With ever mounting workload, increasing patient complexity and rising patient expectations and complaints, work is becoming increasingly stressful in the NHS.
Life outside work is more stressful too. Notwithstanding stresses that we may have in our home life, we are now living in a 24/7 on-demand, fast-paced culture that lacks stop cues as we consume countless Netflix and apps on our phones. We have so many distractions at our fingertips all vying for our attention. We have multiple choices for pretty much everything. Not great if you are a maximiser, who sets high standards in decision making.
According to Dr Mithu Storoni, we no longer have the natural stress buffers in our day that previous generations have had. For example, in the past we had to physically move for daily tasks like answering the phone, or doing the shopping. We connected with others face-to-face which would have required movement on at least one person’s part. That activity and connection would have provided a natural way to de-stress. In order to survive and thrive in the 21st century, we have to create conscious buffers to get the balance back.
What is stress and what causes it?
Stress can be literally defined as our body’s response to pressure from a situation or life event. It is often stimulated by something new or unexpected (a new baby, moving house), something that threatens our sense of self (a conflict with someone, someone ignoring us in the street) or a situation where we feel that we have little control (our work perhaps).
When we are stressed our body is stimulated to produce stress hormones that activate our immune system and our neural networks to trigger a flight, fight or freeze response. We can measure this activation through pupillary responses and heart rate variability (HRV).
This stress response can be helpful in short term stress, like giving a speech to a large crowd where you can return to a resting state quickly, but if the system is constantly activated it can have negative consequences on our physical and mental health. Our bodies become more inflamed, increasing our risk of insulin resistance, cardiovascular disease, Alzheimer’s disease, depression and many cancers.
Some stress is good for us
When we have a manageable amount of pressure, we are in what is known by some as the “stretch zone”. We feel stimulated and engaged and our performance improves. Our confidence grows, boosting our self-esteem. This impacts positively on our psychological wellbeing.
However if the pressure is too much, our anxiety escalates and performance plummets. We enter the “panic zone”. Conversely, if we remain solely in our “boredom zone” (left part of graph) then we can become disinterested and disengaged . Both these extremes impact negatively on our performance.
Stress awareness is key
The first thing is to be aware that we are feeling stressed. This may sound obvious but all too often we ignore stress through habit. This may be a banker who is excited closing a deal and leading a high octane life, it may be a parent juggling work with young kids, it may be a professional whose drive to do well overrides the stress awareness, or it may be a people pleaser who feels uncomfortable saying no, ends up taking on too much and subsequently feels overwhelmed. Doctors often fall in to the latter 2-3 groups.
This gives back a sense of control, which is the prime goal of stress reduction.
Next is to be being aware of the automatic responses we have when we feel stressed. For example, unhelpful thoughts like “I can’t do this”, “I’m losing control” or unhelpful behaviours like procrastinating or being indecisive. If you understand that a typical pattern for you is catastrophising for example, this is the first step to change. You learn to see your thoughts more objectively as thoughts, rather than truth, also knowing that they will pass. This gives back a sense of control which is the prime goal of stress reduction.
Control and escape
In his book on Lifestyle Medicine, Garry Eggers et al describe a simple model for dealing with stress, the ACE approach: analyse, change and evaluate.
Analyse is simply working out what the stressors are, and whether the problems are a result of external factors or our own coping mechanisms. Often it is a combination of the two.
Change is removing or reducing the potency of the stressor (which may not always be possible in certain home, work or financial situations). We might do this for example by delegating, delaying or dropping the problem. Or by removing, replacing or re-framing it.
Changing our reaction to the stressor involves examining our coping strategies. Are they unhealthy (such as alcohol, caffeine, drugs, blame, violence) or healthy?
Our natural response to stress is to escape (fight or flight). This was helpful evolutionarily to escape from the lion chasing us in the jungle but running away each time is clearly not a practical reaction to the small stressors we encounter daily.
We can escape in different ways though: physically removing ourselves from the stressor (taking a holiday, quitting a job), physically distracting ourselves (exercise, taking a hot bath, massage, sleep) or mentally escaping by reading, art, counting, muscle relaxation or meditation. Each individual will have their own way of coping, some preferring more cerebral methods, others more physical and some a combination of the two.
Fighting is another way of escaping. We can do this without using our fists, either physically through confrontation, challenge or talking, or mentally using techniques such as problem solving, thought challenging, planning or brainstorming.
All these strategies allow us to restore a state of perceived control and calm, alleviating the stress reaction and closing the loop. We can then evaluate what has helped and work on making sure that we build these into our everyday lives.
Making stress your friend
In her TED talk, “Making stress your friend” Kelly McGonigal says that if we view the stress response positively as a means of preparing us for our task ahead, then it has less physiological adverse effects long-term. And if we reach out to others when we are stressed, we release more oxytocin, the “cuddle hormone”. which is a natural anti-inflammatory. This helps counterbalance the inflammatory effects of stress.
So, it seems that how we think about stress, and how we act, matters.
Putting this into practice
I find the stress bucket a useful way to visualise stress and often use it with clients and patients alike.
Listing all the stressors in your life on paper helps you to really appreciate how much you are actually doing. If there is too much going into the bucket it will overflow. So, to prevent that, we need to remove the stressors as in our model previously, or ensure that we have healthy coping mechanisms (the tap to let the water out). These might be the escape strategies above (physical or mental), or changing the way that we think about stress and making sure that we do reach out to others when things are not going so well.