STRESS MANAGEMENT

FOR THE HEALTHCARE PROFESSIONAL

What Every Healthcare Professional Needs to Know

Stress Management for the Healthcare Professional

R: 4/01/2011 E: 3/31/2014
NEEDS STATEMENT: Healthcare professionals experience varying levels and types of stress on a daily basis.
Constructive management of those stressors, their own, and those around them is an important tool in providing
quality care for their patients and families and for their own personal and professional well-being.
TARGET AUDIENCE: This activity is designed for healthcare professionals interested in the area of stress
management for themselves and/or the patients they serve.
COURSE GOAL: This course provides healthcare professionals with a fresh and practical look at stress as it affects
the individual at work and in life. Students will have the opportunity to define and critically analyze physiological
and psychological stress, develop a repertoire of stress management tools, and employ those skills to mitigate
both personal stress and the stress experienced by patients and coworkers.
LEARNING OBJECTIVES:
After the completion of this course, the learner should be able to:
1. Define the types of stress as it applies to the healthcare professional;
2. Define the stress as it applies to the healthcare professional;
3. List the common triggers of the stress reaction;
4. Describe the results of stress in the healthcare professional;
5. Describe the effects of stress on the Type D personality healthcare professional;
6. Explain the three-fold approach to stress management;
7. Explain stress resistance and list its components;
8. Explain how to learn effective coping skills for stress management;
9. Describe cognitive reframing (using the Rational Nursing for Healthcare Professional model) to manage stress;
10. Discuss the Rational Nursing basics (N-U-R-S-E);
11. List common irrational thoughts that lead to stress thinking;
12. List the four basic feelings of Rational Nursing and their corresponding four thoughts;
13. Explain why healthcare professionals need to practice to manage stress;
14. Define Post Traumatic Stress Disorder and how it can affect healthcare professionals.
ABOUT THE AUTHOR:
Park S. Balevre, MSN, RN-BC, has served in a variety of nursing staff and leadership positions, both in medical and
behavioral health, at several medical centers and psychiatric facilities in Northeast Florida. He is currently Assistant
Professor of Nursing at Chamberlain College of Nursing in Jacksonville and serves as the Lead Faculty Area Chair for
Nursing at the Jacksonville Campus of the University of Phoenix. Park has a Certification in Psychiatric and Mental
Health Nursing from the American Nurses Credentialing Center and is a member of Sigma Theta Tau International
Honor Society of Nursing. He is also active in the Florida Organization of Nurse Executives, Northeast Florida
Organization of Nurse Executives, and American Psychiatric Nurses Association. He was selected as one of the
Great 100 Nurses of Northeast Florida in 2000. He has published research and other professional publications on
nursing theory, ethics, and practice.
DISCLOSURE STATEMENT: Mr. Balevre discloses no significant financial relationships with pharmaceutical
or medical product manufacturers.
ACCREDITATION STATEMENT:
NURSING:
AKH Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers
Commission on Accreditation (ANCC-COA).
AKH Inc. designates this activity for 3 contact hours (0.3 CEUs). Accreditation applies solely to educational
activities and does not imply approval or endorsement of any commercial product by the ANCC-COA.
FL CSW, MFT, MHC:
Florida Department of Health: BAP 30. Approved for 3.0 clock hours.
FL Occupational Therapy:
Board of Occupational Therapy Practice, Provider # 29. approved for 3.6 contact hours.

METHOD OF PARTICIPATION:
In order to receive credit, participants should read the entire monograph, complete and submit an evaluation and
score at least 70% on the self-assessment test. AKH Inc. allows for one (1) re-test at no additional charge;
additional re-tests must be purchased again at the full cost. Certificates will be available in the transcripts upon
successful completion of the self-assessment test. If you have questions about this CME/CE activity, please contact
AKH Inc. at trish@akhealthcare.com.
DISCLAIMER:
AKH Inc.s courses are designed solely to provide healthcare professionals with information to assist in their
practice and professional development. The courses are researched thoroughly, utilizing current literature and
including practical experiences. AKHs courses are not to be considered a diagnostic tool to replace professional
advice or treatment. The courses serve as a general guide to the healthcare professional, and therefore, they
cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKHs
educational courses do not endorse commercial products. The author(s) and the publisher specifically disclaim
responsibility for any adverse consequences resulting directly or indirectly from information in the courses. AKH
further disclaims any responsibility for undetected error, or from the readers misunderstanding of the course.
CONFLICT OF INTEREST STATEMENT:
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its
continuing education activities. The faculty must disclose to the participants any significant relationships with
commercial interests whose products or devices may be mentioned in the activity or with the commercial
supporter of this activity. Identified conflict of interest is resolved by AKH prior to certification of the activity.
Copyright 2013, AKH Inc. No part of this publication may be produced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical photocopying, recording, or otherwise, without
the prior permission of the publisher.

TABLE OF CONTENTS
Youve got Stress?..........................................................................................................................................................1
Defining Stress ...............................................................................................................................................................1
Common Triggers of the Stress Reaction ......................................................................................................................2
Results of Stress in the Healthcare Professional ...........................................................................................................3
Warning, Warning: Results of Stress in Type D Personality Healthcare Professional ...................................................3
Stress Management: A Three-fold Approach ................................................................................................................3
Stress Resistance ...........................................................................................................................................................4
Learning Effective Coping Skills .....................................................................................................................................4
Cognitive Reframing: Rational Nursing for Stress Management in the Healthcare Professional ..................................4
Rational Nursing Basics ..................................................................................................................................................5
Common Irrational Thoughts.........................................................................................................................................5
Rational Nursing has only Four (4) basic feelings!! .......................................................................................................6
Putting it Together to Fight Stress .................................................................................................................................7
Rational Nursing and Pain..............................................................................................................................................9
Practice Rational Nursing To Keep Stress Away ............................................................................................................9
Using Rational Nursing in Healthcare Practice: Stressed Out Patient Scenario ..........................................................10
Post-traumatic Stress Disorder in Healthcare Professionals: A Common-Yet Under Treated Illness ..........................14
Conclusion: Youve got Stress? ....................................................................................................................................16
References ...................................................................................................................................................................17
Post Test ......................................................................................................................................................................18

Youve got Stress?

Just get over it! You call yourself a healthcare professional; its not like youre the only one around who feels the
time crunch.
What? Youre worried about that patient in 402, but youve got to deal with 417 first? Well tough! Thats the life of
a healthcare professional, and I didnt see anyone hold a gun to your head when you signed on.
You wanted it you got it. Stressed out? Then go watch a few ER reruns; it cant be as bad as those episodes.
A good RN can handle 15 patients easily (youre just pushing a few pills); any Respiratory Tech should be able to
cover the house (after all, youre just giving out inhalers); its not like the pharmacist has a lot to do. Why make
such a big deal about things.
You get everything you need with which to do your jobs. Youre paid a ridiculously inflated salary. You get time off
for meals and a couple of breaks a shift its like your not even really working.
So whats the problem? Do you just like using the new buzz phrase, stressed out? Just want to jump on the Imstressed-out bandwagon?

STOP!
Is your pulse beating any faster? How about your respirations?
Did you feel emotion: insult, indignation, righteous anger, and appalling disbelief that someone would write
something like that? Anything?
Well, if you did, I was at least somewhat successful in placing you in my stress simulator.
Now lets look at this real workplace phenomenon and examine strategies to deal with it.

