16 American Nurse Today Volume 12, Number 1 AmericanNurseToday.com

Stress can influence diseasedevelopment and exacer-bation—but managing iteffectively can reduce itseffects. To promote our

own wellness, we need to developstrategies to reduce the effects ofstress and protect against it. How you perceive stress is im-

portant. Researchers RichardLazarus and Susan Folkman pro-posed that stress is a two-way

street involving both theproduction of stress

by the environ-ment and theresponse ofthe personsubjectedto it. So,in asense,stress is aseries oftransactionsbetween the

individual andthe environment.

Stressful events have aninteractive effect with our immunesystem, physical and mental health,and future responses to stress.Lazarus’ model asserts that our

emotions are determined by ourappraisal of the stressor. Based onour personal characteristics and ex-periences, we evaluate how harm-ful or challenging the stressor is(cognitive appraisal) and to whatdegree we feel capable of respond-ing to it. If the stressor seems man-ageable, its physical effects are re-

duced. (See Cogni-tive appraisal ofstress: Twophases.) Stress may

cause illness ifthe threat over-whelms ourability to re-spond, as duringan acute trauma, anunresolved chronicexposure, or cumulativeexposure to stress. But ifyou’ve used effective coping strate-gies in the past, you’re likely to beable to cope with similar situationseffectively in the future with dimin-ished health consequences.

Making connections: Stress,disease, and wellnessStress-related diseases may includecardiovascular disease, metabolicsyndrome, diabetes, and obesity. Ev-idence also suggests stress plays arole in tumor formation, depression,mental illness, and autoimmune dis-orders (including systemic lupuserythematosus, rheumatoid arthritis,and inflammatory bowel disease).These conditions are intimately con-nected with chemical messengersthat relay information about thephysical and emotional environmentto and from the brain, immune sys-tem, and endocrine system. Although the traditional medical

model is beneficial in treatingchronic disease symptoms, it maybe insufficient when it comes tosystemic dysregulation. The theory

that the stress re-sponse and im-mune systemscommunicatewith one anoth-er has revolu-tionized ourconcepts of dis-ease and well-ness and led todevelopment of,

and continued inter-est in, the connections

between physiology and ourthoughts and emotions. It has alsoopened exciting new avenues forexploring disease development andprogression. Perhaps more impor-tant, it has helped healthcare practi-tioners, researchers, and patientsenvision new pathways to wellnessand healing. New interventions and prevention

methods exist for treating the wholebody rather than just disease signsand symptoms. Knowing how dys-regulated stress responses and sys-tems contribute to disease empow-ers us to identify andengage in behaviorsthat may stabilizeor return a dys-regulated sys-tem to amore proper-ly function-ing state. Instead ofoperatingfrom a patho-genic model thatfocuses on symp-

Subduing stress: A physiology-based approachLearning how to handle your stress can make a demanding nursing

career more manageable.

By Debra Rose Wilson, PhD, MSN, RN, IBCLC, AHN-BC, CHT; and Dana M. Dillard, MS PhD(c)

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tom management, we can focus ona holistic perspective that helps ussee how certain behaviors contributeto health and wellness, which inturn may help stave off disease.

Effective stress-managementstrategyHere are three basic steps for man-aging stress effectively:

1. Change thestressor. De-termine ifyou caneliminatewhat’s causingstress. For in-stance, perhapsyou could ask yourmother-in-law not to come for a

3-week visit. Of course, she maycome even if you ask her not to.Unfortunately, we don’t alwayshave control over our stressors.

2. Change how you feel about thestressor. We can’t always changehow we feel about a stressful sit-uation, but it’s worth a try. Forexample, you might feel betterabout your mother-in-law’s visit ifyou planned a pleasant trip withher to the farmer’s market orasked her to teach you that fami-ly recipe you’ve been meaning tomake.

3. Change how your body respondsto the stressor. Choose to man-age the stress. Consider meditat-ing, exercising, listening to mu-sic, getting a massage—whateverit takes to reduce your stress.(See Ways to manage stress.)Here are more examples of tech-

niques you can use to manage yourstress.

