5.3 Stress & Coping

Nurses support the emotional, mental, and social well-being of all clients, including those experiencing stressful events and those with acute and chronic physical and mental illnesses. Supporting the well-being of clients includes recognizing signs and symptoms of stress and promoting healthy coping strategies. This section will review symptoms of stress, strategies for stress management, positive coping strategies, and self-regulation skills.^[1]

Stress

Everyone experiences stress during their lives. High stress levels can cause symptoms like headaches, back pain, and gastrointestinal symptoms. Chronic stress is correlated with the development of chronic illness. It is important for nurses to recognize signs and symptoms of stress in themselves and others, as well as encourage effective stress management strategies. We will begin this section by reviewing signs and symptoms of the stress response and then discuss stress management techniques.

Acute Stress Response

Stressors are any internal or external event, force, or condition that results in physical or emotional stress.^[2] The body’s endocrine and sympathetic nervous systems respond to actual or perceived stressors with the “fight, flight, or freeze” stress response. Several reactions occur during the stress response that help the individual to achieve the purpose of either fighting or running. The respiratory, cardiovascular, and musculoskeletal systems are activated to breathe rapidly, stimulate the heart to pump more blood, dilate the blood vessels, and increase blood pressure to deliver more oxygenated blood to the muscles. The liver creates more glucose for energy for the muscles to use to fight or run. Pupils dilate to see the threat (or the escape route) more clearly. Sweating prevents the body from overheating from excess muscle contraction. Because the digestive system is not needed during this time of threat, the body shunts oxygen-rich blood to the skeletal muscles.

When a client is actively experiencing the stress response, the nurses may recognize the following cues:

• Elevated heart rate
• Elevated respiratory rate
• Elevated blood pressure
• Dilated pupils
• Diaphoresis

Nurses can immediately implement interventions to help clients manage an acute stress response by encouraging techniques like relaxation breathing. Review techniques for teaching relaxation breathing in the following box.

Chronic Stress

Chronic stress keeps the sympathetic nervous system activated, similar to a car engine that has been idling too high for too long. Stress over extended periods of time contributes to health problems like weight gain, myocardial infarctions, cerebrovascular attacks, and an impaired immune system. Signs and symptoms of chronic stress are as follows^[4]:

• Irritability
• Fatigue
• Headaches
• Difficulty concentrating
• Rapid, disorganized thoughts
• Difficulty sleeping
• Digestive problems
• Changes in appetite
• Feeling helpless
• A perceived loss of control
• Low self-esteem
• Loss of sexual desire
• Nervousness
• Frequent infections or illnesses
• Vocalized suicidal thoughts

Stress Management Techniques

As frontline health professionals, nurses are often the first to recognize cues of chronic stress and can teach clients about effective stress management and relaxation techniques. Stress management techniques are used to manage a person’s response to stressors that are perceived as changeable or temporary. Effective strategies for managing stress include the following:

• Engaging in regular physical exercise
• Getting an adequate amount of sleep each night
• Selecting healthy food choices
• Maintaining a healthy social support network
• Setting personal and professional boundaries
• Setting realistic and fair expectations

Physical activity increases the body’s production of endorphins that boost the mood and reduce stress. Nurses can educate clients that a brisk walk or other aerobic activity can increase energy and concentration levels and lessen feelings of anxiety.^[5]

People who are chronically stressed often suffer from lack of adequate sleep and, in some cases, stress-induced insomnia. Refer to the “Healthy Lifestyles” chapter for interventions to encourage effective sleep.^[6]

A complex relationship exists among diet, stress, behavior, and mental health. When feeling stressed, many people select foods and beverages with simple carbohydrates, caffeine, or alcohol. Simple carbs like sweets and soda are digested quickly, leading to a spike in serotonin and blood sugar but should be limited because of their empty calories and risk for obesity. Caffeine can provide an energy boost, but it increases the heart rate and feelings of anxiety, as well as impacting sleep. Alcohol may be selected as a calming or relaxation strategy, but it acts as a depressant and can contribute to feelings of low mood and fatigue. If misused, it can lead to more significant problems, including substance use disorder. Furthermore, stress-induced overeating can cause changes in neurotransmitters that have effects on both mood and subsequent eating behaviors.15 Nurses encourage clients to make healthy diet choices and avoid simple carbohydrates, caffeine, alcohol, and overeating.