What is Stress?
1

The modern day word stress comes from the Middle English word for distress. This explains why the
connotation of the term is generally negative (although small amounts of stress are actually healthy). More
specifically, the definition of physiological stress is . . . a specific response by the body to a stimulus, as fear or
1(p1882)
pain, that disturbs or interferes with the normal physiological equilibrium of an organism.
But stress is also a
psychological response to a perceived stimulus (either internal or external) to which both the body and the mind
(cognitively and emotionally) respond in attempts to equalize those pressures, demands, worries, and irritations.
From this extended definition, it is important to recognize that stress is a specific response that is internal; it is
felt physically and emotionally. Stress is an internal physical, mental, and emotional strain or stretching beyond
1(p1879)
the proper point.
So stress is internal. But stressors are not necessarily external. Look at the definitions again. The stressors are
stimuli such as fear or pain, external demands, internal worries and irritations, and pressures. Whereas pain can be
generated both externally and internally, fear is an internal stimulus (often in response to an external pressure). It
is the individuals perception, however real, that significantly affects the physiological equilibrium. The first key to
managing stress is to understand that stress is internal, and that it is an individual perception. Have you noticed
that what stresses you may not cause stress in your family or friends, and visa-versa? Stress is an individual
perception physically, mentally, and emotionally.
Black and Hawks broaden the definition by showing that stress is the bodys response to demands. If we are
2
stressed by cold, we shiver physiologically for warmth. The shiver is an adaptation to the stressful condition
caused by the cold. Still it is an internal response. Furthermore, the cold stressor requires an adaptive response by
the individual to protect himself/herself this requires an internal process. Therefore, the level of perceived stress
is in direct proportion to the individuals physical and mental ability to adapt to that stressor. An imbalance
between the two increases the level of stress.

Unlike my stress simulator scenario, stress is not something that one can just get over. As a matter of fact, the
World Health Organization (WHO) projects that stress-related conditions will be the number two health problem in
3
the world by 2020. Ironically, WHOs number one projection is ischemic heart disease, a condition directly
4
affected and often precipitated by stress.
Returning to our definition, stress is an internal strain on three systems: physical, mental, and emotional. Most of
us have experienced an event something like this: Youre driving down the street and suddenly another car pulls
out in front of you from nowhere. Your brain instantly processes the event, and your body slams on the breaks and
swerves to avoid the collision as you experience that heightened awareness and reactivity that comes with the
fight-or-flight response. As healthcare professionals, we already know this is because the sympathetic nervous
system releases adrenaline rapidly to divert blood to our arm and leg muscles to prepare us physiologically for
fight or flight. At the same time, the adrenal glands flood the body with cortisol (the stress hormone) in a primitive
5
response to accelerate cardiovascular functions and fuel the flight-or-fight systems by dumping sugar (glucose) for
a quick burst of energy. Concurrently, cortisol temporarily lowers pain sensitivity and increases mental acuity.
As you feel this, your pulse, blood pressure, and respirations increase; there is more oxygen in the blood for the
muscles and the brain; glucose is pumped in for extra ready fuel.
When I experience events such as this, it seems that my heart drops down into my stomach; my arms, face, and
lips tingle with a numbness type of feeling; and my body feels at first charged with electricity and then drained by
the experience (especially after the episode is over). All of this occurs in a few seconds.
This is stress acute, survival stress. Other forms of stress may not be as dramatic or physically noticeable, but
the same physical-mental-emotional reaction is still operating.
As many researchers are discovering, these descriptions of the sympathetic nervous systems reaction, adrenaline
release, and cortisol infusion are an oversimplification of the process. At University College Cork, Dr. John Cryan
6
studies the physiological and psychological implications of stress, mapping out the brains response to it. He
explains that the hypothalamic pituitary adrenal axis (HPA axis) is primarily responsible for controlling the bodys
response to stress. As such, the intricate physiologic feedback and regulation of the systems of the HPA axis affect
many body functions, including blood pressure, temperature, pulse, and respirations. The HPA axis also responds
6
to stress by altering mood, energy use, digestion, and the immune system.
Chronic stress is a state in which the physical-mental-emotional events just described are occurring almost
continuously, day after day, situation after situation. Very often, todays healthcare professional lives with chronic
stress. The high paced job atmosphere, the hectic modern lifestyle, the traffic, the deadlines, the responsibilities,
and the interpersonal tensions can continually trigger our stress responses (HPA axis, etc.) until our regulated
functions become overregulated dysfunctions. Cooper showed how emergency healthcare workers are especially
7
at risk for this type of stress as well as the next type.
Traumatic stress occurs when a healthcare professional is faced with a traumatic situation involving intense
8
horror, fear, or helplessness. Very often, this type of stress leads to Post Traumatic Stress Disorder (PTSD) and,
without effective intervention, can adversely affect an individual for a lifetime. We will examine PTSD later in this
study.

Common Triggers of the Stress Reaction

9

The American Heart Association and Mount Sinai School of Medicines Cardiovascular Institute and Center for
10
Cardiovascular Health both provide helpful websites that discuss situations and events that for many people are
stress triggers (stressors). The latter site has an especially enlightening section which delineates these stressors
under three headings: life events (such as the death of a loved one or being fired), physical stressors (like weather
extremes, smoking, and sleep deprivation), and daily hassles (time constraints, pressures of responsibilities,
deadlines, money problems, etc).
Instead of giving you a laundry list, develop your own personal stress triggers list with this in mind: (a) Your life
events, physical stressors, and daily hassles are things that stress or upset you not necessarily anyone else; and
2

(b) your list (i.e., your triggers) will change over time and from situation to situation, especially as you accumulate
your own healthcare experiences.

Results of Stress in the Healthcare Professional

Take a moment to think about your most recent stressful day in the pharmacy, on the floor, at the office, or in
what my father affectionately calls physical therapy, the gym. How do you experience stress? I feel tense; my
shoulders become stiff; I almost always get a headache behind my eyes; I know (because I take it) that my blood
pressure goes up. How about you? Do you sigh often? Do you bite your fingernails, bounce your knee up and down
constantly, or worry so much that you cant fall asleep or fall back to sleep when you wake up or both? These are
typical symptoms of acute stress, but the results of stress can be more insidious.
Lucinis team measured the R-R interval variability to determine how stress affected cardiovascular dysregulation.
Specifically, the study supported the hypothesis that work-related stress increased R-R variability and increased
cardiovascular risk. The R-R interval is the time that has elapsed between two consecutive R waves in the
electrocardiogram. Since the mid 1980s, a number of researchers have studied R-R interval variability to explain
cardiovascular physiology as a predictor of death in patients with cardiac disease. In this particular study, the
investigators were interested in reversing the deleterious R-R variability through stress management programs in
the workplace. Their study supported this hypothesis.

Purgason describes the condition of stress-induced cardiomyopathy, presents case scenarios, and reviews its
11
historical literature. She shows the link between both physical and emotional stressors and the syndrome,
especially in postmenopausal women. The link is stress. Patients identified with this syndrome on presentation to
the emergency department experienced either a psychological trigger (such as the death of a loved one or
exceptionally bad news) or a physiological trigger (such as exacerbation of a chronic physical condition).
Rozanski, Blumenthal, and Kaplan examined how psychological stress causes excess stimulation of the sympathetic
nervous system and leads to coronary and carotid artery atherosclerosis, myocardial ischemia, arrhythmogenesis,
increased platelet function, coronary vasoconstriction, hypertension, hypercholesterolemia, and increases in blood
12
viscosity through hemoconcentration. Long story short: These things are bad and stress causes them. The good
news: stress management can help reverse the process.
As we all should know, the results of stress are not just physical. Studies on healthcare and nursing burnout show
13,14
the significant impact of stress, perception, and personality on job burnout rates.
Milani and Lavie discuss the
global impact of work-related stress and describe such psychosocial symptoms as nervousness, tension,
15
absenteeism, and customer service problems. Kalia further describes how stress is responsible for many
16
workers compensation claims, accidents, and litigation.

