Job stress - nursing.

When Nora, a 36-year-old registered nurse, punches the time clock at the large inner-city hospital, she feels as exhausted as if she'd already put in a full day's work. She's risen at 5:00 a.m., washed three loads of clothes, cooked breakfast for her family, and dropped her infant daughter off at the day-care center.

On the respiratory unit where she is assigned team leader responsibilities for 20 patients, she learns today that two staff members are out again with the flu. Not only will Nora have to give medications and supervise patient care, she'll have to help provide that care as well.

One patient with end-stage lung cancer probably won't live until the end of the shift, and her other 19 patients are acutely ill. But Nora doesn't ask for help. She pulls patients up in bed by herself, passes medications with a weary smile, practices good infection control techniques, documents everything she's accomplished--in short, tries to be all things to all people.

As Nora gives a report to the oncoming shift, she mentally rehearses her evening responsibilities: stop by the grocery store, make dinner, bathe the baby. And come morning, it all starts again.

Nora's life is a typical example of the day-to-day stress experienced by nurses. Studies indicate that eight of the 12 most stressful jobs today are positions in health care. In a 1990 survey half the nurses polled admitted that they've even considered leaving the profession. The reasons given included lack of time for family, short-staffing, lack of respect and a voice in hospital decision-making, and the pay not being commensurate with responsibilities and education. Thirty percent of nurses polled couldn't identify a single stressor, but cited job-related stress in general as the problem.

Job-related stress, however, isn't unique to nurses. Eighty-three percent of Americans experience it. According to Morton C. Orman, M.D., who conducts stress management workshops, "stress is merely a word that we use to stand for hundreds of specific problems and conflicts in our lives."

With the nursing shortage expected to continue well into the year 2000, nurses must learn to prevent, recognize, and manage stress effectively. As Hans Selye, the pioneer of stress research, pointed out, "it's not what happens to you; it's how you take it." Here are suggestions for managing not only the stress associated with nursing, but job stress in general.

1. Maintain physical, psychological, social, and spiritual balance.

Stress management is, to a large degree, substituting healthy activities for unhealthy ones. Get sufficient rest and exercise. Eat a proper diet. Limit your caffeine intake.

"You don't have the time not to take care of yourself," emphasizes nurse educator and publisher Linda Smith, R.N., M.S.N. And when you take care of your own health, you feel better, are more productive, and are less prone to accidents and errors.

Use your lunch and break times to replenish yourself on the job, and make time for recreation and creative expression away from your job. Recreation is not a luxury reserved for the affluent. It is essential for a healthy balance.

2. Face your feelings. Don't sever yourself from your feelings or bury your frustrations with frenetic activity, rituals, or unhealthy behaviors. Acknowledge your feelings, be they anger, depression, sadness, guilt, frustration. But keep in mind that when these feelings persist over time, they are a signal that something is wrong.

3. Banish the myth of having it all. Like Nora, you can't be all things to all people all the time and in all situations. It's important to allow people--your family, coworkers, or patients--to do what they can and should do for themselves. Don't be a caretaker who meets others' needs to the exclusion of your own.

4. Be true to your convictions. Seventy percent of American workers are employed in jobs they either don't like or are not suited to. It's important that your employer's values, ethics, and goals be congruent with your own. In her book Daring to Be Yourself (New York: Doubleday, 1990), Alexandra Stoddard says: "Until something pleases you, it is not right for you." And only you can determine what is appropriate for you.

5. Organize, prioritize, and simplify. Ask yourself, "What is really important?" This helps prevent stress from becoming distress. "Because nurses in clinical and administrative roles may appear to have differing priorities, it's essential to clarify standards and expectations,'' says Katie Bonnett, R.N. M.S, a nurse educator. When staff nurses recognize, for instance, that the standards of accrediting agencies are not an unnecessary ritual but an expectation, the two groups then share a common priority and goal. And whatever the goal, simplify it as much as possible.

6. Ask for help when you need it.

Develop work plans that share responsibility. Request a helping hand when the situation calls for it. And learn how to delegate effectively. "Before I delegate a task to one of the nurses I supervise," says Jean Yates, R.N, and ICU head nurse, "I first develop trust in that person. Then I offer support and guidance and periodically evaluate the outcome, but I don't follow up on every minute detail. That gives the impression that you doubt the person's abilities, and creates extra work for you."

7. Use available support systems effectively. Brainstorm new ideas with your colleagues and superiors and seek outside help if necessary. If your unit is having difficulty dealing with the stress of caring for dying patients, consult a nurse with expertise in that area.

Resist the urge to complain, which often feeds the stress cycle. Rather, direct your focus to goals (not problems), how to make things better (not why things are bad), possibilities (not limitations), and feedback (not failure).

Share anecdotes during the change-of-shift report that affirm the value of what you're accomplishing in your daily routine. This helps to create a climate of purpose, respect, and unity. And when someone does something commendable, build that person up. A nursing editor recalls the time one of her books received a national award: "My coworkers said, 'Who does she think she is?' How much better if their response had been 'If she can do that, so can I!'" Nurses readily identify the struggles of their patients, while oftentimes the struggles and accomplishments of coworkers go unobserved. Look for ways to encourage.

8. Replace rituals with reason. In their book Why America Doesn't Work (Waco, Tex.: Word Publishing, 1991), authors Chuck Colson and Jack Eckerd ex- plore the need for meaningful work. "Nursing with all its accompanying tasks-- IVs, medications, vital signs--can be as repetitive as working on an assembly line," explains Mary Poole, R.N., M.A., a psychiatric clinical nurse specialist.

"Such boredom can significantly contribute to stress. What is needed is a way to look beyond the eight-hour shift to the big picture.

This can be accomplished by hanging a question mark on things you've long taken for granted and by approaching traditional ways of doing things with the wonder of a child. Nothing is mundane if you really pay attention. Join a committee to become better informed about your institution and to learn how you can make a difference.

9. Focus on excellence, not perfectionism. Every aspect of nursing does not need to be rigidly controlled. Perfectionism and unrealistic expectations snuff creativity and spontaneity. Rather than demanding perfection, ask yourself, "How can this be better next time?"

10. Create beauty around you. Make your physical surroundings as pleasant and appealing to your senses as possible. Play peaceful music. Nancy, a nurse researcher, displays family photographs and other mementos on her desk, and stores slides for research presentations in lovely ribboned boxes.

11. Develop a sense of humor How often have you heard someone in the midst of a trying situation remark, "Someday we'll look back on this and laugh"? Well, why wait to enjoy a good laugh? If memory can change our perceptions, then we also have the ability to change them in the present moment. "A merry heart doeth good like a medicine" (Proverbs 17:22).

12. Learn to view thin.gs from a different perspective. Managing stress is often a matter of changing your outlook. Ask yourself, "What is the worst that can happen? What difference will this make 100 years from now?" And when things get really difficult, remind yourself,

"This too shall pass." Keep a journal to record fulfilling moments of your career. As you reflect on your entries at a later date, you'll have new insights. Always keep in mind that there is no such thing as failure, only feedback. Edison, you may recall, made 9,999 attempts to invent the electric light bulb. When someone asked him if he had planned to have 10,000 failures, he replied, "I didn't have any failures. I discovered 9,999 ways not to do it." It's all a matter of having a positive perspective.

Roberta L. Messner, R.N.C., Ph.D., C.P.Q.A., is quality management nursing coordinator at Veterans Administration Medical Center, in Huntington, West Virginia. William A. McDowell, Ph.D., is a licensed psychologist and professor at Marshall University in Huntington, West Virginia.