Maintaining a healthy social support network with friends and family can provide emotional support. Nurses encourage clients to create caring relationships and healthy social connections for achieving resilience. Relationships with pets can also be a stress reliever.^[7]

Projects, deadlines, and commitments can cause individuals to feel overwhelmed and stressed. Nurses encourage clients to set limits, ask for help for coworkers, and refrain from accepting additional commitments until they feel their stress is under control. Nurses can encourage clients to set realistic expectations, look at situations more positively, see problems as opportunities, and refute negative thoughts to minimize stress. Clients should be encouraged to keep challenges in perspective and do what they can reasonably do to move forward.^[8]

WHO Stress Management Strategies

Nurses can teach additional stress management techniques tested by the World Health Organization (WHO). These techniques begin by teaching clients that powerful thoughts and feelings are a natural part of the stress response, but problems can develop if we become “hooked” by these thoughts and feelings.^[9]

There are many kinds of difficult thoughts and feelings that can “hook us.” Thoughts, such as “This is too hard,” “I give up,” “I am never going to get this,” or “They shouldn’t have done that,” can hook us. Feelings regarding memories of previous difficult events can also hook us and initiate the stress response.

When we get “hooked,” our behavior changes. We may do things that make our lives worse, like getting into more disagreements, withdrawing from others, or spending too much time lying in bed. Getting “hooked” by the stress response can make someone feel as if they are being pulled away from the values of the person they want to be, such as being calm, caring, attentive, committed, persistent, and courageous. We can “unhook” ourselves by focusing on and engaging in what we are doing, referred to as “grounding.”^[10] In addition to grounding, there are several techniques that can be used for a few minutes every day to reduce overall stress levels, called unhooking, acting on our values, being kind, and making room.^[11] These techniques will be discussed in more detail in the following subsections.

Grounding

The “grounding” technique helps when a person feels distracted or if they are having trouble focusing on a task and/or the present moment. The steps in grounding include the following^[12]:

• Notice how you are feeling and what you are thinking.
• Slow down, focus on your breathing, and connect with your body. Exhale completely and wait three seconds, and then inhale as slowly as possible. Slowly stretch your arms and legs and push your feet against the floor.
• Focus on the world around you. Notice where you are and what you are doing. Use your five senses. What are five things you can see? What are four things you can hear? What can you smell? Tap your leg or squeeze your thumb and count to ten. Touch your knees or another object within reach. What does it feel like?

Grounding helps us engage in life, refocus on the present moment, and realign with our values.

Unhooking

At times, unwanted, intrusive, or negative thoughts can negatively affect us. Unhooking is a tool to manage and decrease the impact of these unwanted thoughts. The steps of unhooking include the following^[13]:

• Notice that a thought or feeling has hooked you.
• Name the thought or feeling. Naming begins by silently saying, “Here is a thought,” or “Here is a feeling.” By adding “I notice,” it unhooks us even more. For example, “I notice there is a knot in my stomach.”
• Refocus on the activity you were doing before the thought or feeling hooked you. Fully engage in that activity and pay full attention to whoever is with you and whatever you are doing. For example, if you are having dinner with family and notice feelings of anger developing, note “I am having feelings of anger,” but consciously choose to refocus and remain engaged with the conversation.^[14]

Acting on Our Values

The third strategy is called “acting on our values.” This strategy means that despite experiencing challenges and struggles, we choose to act in line with our beliefs and what is important to us. The more we focus on our own actions, the more we can influence our immediate world and the people and situations we encounter every day. We must continually ask ourselves, “Are my actions moving me toward or away from my values?” Remember that even the smallest actions have an impact. Acting on our values should also include self-compassion and self-care. By caring for oneself, we ultimately have more energy and motivation to help others.^[15]