Warning, Warning: Results of Stress in Type D Personality Healthcare Professional

Oginska-Bulik studied healthcare professionals (primarily nurses and physicians) who met the profile of the Type D
17
personality. Even though healthcare professions are very stressful (trauma related situations, responsibility for
the well-being of patients, coping with death, dealing with aggressive people, etc.), she found that the Type D
nurse and doctor perceived job stress as significantly worse than their peers and experienced more deleterious
affects of stress both psychologically (emotional upset, burnout, etc.) and physically (somatic diseases, primarily
cardiovascular).
So if you are a Type D person, be forewarned that you are at risk. Type D healthcare professionals are similar to
Type As (and we all joke about them). If you are Type D, you tend to have a lot of negative emotion, anxiety, even
17
sadness. Type Ds, typically have more irritability and restlessness than most. Small obstacles at work can really
bother the Type D. The Type Ds are generally negative in mood, socially inhibited, and often have a negative view
of themselves. They tend not to express emotion and avoid social situations in which they may face disapproval
from others. These individuals often experience chronic stress, and they are particularly at risk for PTSD.

Stress Management: A Three-fold Approach

2

Black and Hawks summarize three components of stress management. The first they call stress resistance. The
second component explores the development or re-learning of effective coping skills during stress situations. The
20
third deals with cognitive reframing which is presented here as Rational Nursing for the healthcare professional.
3

As previously discussed, onsite stress management programs and other types of interventions can actually reverse
4
the physiological and the psychological effects of stress.

Stress Resistance
When one builds up resistance to colds, flu, and other maladies, he or she concentrates on eating well, getting
2
adequate rest, and exercising. Simple? Well it seems so, but so many of us healthcare professionals, perhaps
inadvertently, dont do these simple things.
Obviously, diet is important. We all know that and doggedly watch our patients nutritional status. Sugars,
carbohydrates, proteins, fats, vitamins, minerals, calories, cholesterol, and fiber are essential to well rounded diet
and stress resistance. How many items on this list are you avoiding because of diet, misinformation, or dislikes? Do
you keep trying fad diets? Are you an overeater? Do you consume too much caffeine or alcohol? All of these
components affect stress resistance. To deal with stress adequately, one must be physiologically prepared for the
event diet is the starting place.
We healthcare professionals also know that sleep and rest are essential for health, not to mention stress
resistance. "Lack of sleep disrupts every physiologic function in the body," said Eve Van Cauter of the University of
18
Chicago. "We have nothing in our biology that allows us to adapt to this behavior." Stein also shows that lack of
sleep or rest increases the bodys stress hormones (cortisol), and weve already discussed how that raises vital
signs, increases cardiac risks, stimulates the bodys inflammatory response, and contributes to other serious
conditions such as diabetes, cancer, and stroke. Obviously one who chronically (or even temporarily) goes with out
sleep, rest, relaxation, or downtime is not very resistant to stress. So dont discount other down time activities
either: meditation, relaxation techniques, calming activities, enjoyable events.
Exercising! As healthcare professionals, much of our patient care is focused on physical therapy, occupational
2
therapy, and the other rehabilitation sciences. Stress resistance requires the positive stressor of physical activity
to promote the physiological adaptive response.

Learning Effective Coping Skills

Every healthcare discipline teaches a problem-solving methodology. If you have learned this discipline, you already
possess an excellent coping methodology. If youre good at it, you are also good at applying effective coping skills.
The problem is that many healthcare professionals apply their problem-solving methodologies only to their
respective professional practices, not to themselves.
If you are a nurse, you know the nursing process: Assessment, Diagnosis, Outcome, Plan, Intervention, Evaluation
(ADOPIE). This critical thinking tool enables the nurse to frame all clinical patient problems and approach them in a
rational, logical problem-solving manner. However, according to a study by Lea et al., nursing students did not
19
have a working understanding of the nursing process. I suggest that this process is not only essential for good
nursing practice, but also a viable tool for stress management. If nurses practice A-D-O-P-I-E-ing their own stress
related events, they will be better prepared to effectively cope with them.
In addition to healthcare methodologies like the nursing process, there are many tools available to help the
healthcare professional with other coping challenges, such as time management, assertiveness training, and a
plethora of self-help programs (no doubt one to fit your need).

Cognitive Reframing: Rational Nursing for Stress Management in the Healthcare Professional
The third and most challenging approach to stress management is cognitive reframing. One of the most successful
approaches to changing perceptions is found in the cognitive-emotive-behavioral therapies of psychology.
20

The Rational Nursing Model is based on the cognitive therapy of Albert Ellis called Rational Emotive Behavior
21
Therapy (REBT) and reframes our thinking about the stress we perceive in ourselves and our patients.
Rational Nursing is a method that can frame how healthcare professionals think, behave, and interact with their
stressful world consistently and successfully. It deals with the here-and-now and targets acute and chronic stress
situations in order to manage them effectively. Although this brief therapy model is called Rational Nursing
because it was originally developed for the staff nurse, it is designed for any therapeutic discipline.
4

Rational Nursing targets our internal responses: sadness, pain, upset, vomiting, fear, incontinence, anger, etc.

Rational Nursing Basics

Rational Nursing believes that emotional and physical stress reactions to events (situations, injuries, illnesses, pain,
etc.) are caused primarily by the thought processes in response to those events. Upsetting feelings and reactions
are often caused by cognitive (thinking) exaggerations or irrational thoughts in our "chain" of thinking (example:
you hear a song on the radio which changes your mood because it reminds you of a sad event, and that thought
causes stressful feelings that in turn make your back pain feel worse, or give you a headache, etc.).
By examining and questioning (or dealing with) thoughts, the healthcare professional can relieve or lessen the
stressful feelings and the resulting physical reactions to that stress.
The ancient Greek philosopher, Epictetus said that people are not upset or stressed by things, but by the way they
22
view things. Therefore, nothing or no one can STRESS you out. Its what you THINK about nothing or no one that
stresses you.
Simply put,
when something happens,
we think about it,
and then react to it.
Even if it is not on a conscious level,
our thoughts or beliefs (our view of things)
makes us feel and react the way we do.
So thenTHOUGHTS make FEELINGS which generate REACTIONS
And likewise:
Irrational Thoughts cause
Dysfunctional Feelings which result in
Dysfunctional Reactions = STRESS
When we recognize inaccuracies in our thinking, we will feel and react more realistically and less stressed. So what
thoughts need to change?

Common Irrational Thoughts

There are millions! And each one can stress, upset, anger, depress, frighten, or even elate (also a type of stress).
21
23
24
Ellis and MacLaren , Bishop , and Pearlman describe a number of core irrational beliefs and irrational ideas
(stress generating thoughts) that people have. Here are examples of those types of thoughts:
Thought
Musts: Irrational Demand

Example
The nurses station must stay clean all the time.
I demand perfection of myself as a pharmacist.

Shoulds: Unreasonable Expectation

I should be a perfect nurse and never make a

mistake.
My patients should always like me.

Awfuls: Unrealistic Exaggeration

If people dont do what I expect, its terrible.

I cant stand being on 2 south. Its awful, the worst
place there is; its horrible!

Catastrophizing: Exaggerating the undesirable

I cant go to work today! I have a zit! This is awful;

the most horrible thing that could happen.
Chicken Little, the sky is falling!

