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An algorithm to help you manage your stress


Nurses face tremendous stress in their daily practice. Various environmental and personal factors can exacerbate or mitigate stress. High stress levels impair cognitive and psychomotor functioning, leading to potential errors in patient care. Experts have identified common physiologic and psychosocial responses to stress and suggested ways individual nurses and their employers can deal with stressors. To help ease stress, everything from stress-management classes to painting warm colors on walls has been tried in one venue or another.

Nurses often struggle to manage their stress, but many report they feel powerless to improve their situation. This article describes a tool to help nurses identify their stressors and act assertively to address them. Addressing stress promotes a healthier work environment where nursing practice can thrive and nurses can deliver higher-quality patient care.

How we respond to stress

No common denominator exists to determine how individuals respond to similar stressors—and this poses an obstacle to developing generalized interventions. (See Stress among nurses: What the literature shows by clicking the PDF icon above.) Some organizational initiatives, such as better leadership and management training and creative staffing solutions, have proven somewhat effective. Yet a pressing need exists to develop strategies that enhance nurses’ personal stress-management skills.

Numerous initiatives have been undertaken to address the stress induced by factors that can cause stress in nurses (such as workload, relationships with coworkers, and lack of reward or recognition). An American Association of Critical-Care Nurses’ 2005 document emphasizes multiple contributors to healthy work environments—skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. These factors influence, and are influenced by, how the nurse deals with stress. The American Nurses Credentialing Center (ANCC) supports the value of a healthy workplace through two of its organizational credentialing programs. The Magnet Recognition Program® recognizes healthcare organizations for nursing excellence, high-quality patient care, and demonstrating superior nursing practices and outcomes. The Pathway to Excellence Program® recognizes healthcare organizations for creating positive practice environments that focus on collaboration, professional development, and accountable leadership to empower nurses. These programs have standards that organizations must meet to receive the Magnet® or Pathway® designation. Many of the standards relate to effective leadership, nurse empowerment, and creative approaches to advancing nursing practice.

Decision-making matrix

While it’s well established that healthy work environments contribute to the quality of nursing practice, challenges remain in helping nurses effectively address stressors that hinder their ability to practice effectively. A gap remains between the stress experience and the nurse’s ability to analyze and effectively deal with specific stressors.

To fill that gap, this author developed an algorithm to assist nurses in addressing personal stressors. (See Stress-management algorithm by clicking the PDF icon above.) While no formal research has been done to assess the tool’s effectiveness, anecdotal evidence indicates nurses find it useful in identifying and promoting actions to address their stressors. Further study may lead to empirical evidence that supports the algorithm’s value. I originally designed the model for nurses, but it has general applicability and can be used in any setting. Here’s a summary of the algorithm’s main steps.

What is the stressor?

First identify the stressor, which isn’t always easy. You may have a sense of unease, yet be unable to pinpoint its exact cause. But unless you identify it, you can’t take specific and focused action. To think through an uncomfortable situation to find the cause of the stress, you can use reflection (a process crucial to critical thinking).

How is it making me feel?

Next, examine the feelings the stressor generates. How much discomfort does it cause? Is it tolerable? Is it enough to warrant further action? Does it cause physiologic or psychosocial symptoms that typically accompany stress? Uncomfortable symptoms may indicate you need to take action to address the stressor.

When I’ve presented this algorithm in seminars, I’ve asked participants to reflect on how their stress manifests. Some said it primarily manifests internally—for instance, as headaches, “butterflies” in the stomach, or a short temper. Others described external manifestations. Parallels have been drawn between bullying (repetitive, purposeful actions intended to demean or belittle others) and one’s reaction to stressors. One seminar participant used the term “self-bullying” to describe her internal response to stress.

Do I want to change it?

