Self-Management: Stress and Time



Self-Management


Stress and Time


Catherine A. Hill




Objectives



• Define self-management.


• Explore personal and professional stressors.


• Analyze selected strategies to decrease stress.


• Assess the manager’s role in helping staff manage stress.


• Evaluate common barriers to effective time management.


• Critique the strengths and weaknesses of selected time-management strategies.


• Evaluate selected strategies to manage time more effectively.



Terms to Know

















The Challenge



Stress seems to come at me from different directions and never disappears! This is a high-stress time for me. I am a full-time graduate student in nursing, and I have a full-time job at Parkland Hospital. I have a wife and children who deserve my time and attention too. It seems I always have to be somewhere and I still have to try to get homework done!


What do you think you would do if you were this nurse?




Introduction


What should you do when you have tried your best, but things are not going well? What needs changing? Where do you begin? Self-management involves self-directed change to achieve important goals (Stuart & Laraia, 2008). As a nurse leader, your goals will require balancing personal and professional objectives and organizing your time and activities to reach them. The literature suggests that stress hardiness of nurse leaders is essential to safe, high-quality patient care (Halm et al., 2005), as well as staff recruitment and retention (Bailey, 2009). In the past, nursing research on stress focused on individual acceptance of demanding work environments, complex role requirements, and staff shortages instead of proactive problem solving (Shirey, 2006). Several thought leaders, reflected in the meta-analysis of Zangaro and Soeken (2007), suggest that cultivating stress hardiness produces nurse managers with a leadership style and resilience that improves working conditions. However, using both internally and externally available psychosocial resources did not compensate for the stress experienced by nurse managers and physicians (Lindholm, 2006). Luckily, stress hardiness can be taught (Judkins, Reid, & Furlow, 2006).


To develop stress hardiness, we must actively improve our skills related to stress management, adaptive coping, healthy communication, and problem solving. The three key strategies introduced in this chapter—stress management, time management, and meeting management—are important ways to do more with fewer resources. Time and stress are somewhat of a “chicken and egg” phenomenon—not enough time contributes to stress, and stress can erode efficiency and thus decrease time on task. The key lies in our ability to manage both time and stress, not only personally but also professionally. The outcome of effective self-management is hardiness and the ability to accomplish professional and personal goals.



Understanding Stress


Nurses have learned about the effect of stress on patients and how to teach them to manage its consequences. However, only one third of nurse managers have any sort of formal leadership or managerial training (Bailey, 2009) that would prepare them for dealing with multiple sources of stress at the same time. Nurses need to recognize the unique stressors in their professional and personal lives. Everyone experiences stress—the exhilaration of a joyous event, as well as the negative feelings and unpleasant physical symptoms that may be associated with a difficult life situation or even the anticipation of difficulty. Stress is the uncomfortable gap between how we would like our life to be and how it actually is. Nurses are not immune to the effects of stress. Learning what stress is, its dynamics, and some strategies to manage distress is a part of the personal and professional maturation of nurses.



Definition


In this chapter, stress and distress (Selye, 1965) are used interchangeably, although some writers regard stress as neutral and refer to the positive and negative attributes of eustress and distress, respectively. Stress is a consequence or response to an event or stimulus. Stress is not inherently bad. It is each individual’s interpretation that determines whether the event is viewed as positive or threatening. In addition, stress management does not necessarily mean stress reduction. Rather, stress management is characterized by emotional and behavioral control, perseverance, and challenge in the face of stressful events (Kobasa, Maddi, & Kahn, 1982). Stress management is a nurse manager competency (Jennings, Scalzi, & Rodgers, 2007). Stress management has important implications for the workplace because of its link to low absenteeism rates, improved quality, and increased productivity (Judkins, Reid, & Furlow, 2006).



Sources of Job Stress


Job stress can be defined as the physical and emotional responses that arise when the job requirements do not match the abilities, resources, or needs of the worker. Work-related stress can lead to poor physical and emotional health and injury. There is a difference between job-related challenges (eustress), which motivate us to learn new skills and master our jobs, and distress, which can lead to exhaustion, feelings of inadequacy, and failure. If you are involved in an oral interview for a job, you will benefit from a certain amount of stress (eustress). It is stress that provides you with determination and gives you your “edge” that will help you think quickly and clearly and express your thoughts in ways that will benefit your interview process. Having your car break down on the way to the interview creates stress (distress) as you realize that you will be late for the appointment. As more is learned about the relationship of stress to physiologic changes, stressors will become even easier to identify. When one looks at job-related stressors, the stressors fall into one of two categories: external (working conditions) and internal (worker characteristics).



