UNDERSTANDING STRESS

What Is Stress?

Stress is the body’s response to pressure. It is the feeling of being overwhelmed or unable to deal with physical or mental pressure. Everyone deals with stress in different ways. The ability to respond effectively to stress depends on genetics, childhood events, personality, traumatic life experiences, and social and economic circumstances (MHF, 2021).

Work-related stress is defined as the “response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities and which challenge their ability to cope.” Work-related stress is often unavoidable in the healthcare field due to the demands of the work environment. In fact, some work demands may be perceived as acceptable since they may keep healthcare workers alert and motivated. However, when these demands lead to excessive or unmanageable stress, the results can be devastating (WHO, 2020).

EARLY RESEARCH ON STRESS

In his pioneering work, Walter Cannon (1871–1945) investigated the sympathetic nervous system as it reacts to heat and noticed that the body responds in a predictable sequence, which he called the fight-or-flight response (also known as the stress response). This automatic reaction to stressful (and possibly dangerous) circumstances is considered a survival mechanism that enables people to react swiftly to threatening situations (Harvard Medical School, 2020).

Causes of Work-Related Stress in Healthcare

Healthcare environments are busy and complex. Meeting the needs of patients, some of whom are critically ill or injured, can become overwhelming. Some of the causes of stress in the healthcare profession include:

  • Long work hours. Many healthcare professionals work long, 10- or 12-hour shifts and often put in overtime. Additionally, it is frequently hard to leave work on time when shifts end. Shift rotation as well as planned and unplanned overtime can increase job-related stress by triggering such problems as fatigue and inability to plan for activities outside the workplace (e.g., family obligations, pursuit of academic education).
  • Putting others first. Many healthcare professionals feel compelled to put the needs of others before their own needs. This can be characterized by a drive to take care of others. Combining this drive with family obligations and, for some, the pursuit of academic education can increase the risk of stress.
  • Busy, high-stress environments. Thanks to technology advances, improvements in diagnosis and treatment, patient acuity, and ongoing pursuit of academic and/or continuing education to increase their knowledge, healthcare professionals’ responsibilities in the workplace have increased significantly over the past several decades. The fast-paced, complex workplace can cause them to feel overwhelmed and stressed.
  • Coping with sickness and death. Daily exposure to illness and death, as well as to the emotional toll illness and death takes on patients and families, can be overwhelming and physically and emotionally exhausting. Healthcare professionals may not have time to decompress or grieve over taxing workplace situations.
  • Additive effects of stress. Research has established that the cumulative effects of stress impact both family functioning and job performance. Job conditions associated with work-to-family conflict may have broad impacts across the workforce.
  • Lack of control. Feeling unable to influence decisions that affect job performance, assignments, work load, etc., can contribute to burnout.
  • Unclear job expectations. Being uncertain of what is expected regarding one’s job performance contributes to burnout.
  • Dysfunctional workplace dynamics. For example, if a workplace is affected by bullying, the risk for stress increases.
  • Lack of social support. Feelings of isolation at work and/or at home add to stress.
    (Ericksen, 2018; Mayo Clinic, 2021)

Additional pandemic-related stressors for health professionals may include:

  • Dealing with an overwhelming surge of patients
  • Inability to save lives despite maximal effort
  • Experiencing death on a mass scale
  • Observing population-wide bereavement
  • Dealing with chronic shortages of supplies, vaccines, treatments, or facilities
  • Elevated and/or extreme risk for infection, illness, and death
  • Overwork and fatigue
  • Witnessing illness and death of colleagues
  • Constantly working in PPE
  • Enforced separation from family and loved ones
  • Ongoing and seemingly unending duration of work shifts
  • Inability to be home to support ailing, dying, or bereaved loved ones
  • Fear of spreading infection from exposure at work to loved ones at home
  • Witnessing illness on a mass scale
  • Witnessing persons suffering with extreme symptoms
  • Dealing with extreme reactions and possible panic
  • Threats of violence from persons seeking scarce or limited services
  • Lack of communications
    (Shultz, n.d.)
STRESS AMONG MANAGERS

