In comparison, the current nursing workforce is mostly women in their 40s, said Shelkey, a clinical coordinator of an Alzheimer's special care unit in New York City. However, she can't say whether "the nurse in the family" has greater caregiving responsibilities than other family members.

"I think that families may act in a variety of ways," she said. "The nurse in the family may be utilized more when it comes to trying to navigate the managed care system. On the other hand, her advice may not be taken at all because she is not seen as a 'professional' but as a 'daughter' or a 'sister.'"

However great the role, nurses who serve as family caregivers are often loaded with stress.

Shelkey said that among the many problems caregivers report are: feelings of frustration and isolation, depression, sleep deprivation, loss of personal and leisure time, and physical problems.

In terms of the stress caregiving places on a career and finances, Shelkey again quoted The Gerontologist. Fifty-seven percent of caregivers reported having to leave work early, go to work late or take time off. Nine percent reported having to give up their jobs entirely.

Shelkey pointed out that although nurses may, in general, be able to choose more flexible schedules, they often have difficulty changing their schedules on short notice because of tight staffing.

The art of de-stressing

"Stress manifests itself in a large number of ways and is very individualized," said Herman, an associate professor at the University of South Carolina's College of Nursing who also works with cardiac rehab patients on stress management techniques.

"Some people are aware that their bodies are charged up -- their face is flushed, they can feel their pulse and may have difficulty swallowing," she said. "Other people may notice they have difficulty concentrating and are uncharacteristically clumsy, or they feel out of control and angry.

"But one thing I've noticed in my practice is that some people aren't aware of what's going on in their own bodies. They can't describe when they are stressed or when they are relaxed."

In terms of long-term effects, research has shown a clear link between stress and heart disease, as well as stress and diabetes. Preliminary reports indicate that stress in pregnant women can lead to low birth-weight babies, Herman said.

To effectively manage stress, nurses have to be able to switch on its polar opposite -- the relaxation response. They have to remember what it feels like to let go and relax.

This can be done in many ways. Some techniques are quick and easy and can help nurses while they are in the throes of a stressful event, while others take practice or require a whole new way of thinking (see accompanying box).

"There is no activity, event or situation that is stress. Stress is all perception -- it is in the mind of the beholder," Herman explained. "So one way to manage stress is to learn how to perceive a situation in a healthful way."

Helen Kogan Budzynski, PhD, RN, FAAN, a professor emeritus at University of Washington's School of Nursing, has done extensive research on stress management through the use of biofeedback and relaxation techniques for more than two decades. She provided this real-life example of how she recently managed a stressful event by changing the way she was thinking about it.

She and her husband had just finished filling a 90-gallon fish tank that her son had left behind when she noticed it was leaking.

"At first, I started worrying about the water ruining the Oriental rug," Kogan Budzynski said. "Then I told myself, I didn't really want the tank to begin with, so this solves my problem of having to keep it."

Basically, she substituted a stress-producing thought with a positive one.

A change in attitude or perspective can also change group dynamics. Sometimes a situation that is stress-producing for all involved can be defused simply by saying, "It's all right," Kogan Budzynski said. "Then you can begin to problem-solve, which helps other people look at the situation differently and changes their behavior."

And yet another tool is humor. "Laughter changes the social environment," said the Washington State Nurses Association member.

Both Kogan Budzynski and Herman also believe in the positive effects of breathing exercises and audiotapes to bring on the relaxation response.

"The old wives' tale is true," Herman said. "If you're in the midst of a stressful situation, take a deep breath and count to 10 before you do anything. Diaphragmatic breathing is the best, because it lowers your demand for oxygen and becomes the focus of your attention."

Kogan Budzynski suggests a 90-second exercise in which the person thinks about systematically clearing stress from every part of the body while slowly breathing in and out.

She also urges nurses to try audiotapes that utilize specific beats designed to de-stress.

Both experts agreed that nurses need to practice relaxation at home. Once nurses rediscover what it's like to experience the relaxed state -- in which the heart rate is slowed, the blood pressure lowered and the muscles tension-free -- they will be able to conjure up that feeling when it's needed at work.

This can be done through associating the relaxed state with a physical cue, like rubbing a thumb and index finger together, Herman said. The relaxation response will stop the stress response Ð they simply cannot co-exist.

A group approach

Every year, the Third District Nurses of the Minnesota Nurses Association holds its "Spring Fling," an event designed to help nurses unwind.

The one-day, free event was started because district leadership realized that nurses needed a break from the ongoing stresses they face at work and at home.

"We wanted to give our members the opportunity to leave their cares outside the door -- at least for a day," said Bloch, second vice president of the Third District Nurses.

Past offerings have included neck and shoulder massages, booths that showcase other nurses' stress-relieving hobbies, such as dried-flower arranging, and a fake beach where participants can just relax and fantasize that the long, Minnesota winter is over, according to Molly Maxwell, RN, district president.

She believes giving nurses the opportunity to relax and have fun is serious business.

"As nurses, we're often so focused on taking care of other people," said Maxwell, "we forget to take care of ourselves."

Susan Trossman, RN, is the senior reporter for The American Nurse.

Tips for de-stressing

* To better handle stressful events, get enough sleep, eat a well-balanced diet and exercise regularly.

* Learn how to recognize when you are feeling stressed.

* Check out a book or audiotape that teaches relaxation techniques.

* When you need stress relief right away, try slow, deep breathing. Use your diaphragm and concentrate on your breathing. Or take a 90-second break in which you focus on clearing out the stress from every part of your body down to your fingers and toes as you breathe in and out slowly.

* Try to change the way you think about a potentially stressful situation by substituting a positive thought for an anxiety-producing thought.

* If performing a particular skill routinely stresses you out, get someone to sign you off on the skill or make a cheat sheet for yourself that you can review until you have the process down.

* Do a stress assessment of your daily life, and look at how you can deflate stress through techniques like time management, assertiveness training and conflict resolution.

* Once you've learned how to truly relax, choose a physical cue, like rubbing your thumb and index finger together, that you can use to bring on the relaxation response when you are faced with a stressful event.

* Learn to prioritize and set limits.

* Cultivate and develop new friendships. Find time to talk with some co-workers.

* Support each other. If someone can't get away for lunch, bring him or her back something.

* When youÕre outside of work, focus on the development of the whole self.

* Take time to replenish yourself during your down time by doing something you enjoy -- whether it's going to the theater or out to dinner. Or allow yourself just to do nothing.

* Give your cell phone and beeper a break.

* If you are a caregiver, access resources that can help you and use them. Involve other people in the caregiving responsibilities. Take care of yourself.

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