External Sources


Occupational stress in nursing has been well-defined and documented. Work-related stressors, such as workload, rotating shifts, high patient acuity, inadequate staffing, ethical conflicts, dealing with death and acute illness, role ambiguity, the intensity of complexity compression, and job insecurity have all been associated with increased stress and burnout. Nurses spend more time at work, and nurse managers report 12- to 14-hour days with 24-hour accountability (Rudan, 2002).




Social


Interpersonal relations can buffer stressors or can in themselves become stressors. Outside the work setting, home can be a refuge for harried nurses; however, stresses at home, when severe, can impair work performance and relationships among staff or even result in violence that may invade the workplace.


Changes in healthcare delivery systems, as well as the current nursing shortage, have reduced the number of professional nurses, often creating situations of minimally safe staffing levels. Consequently, some nurses lose supportive, collegial relationships that may have been established over many years. Many institutions now depend on supplemental staffing with agency or “traveling” nurses, thus creating a very transient nursing staff. In other situations, nurses are reassigned or they “float” to various patient-care units, which requires that they work with unfamiliar staff. Thus they may feel isolated or become unwillingly involved in dysfunctional politics on the unit. Such situations may also necessitate that nurses work with patients whose requirements for care may be unfamiliar, resulting in further stress related to patient safety concerns.


Persons in management-level positions may also become stressors. Communication may come from the top down, with little opportunity for nurses to participate in decisions that affect them directly or that they may need to implement without proper training or support. Nurses may experience distress from feelings of frustration and helplessness with this lack of opportunity for input to decisions.


In addition, disruptive behavior poses considerable work stress. Although healthy workplaces include freedom from such behavior, too many instances occur in healthcare settings. In addition to being stressful for nurses, such behavior can disrupt patient safety efforts (see the Research Perspective above).



imageResearch Perspective


Resource: Rosenstein, A. H., & O’Daniel, M. (2008). A survey of the impact of disruptive behaviors and communication defects on patient safety. Joint Commission Journal on Quality and Patient Safety, 34, 464-471.


This study involved a survey related to nurses and physicians and the effect of disruptive behavior on patient care. Although the sample was a convenience sample, over 4500 responses were analyzed. Nurses (88%) observed disruptive behaviors in physicians. Physicians (51%) acknowledged observing disruptive physician behaviors. In addition, 67% identified that disruptive behaviors contributed to adverse events.




The Position


Upon entering nursing school, most students expect that caring for patients who are chronically or critically ill and for families who have experienced tragedy will be stressful. The current environment in many healthcare agencies, however, is more complex and is often characterized by overwork, as well as by the stresses inherent in nursing practice. In some settings, direct care nurses have been expected to stay beyond the designated assignment period, often with little or no notice. Some managers experience stress in those situations and resort to threatening behaviors and statements, such as the potential for dismissal. These situations often escalate when direct care nurses do not believe they can deliver safe care and nurse managers exhaust creative ways to provide adequate coverage.


Role stress is an additional stressor for nurses. Viewed as the incongruence between perceived role expectations and achievement (Chang & Hancock, 2003), role stress for new graduates is related to role ambiguity and role overload. Role stress is particularly acute for new graduates, whose lack of clinical experience and organizational skills, combined with new situations and procedures, may increase feelings of overwhelming stress. Conflict between what was learned in the classroom and actual practice may add additional stress.



Gender Roles


Approximately 94% of the nation’s 2.9 million nurses are women (Health Resources and Services Administration, 2005), and many go home to traditionally gender-related responsibilities that may include household management, children, and aging parents. When added to the already stressful workday of the nurse, the additional responsibilities often contribute to the level of distress felt by the nurse. Thanks to generation Y’s entry into the workforce, greater emphasis on work-life balance has become increasingly important.


Evans and Steptoe (2002) examined the associations of work stress and gender-role orientation to psychological well-being and sickness-related work absences in male-dominated (accounting) and female-dominated (nursing) occupations in England. They concluded that when men and women are occupationally engaged in gender-dominated occupations in which they are in the gender minority, the men and women perceived more work-related hassles and exhibited gender-specific health effects.