It is not only front-line professionals who deal with stress. Managers must deal with these issues, too. Managers have one of the most demanding jobs in the healthcare setting. They are pushed to increase productivity while simultaneously decreasing costs, supporting their staff members, and ensuring the delivery of quality patient care. The turnover rates of managers is significant, and their intent to leave their positions, in part due to stress, within the next five years has reached over 70% (Loveridge, 2017; Warshawsky & Havens, 2014).

STRESS AND VIOLENCE

Adding to the stress found in the healthcare setting is the threat of violence. Violence in the workplace is a serious problem. According to the Occupational Safety and Health Administration (OSHA), about 75% of the nearly 25,000 workplace assaults reported annually occurred in healthcare and social service settings. Research data show that persons who work in healthcare settings are four times more likely to be victimized than workers in private work settings. Additionally, healthcare workers have a 20% higher chance of being the victim of workplace violence than workers in other settings (Joint Commission, 2018).

When talking about violence in the healthcare setting, physical and verbal abuse by patients and visitors quickly comes to mind. However, there are other types of violence. Stress and burnout can be caused by horizontal violence (also referred to as HV or lateral violence), which is defined as aggression against peers and coworkers who are on the same hierarchical level of an organization (Bartholomew, 2014; Dellasega, 2021). Additionally, aggression may take the form of those in powerful positions bullying subordinates and even subordinates bullying managers.

Impacts of Stress

In early research into stress, published in 1946, Hans Selye observed that stress caused patients to suffer physical effects not caused directly by a disease or medical condition. Selye found that stressors may be physical (such as infection, injury, and pain) or psychological (such as fear, anger, and sadness) and that stress also has both physical and mental impacts. Selye described what he called a general adaptation syndrome, whereby the body seeks to maintain homeostasis, or balance. He divided his general adaptation syndrome into three stages (see box below) (APA, 2021).

Stress can have a major impact on the physical functioning of the human body. It raises the levels of adrenaline and corticosterone, which in turn increases the heart rate, respiration, and blood pressure and puts more physical stress on bodily organs. In the short term, this allows a person to perform at levels beyond their normal limits (Burgess, 2017; Office on Women’s Health, 2019).

Stressors may, at times, lead to a useful response such as helping people to address and move on from fear, disappointment, pain, and emotional distress. Stress may also help individuals deal with challenging situations, such as speaking in public. In these types of cases, stress hormones quickly return to normal as the stress dissipates.

Too much stress, however, can have a significant physical and mental impact. It can leave the body in a permanent state of “flight or fight,” which leads to feelings of being overwhelmed and/or unable to cope not only with stress but with activities of daily living (MHF, 2021).

GENERAL ADAPTATION SYNDROME (GAS)

Alarm Reaction (the body detects the external stimulus)

  1. A “threat-to-survival” message is conveyed by nerves to the hypothalamus in the brain, which chemically communicates with the pineal gland and the pituitary gland, the “master control center.”
  2. The pituitary gland begins mobilizing the release of adrenocorticotropic hormone (ACTH) and activating hormone release from the adrenal medulla.
  3. The adrenal medulla pumps epinephrine, norepinephrine, and other catecholamines into the bloodstream. This causes:
    • Heart rate and blood pressure to rise, increasing blood circulation throughout the body
    • Airways in the lungs to dilate, facilitating oxygenation of blood
    • Plasma levels of glucose, triglycerides, and free fatty acids to elevate, giving the body more fuel
    • Platelet aggregation, increasing blood clotting
    • Kidney clearance to reduce, preventing water loss
    • Blood flow to shift from intestinal smooth muscles to skeletal muscles, enabling fight or flight

Adaptation/Resistance (the body engages defensive countermeasures against the stressor)

  1. Body systems stabilize.
  2. Hormone levels return to normal.
  3. Parasympathetic nervous system activates.
  4. Individual adapts to stress and recovers; however, when the threat continues without relief, then …

Exhaustion (the body begins to run out of defenses and the individual fails to adapt to stressors)

  1. A physiological response occurs, as in the earlier alarm reaction.
  2. Energy levels decrease.
  3. Physiologic adaptation decreases.
  4. Death occurs.

