Healthcare is defined as the field concerned with the maintenance or restoration of the health of the body or mind. Although the goal is to maintain and restore, everyday in healthcare patients die. Death is not selective and does not only come to those who have lived long wonderful lives. We discussed in the last chapter that death comes in many forms to every age group: babies, children, teenagers, sons, daughters, mothers, and fathers. Those of us who entered healthcare to care for others often become attached to our patients, therefore the loss of a patient can be upsetting and stressful. Dealing with stress correctly will help you to be resilient through the loss of a patient and will allow you to stay strong to help others.

Stress Responses

For years researches believed that there was only one response available to deal with stress, Fight or Flight. This meant that the only options to deal with an everyday stress such as a late mortgage payment, missing assignment, or traffic accident would be to fight or run. Because this would be inappropriate, if we only have one stress response, we would have to learn to turn off the Fight or Flight response, or choose to avoid all types of stress. In healthcare, both of these options are impossible tasks. Due to recent research, it has been found that fleeing and fighting are not the only strategy that the body supports. The stress response has evolved, adapting over time to better fit the world we now live in.

Your stress response has the ability to help get you out of a burning building and engage with challenges, connect with social support, and learn from experience. Despite the fact that it feels like we do not choose our response, research shows we actually can! Choosing an appropriate stress response will allow you to be effective in healthcare and help others for the rest of your career. There are three main responses to stress, Fight or flight,  Challenge, and Tend and Befriend response. So, how do we deal with the many stressors found in healthcare. It is important to understand the available stress responses and practice being mindful, or aware, that we have the strength to select the right one.

Fight or Flight

Stressors are any internal or external event, force, or condition that results in physical or emotional stress.^[1] The body’s sympathetic nervous system (SNS) responds to actual or perceived stressors with the “fight, flight, or freeze” stress response. Several reactions occur during the stress response that help the individual to achieve the purpose of either fighting or running. The respiratory, cardiovascular, and musculoskeletal systems are activated to breathe rapidly, stimulate the heart to pump more blood, dilate the blood vessels, and increase blood pressure to deliver more oxygenated blood to the muscles. The liver creates more glucose for energy for the muscles to use to fight or run. Pupils dilate to see the threat (or the escape route) more clearly. Sweating prevents the body from overheating from excess muscle contraction. Because the digestive system is not needed during this time of threat, the body shunts oxygen-rich blood to the skeletal muscles. To coordinate all these targeted responses, hormones, including epinephrine, norepinephrine, and glucocorticoids (including cortisol, often referred to as the “stress hormone”), are released by the endocrine system via the hypothalamic-pituitary-adrenal axis (HPA) and dispersed to the many SNS neuroreceptors on target organs simultaneously.^[2] After the response to the stressful stimuli has resolved, the body returns to the pre-emergency state facilitated by the parasympathetic nervous system (PNS) that has opposing effects to the SNS. See Figure 3.1^[3] for an image comparing the effects of stimulating the SNS and PNS.

The purpose of the Fight or Flight response is to help you deal with danger, such as being inside a burning building. Your heart races, delivering oxygen, fat, and sugar to your muscles and brain, your breathing quickens: which delivers oxygen to the heart. This offers extraordinary physical abilities that make you ready for action. Your pupils dilate to let in more light, hearing sharpens, and your brain processes more quickly. All of these responses help you fight or run. While the “fight or flight” stress response equips our bodies to quickly respond to life-threatening stressors, exposure to long-term stress can cause serious effects on the cardiovascular, musculoskeletal, endocrine, gastrointestinal, and reproductive systems.^[4] Consistent and ongoing increases in heart rate and blood pressure and elevated levels of stress hormones contribute to inflammation in arteries and can increase the risk for hypertension, heart attack, or stroke.^[5]

While this response is essential for human survival, it is hard on the body and therefore cannot be the only stress response used for any areas of stress in our lives.

Challenge Response

The challenge response is an excellent response for many stressful situations or challenges, including stressful moments while caring for others. Adrenaline still spikes and the muscles and brain get more fuel. The response is a focused, but not fearful response, that allows the body to recover and learn from the stress. Top athletes, artists, surgeons, or gamers are not physiologically calm under pressure; rather, they have strong challenge responses.

