By Debra Wood, RN, contributor
August 18, 2010 - Caring for patients can be quite stressful and take a toll on nurses, unless they learn to manage the pressure.
Kate Kravits, RN, MA, developed a psycho-educational self-care program at City of Hope and found it successful.
“Nurses spend hours at a time with a set of patients and get the opportunity for a deeper connection,” said Kate Kravits, RN, MA, senior research specialist in the nursing research and education department at the City of Hope in Duarte, Calif. “Providing compassion and reducing suffering has a cost for us.”
Nurses’ desire to help makes them vulnerable to depletion, stress and fatigue, added Diane Schofield, RN, CDE, CBN, nurse clinician and educator at the Weight Loss Surgery Center in Margate, Fla., and author of the recently released book The Stress Rescue: Your Guide to Stressless Living. She emphasized that nurses must understand the importance of taking care of themselves.
“Nurses are natural helpers and caregivers,” Schofield said. “But if they don’t keep themselves strong and in balance, they are not able to help others.”
Janet DeJean, RN, CPON, suggests volunteering and exercise as stress management tools.
In fact, when nurses are stressed and do not appropriately deal with this stress, they potentially place their patients in harm’s way, said Janet DeJean, RN, CPON, outpatient education coordinator at Texas Children's Hospital Cancer Center in Houston. “Errors are made when nurses are feeling stressed, burned out, fatigued or ill.”
Lucia Thornton, RN, MSN, AHN-BC, immediate past president of the American Holistic Nurses Association, agreed, saying that people who are stressed do not perform as well as other nurses. Stress also can contribute to turnover and poor patient satisfaction.
Long-term stress can led to chronic illnesses and depression, added Leila McKinney, RN, DNP, ARNP, NP-C, dean of nursing at Rasmussen College in Maitland, Fla.
“There are a lot of risks with not finding ways to be less stressed,” McKinney said.
Jeanne Geiger-Brown, Ph.D., RN, said stress reduction requires a two-pronged approach, dealing with both the stressor and your reaction to it.
Emotional exhaustion, physical fatigue and cognitive weariness can set in, and biological changes can take place, added Jeanne Geiger-Brown, Ph.D., RN, associate professor at the University of Maryland School of Nursing in Baltimore.
While there are many things that cause nurses stress, individuals also deal with these factors in different ways.
“There’s the actual stress and then there is the way we think of the stress,” Geiger-Brown said.
Kravits and colleagues at City of Hope investigated stress among nurses at City of Hope and learned that many nurses were caring for patients at work and for family members when they left the hospital. Often nurses had symptoms of burnout and emotional exhaustion.
“We found nurses were so focused on others they did not explore ways to make their lives more satisfying,” Kravits said.
The City of Hope researchers offered an eight-hour, psycho-educational self-care program to help nurses develop techniques to manage stress. Nearly 300 nurses participated. The program provided information about stress, compassion fatigue and the science behind it.
Then the team taught them deep breathing, relaxation techniques and guided imagery and let the nurses practice. Kravits also introduced an art tool to help nurses assess their level of burnout and create an affirmation that outlined what the nurse most wants in life and identify options for achieving that goal. Kravits offered an example of a positive affirmation: “I am emotionally healthy, energetic and vital.” And the actions to help achieve that might include mind-body therapy or massage. Participants then kept a log to track their progress.
“We were able to reduce significantly emotional exhaustion,” Kravits said. Depersonalization also declined, but it did not approach statistical significance. “And we were able to help with personal accomplishment.”
Kravits added that self-appreciation forms a foundation and helps nurses be less vulnerable to a variety of stresses.
Here are a few key things that nurses can do to help de-stress their lives:
1. Think positive self-thoughts
“Every thought you think about yourself affects your body,” Thornton said. “Every idea you have about who you are has probably been formed at an early age and is not very valid anymore.”
Holistic nursing includes spiritual aspects of life.
“Until we treat ourselves with reverence and respect, we cannot treat others that way,” Thornton said. “It’s beginning to appreciate who you are.”