(Adapted from Selye, 1956; APA, 2021)

IMPACTS OF STRESS ON PHYSICAL HEALTH

Stress can have significant negative health impacts on the human body. The impact of stress on cardiovascular status has been well documented. Studies show that workplace stress is a significant risk factor for cardiovascular disease. Stress is linked to obesity, elevated cholesterol, hypertension, heart attack, and stroke (Corporate Wellness Magazine, 2021).

Stress causes the muscles to tense, which can lead to headaches, migraine, and generalized body aches and pains. Tension-type headaches are common in women (Office on Women’s Health, 2019).

Stress is also linked to gastrointestinal problems. Short-term stress can cause nausea, vomiting, and/or diarrhea. Long-term stress can trigger the development of irritable bowel syndrome (IBS), which is twice as common in women as in men. Additionally, stress can exacerbate IBS symptoms such as flatulence and bloating (Office on Women’s Health, 2019).

Stress increases the amount of the hormone cortisol, which can lead to overeating. In turn, this causes the body to store fat and can lead to obesity, which is linked to a large number of health issues such as heart disease and cancer (Office on Women’s Health, 2019).

The respiratory system is also negatively impacted by stress. Stress can cause hyperventilation and shortness of breath, which exacerbates conditions such as asthma and chronic obstructive pulmonary disease (COPD) (APA, 2018).

Stress can also affect reproductive functioning. Women who experience chronic or long-term stress are vulnerable to more severe premenstrual syndrome symptoms or irregular menstrual cycles. Stress can interfere with the ability of a woman to become pregnant and may also decrease the sex drive. Additionally, women dealing with stress may take longer to become aroused during sexual activity (Office on Women’s Health, 2019).

Stress may also cause infertility problems in men. Studies have confirmed a link between stress and sperm concentration, appearance, and mobility in semen. It is hypothesized that the release of steroid hormone during periods of stress can decrease both testosterone levels and sperm production (Cheriyedath, 2019).

IMPACTS OF STRESS ON MENTAL AND BEHAVIORAL HEALTH

Long-term stress increases the risk for depression and anxiety. In the workplace, in addition to the risk for anxiety and depression, the risk of burnout increases. In an effort to cope with stress, people may turn to substance use to alleviate its effects. Employees who are stressed at the workplace are more likely to take part in unhealthy behaviors such as smoking cigarettes, vaping, alcohol and drug abuse, and poor dietary intake (Corporate Wellness Magazine, 2021).

Stress can lead to a number of signs and symptoms of mental and behavioral health impacts. Cognitive symptoms include:

  • Problems concentrating and/or thinking
  • Memory problems
  • Lack of self-confidence
  • Negative self-perception
  • Ongoing anxiety and worrying
  • Difficulty making decisions

Emotional symptoms may include:

  • Moodiness
  • Low morale
  • Irritability
  • Agitation
  • Feelings of hopelessness
  • Feelings of helplessness
  • Feelings of apprehension, anxiety, and/or nervousness
  • Feelings of depression
  • Feelings of unhappiness
  • Feelings of guilt
  • Being unable to relax

Behavioral symptoms may include:

  • Changes in appetite
  • Changes in sleeping patterns
  • Nervous habits (e.g., biting nails, grinding teeth, tapping one’s foot)
  • Increase in use of caffeine, cigarettes, alcohol, and/or other drugs
  • Neglect of family
  • Neglect of work responsibilities
  • Decline in productivity
    (CAMH, 2021)

IMPACTS DUE TO A PANDEMIC

Healthcare workers have been at the center of the crisis caused by the COVID-19 pandemic. In addition to taking care of patients who have COVID-19, they must also take care of non-COVID-19 patients. The stress and exhaustion experienced by healthcare workers due to the pandemic may lead to medical errors, a decrease in empathy, decreased productivity, and higher turnover rates. Additionally, fears of exposure to COVID-19 and the possibility of bringing infection home to families and friends compound this hyperstressful situation.