Generalization: Believing that something

I made a B on that RT test; I might as well give up

and quit school.
If Dr. Joe doesnt like me, everyone must hate
5

Undesirable makes everything bad.

Black & White: Things are one way or another

me.
If hes not a Christian, then hes a bad person, and
I shouldnt take care of him.

And there are more............

Thoughts like these (and there are many more categories as well as thoughts) cause feelings. What about
Feelings?

Rational Nursing has only Four (4) basic feelings!!

In the Rational Nursing model, there are only four (4) categories of feelings.
The four feelings are: Happiness, Sadness, Anger, & Fear.

20

All other emotions fit in one of these four categories. Sadness, anger, and fear generate negative stress.
Happiness can generate positive or negative stress. These Emotions are the result of Thoughts!
These are the four emotion-generating thoughts associated with each of the four emotions:

Emotion
Happiness
Sadness
Anger
Fear

23

Thought that causes the emotion

I think something I like is added to my life.
I think something I like is taken from my life.
I think something threatens me and I want to attack it.
I think something threatens me and I want to avoid it.

Now consider these emotions in yourself:

If you are happy, you think something you like has been added to your life.
I just got my evaluation and my boss gave me a 5% raise!!!
If you are sad, you think something has been taken from your life.
My boyfriend broke up with me; I feel so sad & stressed; I dont think I can face my patients today.

If you are angry, you think something is a threat, and you want to attack it.
How dare she question my competency!! Im stressed and Im going to report her for harassment!!!

If you are afraid, you think something threatens you and you want to avoid it.
Hep B Shot? NEEDLE?! Youre not getting near me with that! Im outta Here!!!!!

Putting it Together to Fight Stress

So now that we know the basics of Rational Nursing for the healthcare professional, how do we frame it? What can
we look at inside our heads to visualize our thinking-feeling-acting, and mitigate our stress reactions? So far weve
learned that when we experience something, we think about it and then react to it:
Something happens to me =
I think about it =
I react to it with feelings or stress feelings =
Then I react with behaviors or stress reactions.
In the original concept analysis for Rational Nursing, a simple table was used as a model for Rational Nursing.
Table 1 represents what is going on within a persons head. It looks like this (note the symbol is used for
therefore):
Table 1
Something Happens to Joe
Joe looks in the mirror and sees a
pimple on his face.

He thinks about it
I have a zit!

20

He reacts to it with feelings & actions

This is awful; the most horrible thing

that could happen.
I cant go out in public!
People will think Im ugly and dumb.
Having this zit threatens me and I
want to avoid it,
So
I Feel Afraid and stressed out!
Joe hides in his room and refuses to go out
As the concept developed, so did the table and the table headings. In the Understanding column of table 2, Joe
can identify his exaggerations or irrational (I) thoughts.

Table 2
Name or Identify (ID) the
event
Something Happens to Joe
Joe looks in the mirror and
sees a pimple on his face.

Understanding thoughts: ID the patients

thinking or physiological response mechanism
He thinks about it
I have a zit!

Reaction: Emotional & Behavioral

He reacts to it with feelings & actions

This is awful; the most horrible thing that

1
could happen. (I )
2

I cant go out in public! (I )

3

People will think Im ugly and dumb. (I )

Having this zit threatens me and I want to
avoid it,
So

I Feel Afraid & Stressed out

Joe hides in his room and refuses to go out

In the next step, Joe can challenge (C) his (I)s :

1

Its unfortunate I have a zit, but its not awful.

Why cant I go out in public? Most people wont even notice.

Why do I think a zit makes me ugly?

I
I
I

If one of these challenged irrational thoughts will help Joe view things differently, Joe can exchange (E) his
irrational thoughts for rational ones that can make new, LESS STRESSFUL feelings and reactions to his zit (Table 3).
Follow this example all the way through:
Table 3
Name: Identify
Understand:
the event or
ID the thinking or
situation
physiological response
mechanism
Something
happens to Joe
Joe looks in the
mirror and sees
a pimple on his
face.

He thinks about it

React:
Emotional &
Behavioral

Select:
Help patient Select a
better thought

He reacts to it
with feelings &
actions

Joe challenges his

thinking

Exchange:
Help patient Exchange
(and practice exchanging)
the old thought with the
new thought
Joe practices exchanging
the rational thoughts for
the irrational thoughts.

I have a zit!
1

This is awful; the most

horrible thing that could
1
happen. (I )

C Its unfortunate...
but its not awful.

(E ) Its not awful after all.

2

I cant go out in public! (I )

(E ) I can go out no one is

looking for it.

(E ) A zit may be unsightly,

but doesnt make me ugly.

C Why cant you go

out in public?

People will think Im ugly

3
and dumb. (I )

C Why do you think a

zit makes you ugly?

Having this zit threatens

me and I want to avoid it,
So

Every time I see a zit, I

need to remind myself of
this before I freak out!
I Feel Afraid
and Stressed out
Joe hides in his
room and refuses
to go out.
8

By using the Rational Nursing Table, the healthcare professional can come to understand the stress he or she is
experiencing and intervene consistently to decrease it. As a mnemonic reminder of this process, the words from
each column form the acronym N-U-R-S-E.

Rational Nursing and Pain

The same conceptual grid can be used with physiological interventions to the human response in our patients
(Table 4).
Table 4
Name: Identify the
event or situation

Something
Happens to Joe

Joe awakes from

knee surgery.

Understand:
ID the patients
thinking or
physiological response
mechanism
He thinks about it or
He physiologically
experiences it.

React: Emotional &

Behavioral

Select:
Help patient select a
better thought

He reacts to it with
feelings & actions
(Reactions)

In this case, the Nurse

validates Joes
thoughts and takes
external action to
change them

Exchange:
Help patient exchange
(and practice exchanging)
the old thought with the
new thought
Staff helps Joe practice
exchanging the rational
thoughts for the irrational
thoughts.

I feel pain in my knee!

1

(E ) Its not awful because I

have pain meds.

(E ) I trust this nurse she

wont let me die.

(E ) I can stand it because

the Dilaudid will soon take
it away.

This is awful; I dont

think I can stand the
1
pain. (I )

C I know it hurts but

I can give you
something for it now.

Im going to die from

2
this pain! (I )

C I wont let that

happen.

This is the worst pain

3
Ive ever felt. (I )

C Not for long! This

Dilaudid will make it
much better.

Having this pain

threatens me and I
want to avoid it,
So

I Feel Afraid and

Stressed Out

Every time I start feeling

pain, I must tell the nurse
and get pain medication.

Joe moans and

says, Nurse Im in
horrible pain.

Practice Rational Nursing To Keep Stress Away

Keep the conceptual grid in your head and practice it. When you feel stressed, raise the following questions:
1.

What just happened that "stressed" me? (Name the event/situation)

2.

What am I perceiving/thinking/believing? (Understand and explore the realistic (like pain), irrational, and
exaggerated thoughts.

3.

Examine your emotional and behavioral responses (Responses come from the 4 thoughts or physiological
reactions).

4.

Ask yourself what you can do to keep that thought from stressing/upsetting/hurting you (Select a more
accurate thinking).

5.