Being Kind

Being kind is a fourth strategy for reducing stress. Kindness can make a significant difference to our mental health by being kind to others, as well as to ourselves.^[16]

Making Room

Making room is a fifth strategy for reducing stress. Sometimes trying to push away painful thoughts and feelings does not work very well, even when trying to implement the techniques previously described. In these situations, it is helpful to notice and name the feeling, and then “make room” for it. “Making room” means allowing the painful feeling or thought to come and go like the weather. Nurses can teach clients that as they breathe, they should imagine their breath flowing into and around their pain and making room for it. Instead of fighting with the thought or feeling, they should allow it to move through them, just like the weather moves through the sky. If clients are not fighting with the painful thought or feeling, they will have more time and energy to engage with the world around them, act on their values, and do things that are important to them.^[17]

Coping Strategies

Stress management techniques discussed in the previous subsections are used to manage a person’s response to stressors that are perceived as changeable or temporary. Coping refers to cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts.

Coping is classified as maladaptive or adaptive. Maladaptive coping refers to an ineffective response to stressors, such as avoidance of the stressful condition, withdrawal from a stressful environment, disengagement from stressful relationships, aggression, or misuse of alcohol or other substances. Nurses identify maladaptive responses to stressors and request referrals for counseling or therapy. They also teach clients and their family members about healthy, adaptive coping strategies. Read more information about maladaptive behaviors in the “Maladaptive Coping” chapter.

Coping strategies are actions or thought processes used to modify one’s emotional reactions to a stressors that are perceived to be long-term or unchangeable. Adaptive coping strategies refer to effective responses to stressors and include problem-focused coping and emotion-focused coping. Problem-focused coping refers to seeking treatment related to a stressor, such as counseling or cognitive behavioral therapy. Emotion-focused coping refers to strategies used to manage one’s emotional response to stressors, such as participating in mindfulness, meditation, or yoga; using humor and jokes; seeking spiritual or religious pursuits; engaging in physical activity or breathing exercises; and seeking social support. Emotion-based coping strategies are further discussed in the following subsections.

Meditation

Meditation can induce feelings of calm and clearheadedness and improve concentration and attention. Research has shown that meditation increases the brain’s gray matter density, which can reduce sensitivity to pain, enhance the immune system, help regulate difficult emotions, and relieve stress. Meditation has been proven helpful for people with depression and anxiety, cancer, fibromyalgia, chronic pain, rheumatoid arthritis, type 2 diabetes, chronic fatigue syndrome, and cardiovascular disease.^[18]

Mindfulness is a form of meditation that uses breathing and thought techniques to create an awareness of one’s body and surroundings. Research suggests that mindfulness can have a positive impact on stress, anxiety, and depression.^[19]

Additionally, guided imagery may be helpful for enhancing relaxation. The use of guided imagery provides a narration that the mind can focus on during the activity. For example, as the nurse encourages a client to use mindfulness and relaxation breathing, they may say, “As you breathe in, imagine waves rolling gently in. As you breathe out, imagine the waves rolling gently back out to sea.”^[20] See Figure 5.5^[21] for an image of an individual participating in meditation.

Yoga

Yoga is a centuries-old spiritual practice that creates a sense of union within the practitioner through physical postures, ethical behaviors, and breath expansion. The systematic practice of yoga has been found to reduce inflammation and stress, decrease depression and anxiety, lower blood pressure, and increase feelings of well-being.^[22] See Figure 5.6^[23] for an image of an individual participating in yoga.

