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This site is for student nurses or nurses starting out. Letters to a Young Nurse are blog posts written like letters to help you find your way and make your journey as a nurse less difficult. 


Stress Management

Stress management and self-care

Let me ask you a question, how many of you know the feeling that life is unfolding faster than you can imagine?

How many of you would describe yourself as "crazy busy"?

The following is from a TED talk by Darria Long, MD, an ER physician who has daily experience with stress and triaging.

When we talk about stress the words we use are important. Saying that you are “crazy busy” gives your brain the wrong message. When we say we are “crazy busy” we are telling our brains to always be in a stress response mode.

What happens when we are stressed?

Stress hormones rise in the fight, flight, or freeze mode. The fight or flight system uses the sympathetic pathway. When stress hormones flood the brain, our executive function declines; memory, judgment, and impulse control deteriorate. The same areas in the brain activated by anger and anxiety are activated when we are stressed or when we perceive ourselves to be stressed.

The neurotransmitters: cortisol, acetylcholine, epinephrine, and adrenaline, are stimulated under stress. These neurotransmitters can be two sometimes their normal level in the brain when you are stressed. Sustained increases in these neurotransmitters are toxic to the brain. The goal should be to stop the sympathetic response and get into the parasympathetic response which is rest and digest.

Imagine you're hiking on a beautiful trail in the woods. You come around a bend and there's a grizzly bear standing in the middle of the trail, and he looks like he wants to eat you for lunch. What immediately happens in your body? Your heart races, your breathing gets shallow and fast, glucose spikes and your primitive animal brain takes over. Your focus becomes narrow, your judgement becomes impaired, and you respond through impulse rather than react with reason and logical thought. This is our survival mode kicking in and it tells us to either stay and fight, take flight or freeze. This autonomic, sympathetic response is effective for short amounts of time, but chronic activation of this system leads to ill health and chronic disease.

I saw this video recently of a group of women hiking in Mexico. A bear casually walks up to them and there are 3 different reactions to the stressful situation.

One woman takes small and slow steps away from the bear, one turns her back to the bear and freezes and the third takes a selfie with the bear. She takes a selfie??? Perfect example of losing your judgement and reason during stressful situations.

How do we triage stressful situations? Instead of seeing your day as “crazy busy” we need to reframe our perception and be in ready mode. During Mass Casualty events like school shootings, explosions, bombings, etc., healthcare professionals use Triage Tags that are color coded. The victim is assessed, and the appropriate tag is attached to them.

The steps for triaging any stressful situation are as follows:

1. The first step in meeting stress positively is to “relentlessly triage”.

We need to always be prioritizing and triaging events in our day.

Red tag – Immediate: immediately life-threatening. If care is not given soon, the patient will succumb to their injuries.

Yellow tags – Delayed: there are serious injuries, but the patient can wait to be treated.

Green tags – Minor: this tag indicates only minor injuries, and the patient or condition can wait to be treated.

Black tags – No hope or deceased – no matter what is done the patient will die of their injuries.

To relentlessly triage means that you do not immediately assign Red to the event or situation. That is your primitive, sympathetic brain kicking in. Take a breath, reevaluate, stay calm. With medication, education, and treatments a “red tag” situation can be turned into green.

2. Prepare for, expect, and design for “crazy.”

Research has shown that the more options or decisions we have, the less capable we are of making good decisions. The brain becomes exhausted and does not make effective decisions.

· Know what to do when faced with a red tag event.

· Dig into your toolbox of knowledge.

· If you can’t find the answer, call a colleague or doctor.

· Plan ahead by doing simple things like ordering comfort meds before the patient transitions.

· Automate responses – practice the words you will use in tough patient situations.

· Make sure your equipment is in good, working condition.

And most importantly always have the right equipment with you. At a minimum you should always have a pen, paper, stethoscope, BP cuff and pulse oximeter. Oh, and don't forget to bring thinking cap (brain) with you.

Plan, prepare, expect for the tough moments that can cause you to automatically switch into crazy mode.

3. Get out of your head – get out of your own way.

We all get nervous, we all get scared, even someone with 30 years of experience gets anxious. But it is what we do next that matters. When our internal monologue starts, we catastrophize. We get tunnel vision. Victor Frankl said: Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom."

See the bigger picture. Do not make the decision personal. Remember where you are in this moment.

What is needed in this moment to turn the situation around? How can you change the situation from stressful to calm?

4. Put the focus on someone else – the patient and their family.

What does the patient need right now? What can wait for another time? What education can I give the patient/family to help in the situation. Keep the decision patient centered. Many research studies show time after time that compassion interrupts tunnel vision (stress response) and stops the negative internal monologue.

5. Change your perception

We can never, truly, prevent or escape from stress. But when we are getting overwhelmed, stop, take a breath, and rethink the situation. If you are presented with a red moment or situation, think about how you can change your thoughts about the situation. If you cannot change the situation, change your mind about the situation. Instead of catastrophizing see the situation differently.

An example is my three-year-old grandson has been coming to visit us since he was a day old. As he has grown up, he is getting into more and more things that could hurt him. In the beginning I saw every movement as a potential catastrophic event! He would stand on the top of the sofa and all I could see was him taking a header into the end table. When running I always saw him trip and go headfirst into our glass TV stand. I finally had to let go of these what ifs and realize that I could not enjoy him if all I could see was the potential catastrophes. Let it go, let it go!

Recent studies in stress management are showing that our perception of the stressful event will determine if it has ill effects on our physical and mental health. Seeing the experience as a learning opportunity or looking it as a positive experience has been shown to prevent the toxic effects of stress in the brain and body. By looking differently at stress, we can protect our hearts and minds from its deleterious effects. If you cannot change the situation, change your mind!

Remember the steps:

1. Relentlessly triage.

2. Plan, prepare, expect.

3. Get out of your head.

4. Focus on someone else.

5. Change your view.


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