Exchange your threatening or disturbing thoughts with their replacements when you start to get stressed or
freak out (Exchange and practice exchanging thoughts in the here and now).
9

Using Rational Nursing in Healthcare Practice: Stressed Out Patient Scenario

Here is an exercise to distress a patient. Apply the steps you have just learned to Amber and help her de-stress!
Amber, an 18-year-old receptionist, is triaged at the Emergency Room and is diagnosed with acute appendicitis
requiring an emergency appendectomy. Although in pain, she was cooperative during the nursing assessment,
medical exam, and laboratory blood draw.
You, the nurse, return to the room to explain the details of her surgery and explain how you will start an IV with
NaCl TKO. After explaining the procedure to Amber, you leave to get the IV tray.
When you return to the room, Amber is gone. You search the ER and finally realize that she is in the bathroom.
When you tap on the door of the bathroom, you hear Amber crying and ask if she needs help. She replies, Im not
coming out! Im SUPER Stressed Out!! Go Away! You start applying the Rational Nursing Framework:
1.

What just happened that SUPER Stressed Out Amber? (Name the event/situation)

Fill in the gray box (column 1) here (Check your response with the correct response in the Answer Table)
Name: Identify Understand:
React:
Select:
Exchange:
the event or
ID the patients thinking
Emotional &
Help pt. select
Help pt. exchange (and
situation
or physiological response
Behavioral
a better
practice exchanging) the
mechanism
thought
old thought with the
new thought

Answer Table
1. What just happened that "upset" Amber? (Name the event/situation)
Name: Identify
the event or
situation

Understand:
ID the patients thinking
or physiological response
mechanism

React:
Emotional &
Behavioral

Select:
Help pt. select
a better
thought

Exchange:
Help pt. exchange (and
practice exchanging) the
old thought with the
new thought

I left to get the

IV tray. When I
returned,
Amber was
gone
2.

You ask Amber what she is perceiving/thinking/believing.

Amber at first refuses to tell you; but, after some empathetic coaxing from you, she says, I cant have a needle in
my arm.
You know that she had no problem with the blood draw, so you ask, Amber, can you tell me what you think about
IVs?
She says, My mother told me that my grandmother died in the 1950s when an IV needle broke off and went to
her heart. Her name was Amber too.
Please dont put an IV in me!
You help Amber identify her understanding of this and identify the base thought that caused her emotional and
behavioral reaction:

10

Fill in the gray box (column 2) here (Check your response with the correct response in the Answer Table)
Name:
Understand:
React:
Select:
Exchange:
Identify the event or
ID the patients
Emotional &
Help pt. select
Help pt. exchange (and
situation
thinking or
Behavioral
a better
practice exchanging) the old
physiological
thought
thought with the new
response
thought
mechanism
I left to get the IV tray.
When I returned,
Amber was gone.
Answer Table
2. You ask Amber what she is perceiving/thinking/believing.
You help Amber identify her understanding of this and identify the base thought that caused her emotional and
behavioral reaction:
Name: Identify
the event or
situation

Understand:
ID the patients thinking or
physiological response
mechanism

I left to get the IV

tray. When I
returned, Amber
was gone

IV = Steel needle that stays

in arm.
Steel needle may break &
kill me.
Grandma died that way.
I will probably die that way
cause Im like my
Grandma. Having an IV
threatens me and I want to
avoid it; therefore, I feel

React:
Emotional &
Behavioral

Select:
Help pt. select a
better thought

Exchange:
Help pt. exchange (and
practice exchanging) the
old thought with the new
thought

3. You identify the patients emotional and behavioral responses.

You tell Amber that you know she is afraid, super stressed out, and wants to avoid the IV because she ran away
and locked herself in the bathroom.
Fill in the gray box (column 3) here (Check your response with the correct response in the Answer Table)
Name:
Understand:
React:
Select:
Exchange:
Identify the
ID the patients thinking or
Emotional &
Help pt. select a Help pt. exchange (and
event or
physiological response
Behavioral
better thought
practice exchanging) the
situation
mechanism
old thought with the
new thought
I left to get
IV = Steel needle that
the IV tray.
stays in Arm.
When I
Steel needle may break
returned,
& kill me.
Amber was
Grandma died that way.
gone
I will probably die that
way cause Im like my
Grandma.
Having an IV threatens
me and I want to avoid
it; therefore, I feel

11

Answer Table
3. You identify the patients emotional and behavioral responses.
Name:
Identify the
event or
situation

Understand:
ID the patients thinking
or physiological response
mechanism

I left to get
the IV tray.
When I
returned,
Amber was
gone

IV = Steel needle that

stays in Arm.
Steel needle may break
& kill me.
Grandma died that
way.
I will probably die that
way cause Im like my
Grandma.
Having an IV threatens
me and I want to avoid
it; therefore, I feel

React:
Emotional &
Behavioral

Select:
Help pt. select a
better thought

Exchange:
Help pt. exchange (and
practice exchanging) the
old thought with the new
thought

AFRAID
(Fear)

STRESSED

Lock myself in
bathroom &
cry.

4. You next explore with Amber what she can do to keep that thought from stressing/upsetting/hurting her
(help her Select a more accurate thinking).
You tell Amber that years ago metal needles were used and left in the patients arm, but now days, only small, nonbreakable plastic tubing stays in the arm. No needles will stay in the arm; a needle guide is used only to insert the
IV and then is removed. You then show Amber an IV stylet and how it works. You emphasize the selected
replacement thought again: No needle stays in your arm.
Fill in the gray box (column 4) here (Check your response with the correct response in the Answer Table)
Name:
Understand:
React:
Select:
Exchange:
Identify the
ID the patients thinking or Emotional &
Help pt.
Help pt. exchange (and
event or
physiological response
Behavioral
select a
practice exchanging) the old
situation
mechanism
better
thought with the new
thought
thought
I left to get
IV = Steel needle that
the IV tray.
stays in Arm.
When I
Steel needle may break
returned,
& kill me.
Amber was
Grandma died that way.
gone
I will probably die that
way cause Im like my
Grandma.
Having an IV threatens
me and I want to avoid
AFRAID (Fear)
it; therefore, I feel

STRESSED

Lock myself in
bathroom & cry.
12

Answer Table
4. You next explore with Amber what she can do to keep that thought from upsetting/hurting him (help
him/her Select a more accurate thinking).
Name:
Identify the
event or
situation
I left to get
the IV tray.
When I
returned,
Amber was
gone

Understand:
ID the patients thinking
or physiological response
mechanism

React:
Emotional &
Behavioral

IV = Steel needle that

stays in Arm.
Steel needle may break
& kill me.
Grandma died that
way.
I will probably die that
way cause Im like my
Grandma.
Having an IV threatens
me and I want to avoid
it; therefore, I feel

Select:
Help pt. select a
better thought

Exchange:
Help pt. exchange (and
practice exchanging) the
old thought with the new
thought

Modern day IVs

are plastic
Needle only
used to start
IVs
No needle
stays in arm
Having an IV is
no longer a
threat.

5. Remind your patient to exchange threatening or disturbing thoughts with their replacements when they
start to freak out (Exchange and practice exchanging thoughts in the here and now).
You give Amber the package cover to the IV stylet and tell her: This package cover will remind you that there is no
longer any reason to be afraid of the IV because there is no longer a needle left in your arm. Whenever you feel
like youre going to freak out, just look at that package and remember its ok.
Fill in the gray box (column 5) here (Check your response with the correct response in the Answer Table)
Name:
Understand:
React:
Select:
Exchange:
Identify the
ID the patients thinking
Emotional &
Help pt. select a
Help pt. exchange (and
event or
or physiological response
Behavioral
better thought
practice exchanging)
situation
mechanism
the old thought with
the new thought
I left to get
IV = Steel needle that
Modern day
the IV tray.
stays in Arm.
IVs are plastic
When I
Steel needle may break
Needle only
returned,
& kill me.
used to start
Amber was
IVs
Grandma died that
gone
way.
No needle
stays in arm
I will probably die that
way cause Im like my
Having an IV
Grandma.
is no longer a
threat.
Having an IV threatens
me and I want to avoid
AFRAID (Fear)
it; therefore, I feel

STRESSED

Lock myself in
bathroom & cry.

