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Patients and RNs Face Unprecedented Stress

Monday December 8, 2008
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This year, along with all the typical seasonal stressors — clogged airports and freeways, unrealistic expectations of family and friends, tempting holiday meals that threaten diets, guilt over spending money, and the shrinking hours of sunlight — Americans have a faltering economy with which to contend.

"In some ways, it's kind of like a perfect storm," says Julie Kuebler, APRN, MS, BC, a psychiatric nurse practitioner in adult outpatient psychiatry at the University of Michigan in Ann Arbor.

But psychiatric nurse practitioners and clinical psychologists say merely being aware of stress and one's vulnerability to it is an important first step in keeping it under control. Nurses who practice good stress management techniques can do much to help their patients and themselves weather what could be a fierce and lengthy tempest.

Positive Resources

How people respond to stress, whether it's a result of the economy, the holidays, or both, depends more on their resources — support from family and friends, stress management techniques, and even genetic makeup — than the source of the stress itself, say clinical psychologists and nurse practitioners.

Much depends on "whether or not the person thinks that they have the resources to be able to cope with what is happening," says Elizabeth R. Barker, RN, PhD, CNP, BC, FACHE, FAANP, director of the master's programs and the family nurse practitioner program at Ohio State University's College of Nursing in Columbus.

Most people who report feeling stressed about the economy say they are managing that stress fairly well, according to an October survey of 2,507 people commissioned by the American Psychological Association. But some seem to be managing better than others. Nearly half reported overeating or eating unhealthy foods as a way to manage stress and nearly one in four reported skipping a meal because of stress. One-fifth said they used alcohol and 16 % said they smoked to manage stress.

People most vulnerable to stress include those who have been diagnosed with a mental illness, such as depression or bipolar disorder; had a buildup of stressful events; responded poorly to stressful events in the past; or are isolated from their communities. Some studies have shown molecular-level differences in the brains of mice that seem to affect their resiliency or vulnerability to stress.

Losing a house or a job might make some people feel sad, but they will not lose control of their ability to concentrate and make decisions, says Reg Williams, RN, PhD, BC, FAAN, professor at the School of Nursing and Psychiatry, Medical School at the University of Michigan. For others, the event may trigger a full-blown depression. They may be unable to sleep or sleep too much and they stop eating, cut themselves off from friends, and ignore phone calls from creditors, hoping the problem will go away.

"When you're suffering from depression, your head isn't there," Williams says.

Guilt and shame, lack of concentration, and the inability to make decisions all feed on one another until the situation spirals out of control. "This can go on for weeks or months," he says.

Finding Calm in the Storm

Though healthcare providers can't change the direction of the stock market or replace lost jobs or homes, they can screen patients for depression and anxiety, offer education about stress management, and spend time talking to patients about their concerns.

"You help them to explore what they can do, what strengths they have, and how they can apply these strengths," says Jeanne A. Clement, RN, EdD, PMH, CNS-BC, FAAN, associate professor of nursing and psychiatry at the Ohio State University College of Nursing and the immediate past president of the American Psychiatric Nurses Association.

People often experience stress when they feel they have no control over a situation, say psychiatric nurse practitioners. Reports of a faltering economy can cause people to worry about losing their jobs, homes, and retirement savings, even if these things haven't happened.

Kuebler tries to get patients to look at their situations realistically. If they are in their mid-40s or younger and are worried about their retirement accounts, she reminds them economic recessions come and go, stock markets fluctuate naturally, and their savings have plenty of time to recover before they reach retirement.

When one of Barker's patients talked about how angry she was because the economy was forcing her to put off her retirement, Barker helped her reframe the situation by asking her what she liked about her job and what was going on in her profession to keep her stimulated.

"I try to find out what the patient would like out of the situation," Barker says. She asks patients, "What will make you feel better? What do you think will make it better?"

With patients who face a life-changing event, such as losing a house, providers might talk about things they can do immediately, such as finding a place to stay, making arrangements with creditors, and talking to financial planners. They might discuss ways of breaking the news to friends and family members and talk about what emotional support is available, including therapists, church groups, and social services.

Providers also can offer education about the importance of proper diet, exercise, good sleeping habits, and relaxation techniques, such as yoga or meditation, to help manage stress.

Often, just talking about problems helps relieve people's stress, Kuebler says. Primary-care providers who have a short time to spend with stressed patients can do a great deal, she says, such as screening mental health, offering information about good stress management, and listening to them.

Nurses also need to remember to take care of themselves during stressful times, says Lisa B. Gordon, PhD, a licensed clinical psychologist at The Family Institute at Northwestern University in Evanston, Ill. Gordon has found many of the nurses she has treated in her practice feel chronically stressed because of demanding jobs, home responsibilities, and more. They may be especially vulnerable to additional stress created by the economy and the holidays.

"Nurses are so conscious of everyone else's needs," Gordon says, "that they take very poor care of themselves."

Stress-Management Tips

Some warning signs of stress-related mental illness include an increase in general sadness that continues for more than two weeks, difficulty enjoying things that were once pleasurable, sleep or appetite disturbances, difficulty concentrating, difficulty focusing at work, and suicidal thoughts.

The following tips can help counteract stress build-up.

• Get a good night's sleep. Avoid exercise and stimulating activities close to bedtime.

• Eat regular, well-balanced meals. Don't overindulge on sweets and fatty foods or skip meals.

• Exercise regularly. Exercise is one of the best stress relievers and should be a priority during stressful times.

• Do something relaxing and pleasurable every day, such as yoga, massage, meditation, or even a hot bath.

• Socialize with family members, friends, or community groups. People with strong social and spiritual systems seem to handle stress better than those who feel isolated.

• Do something for others — volunteer at a shelter, help in the classroom, visit a homebound friend. Altruistic behavior often helps people feel better about themselves and their own situations.

• Avoid using alcohol, narcotics, cigarettes, and excessive shopping to manage stress.



Cathryn Domrose is a staff writer for Nursing Spectrum and NurseWeek magazines. To comment, e-mail editorNTL@gannetthg.com.