The Challenge response is similar to exercise. Blood vessels relax to maximize blood flow and energy, the heart maintains a fast and strong beat, pumping even more blood than during the Fight or Flight response. Strong Challenge responses can be associated with superior aging, cardiovascular and brain health. Because the stressor is looked at as a challenge, you may feel anxious, excited, energized, enthusiastic, and confident. People who have strong Challenge responses will better learn resilience, suppresses fear, and enhance positive motivation during stress (McGonigal, 2016).

Tend and Befriend

The third response is Tend and Befriend. Oxytocin released by pituitary gland which calms the fear response and builds courage. This response will actually build and strengthen social bonds because you will talk with friends, family, and coworkers about stress. It will help you connect to others and the support will help recover from the stress. This response is actually good for cardiovascular health (McGonigal, 2016).

Mindfulness

Mindfulness is the ability to consciously choose the appropriate stress response for each situation. You are in a burning building, Fight or Flight. You are involved in the care of a crashing trauma patient, the Challenge response. You are faced with the death of a patient after caring for them for months, the Tend and Befriend response.

When experiencing a stressor, you should first acknowledge your feelings and not ignore that a stress is present. When feeling the physical symptoms such as a racing heart, recognize this is your body preparing you to deal with the stress, and does not mean you should automatically select the Fight or Flight response. Mindfully, choose the correct response when working in healthcare. Understand that there are many stressful moments while caring for others. Using the appropriate response will give you the tools you need to be courageous rather than fearful, and will allow you to recover from the stress of caring for others.

Mindfully choosing the correct stress response while dealing with the many difficulties in healthcare, will calm your fears and help you build and strengthen social bonds that will help build the resilience needed to work in healthcare. Please remember, important work is stressful, and healthcare is important work. Always remember why you chose this career and why it is important for you. The connection you maintain with friends family and coworkers

Stress Management

Effective stress management strategies can also be effective when dealing with stress and include the following^[6],[7]:

• Set personal and professional boundaries
• Maintain a healthy social support network
• Select healthy food choices
• Engage in regular physical exercise
• Get an adequate amount of sleep each night
• Set realistic and fair expectations

Setting limits is essential for effectively managing stress. Individuals should list all of the projects and commitments making them feel overwhelmed, identify essential tasks, and cut back on nonessential tasks. For work-related projects, responsibilities can be discussed with supervisors to obtain input on priorities. Encourage individuals to refrain from accepting any more commitments until they feel their stress is under control.^[8]

Maintaining a healthy social support network with friends and family can provide emotional support.^[9] Caring relationships and healthy social connections are essential for achieving resilience.

Physical activity increases the body’s production of endorphins that boost the mood and reduce stress. Nurses can educate clients that a brisk walk or other aerobic activity can increase energy and concentration levels and lessen feelings of anxiety.^[10]

People who are chronically stressed often suffer from lack of adequate sleep and, in some cases, stress-induced insomnia. Experts recommend going to bed at a regular time each night, striving for at least 7-8 hours of sleep, and, if possible, eliminating distractions, such as television, cell phones, and computers from the bedroom. Begin winding down an hour or two before bedtime and engage in calming activities such as listening to relaxing music, reading an enjoyable book, taking a soothing bath, or practicing relaxation techniques like meditation. Avoid eating a heavy meal or engaging in intense exercise immediately before bedtime. If a person tends to lie in bed worrying, encourage them to write down their concerns and work on quieting their thoughts.^[11]

Mindfulness is a form of meditation that uses breathing and thought techniques to create an awareness of one’s body and surroundings. Research suggests that mindfulness can have a positive impact on stress, anxiety, and depression.^[12] Additionally, guided imagery may be helpful for enhancing relaxation. The use of guided imagery provides a narration that the mind can focus in on during the activity. For example, as the nurse encourages a client to use mindfulness and relaxation breathing, they may say, “As you breathe in, imagine waves rolling gently in. As you breathe out, imagine the waves rolling gently back out to sea.”