Journaling

Journaling can help a person become more aware of their inner life and feel more connected to experiences. Studies show that writing during difficult times may help a person find meaning in life’s challenges and become more resilient in the face of obstacles. When journaling, it can be helpful to focus on three basic questions: What experiences give me energy? What experiences drain my energy? Were there any experiences today where I felt alive and experienced “flow”? Individuals are encouraged to write freely when journaling, without stopping to edit or worry about spelling and grammar.^[24]

Spirituality

Spirituality is defined as a dynamic and intrinsic aspect of humanity through which persons seek ultimate meaning, purpose, and transcendence and experience relationships to self, family, others, community, society, nature, and the significant or sacred.^[25] Spiritual needs and spirituality are often mistakenly equated with religion, but spirituality is a broader concept. Other elements of spirituality include meaning, love, belonging, forgiveness, and connectedness.^[26]

Prayer can elicit the relaxation response, along with feelings of hope, gratitude, and compassion, all of which have a positive effect on overall well-being. There are several types of prayer rooted in the belief of a higher power. This belief can provide a sense of comfort and support in difficult times. A recent study found clinically depressed adults who believed their prayers were heard by a concerned presence responded much better to treatment than those who did not believe.^[27] Nurses can encourage individuals to find a spiritual community, such as a church, synagogue, temple, mosque, meditation center, or other local group. The benefits of this type of social support are well-documented.^[28]

Spending time in nature is also cited by many individuals as a spiritual practice that contributes to their mental health.^[29]

Supportive Relationships

Individuals should be encouraged to nurture supportive relationships with family, significant others, and friends. Relationships are living, dynamic aspects of our lives that require attention and care. To benefit from strong connections with others, individuals should devote time and energy to support them. With busy schedules and the presence of online social media that offer the façade of real contact, it’s very easy to drift from friends. Research has found that people who deliberately make time for gatherings enjoy stronger relationships and more positive energy. Nurses can encourage clients to create standing rituals with family and friends that doesn’t create more stress, such as scheduling a phone call every week on a certain day of the week or sharing a walk during lunch breaks.^[30]

Support groups are another option for clients to find strength and companionship with others experiencing similar situations. Sometimes when clients are experiencing an illness or assisting a family member with an illness or condition, they feel isolated and alone. At a support group, clients can share life experiences and struggles while learning to cope and gaining support from others, reducing the feeling of loneliness and helplessness. Support groups exist for almost any condition a person might experience and are usually open to the public. They may be peer-run or guided by a professional, in person, or online. They may be for the client, caregivers, or for those affected by the client’s situation. They may be for mental health, maladaptive conditions, or physical illnesses. Another benefit is support groups are usually free of cost. Nurses can recommend and help clients find support groups.

Self-Regulation Skills

In addition to teaching clients stress management and adaptive coping skills, nurses can also teach clients self-regulation skills. A simple definition of self-regulation skills is control of oneself by oneself.^[31]

Self-regulation skills include paying attention to symptoms of the stress response and learning how to balance the action of the sympathetic nervous system (SNS) with the calming of the parasympathetic nervous system (PNS) so that hormones released during the “fight, flight, or freeze” SNS response do not block conscious information processing by the brain.

Self-regulation skills enable the individual to use techniques to purposefully stimulate the PNS. For example, they focus on their breathing, heart rate, and muscle tension and use relaxation breathing, progressive muscle relaxation, meditation, or other methods to stimulate the PNS. These skills can be used prior to and during challenging events, as well as practiced over time to enhance the balance of the nervous system.^[32]

Self-regulation skills also include emotional self-regulation and behavioral self-regulation. Emotional self-regulation refers to controlling one’s emotions. If you had ever talked yourself out of a bad mood or calmed yourself down when you were angry, you were displaying effective emotional self-regulation. Behavioral self-regulation refers to the ability to act in one’s long-term best interest, consistent with one’s deepest values. It is what allows us to feel one way but act another. If you’ve ever dreaded getting up and going to work in the morning but convinced yourself to do it anyway after remembering your goals (e.g., a raise or promotion) or your basic needs (e.g., food, shelter), you displayed effective behavioral self-regulation. Self-regulation theory states that behavior is determined by our personal standards of good behavior, our motivation to meet those standards, the degree to which we are consciously aware of our circumstances and our actions, and the extent of our willpower to resist temptations and choose the best path. The goal of many types of psychotherapy is to improve an individual’s ability to self-regulate and to gain a sense of control over their behavior and life.^[33]