13

Answer Table
5. Remind your patient to exchange threatening or disturbing thoughts with their replacements when they
start to freak out (Exchange and practice exchanging thoughts in the here and now).
Name: Identify
the event or
situation

I left to get the

IV tray. When I
returned,
Amber was
gone

Understand:
ID the patients
thinking or
physiological response
mechanism
IV = Steel needle that
stays in Arm.
Steel needle may
break & kill me.
Grandma died that
way.
I will probably die
that way cause Im
like my Grandma.
Having an IV
threatens me and I
want to avoid it;
therefore, I feel

React:
Emotional &
Behavioral

Select:
Help pt. select a
better thought

Exchange:
Help pt. exchange (and
practice exchanging) the
old thought with the new
thought

Modern day
IVs are plastic
Needle only
used to start
IVs
No needle
stays in arm
Having an IV is
no longer a
threat.
AFRAID (Fear)

STRESSED

Lock myself in
bathroom & cry.

IV package is my reminder
that theres no longer a
needleno longer a
reason to be afraid.

Post-traumatic Stress Disorder in Healthcare Professionals: A Common-Yet Under Treated Illness

There are many anecdotal accounts of nurses and other healthcare professionals who call the behavioral health
department to get advice after they experience traumatic events like emergency casualties, violent encounters,
or the death of a child.
24
PTSD and stress related burnout has been well documented in emergency department nurses. The need for
leadership to recognize and proactively counter the phenomenon in occupations subject to traumatic stress has
25
also been established. [Violence] is a common problem in primary care, in accident and emergency
26
departments, and in psychiatric facilities, particularly for ambulance staff and nurses. Violence has become an
27
accepted occupational hazard of nursing, equaling that of bloodborne pathogens. Badger described how the
28
nurses war zone is often his/her own unit, the direct origin of nursing PTSD. Because of this, all healthcare
professionals must be able to recognize and deal with PTSD in themselves and others. Failure to do so results in
physiologic symptoms, psychological disabilities, and nursing burnout. Here is one example.
Eight AM, Christmas 1992. I was making rounds on the drug and alcohol abuse unit where I worked. I knocked on
the door of room 4. Bobby didnt answer. When I opened the door, I saw Bobby lying in bed, wearing his distinctive
cut-off jeans and sleeveless army tunic. Bobby was gray.
Time froze. I couldnt believe what I was seeing. Bobby was 43, two years older than I was. We had been in Viet
Nam at the same time. We had survived. We had stories. We both liked the Beatles. We could talk about the bad
stuff and get rid of it. Bobby was clean now; he was ok; but he was gray....
Time accelerated. I yelled, Maggie, Code Blue, Room 4, call it now! I pulled Bobby to the floor. I did my A-B-Cs. I
did them perfectly. In about a minute, Bobby was pink again. It was working.
But his abdomen started swelling. Oh no, I thought, Im blowing through. Ive got to blow softer. Dont get hyped
up. Hes still pink, take it easy.
12-and, 13-and, 14-and, 15-and, breathe. Oh no! I got a mouth full of vomit. Spit it out and keep going. Hang on
Bobby, helps on the way. Youve made it through Nam, the drugs, and the booze; dont die on me now pal! Whats
taking so long? More horrible taste in my mouth; just spit it out and keep going. . . Keep his lungs clear.
Then
14

Ok, step back, weve got him. Exhausted and sick, I watched the Advanced Life Support team. They worked and
worked, but Bobby was gone. They called it.
It was the end of January before I could sleep without being awakened by the horror of Bobbys recurrent
videotaped death scene. Even then, the bad thoughts and the bad taste would intrude from time to time.
Whenever I passed room 4, I would involuntarily see it again, always in a cold sweat with a sick lump in the pit of
my stomach. I started avoiding room 4.
For months I dreaded going to work. I had problems concentrating on my job because I was so afraid that others
would code, and I would be unable to save them. I became irritable and short tempered. Small things would set
me off (any joke about death freaked me out). I started to believe that Bobby died because of me. I kept secondguessing myself. I started thinking of things I should have done differently. I started calling in sick. I even, at one
point, decided to quit nursing. I saw no future in it. I didnt care much about anything.
PTSD, an anxiety disorder, results when an individual experiences a traumatic event involving actual or threatened
death or serious injury to the individual or others in that persons experience, and that persons reaction to the
8
event involves intense horror, fear, or helplessness. In nursing practice, the traumatic experience is often
cumulative. For example, an emergency nurse might experience a series of traumatic events over several months,
each generating some intense aspect of horror, fear, or helplessness. This is comparable to the combat soldiers
29
experience. As with most affective disorders, diagnosis is a matter of intensity. Symptoms that significantly
disrupt or interfere with life (at work or at home) for more than a month establish the diagnosis of PTSD, which
can be acute, if less than three months in duration; chronic, if over three; or delayed onset, if symptoms present at
least six months after the traumatic episode.
There is a precise taxonomy for symptomalogic diagnosis. This criterion is the focus of recognizing PTSD in yourself
or other healthcare workers. Examine (cut and save) the following 1-2-3 PTSD Symptom Assessment Chart (table 5)
8
adopted from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). PTSD is defined by at least
one symptom from the first category, two from the second, and three from the third.
Table 5
8

1-2-3 PTSD Symptom Assessment Chart for Nurses (DSM-IV-TR Diagnostic Criteria)
1 (or more) of the following Recurrent, Intrusive Symptoms that Re-experience the Event:
Recollections
Nightmares
Deja vu Flashbacks
Physical distress to event cues or symbols
Psychological distress to event cues or symbols
2 (or more) of the following Persistent Symptoms of Increased Arousal
Sleep problems (cant go or stay asleep)
Irritability, Anger
Decreased concentration
Hypervigilance
Exaggerated startle response
3 (or more) of the following Persistent Avoidance Symptoms to Event Stimuli
Triggers involving thoughts, feelings, conversations
Triggers involving activities, places, people
Unable to recall important details of the trauma
Decreased interest/participation in significant activities
Feeling of detachment
Loss of normal feelings/affect
Sense that the future is lost
Help for healthcare professionals with PTSD is available. An ounce of prevention works best. Research supports
30
that debriefing after a PTSD generating critical incident helps to mitigate PTSD symptoms. Facilities with critical
stress debriefing teams can successfully intervene to prevent exacerbation of the disorder. Certainly discussing the
trauma thoroughly details, thoughts, feelingsis a therapeutic exploration that has been noted to defuse PTSD
symptoms. An Employee Assistance Program can also accomplish this function and can be a lifesaver for the
healthcare professional experiencing PTSD.
15

One of the best approaches to unraveling healthcare PTSD can be found in Rational Nursing as outlined above.
Rational Nursing examines and counteracts the damaging thoughts created by the trauma to prevent debilitating
emotional and behavioral reactions.
Other approaches to reversing PTSD include anxiolytic/antidepressant medication, which is adjunctive but not a
29
panacea. The education and training of family and friends is also vital. When the healthcare professionals
significant support people are involved in the therapeutic process, recovery (as measured by successful coping at
work and home) is much more successful than without. PTSD support groups are also beneficial and can be found
in many areas. The Anxiety Disorders Association of America (ADAA) Self-Help Support Group Network can be
accessed through http://www.adaa.org. The National Center for PTSD can be accessed through
http://www.ncptsd.org. Both of these links provide connections for the healthcare professional with PTSD.
Although traumatic events are increasing in the healthcare environment throughout the world, early recognition of
the causes, symptoms, and interventions of PTSD can effectively mitigate and resolve the disorder in healthcare
workers, especially when healthcare professionals themselves are aware of the hazard. As with bloodborne
pathogens, back injuries, and other healthcare occupational hazards, healthcare professionals must arm
themselves with the knowledge and resources to protect themselves against the increasing threat of the most
debilitating form of stress: PTSD.