WHO Stress Management Guide

In addition to the stress management techniques discussed in the previous section, the World Health Organization (WHO) shares additional techniques in a guide titled Doing What Matters in Times of Stress. This guide is comprised of five categories. Each category includes techniques and skills that, based on evidence and field testing, can reduce overall stress levels even if only used for a few minutes each day. These categories include 1) Grounding, 2) Unhooking, 3) Acting on our values, 4) Being kind, and 5) Making room.^[13]

Nurses can educate clients that powerful thoughts and feelings are a natural part of stress, but problems can occur if we get “hooked” by them. For example, one minute you might be enjoying a meal with family, and the next moment you get “hooked” by angry thoughts and feelings. Stress can make someone feel as if they are being pulled away from the values of the person they want to be, such as being calm, caring, attentive, committed, persistent, and courageous.^[14]

There are many kinds of difficult thoughts and feelings that can “hook us,” such as, “This is too hard,” “I give up,” “I am never going to get this,” “They shouldn’t have done that,” or memories about difficult events that have occurred in our lives. When we get “hooked,” our behavior changes. We may do things that make our lives worse, like getting into more disagreements, withdrawing from others, or spending too much time lying in bed. These are called “away moves” because they move us away from our values. Sometimes emotions become so strong they feel like emotional storms. However, we can “unhook” ourselves by focusing and engaging in what we are doing, referred to as “grounding.”^[15]

Grounding

“Grounding” is a helpful tool when feeling distracted or having trouble focusing on a task and/or the present moment. The first step of grounding is to notice how you are feeling and what you are thinking. Next, slow down and connect with your body by focusing on your breathing. Exhale completely and wait three seconds, and then inhale as slowly as possible. Slowly stretch your arms and legs and push your feet against the floor. The next step is to focus on the world around you. Notice where you are and what you are doing. Use your five senses. What are five things you can see? What are four things you can hear? What can you smell? Tap your leg or squeeze your thumb and count to ten. Touch your knees or another object within reach. What does it feel like? Grounding helps us engage in life, refocus on the present moment, and realign with our values.^[16]

Unhooking

At times we may have unwanted, intrusive, negative thoughts that negatively affect us. “Unhooking” is a tool to manage and decrease the impact of these unwanted thoughts. First, NOTICE that a thought or feeling has hooked you, and then NAME it. Naming it begins by silently saying, “Here is a thought,” or “Here is a feeling.” By adding “I notice,” it unhooks us even more. For example, “I notice there is a knot in my stomach.” The next step is to REFOCUS on what you are doing, fully engage in that activity, and pay full attention to whoever is with you and whatever you are doing. For example, if you are having dinner with family and notice feelings of anger, note “I am having feelings of anger,” but choose to refocus and engage with family.^[17]

Acting on Our Values

The third category of skills is called “Acting on Our Values.” This means, despite challenges and struggles we are experiencing, we will act in line with what is important to us and our beliefs. Even when facing difficult situations, we can still make the conscious choice to act in line with our values. The more we focus on our own actions, the more we can influence our immediate world and the people and situations we encounter every day. We must continually ask ourselves, “Are my actions moving me toward or away from my values?” Remember that even the smallest actions have impact, just as a giant tree grows from a small seed. Even in the most stressful of times, we can take small actions to live by our values and maintain or create a more satisfying and fulfilling life. These values should also include self-compassion and care. By caring for oneself, we ultimately have more energy and motivation to then help others.^[18]

Being Kind

“Being Kind” is a fourth tool for reducing stress. Kindness can make a significant difference to our mental health by being kind to others, as well as to ourselves.

Making Room

“Making Room” is a fifth tool for reducing stress. Sometimes trying to push away painful thoughts and feelings does not work very well. In these situations, it is helpful to notice and name the feeling, and then “make room” for it. “Making room” means allowing the painful feeling or thought to come and go like the weather. Nurses can educate clients that as they breathe, they should imagine their breath flowing into and around their pain and making room for it. Instead of fighting with the thought or feeling, they should allow it to move through them, just like the weather moves through the sky. If clients are not fighting with the painful thought or feeling, they will have more time and energy to engage with the world around them and do things that are important to them.^[19]

Strategies for Self-Care

By becoming self-aware regarding signs of stress, you can implement self-care strategies to prevent compassion fatigue and burnout. Use the following “A’s” to assist in building resilience, connection, and compassion^[21]:

• Attention: Become aware of your physical, psychological, social, and spiritual health. What are you grateful for? What are your areas of improvement? This protects you from drifting through life on autopilot.
• Acknowledgement: Honestly look at all you have witnessed as a health care professional. What insight have you experienced? Acknowledging the pain of loss you have witnessed protects you from invalidating the experiences.
• Affection: Choose to look at yourself with kindness and warmth. Affection and self-compassion prevent you from becoming bitter and “being too hard” on yourself.
• Acceptance: Choose to be at peace and welcome all aspects of yourself. By accepting both your talents and imperfections, you can protect yourself from impatience, victim mentality, and blame.