2. Identify stressors
Not everyone reacts to stressors in the same way. Schofield recommends nurses identify what stresses them, acknowledging those triggers, accepting the ones out of their control and planning how they will deal with the others.
“Awareness is how you get started,” Schofield said.
Thornton advised taking that a step further, suggesting nurses recapture the essence of why they went into nursing, determine what is not working as expected and what keeps them from achieving the things they want out of life.
3. Collaborate with administration to resolve workplace issues
“In addition to the things individuals can do; organizations have to change too,” Geiger-Brown said.
Working short staffed and putting in frequent overtime contributes to many nurses’ high stress levels. Both are problems administration can help resolve. Geiger-Brown recommends working through shared-governance councils to resolve outstanding workplace issues.
Texas Children’s Hospital offers solutions in dealing with stress, including an employee assistance program, which allows nurses to discuss their situation with a counselor.
“We have employee satisfaction committees that collaborate with leadership to offer stress-relieving activities,” DeJean said. “These activities range from juice and donuts in the morning, to a come-and-go lunch with some fun activity.”
4. Take time for yourself
Nurses must make the effort to balance their lives and pursue supportive relationships with people outside the job.
Leila McKinney, RN, DNP, ARNP, NP-C, calls supporting fellow nurses and taking the time to acknowledge successes key to reducing stress in the workplace.
“Nurses often don’t take time for themselves,” McKinney said. “We deserve and need that time.”
One of the most important things nurses can do is not to overwork, said Geiger-Brown.
“Make sure you get out of work on time and take your breaks, a completely relieved break,” Geiger-Brown said. “Decline requests for overtime.”
McKinney cautions that taking the time but feeling guilty about it will only add to the stress level.
5. Support each other
Supporting fellow nurses and acknowledging successes also helps reduce workplace stress.
“It’s an ongoing weakness we have in our profession,” McKinney said. “Nurses tend to be highly critical of themselves and, therefore, of each other. When you are working in a high-stress environment, it is so important that everyone is seeking the best in each other.”
Thornton also encouraged nurses to foster teamwork and partnering in caring for patients.
6. Adopt healthy habits
Although nurses easily talk with patients about eating healthier, exercising and getting enough sleep, nurses often do not follow their own advice.
“We need to figure out on an individual basis what our body needs and try to provide more of that,” McKinney said.
DeJean said many Texas Children’s nurses find exercise is a great way to relieve stress.
“Once they realized that running really clears their mind and they are able to unwind, they have started running marathons,” DeJean said. “Others set up an exercise routine, and they report great success in decreasing their stress levels. Eating healthy and exercise appears to be one of the best ways of reducing stress.”
Geiger-Brown emphasized the importance of sleep, which restores and protects the body.
Annette Tersigni, RN, recommends yoga to reduce stress.
7. Try yoga therapy
Annette Tersigni, RN, in Morehead City, N.C., has combined yoga with nursing and teaches nurses how to reduce stress through deep diaphragmatic breathing techniques, seven gentle yoga postures and yoga nidra, a deep relaxation.
“Breath, mind and consciousness are interwoven, intertwined,” said Tersigni, who modifies the postures so nurses can succeed with the program. Nurses can apply the techniques on the job or after work and teach their patients the techniques.
8. Give back to others
Some nurses, such as DeJean, find giving time to worthy causes relieves stress.
“One of the activities that I thoroughly enjoy and one that seems to reduce stress is to volunteer,” said DeJean. “Nurses must find a way to re-energize their hearts and minds.”
9. Find joy in life
Geiger-Brown encouraged nurses to involve themselves in activities they enjoy. Simply “vegging out” in front of a television is not enough to relieve stress. Nurses must participate in relaxing pursuits.
“A personal stress rescue is not something you can buy at a spa for a weekend; it’s an ongoing personal journey,” Schofield added. “It’s finding things to balance active energy during the shift, having fun, finding pleasure in your life, and balancing the chaotic and fast-paced life we lead.”
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