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Stress managementBingi 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

IMPORTANCEThe 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 workplaceGeneral 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 Work1. 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 STRESSORS7 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 stressorsJob 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 stressJob 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 stress1. 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 aware13

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?15

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 response17

BurnoutM 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 FatigueMeaning: 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-workers22

Compassion fatigue model

23

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-memor