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By Emil Vernarec

The 10-year-old girl arrived just moments after the trauma unit got the alert. She had a collapsed lung and intracerebral bleed.

When an accident victim is a child, even experienced acute caregivers, who are no strangers to trauma, wince. But ED nurse Bernie Driscoll could not anticipate the more profound shock she felt when she went to speak to the victim's parents. The mother turned out to be a Girl Scout leader in the local school, and the fatally injured girl, whom Driscoll hadn't recognized, played on the same baseball team as her own daughter.

"It was overwhelming, like being hit by a two-by-four, in spite of more than 20 years as a nurse," says Driscoll, an RN and assistant EMS coordinator at Lutheran GeneralHospital in Park Ridge, Ill. "I couldn't function for the rest of the afternoon."

For days afterward Driscoll had dreams about the incident and sudden bouts of crying. "Intellectually, you know that a person with such injuries is likely to die," she says. "Emotionally, you go through days of self-questioning."

As a peer counselor to emergency responders, Driscoll understood that her grief was natural, as was the guilt of wondering, "Could I have done more?"

Few jobs put a person in the face of such acute stress. Nurses accept it as part of the profession they've chosen. What they may overlook, however, is their own vulnerability to stress-not just the acute incidents, but the less obvious, chronic stresses of working in healthcare and being human.

Susan Lewis, ARNP, CS, PhD, an advanced practice nurse in adult psychiatry and mental health at the VA Medical Center in Louisville, Ky., says there's a simple reason for this oversight: "Nurses are accustomed to taking care of everyone else, not themselves."

Nurses also work in a fast-changing environment and in a field that is becoming increasingly more complex. "There's more that nurses need to know about medications, the risks of interactions, which enzyme systems metabolize which drugs," says Lewis. "In addition, there are fewer nurses, and they have to care for sicker patients who are discharged more quickly. It's frustrating because you can't give the care you want to give."

Add the pressures of family and everyday life, and it's clear that unless nurses learn how to deal with stress, they're at high risk for burnout.

The wear and tear of chronic stress

When you're faced with a demand or an outright threat, your stress hormones-adrenaline and cortisol-trigger a cascade of physiological events that put your nervous, endocrine, cardiovascular, and immune systems on alert. Those changes provide the fuel you need to face a crisis, large or small.

The problem comes when this response doesn't shut off. This can occur because the threat-real or perceived-is frequent or prolonged, and you feel powerless to resolve it. If you're predisposed to health conditions that are aggravated by stress (such as hypertension), you may be unable to calm down physiologically, even after the stressful event has passed.

Being exposed to constant stress can result in long term adverse effects on health. Medical studies have linked stress to depression, immune system suppression, cardiovascular disease, infertility, miscarriage, and premature birth.1

The short-term effects aren't pretty, either. We become tense and irritable. We develop headaches or muscle pain. Our blood pressure goes up. We don't eat, or we overeat. Stomach and bowel problems may ensue. At work we find it harder to concentrate. At home we can't sleep, or we see stress disrupt our family life.

The solution, experts say, is to either alter our external environment or alter our response to stress. Three personal factors in particular affect that response: how we interpret the stresses we face, our degree of social support, and our general state of health. The more we take control of those factors, the better able we'll be to focus on resolving the sources of stress instead of feeling powerless against them.

"Faulty beliefs" contribute to stress

"Stress is one-third what happens and two-thirds how you react to it," estimates Edward E. Bartlett, a risk management consultant in Rockville, Md., who teaches healthcare providers how to manage job stress. "It depends not just on the phenomenon of stressors, which are inevitable, but on how you conceptualize them, how you choose to react."

What determines how we interpret a stressful event are faulty beliefs that developed from our earliest experiences in life. One faulty belief that's especially common among nurses, says Bartlett, is that they must be self-sacrificing, that it's somehow wrong for them to pay attention to their own personal needs. Trouble is, he says, "You have needs as much as anyone else. Ignoring them is a key ingredient for burnout."

Bartlett also sees high achievers in healthcare who create added stress for themselves by completely basing their value as caregivers on a patient's outcome. Picture a nurse who feels overly responsible for a patient. Even though intellectually she understands that many factors determine whether treatment is successful-including the doctor's choices and the patient's willingness to comply with care-emotionally, she'll tend to feel at fault and question her competence.

A nurse who believes she must be perfect or superhuman, and that anything less means she's failed, is also headed for trouble. It's a faulty belief because it does not acknowledge the reality that being human means having limitations and living in a world you cannot control. Instead of perfection, Bartlett advises providers to "strive for excellence."

