Charlie Granger FRCA
Consultant in Anaesthesia and Intensive Care
Royal Lancaster Infirmary
The Intensive Care Unit (ICU) can be a highly stressful environment - not just for our patients and their relatives but also for us, the staff who care for them. This stress comes at a price – even if we have chosen to work in such a highly charged environment (Lederer et al. 2008). This article will discuss how ICU staff can reduce the price they pay for the career they have selected.
Stress arises when an individual feels obliged to respond to a situation but unable to cope with the situation’s demands. This emphasises the most important aspect of stress: Stress is subjective. The source of the stress – professional, organisational, clinical, domestic or internal – might influence the effect the stress has or how it might best be dealt with, but this central truth remains: Stress is in the eye of the beholder. This is not a new observation – Marcus Aurelius (Roman Emperor 161 – 180 AD) said much the same thing: “If you are distressed by anything external, the pain is not due to the thing itself but to your own estimate of it; and this you have the power to revoke at any moment.”
Because stress is essentially subjective it is logical that coping with stress should also fundamentally be a subjective process. Coping with stress means solving problems that can be solved and converting those that can’t be solved into positive challenges. It means handling a situation that cannot be mastered.
Locus of Control
The impact stress has on an individual therefore depends not only on the nature and severity of the stress but also on the psychological makeup of the individual. Learning to cope with stress involves learning techniques that bolster our resistance to stress. Foremost amongst these is the ‘Locus of Control’. This refers to the individual’s belief concerning ‘who or what influences things’, the polarities by one account being ‘Internal’, ‘Chance’ and ‘Powerful Others’ (Levenson 1973). Of these options, it is an Internal locus of control that is the most effective in supporting sound coping skills – that is, the individual believes that control of future outcomes resides primarily in themself, in contrast to believing that control lies in the hands of ‘Powerful Others’ or, more fatalistically ’Chance’. Though our ability to control events is inescapably linked to personal power – the higher I am in a hierarchy the more likely I am to be able to influence events – the concept is more fundamental that that.
Although control over events will inevitably be shared between different loci in different circumstances, the individual with an internal locus of control believes, generally speaking, that they are in charge of their own lives. With this belief come a number of other beneficial effects: a greater likelihood to make long-term plans, to work for success, resist coercion and, most importantly from the point of view of this article, tolerate stress (Krause and Stryker 1984). The late media mogul Sam Goldwyn, who started life as a refugee, liked to say “The harder I work, the luckier I get” - his career and aphorism both epitomise not only a strong internal locus of control but also, quite possibly, some of the benefits from having one. Fortunately, for those of us born with a less well-developed sense of self-belief, an internal locus of control is also an attribute that can be developed (Hattie 1997).
Forms of Stress
The psychological impact of a stress is also inevitably influenced by the nature of the stress itself – the polarities in this case being ‘challenge-related’ and ‘hindrance-related’. The former describe stresses, which are linked to some sort of potential positive outcome or individual personal growth – for example studying for exams or applying for promotion – whereas the latter are stresses that are without associated gains and which only constrain or interfere with our activities – examples might be limitations in resources or obstructive bureaucracy. The link between possible personal advancement and a challenge-related stress does not remo ve the stressful aspect completely, but it does make the stress more manageable. It is, therefore, easier to cope with a stress if it can be viewed as setting a challenge rather than imposing a hindrance.
Stress Management Techniques
A number of studies have demonstrated that stress management techniques can be taught. One of these involves learning ‘Mindfulness Meditation’, a formal discipline by which subjects are taught to ‘pay attention on purpose’ – with specific attention to encouraging compassion, impartiality and acceptance of self and others. This increases the subjects’ sense of control over stress as well as their ability to accept and let go of events that are not controllable. In a short study involving medical students, mindfulness meditation reduced anxiety levels, reduced psychological distress and increased empathy – benefits which were maintained during a time of increased stress as exams appro ached (Shapiro 1998).
A study of cognitive behavioural training in GPs demonstrates a second technique in developing skills at coping with stress – in this case the emphasis lies on distinguishing between positive and negative thoughts and analysing stresses logically, as opposed to emotionally. These coping skills were then used during stressful periods, in distinction to the meditative approach which is more a continuous ‘way of being’. This training improved the quality of the GP’s work life and reduced their work-related and general psychological distress – results which were maintained or improved at follow-up 12 weeks later (Gar diner 2004).
In this study, the best results came from subjects who had developed a ‘Problem-Focussed’ coping style. Problem Focussed coping is made up of two strands: ‘Problem-Solving’ and ‘Stress Reducing Appraisal’. The former uses deliberate policies of Simplification (start with the most obvious steps when faced with a problem), Priori tis ation (deal with the most important things first) and Delegation (delegate when possible) to reduce the number of stressful events the individual is exposed to. The latter aims to reduce the emotional load of the stresses that remain – in this case by: (1) Accepting that difficulties are an inherent part of the working environment, (2) Accepting that there are personal and medical limits to what can be done – and that these limits do not necessarily imply failure, (3) Accepting that periods of high demand are an inevitable component of our career and finally, (4) Retaining the right to say ‘No’. These simple steps help the stressed individual to accept the stress they are exposed to, divorce them from a sense of failure and encourage a more constructive coping response (Gardiner 2004).
A third approach to managing stress focusses on assertiveness training. Our personal levels of assertiveness influence our perception of stress – more assertive people tend to perceive a specified stress (giving a talk in public, for example) as a challenge whilst less assertive individuals perceive the same stress as a threat. As outlined above, challenge-based stresses are associated with lower levels of personal stress than hindrance-based stresses, so the more assertive we are the greater the chance that we will perceive a stress as a personally enhancing challenge rather that a stressful hindrance. Once again, this process can be taught (Lee and Crockett 1994).
The final contributions to coping with stress, methods that might be more practical than some of the others mentioned above, involve promoting physical fitness and learning to relax (Bellarosa and Chen 1997). One image that helps here is the ‘stress jug’, which expresses our capacity to absorb stress – the bigger the jug, the greater our ability to deal with stress. The importance, however, is that no matter how large the jug, sooner or later it will fill, at which point additional stresses – even if they are, in themselves, trivial – might lead to a seemingly disproportionate response. In this case, though the response has been triggered by the final stress, the underlying cause is the addition of one stress too many to a person who has already absorbed all the stress they can. The implication is that, if we are to fill the role expected of us, both at home and at work, we have to make sure we take the time to empty our stress jug through adequate relaxation. A supportive family is obviously of central importance in this process.
If we fail to take these simple steps in self-preservation we risk being slowly and relentlessly ground down by the stresses that are inherent in one of the most demanding, absorbing and rewarding jobs in the field of health – a career in intensive care.