Research conducted on the impact of COVID-19 shows that healthcare professionals display high rates of psychological stress, fear, anxiety, depression, and suicide. A 2020 survey of 695 U.S. nurses on the most stressful situations they had experienced during the pandemic identified six distinct themes that are similar to previous research findings among healthcare professionals:

  • Exposure/infection: Fear of being exposed to COVID-19 and becoming sick oneself as well as the fear of passing the virus on to family, friends, and other patients
  • Illness/death: Dealing with serious illness and death of others, most often patients, co-workers, or loved ones
  • Workplace: A high workload of extremely ill patients and/or being assigned to new departments without sufficient training, problems in relationships with coworkers, perceived administrative failings
  • PPE/supplies: Not having enough or having to re-wear PPE; insufficient cleaning supplies, ventilators, and testing supplies
  • Unknowns: Constant unknowns of a pandemic, including changing symptoms and guidelines, and fears related to job and financial/economic security
  • Opinions/politics: Opinions and the politicization related to COVID-19, including having to deal with perceived failings of government, the spread of false information, people who believe that COVID-19 is a hoax, and verbal and physical assaults on healthcare workers
    (Arnetz et al., 2020; Shreffler et al., 2020)
CASE

Carol Williams, Ph.D, is a clinical psychologist on the spinal cord injury unit in a large rehabilitation hospital. Because of recent staff shortages, she has been required to work extremely long hours and has been assigned dangerously high patient-to-staff ratios. She previously felt good about her job and confident that even though her patients were severely injured she was making a difference in their lives. Lately, however, she has been emotionally and physically exhausted and can’t seem to relax. She has been having “nervous headaches,” stomach pains, and mood swings, exploding in a rage of anger one moment and bursting into tears the next.

To cope with the stress, Carol has become distant and detached from her team members and patients. She does not actively engage with her coworkers during her shift and has insufficient time to meet all of the needs of the patients. She has expressed her frustration and anger during team meetings when discussing cases, verbally accusing her coworkers of being lax in their commitment to patients.

Because of her behaviors, Carol’s coworkers have complained to their supervisor about her attitude. Carol knows she is not managing the situation well, but the stress of the job and lack of support from her supervisor are wearing her down. She feels angry, trapped, insecure, inadequate, and a bit fearful she will lose her job.

Carol decides to visit her primary healthcare provider for help because of all the impacts she’s been experiencing related to her work-related stress. When asked by her physician, Carol describes her nausea, vomiting, diarrhea, and frequent tension-type headaches. Her exam also indicates an elevated blood pressure (physical health impacts). Carol also describes having trouble making work-related decisions and difficulty concentrating (cognitive symptoms). Emotionally, Carol is also experiencing anxiety, moodiness, feelings of helplessness, irritability, and unhappiness (emotional symptoms).

Discussion

Carol feels overworked and underappreciated. At some point she realized that she was overwhelmed by circumstances related to workload and staffing. She knew she was not performing at the level she expected of herself, and she recognized the physical, cognitive, and emotional symptoms related to the impact of her work-related stress. Carol needed to take steps to improve her work situation to avoid serious physical and emotional consequences. By acknowledging her difficulties and seeking appropriate help, Carol is beginning to learn how to respond and adapt to the stress. Otherwise, if her stress reaction continues unchecked, a state of exhaustion can develop. It is imperative that, for her physical and emotional health, Carol addresses what is causing her stress and that she develops effective coping strategies.