Internal Sources


Personal stress “triggers” are events or situations that have an effect on specific individuals. A personal trigger might be a specific event such as the death of a loved one, an automobile accident, losing a job, or getting married. These events are in addition to daily personal stressors such as working in a noisy environment, job dissatisfaction, or a difficult commute to work. Negative self-talk, pessimistic thinking, self-criticism, and overanalyzing can be significant ongoing stressors. These internal sources of stress usually stem from unrealistic self-beliefs (unrealistic expectations, taking things personally, all-or-nothing thinking, exaggerating, or rigid thinking), perfectionism, or the type A personality.


An individual’s ability to deal with stress may be moderated by psychological hardiness. According to Lambert, Lambert, and Yamase (2003), psychological hardiness is a composite of commitment, control, and challenge. These form a constellation that (1) dampers the effects of stress by challenging the perception of the situation and (2) decreases the negative impact of a situation by moderating both cognitive appraisal and coping. Maddi (2002), in a 12-year longitudinal study, found that individuals thriving in a stressful work environment displayed the same psychological hardiness. The commitment attitude led the individuals to be actively involved in the changes that decreased isolation. The control attitude led them to try to influence outcomes rather than sink into powerlessness and passivity. The challenge attitude led them to believe that the stressful events were opportunities for new learning.


Lifestyle choices, such as the use of caffeine, lack of exercise, poor diet, inadequate sleep and leisure time, and cigarette smoking, have a direct effect on the amount of one’s stress. Most of the stress an individual has is self-generated. Recognizing that we create most of our own stress is the first step to dealing with it.



Dynamics of Stress


Stress may result from unrealistic or conflicting expectations, the pace and magnitude of change, human behavior, individual personality characteristics, the characteristics of the position itself, or the culture of the organization. Other stressors may be unique to certain environments, situations, and persons or groups. Initially, increased stress produces increased performance. However, when stress continues to increase or remains intense, performance decreases. Hans Selye’s mid-century investigations of the nature of and reactions to stress (Selye, 1956) have been very influential. In his classic theory, Selye (1991) described the concept of stress, identified the general adaptation syndrome (GAS), and detailed a predictable pattern of response (see the Theory Box on p. 556 and Figure 28-1).


image
FIGURE 28-1 The stress diagram.


Theory Box


Theories Applicable to Self-Management

























KEY CONTRIBUTORS KEY IDEAS APPLICATION TO PRACTICE
Maslow’s Hierarchy of Needs: Maslow (1943) identified five need levels of every human. Although recent research shows the five levels are not always present or in order, it is reasonable that unmet needs motivate most employees most of the time. Nurse wages should be sufficient to provide shelter and food. Job security and a social environment that rewards and recognizes nurse performance are important.
General Adaptation Syndrome: Selye (1956) is credited with developing this theory. The “stress response” is an adrenocortical reaction to stressors that is accompanied by psychological changes and physiologic alterations that follow a pattern of fight or flight. The general adaptation syndrome includes an alarm, resistance, and adaptation or exhaustion. Change, lack of control, and excessive workload are common stressors that evoke psychological and physiologic distress among nurses.
Complex Adaptive Systems: Plsek and Greenhalgh (2001). This theory of unpredictable interactions between interdependent people and activities emphasizes the importance of innovation and rapid information sharing to improve performance. Nurse engagement in self-managed groups and teams allows organizations to shape their environment through controlled “experimentation” using the rapid-cycle plan-do-study-act improvement method.
The Pareto Principle: Hafner (2001). The “Pareto Principle” refers to a universal observation of “vital few, trivial many.” Pareto (1848-1923) studied distribution of personal incomes in Italy and observed that 80% of the wealth was controlled by 20% of the population. This concept of disproportion often holds in many areas. Although the exact values of 20 and 80 are not significant, the observation of considerable disproportion is important to remember. The 80-20 rule can be applied to many aspects of health care today. For example, 80% of healthcare expenditures are on 20% of the population, and 80% of personnel problems come from 20% of the staff. In quality improvement, 80% of improvement can be expected by removing 20% of the causes of unacceptable quality or performance. A nurse can also expect that 80% of patient-care time will be spent working with 20% of his or her patient assignment.