Focus on breathingTake a 3- to 5-minute break to fo-cus on your breathing. Yoga andmeditation start with breath work,and that begins with awareness. Putyour hand on your belly and focuson breathing with your abdominalmuscles. First exhale, putting just alittle effort into getting out the air.Then allow the air to come backinto your lungs easily, using thevacuum you’ve created by exhaling.Allow breathing to happen; watchit gently move your chest and bellyas you inhale oxygen and exhaletoxins. To help you be a calmernurse, take a moment during yourshift to breathe and focus between

patient rooms (perhaps whilewashing your hands).

Keep a journalJournaling can be aneffective way to re-lieve stress, purgeyour feelings, and ex-plore your thoughts ina reflective way. Buy ajournal—or, if you prefer

typing to writing longhand,set up a journaling file on your

computer. You may want to journal

Cognitive appraisal of stress: Two phases Researcher Richard Lazarus developed the cognitive appraisal theory, which holdsthat our emotions derive from our appraisal of a stressful situation. This appraisalshapes our response to the stressor.Cognitive appraisal has two stages.

• Primary appraisal:When you first experience a stressor, you ask yourself, Is thisis threat? Your appraisal is filtered through your life experiences and personalbeliefs. If you decide the stressor isn’t a threat, you don’t respond.

• Secondary appraisal: If you decide the stressor is a threat, you ask yourself, CanI handle this? Do I have the resources, experience, and coping mechanisms to dealwith it?

As the diagram below shows, you can choose to deal with the stressor by chang-ing how you feel about it (emotion-focused coping), using problem-solving meth-ods (problem-focused coping), or accepting it and using relaxation and self-careto reduce your physiologic response (biology-focused coping).

Wilson DR. Stress management for adult survivors of childhood sexual abuse: a holistic inquiry. WestJ Nurs Res. 2010;32(1):103-27. Used with permission from SAGE Publishing.

Emotion-focused copingChange perceptions, alterresponses and defenses,

reappriase

Problem-focused copingChange the stressor directly

Biology-focused copingIncrease awareness of biologicalresponse, use relaxation tools,

reduce stress response

Coping

Secondary appraisal

Primary appraisal

Perception filtered throughpersonal beliefs Perceived as threat

No threat; irrelevant

Assessment of resources,options, experiences,

control

Stressor

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n daily or only on a whim; you’llsoon learn which you prefer. Start by writing a few words to

describe your day. No matter howstressful your day has been, endthe entry by describing somethingfor which you are grateful. Express-ing gratitude has been shown toimprove immune function andchange our perceptions of negativeexperiences. Remember—ourbody’s stress responses are influ-enced by our perceptions, so try tochange how you feel about what’sstressful. Use journaling to exploreyour feelings and thoughts relatedto the stressors in your life. Journaling can be an excellent

stress-management method for peo-ple with disabilities and those un-able to perform yoga or exercise.On the other hand, journaling maynot be the best choice if you’ve re-turned to school. In that case, youmay find the additional writingoverwhelming—the last thing youwant to do when trying to getthrough a graduate program. Likeany stress-management approach,journaling should never add stress.

Do what you enjoyNo matter which stress-reducingmethod you use, plan to includeenjoyment in your life. Write thisgoal on your calendar, tell others ofyour “enjoyment plan,” and chooseto do it intentionally. Make this as important as any-

thing else on your to-do list. Becreative and spend time every daydoing an activity you love, whetherit’s walking in nature, gardening,meditating, drawing, coloring, lis-tening to music, or playing withyour dog. These activities help you get outof the cognitive whirl-wind in your headduring or after astressful day. Asyou do what youlove, be aware ofyour thoughts andfeelings. Gentlyredirect yourselfback to the currentmoment, mindful of the

right now. Intentionally set aside worrying,

reviewing what happened yesterdayand imagining what might happentomorrow. The benefits of beingmindful—being in the moment—

have been shown not just to re-duce the impact of stresson health and to im-prove health, but alsoto increase happi-ness and the qualityof life. For more read-

ing on mindful-ness, try Jon Kabit-Zinn’s book,

Wherever You Go,There You Are: Mindful-

ness Meditation in Everyday Life.“The little moments,” he points out,“they aren’t little.” We spend toomuch time chewing on what hap-pened yesterday or fretting aboutwhat will happen tomorrow. Instead, right in this moment,

breathe. Be aware of what you see,hear, taste, smell, and feel. Ac-knowledge the “right now.” Manag-ing your stress makes a demandingnursing career and a complicatedlife more manageable. v

Debra Rose Wilson is an associate professor atTennessee State University in Nashville and acontributing faculty member at Walden University inMinneapolis, Minnesota. Dana M. Dillard is anassociate faculty member at Ashford University inClinton, Illinois, and a telecommunicator specialistwith the Illinois State Police.