Other nurses may have an unresolved need for the approval of their colleagues, patients, and supervisors. If they don't get approval or can't seem to get enough of it, stress builds because they feel unappreciated. They may also fall into the trap of victimization, where they feel not just unrecognized, but taken advantage of.

Are such beliefs making your life more stressful? Susan Lewis recommends trying the following exercise the next time you feel overwhelmed by stress. Write out the messages you told yourself at the moment the stress hit. Then note how that self-talk influenced your emotional response. Those messages are likely to be based on faulty beliefs that intensified your feelings of stress and may even have gotten in the way of your dealing with the source of stress effectively.

Watch for signs of burnout

When you don't pay attention to the internal contributors to stress, you risk emotional exhaustion. The signs, says nurse-psychotherapist Elaine Gareri Kenney, RN, MS, include "an ongoing uncomfortable anger, a depression marked by apathy or resentment, difficulty being enthusiastic about your work, negative thoughts about the world and people, and low energy.

"I see more critical care nurses in my practice," says Kenney, who specializes in counseling nurses in San Francisco. "They are intense and achievement-oriented, but angry. Cooperation feels like capitulation. And they don't 'get' how much they're appreciated."

Consider the case of one critical care nurse Kenney counseled: As the oldest child in a large family, she was expected to be a "miniadult" and take on family responsibilities. When she became a nurse, she excelled at caregiving, but found that a lot of demands were placed on her, which made her chronically angry and resentful.

What lay beneath her difficulty, says Kenney, was childhood experiences that left her unable to set boundaries to what people could ask of her. She also felt "irrational guilt" from thinking she wasn't doing her share if she did say No. The remedy? She needed to learn that it's OK to take care of herself.

Seek the support of your peers

An essential part of self-care is developing supportive relationships at work. When the 10-year-old girl died in the trauma unit, for instance, Bernie Driscoll shared her feelings with colleagues who'd also been shaken by the event. Several were even reluctant to enter the trauma room days afterward.

Driscoll volunteers for the Northern Illinois Critical Incident Stress Debriefing Team, one of a network of organizations that support healthcare providers and emergency responders who undergo traumatic stress. (See the companion article, "One nurse's story," at right.) In a group setting or one on one, the peer counselors help individuals release their emotions and understand that sleep disturbance, dreams, and even flashbacks are normal reactions to experiencing a critical incident.

Some hospitals have developed internal peer-counseling teams. "Knowing there's a peer you can talk with accelerates recovery," says Driscoll. The support of coworkers and supervisors-beyond their importance during episodes of traumatic stress-is also an important antidote to chronic stress. It gives nurses an opportunity not just to vent but to work out solutions to sources of stress at work.

Peer support is also a matter of health. A recent Harvard study of more than 21,000 female RNs found that those in jobs with high psychological demand and who had low control and low social support had the greatest decline in health status over the course of four years-independent of other factors like smoking and co-morbid conditions.2

Take care of yourself

For nurses feeling run down by job stress, Elaine Kenney gives this tip: Seek out role models and ask them how they deal with stress. "There are nurses who have an inner serenity in a world that's chaotic, despite a long list of their own complaints," says Kenney. "They're around you, but all you may see is what's not working."

Don't discount the stress-reducing tips you read in popular magazines. Making time for a hobby or creative outlet that re-energizes you is also a way of acknowledging your needs. So is getting a massage.

When Bernie Driscoll counsels peers, she reminds them that caring for their own health is a personal responsibility, and that it may take several steps before they find what really helps. She also tells them not to overlook the need for physical exercise, which both moderates the physiological effects of stress and increases stamina.

Eating right matters, too. Unfortunately, because of understaffing, too many nurses may not have time to eat during their shift.

In the long run, reducing job stress requires changes in a work environment that puts unnecessary strain on nurses. That undertaking calls for the collective action of concerned healthcare professionals.

In the meantime, all nurses-you included-need to take charge of their mental health, and if they need help, they shouldn't hesitate to get it.

References

1. McEwen, B. S. (1998). Protective and damaging effects of stress mediators. N. Engl. J. Med., 338(3), 171.

2. Cheng, Y., Kawachi, I., et al. (2000). Association between psychosocial work characteristics and health functioning in American women: Prospective study. BMJ, 320(7247), 1432.

Published in RN.
Copyright © 2001 Medical Economics Co. , Montvale, N.J.
Reprinted with Permission