Once you’ve identified the stressor and related feelings and behaviors, ask yourself if you want to change the situation that’s causing the stress. Even when a change is possible (say, you’re given an opportunity to work a different shift), you may make a conscious choice not to make that change. In that case, you need to let go of the issue causing the stress. This means you recognize the factors that contribute to the stress, are aware of the feelings they elicit, but are making a deliberate decision not to intervene. You must clearly understand the outcome of this decision and take actions to focus inward—for instance, telling yourself, “I accept that I’ve made a decision not to change this situation. How can I best reframe my thinking so I’m not negatively affected by the feelings of stress this situation has generated?”

Can I change it?

Sometimes, a person seeks a change but can’t alter all the dynamics of the situation—for example, the professor can’t dismiss a “problem” student from class, the staff nurse can’t choose his coworkers. But in some cases, other people might be able to help you deal with the stressor. If so, seek assistance from the person who’s best able to serve as a resource.

What should you do if no one is available? In this case, the “letting go” process is critical. However, if the situation can be changed and you wish to change it, you can take a series of action steps to achieve a positive result, as described below.

What needs to be done?

This question moves the emotion of the stress into a cognitive plan for action. Consider the steps you must take to deal with the stressor. Formulating a plan provides momentum to move toward resolution.

Can I do it alone or do I need help?

This question helps frame the action relative to others who might need to be involved to increase the chance for success. If the stress results from your interactions with a coworker and you want to change the situation, you may need to address the issue directly with the coworker. But if the stress relates to how a team works together, you may need to involve others in working toward a solution.

Do I need tools or time—or both?

Sometimes, an action may not require particular resources. You may be able to accomplish it relatively quickly once you’ve addressed the earlier questions. But in other situations, you may need certain resources and tools to help you deal with the situation. Suppose, for instance, you’ve identified a feeling of inferiority you get when working with experienced colleagues.
To address this, you might choose to take a class in assertive behavior or a course to enhance your clinical effectiveness, before talking with colleagues about changing the dynamics of your relationship with them.

Take action

Once you’ve made these decisions, you’re ready to take specific, well-planned actions to achieve the desired outcome. These actions can close the gap between the uncomfortable feelings you experienced initially and the desired feelings that will occur once the stressor has been addressed.

Evaluate outcomes

Did your actions work? Just as in clinical practice, evaluation is an important phase of the process. Reflect on the experience. Recall your initial stressors and associated feelings, and consider the value of the intervention steps you’ve taken to attain the desired outcome.

Let go

Finally, let go of the situation. As one seminar participant stated, “Letting go isn’t giving up. Letting go is an acknowledgement that I’ve worked through the process, I’ve clearly analyzed the situation and my options, and I’ve done the best I can under the circumstances.”

Selected references

American Association of Critical-Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. Aliso Viejo, CA: Author; 2005. Accessed January 6, 2013.

American Nurses Credentialing Center. ANCC Magnet Recognition Program: Program Overview. 2013. Accessed January 6, 2013.

American Nurses Credentialing Center. ANCC Pathway to Excellence: Pathway Program Overview. 2013. Accessed January 6, 2013.

Letvak SA, Ruhm CJ, Gupta SN. Nurses’ presenteeism and its effects on self-reported quality of care and costs. Am J Nurs. 2012;112(2):30-8.

McKinney BK. Withstanding the pressure of the profession. J Nurses Staff Dev. 2011:27(2);69-73.

McVicar A. Workplace stress in nursing: a literature review. J Adv Nurs. 2003:44(6);633-42.

Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005;105(1):54-64.

Ross C. Literature review for nursing stress interventions. Ezine articles. Accessed January 9, 2013.

Stagg SJ, Sheridan D, Jones RA, Speroni KG. Evaluation of a workplace bullying cognitive rehearsal program in a hospital setting. J Contin Educ Nurs. 2011;42(9):395-401.

Townsend T. Break the bullying cycle. Am Nurse Today. 2012;7(1):12-5.

Pamela S. Dickerson is director of Continuing Education for the Montana Nurses Association.

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