More recent investigations of the relationship among the brain, the immune system, and health (psychoneuroimmunology) have generated models that challenge Selye’s general adaptation syndrome. Although Selye states that all people respond with a similar set of hormonal and immune responses to any stress, Kemeny (2003) proposes that there are two stress responses: (1) the classic GAS and (2) a withdrawing reaction, in which the person pulls back to conserve energy. Kemeny hypothesizes that people respond to the same psychological event in different ways, depending on their independent appraisal of the situation (DeAngelis, 2002).


Critical of stress research using predominately (87%) male subjects, Taylor et al. (2000) proposed a model of the female stress response, the “tend and befriend,” as opposed to the male’s “fight or flight” model. The “tend and befriend” response is an estrogen and oxytocin–mediated stress response that is characterized by caring for offspring and befriending those around in times of stress to increase chances of survival.


Most nurses can easily recognize the origins of stress and its symptoms. For example, a healthcare agency may make demands on nurses, such as excessive work, that the nurses regard as beyond their capacity to perform. When they are unable to resolve the problem through overwork, with more staff, or by looking at the situation in another way, the nurses may feel threatened or depressed. They may also experience headache, fatigue, or other physical symptoms. If the stress persists, such symptoms may increase; nurses may attempt to cope by becoming apathetic or by resigning their positions. Table 28-1 gives physical, mental, and spiritual/emotional signs of overstress in individuals.



In 2004, Segerstrom and Miller published a meta-analysis of research on the relationship between stress and the human immune system. They found that acute stressors (very short-term) “revved up” the immune system, preparing for infection or injury. Short-term stressors, such as tests, tended to suppress cellular immunity while preserving humoral immunity. The immune systems of those who are older or already sick are more prone to stress-related immune system changes.


Physical illnesses linked to stress include visceral adiposity, type II diabetes, cardiovascular disease (hypertension, heart attack, stroke), musculoskeletal disorders, psychological disorders (anxiety, depression), workplace injury, neuromuscular disorders (multiple sclerosis), suicide, cancer, ulcers, asthma, and rheumatoid arthritis. Stress can even cause life-threatening sympathetic stimulation.



Management of Stress


Individuals respond to stress by eliciting coping strategies that are a means of dealing with stress to maintain or achieve well-being. These strategies may be ineffective because of their reliance on methods such as withdrawal or substance abuse, or they may be effective in helping restore a greater sense of well-being and effectiveness. Some of these effective strategies are discussed here.



Stress Prevention


One effective way to deal with stress is to determine and manage its source. Discovering the origin of stress in patient care may be difficult because some environments have changed so rapidly that the nursing staff is overwhelmed trying to balance bureaucratic rules and limited resources with the demands of vulnerable human beings. Complexity compression is the name given to conditions in which change occurs with great intensity (Krichbaum et al., 2007). When in distress, nurses may need to step back and look at the “big picture.” By identifying daily stressors, the nurse can then develop a plan of action for management of the stress. This plan may include elimination of the stressor, modification of the stressor, or changing the perception of the stressor (e.g., viewing mistakes as opportunities for new learning) using a reframing technique.


Many of the day-to-day activities of nursing can create workplace stress. Consider the critical nature of nursing work and the potential for serious injury to others. Staffing shortages create situations of caring for more patients with less help. Nurses may have inadequate rest because of rotating shifts or irregular schedules. Nurses are subject to significant musculoskeletal stress caused by lifting, pulling, and turning patients. Nurses give physical care to those who are physically unclean or verbally abusive. Nurses watch patients and families suffer with pain and grief. These stressors are often counterbalanced by the rewards of patient appreciation, the joy of seeing a healthy baby born, or seeing the relief brought by a medication or repositioning. However, given the stressful nature of nursing, it is wise for the nurse to be alert to his or her own signs of stress and to develop lifestyle habits that help reduce stress. Adequate sleep, a balanced diet, regular exercise, and frequent interactions with friends are excellent stress-buffering habits to develop.


According to Stöppler (2005), the top five stress-management mistakes are poor calendar habits, clutter, perfectionism, self-treatment, and following others’ expectations. These may be high on your list of stress experiences. Analyze your stress experiences by completing Exercise 28-1.



Exercise 28-1


Identify what stress you experience and how you usually manage it. Create and complete the following log at the end of every day for 1 week. Review the log and note what situations (e.g., people, technology, values conflict) were the most common. Also identify how you most often react to stress: physically, mentally, and emotionally/spiritually. Keeping this diary for a week is helpful to determine what you respond to with stress and learn about your reactions. Enter a date, and describe a situation and your response. Ask yourself if the stress was good stress (eustress) or bad stress (distress). Then think about what more-positive strategies could be used to deal with a similar situation.