Conclusion: Youve got Stress?

Dont think you can just get over it! Manage your stress now that you have learned the skill sets to do so.
Healthcare professionals apply evidenced-based, critical thinking to their practices; this course has given you the
knowledge to develop the ability to do that.
What? Youre worried about that patient in 402, but youve got to deal with 417 first? Process to manage that
stress! Thats the life of a healthcare professional, and we do it better than most! Watch a few ER reruns and
critique how the characters could have better handled their stress scenarios.
Keep stress management in your attitude. Be ready for the unexpected and creatively face it with the
understanding that this is a big part of the profession. And finally, realize that we as healthcare professionals are in
one of the most stressful occupations. Before we were taught CPR, or IV insertion, or medication safety, we should
have been instructed in how to cope with our own thought-emotion-reaction to stress events. Most of us were
not. Now we can and that is really what every healthcare professional needs to know.

16

References
1

Dictionary.com Unabridged. Random House, Inc. Retrieved from Dictionary.com website: http://dictionary.com/browse/stress

th

Black J, Hawks J. Medical-surgical nursing: Clinical management for positive outcomes 7 ed. St. Louis, MO: Elsevier Saunders;
2005.
3

World Health Organization. The global burden of disease. In: Murray CJL, Lopez AQ, eds. The global burden of disease: A
comprehensive assessment of mortality and disability from disease, injuries and risk factors in 1990 and projected to 2020. (pp.
247-293). Cambridge, MA: Harvard School of Public Health; 1996.
4

Lucini D, Riva S, Pizzinelli P, Pagani M. Stress management at the worksite: Reversal of symptoms profile and cardiovascular
dysregulation. Hypertension. 2007;49:291-297.
5

MacDonald P. Workplace stress and the practice nurse. Prac Nur. 2006;32: 28-30.

Ahlstrom D, Cryan F. Putting stress to the test. Irish Times. Oct 12, 2006.

Cooper C. Cumulative stress: Where does it go? Unpublished masters thesis, Wilmington College Division of Nursing (UMI No.
1411251).2002. Retrieved February 17, 2007, from ProQuest database.
8

th

American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4 ed., Text Revision). Washington:
Author. 2002.
9

American Heart Association. Stress and heart disease.Available at: http://www.americanheart.org/

presenter.jhtml?identifier=4750. Accessed Februray 23, 2007.

10

Cardiovascular Institute and Center for Cardiovascular Health. Stress. Mount Sinai School of Medicine Website. Available at:
http://www.mssm.edu/cvi/stress.shtml. Accessed Februrary 23, 2007.
11

Purgason K. Broken hearts: Differentiating stress-induced cardiomyopathy from acute myocardial infarction in the patient
presenting with acute coronary syndrome. Dim of Crit Care Nsg. 2006,;25:247-253.
12

Rozanski A. Blumenthal J. Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and
implications for therapy. Circ.1999;99:2192-2217.
13

Balevre P. Professional nursing burnout and irrational thinking. J Nurses in Staff Dev. 2001;17:264 - 271.

14

Maslach C. The burnout syndrome and patient care. In: Garfield C Ed. Stress and survival (pp. 111-120). St. Louis: Mosby
Press. 1978.
15

Milani R, Lavie C. Stopping stress at its origins: Editorial commentary. Hypertension. 2007;49:268-269.

16

Kalia M. Assessing the economic impact of stress the modern day hidden epidemic. Metabolism. 2002;51: 49-53 (suppl).

17

Oginska-Bulik N. Occupational stress and its consequences in healthcare professionals: The role of type D personalities. Intl J
Occup Med Envir Hlth (Lodz).2006;19:113-123.
18

Stein R. Scientists finding out what losing sleep does to a body. Wash Post. Oct 9, 2005;A01.

19

Lea S, Anema M, Briscoe V, Allie H. The nursing process: What do students know? ABNF Journal. 2001;12:3-8.

20

Balevre P. Rational nursing: A concept analysis for practical application. J Nur Staff Dev. 2002;18:146-151.

21

Ellis A, MacLaren C. Rational emotive behavior therapy: A therapists guide. Atascadero, CA; Impact Publishers. 1998.

22

Epictetus. The collected works if Epictetus. Boston: Little Brown. 1899.

23

Vallely J. The achievement workbook. Unpublished manuscript. Jacksonville, FL. 1996.

24

Laposa J, Alden L, Fullerton L, Work stress and posttraumatic stress disorder in ED nurses/personnel. Journal of Emergency
Nursing. 2003;29: 23-28.
25

Paton D, Violanti J.Eds. Traumatic stress in critical occupations: Recognition, consequences and treatment. Springfield, IL;
Charles C. Thomas, Publisher. 1996.
26

Warshaw L, Messite J. Workplace violence: Preventive and intervention strategies. J Occup Envir Med. 1996;38: 993-1006.

27

Claravall L. Healthcare violence: A nursing administration perspective. J Nsg Admin. 1996;26: 41-46.

28

Badger J. (2001). Understanding secondary traumatic stress. A J Nsg. 2001;101:26-32.

29

Copel L. Psychiatric and mental health care 2 ed.. Springhouse, PA; Springhouse Corporation. 2000.

nd

30

Irving P, Long A. Critical incident stress debriefing following traumatic life experiences. J Psych Ment Hlth Nsg. 2001;8:307314.

17

Post Test
Please record your answers on the sheet provided, keep this test to check your returned answer sheet.
True = A False = B
1.

The first key to managing stress is to understand that stress is internal, and that it is an individual perception.

2.

The level of perceived stress is in direct proportion to the individuals physical and mental ability to adapt to
that stressor.

3.

Stress, like diabetes or depression, is something that one can just get over.

4.

The World Health Organization projects that stress-related conditions will be the number two health problem
in the world by 2020.

5.

Rational Nursing believes that feelings control behavior and that there is nothing one can do to change his/her
feelings.

6.

Stressful feelings and reactions are often caused by cognitive (thinking) exaggerations or irrational thoughts in
the persons "chain" of thinking.

7.

Many in todays healthcare professions live with chronic stress.

8.

Psychologically, nothing and no one can cause you stress. Its what you THINK about nothing and no one
that stresses you.

9.

When something happens, we react to it first, and then we think about it.

10. When something happens, we think about it thoughts make feelings that generate emotional reactions
followed by behavioral reactions.
11. No matter how much we teach our patients to recognize inaccuracies in their thinking, they will still not be
able to feel and react more realistically.
12. Rational Nursing believes that emotional and physical stress reactions to events are caused primarily by the
thought processes in response to those events.
13. In order to keep stress managed, one must practice to keep stress away.
14. There are many undiagnosed, untreated, and suffering healthcare professionals (especially nurses and ED
personnel) with PTSD.
Match the irrational thought with its description:
15. Generalization

A. Irrational Demand

16. Should

B.

Unreasonable Expectation

17. Catastrophizing

C.

Unrealistic Exaggeration

18. Awful

D. Exaggerating the Undesirable

19. Must

E.

18

Believing that something undesirable makes

everything bad.