Selected referencesGold PW. The organization of the stress sys-tem and its dysregulation in depressive ill-ness. Mol Psychiatry. 2015;20(1):32-47.

Gu L, Xu L, Zhang X, et al. Correlation ofcirculating glucocorticoid-induced TNFR-re-lated protein ligand levels with disease activ-ity in patients with systemic lupus erythe-matosus. Clin Dev Immunol. 2012;2012:265868.

Holmes TH, Rahe RH. The social readjust-ment rating scale. J Psychosom Res.1967;11(2):213-21.

Kabat-Zinn J. Wherever You Go, There YouAre: Mindfulness Meditation in EverydayLife. 10th ed. New York, NY: HachetteBooks; 2005.

Katz DA, Sprang G, Cooke C. The cost ofchronic stress in childhood: Understandingand applying the concept of allostatic load.Psychodyn Psychiatr. 2012;40(3):469-80.

Lazarus RS, Folkman S. Stress, Appraisal,and Coping. New York, NY: Springer Pub-lishing Co.; 1984.

Pecoraro N, Dallman MF. Hypothalamic-Pitu-itary-Adrenal (HPA) Axis. In: Fink G, ed.Stress Science: Neuroendocrinology. SanDiego, CA: Academic Press; 2010; pp. 331-9.

Selye H. The Stress of Life (rev. ed.). NewYork, NY: McGraw-Hill; 1984.

Vinson GP, Whitehouse BJ, Hinson JP. Adre-nal Cortex. In: Fink G, ed. Stress Science:Neuroendocrinology. San Diego, CA: Aca-demic Press; 2010; pp. 137-44.

Wilson DR. Stress management for adult sur-vivors of childhood sexual abuse: a holisticinquiry. West J Nurs Res. 2010;32(1):103-27.

Wilson DR, Dillard DM. Eating better to helpmanage chronic stress. Am Nurse Today.2013;8(9):60-2.

Ways to managestress You can use myriad ways to copewith stress effectively. Here are someideas:

• Meditate or pray.• Do breathing exercises.• Laugh.• Use aromatherapy.• Hug someone you love.• Hang out with your pet.• Create art, or color in an adult coloring book.

• Take a walk.• Leave a toxic work environment.• Be in nature.• Make love.• Set new life goals.• Manage your time more carefully.• Keep a journal.• Dance.• Exercise.• Listen to music.• Go for a massage.• Take a bubble bath.• Get a big dose of uninterruptedsleep.

• Write down reasons why you aregrateful.

• Pamper yourself.• Listen to a guided imagery tape.• Avoid processed foods; eat wholefood.

• Be assertive and say no occasionally.• Be with positive-thinking people.

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Be healthy!Many nurses struggle to maintain the same healthy lifestyle theyadvocate for their patients. Below are some sobering statistics aboutnurses’ health, followed by health tips.

82% of nurses identify workplace stress as a tophealth and safety hazard.*

45% identify lifting and repositioning heavy objectsas a top health and safety hazard.*

60% report working through their breaks and coming in early or staying late to accomplishtheir work.**

80% received the seasonal flu vaccine in the past 12months.**

28 is the average body mass index (BMI) amongnurses; this is considered overweight.**

20% eat five or more servings of fruit and vegetablesper day.**

6% smoke.**

*ANA & Insight Consulting Group. Health Risk Appraisal Exploratory Data AnalysisWebinar Slides. October 31, 2016.**ANA Health Risk Appraisal Executive Summary. Preliminary findings October2013-October 2014. www.nursingworld.org/HRA-Executive-Summary

Visit our Facebook page at facebook.com/americannurse2day/ to share your own health tips.

Eat a balanced diet, even when working shifts.

Do something relaxing before bedtime, such as reading or listening to calming music.

Monitor portion sizes.

Let go of anger. Stay open to other viewpoints.

Exercise on a regular basis.

Use appropriate devices to help you move

patients.

Get recommended vaccinations.

Complete recommendedhealth screenings.

Spend time with family and friends.

Tips for getting—and staying—healthy

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