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Break the cycle of stress with PBR3


Stress and nursing practice may seem entwined. You know the story.

A patient’s family member wants you to do something for the patient’s pain now, but the attending physician hasn’t returned your call; patient call lights are going on all over the place; and the unit secretary just called in sick.

Or maybe you’re done work, and your stress level is rising because the grocery store checkout line is moving slowly, and you’re frustrated because all you want to do is head for your bed after a long shift.

Guess what? It’s not stress and nursing that are entwined. It’s stress and you. The cascade of  physiologic responses triggered by stress isn’t determined by the intensity of the situation, but by your reaction to the situation. Everyone views the world through a unique lens shaped by personal history. The key to stress management is to develop skills that allow you to examine the lens through which you see yourself and your workplace. The goal is to calm yourself, examine your perspective, and move from being reactive to reflective. The PBR3 tool, which you can use anytime and anywhere, can help.

Recognize the signs of stress
First, you need to recognize the signs of the stress response, such as increased heart rate, increased breathing, dilating pupils, and increasing perspiration. After you recognize your physiologic responses to a perceived threat, you can take steps to counter the sympathetic response to stress by initiating the relaxation response—that is, by activating the parasympathetic nervous system to slow the heart and respiratory rates and to return blood flow to the digestive system.

So, how do you do that? Meditation is ideal because it’s a way to find our authentic selves. But for now, the PBR3 tool can help you gain your composure when dealing with day-to-day stress.

Using PBR3
PBR3 stands for pause, breathe, relax, reflect, rewrite. The tool is based on the classic theories of the stress reaction and the relaxation response. It uses techniques borrowed from meditation, breath work, biofeedback, and cognitive restructuring. (See PBR3  at a glance.)
First, you need to pause. How do you do that in the middle of a busy shift? The pause can be as simple as silencing your inner dialogue. That incessant voice that drives you crazy needs to be quiet. Ideally, you should stop your activity and your self-talk, but stopping the self-talk is effective. Some people use a trip to the restroom to achieve this step. Others may just center themselves in the midst of chaos

Next, take a breath.  Not just any breath, but a nice deep breath like this: Breathe in 1-2-3-4, hold it 1-2-3-4, breathe out 1-2-3-4. You may need to do this several times until you feel yourself relax.

When you feel calmer, you need to reflect on the events that led you to this point. Examine your story and make sure it isn’t a reaction to the situation. The story you record in your memory will influence future responses to similar situations. Stress caused by reliving past events that were recorded as a faulty story in our memory needs some reflection and some honest editing of what we tell ourselves.

If you believe that every time you’re assigned a certain caseload your shift will be awful, then it probably will be. You may need to suspend writing the story into your memory until you can use a more detailed reflective process to examine the depth of the circumstances. Some may need professional help to make the connections or sort through convoluted reasoning. Many will instantly recognize their own fuzzy logic (and cloudy lens) and will be able to rewrite the story with a healthy dose of good humor and compassion.

Save yourself
We all know the consequences of unrelieved stress. Save yourself from that fate by trying PBR3. Recognize the signals that tell you when you need to pause. And perform deep breathing to elicit the relaxation response, so you can think clearly. Uncovering the whole story helps change the lens through which you view your world. And an accurate story will prevent the recurrences of internally created stress by breaking the cycle of self-generated threats.

Selected references  
Baldwin C. Storycatcher: Making Sense of our Lives Through the Power and Practice of Story. Novato, Calif: New World Library; 2005.

Kaminski J. Nursing through the lens of culture: a multiple gaze. Available at: Accessed March 15, 2007.

Seaward BL. Managing Stress: Principles and Strategies for Health and Wellness. 3rd ed. Sudbury, Mass: Jones and Bartlett Publishers; 2002.

Sherman DW. Nurses’ stress & burnout: how to care for yourself when caring for patients and their families experiencing life-threatening illness. AJN. 2004;104(5):48-56. Available at: Accessed March 15, 2007.

Wicks RJ. Overcoming Secondary Stress in Medical and Nursing Practice. New York, NY: Oxford Press; 2006.

For a complete list of selected references, see May 2007 references.

Becky Graner, MS, RN, IAC, is a Stress Management Nurse Educator at Dakota Natural Health Center in Bismarck, N.D. You can contact her at

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