Date____________________


Situation_________________


Your Response___________


Good Stress or Bad_________________


Action (How you dealt with your response)_____________________


Evaluation_______________________


Look over your week of stressors. Are there some that you encounter on a regular basis? If so, try to formulate a plan to conquer the problems. You may need to role-play or get continuing education to improve a specific skill. You may need to simply break a task down into smaller pieces or to eliminate interruptions.



Symptom Management


Unpredictable and uncontrollable change, coupled with immense responsibility and little control over the work environment, produces stress for nurses and other healthcare professionals. Consequently, nurses may develop emotional symptoms such as anxiety, depression, or anger; physical alterations such as fatigue, headache, and insomnia; mental changes such as a decrease in concentration and memory; and behavioral changes such as smoking, drinking, crying, and swearing. The important factor is not the stressor but, rather, how the individual perceives the stressor and what coping mechanisms are available to mediate the hormonal response to the stressor.


Multiple “stress-buffering” behaviors can be elicited to reduce the detrimental effects of stress. The stressor-induced changes in the hormonal and immune systems can be modulated by an individual’s behavioral coping responses. These coping responses include leisure activities and taking time for self, decreasing or discontinuing the use of caffeine, positive social support, a strong belief system, a sense of humor, developing realistic expectations, reframing events, regular aerobic exercise, meditation, and use of the relaxation response.


Everyone needs to balance work and leisure in his or her life. Leisure time and stress are inversely proportional. If time for work is more than 60% of awake time or if self-time is less than 10% of awake time, stress levels will increase. Changes should be made to relieve stress, such as decreasing the number of work hours or finding more time for leisure activities. Caffeine is a strong stimulant and, in itself, a stressor. Slowly weaning off caffeine should result in better sleep and more energy. Positive social support can offer validation, encouragement, or advice. By discussing situations with others, one can reduce stress. A great deal of stress comes from our belief systems, which cause stress in two ways. First, behaviors result from them, such as placing work before pleasure. Second, beliefs may also conflict with those of other people, as may happen with patients from different cultures. Articulating beliefs and finding common ground will help reduce anger and stress. Humor is a great stress reducer and laughter a great tension reducer. A common source of stress is unrealistic expectations. Realistic expectations can make life feel more predictable and more manageable. Reframing is changing the way you look at things to make you feel better about them or to obtain a different perspective. Recognizing that there are many ways to interpret the same situation, taking the positive view is less stressful. Regular aerobic exercise is a logical method of dissipating the excess energy generated by the stress response.


Meditation to elicit the relaxation response can be beneficial. The benefits of practicing relaxation techniques for 20 minutes daily include a feeling of well-being, the ability to learn how tension makes the body feel, and the sense that tension can be controlled. In cases of some stress-related disorders (e.g., hypertension), biofeedback may be used to monitor physiologic relaxation processes. Exercise 28-2 outlines one systematic relaxation technique.


Social support in the form of positive work relationships, as well as nurturing family and friends, may be an important way to buffer the negative effects of a stressful work environment (Erdwins, Buffardi, Casper, & O’Brien, 2001). Although friendships may be formed with colleagues, the workload and the shifting of staff from one unit to another often make it difficult to establish and maintain close relationships with peers. However, managers and co-workers who are supportive may improve morale in the workplace (Zangaro & Soeken, 2007) (see the Research Perspective at right). Nurses in a new position or in an unfamiliar geographic area must anticipate that they will benefit from the security of being part of a group that can furnish emotional support. Without easily accessible family and friends, nurses need to be intentional about seeking new, supportive personal relationships. Such efforts may help nurses cope with workplace demands that seem to exceed their capabilities. Positive coping strategies may also make nurses less likely to adopt such potentially negative coping strategies as withdrawing, lowering their standards of care, and abusing alcohol or other substances.



Exercise 28-2


This exercise can be used in the middle of a working day, the last thing at night, or at any time you feel tense or anxious. Review the information and strategies at the Mayo website: www.mayoclinic.com/health/meditation/HQ01070. Make a short list of steps to take, and put it in your smart phone, personal digital assistant (PDA), or notepad.

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Aug 7, 2016 | Posted by in NURSING | Comments Off on Self-Management: Stress and Time

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