Multiple Choice Questions:

20. The four (4) feelings of Rational Nursing are
a. happy, excited, sad, surprised.
b. happiness, sadness, anger, fear.
c. surprised, jealous, depressed, bipolar.
d. mellow, jubilant, furious, panic.
21. When I think something I like is added to my life, I feel
a. happiness.
b. sadness.
c. anger.
d. fear.
22. When I think something I like is taken away from my life, I feel
a. happiness.
b. sadness.
c. anger.
d. fear.
23. When I think something threatens me and I want to attack it, I feel
a. happiness.
b. sadness.
c. anger.
d. fear.
24. When I think something threatens me and I want to avoid it, I feel
a. happiness.
b. sadness.
c. anger.
d. fear.
25. The acronym N-U-R-S-E on the Rational Nursing Model Grid stands for
a. name, understand, react, select, exchange.
b. name, underestimate, return, select, examine.
c. nominate, use, real, sun, eliminate.
d. name, understand, realize, select, examine
26. Stress is an internal strain on three systems, physical, mental, and emotional, that
a. release adrenaline & trigger the flight-or-fight response.
b. Cause the adrenal glands to flood the body with cortisol (the stress hormone)
c. Trigger the stress response through the HPA axis
d. a & c above.
e. all of the above
27. Many healthcare professionals are faced with traumatic stress in their professional lives. Traumatic stress:
a. involves chronic daily stress.
b. often leads to PTSD.
c. is typically called survival stress.
d. is relatively simple for most healthy individuals to cope with.

19

Choose two potential triggers in each of the three stress trigger categories in Common Triggers of the Stress
Reaction section:
Life Events
28.

A. death of a loved one

29.

B.

weather extremes

Physical Stressors

C.

time constraints

30.

D. being fired

31.

E.

smoking / sleep deprivation

Daily Hassles

F.

deadlines / money problems / pressures of

responsibilities.

32.
33.

The Results of Stress in the Healthcare Professional section lists ways one responds to stress physically. Match
each of the following results with their definitions:
34. R-R Interval Variability

A. Triggered by physical or emotional stress

especially in postmenopausal women.

35. Stress-Induced Cardiomyopathy

36. Healthcare and Nursing Burnout

B.

Time elapsed between two consecutive R waves

in the electrocardiogram.

C.

Impact of stress, perception, and personality on

job.

37. Work-related stress has been linked to all of the following cardiovascular events except
a. negative changes in the ECGs R-R interval variability
b. a change in personality from Type A to Type D.
c. coronary and carotid atherosclerosis
d. cardiomyopathy
38. One of the most devastating occupational results of stress in the healthcare professional is:
a. job burnout
b. gastroesophageal reflux disorder
c. nail biting
d. becoming a workaholic
39. Stress has been linked to all of the following job related problems except
a. work related marriages
b. workers compensation claims
c. accidents
d. litigation
40. Type D personality healthcare professionals
a. perceive job stress as significantly worse than their peers
b. experience more harmful effects of stress psychologically
c. experience more harmful effects of stress physically
d. all of the above

20

41. Type D personalities are:

a. more irritable and restless than most
b. have more negative emotions and a negative view of themselves.
c. Avoid social situations involving disapproval from others
d. often experience chronic stress
e. all of the above.
42. The three components of stress management are
a. stress resistance, learning effective coping, and cognitive reframing
b. exercising, sleeping, and eating
c. yoga, yogurt, and yo-yos
d. the same as the A-B-Cs of cognitive reframing
43. Stress Resistance involves all of the following except
a. eating a healthy diet
b. getting adequate sleep and rest
c. exercising
d. cognitive reframing
44. Nurses learn effective coping skills by applying the critical thinking tool called
a. the nursing algorithm
b. the nursing process
c. the nursing method
d. the planning continuum
45. Cognitive Reframing is
a. a way to reframe our thinking about stress events
b. a method that to help us think, behave, and interact with stress successfully
c. a method like Rational Nursing and REBT
d. the nursing process
e. a, b, c only
46. PTSD is
a. a depressive disorder.
b. is not cumulative.
c. involves a traumatic event.
d. involves dreams about clowns.
47. Research supports that debriefing after a PTSD generating event can
a. help mitigate the symptoms of PTSD
b. is a good way to create rapport among healthcare workers.
c. is required by state and federal law
d. is now performed routinely in most healthcare facilities

End of Test

21

P.O. Box 2187 Orange Park, FL 32067-2187

(904) 683-8843 Fax: (904) 683-3803
STRESS MANAGEMENT FOR THE HEALTHCARE PROFESSIONAL
What Every Healthcare Professional Needs to Know
R: 04/01/2011 E: 03/31/2014
To facilitate accurate recording please provide the following information:
Nursing NP/RN/LPN

FL CSW/MFT/MHC

First Name:

OTHER:
Last Name:

Mailing Address:

City

State:

State & License #:

E-mail Address:

Zip:

Please circle or write-in the correct answer:

1.

20.

37.

2.

21.

38.

3.

22.

39.

4.

23.

40.

5.

24.

41.

6.

25.

42.

7.

26.

43.

8.

27.

44.

9.

28.

45.

10.

29.

46.

11.

30.

47.

12.

31.

13.

32.

14.

33.

15.

34.

16.

35.

17.

36.

18.
19.

06/11

CONTINUING EDUCATION PARTICIPANT EVALUATION

STRESS MANAGEMENT FOR THE HEALTHCARE PROFESSIONAL
What Every Healthcare Professional Needs to Know
R: 04/01/2011 E: 03/31/2014
P.O. Box 2187 Orange Park, FL 32067-2187
(904) 683-8843 Fax: (904) 683-3803
Nursing NP/RN/LPN

To facilitate accurate recording please provide the following information:

First Name:

FL CSW/MFT/MHC

OTHER:

Last Name:

Mailing Address:
State & License #:

City

State:

Zip:

E-mail Address:

1. After participating in this activity I am better prepared to:

Define the types of stress as it applies to the healthcare professional

Strongly
Agree
(4)

Agree

Disagree

(3)

(2)

Strongly
Disagree
(1)

Define the stress as it applies to the healthcare professional.

List the common triggers of the stress reaction.
Describe the results of stress in the healthcare professional.
Describe the effects of stress on the Type D personality healthcare professional.
Explain the three-fold approach to stress management.
Explain stress resistance and list its components.
Explain how to learn effective coping skills for stress management.
Describe cognitive reframing (using the Rational Nursing for Healthcare
Professional model) to manage stress.
Discuss the Rational Nursing basics (N-U-R-S-E).
List common irrational thoughts that lead to stress thinking.
List the four basic feelings of Rational Nursing and their corresponding four
thoughts.
Explain why healthcare professionals need to practice to manage stress.
Define Post Traumatic Stress Disorder and how it can affect healthcare
professionals.
2.

The activity met my educational needs.

3.

The faculty was knowledgeable and effective.

4.

The educational materials were effective.

5.

The learning activities were effective and incorporated active learning

methods.

6.

The post-test appropriately measured achievement of learning objectives.

7.

The content was objective, current, scientifically based and free of commercial bias.

8.

Based on information presented in the activity, I will:

Yes

No

If no, please explain: ______________________________________________________________________________

9.

Do nothing because content was not convincing

Seek additional information on this topic

Change my practice

Do nothing as current practice reflects activity recommendations

The most important concept I learned during this activity that may effect a change in patient care is:
_______________________________________________________________________________________________

10. What issue(s) related to the therapeutic area discussed in this activity, or other topics, would you like addressed in future continuing

education? ________________________________________________________________________
11. Time spent completing this activity: ___________
12. Comments: _____________________________________________________________________________________
06/11