Transcript Slide 1

Ordinary Grace and the High Cost of Caring
in a Challenging Environment
Sponsored by:
AWHONN – Oklahoma Section
April 21-22, 2005
Tulsa, OK
Kathleen Brehony, Ph.D.
1. The high cost of caring.
2. Burnout/Stress and
what you can do about it.
3. Remembering Grace and how to
reinvigorate it in your personal
and professional life.
 Nurses number 2.7 million and rank as the nation’s
largest health care profession
 High quality nursing care reduces the rate of
complications and lengths of stay in hospitals
 A growing disparity between the supply and demand of
nurses that is leading to a potentially overwhelming
nursing shortage and health care crisis
 Changing demographics
 Ever-decreasing resources and increased demands
on the health care system
 Declining social value of nursing as a career
 Changes in career opportunities
 In spite of the critical value of the profession,
nursing’s role in decision-making around health care
issues remains limited
 Changing economics of health care reimbusrement
along with other pressures including mounting
documentation requirements and stressful working
conditions have contributed to nurse’s diminishing
sense of career satisfaction
Hospital Nurse Staffing and Patient Mortality,
Nurse Burnout, and Job Dissatisfaction
Cross-sectional analysis of linked data from 10,184
staff nurses surveyed 232,342 general, orthopedic and
vascular surgery patients (between the ages of 20 and
85) discharged from the hospital between April 1, 1998
and November 30, 1999, and administrative data from
168 nonfederal adult general hospitals in Pennsylvania.
Linda H. Aiken, PhD, RN
Sean P. Clarke, PhD, RN
Douglas M. Sloane, PhD
Julie Sochalski, PhD, RN
Jeffrey H. Silber, MD, PhD
October 23/30, 2002. Journal of the American Medical Association, 288, 1987-1993.
Funding Source : National Institute of Nursing Research, National Institutes of Health
Sites for International Study of Hospital Outcomes
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United States
 University of
Pennsylvania
Ontario
 University of
Toronto
 Mt. Sinai WHO
Collaborating
Centre
British Columbia
 University of British
Columbia
Alberta
 University of
Alberta
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Germany
 Hannover Medical
School
England
 London School of
Hygiene and
Tropical Medicine
Scotland
 Glasgow University
 Nursing Initiative of
Scotland
 Scottish NHS
Outcomes in 232,342 Surgical Patients
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4,535 (2.0%) died within 30 days of
admission
53,813 (23.2 %) were observed to
experience a major complication
the death rate among complicated
patients (failure to rescue rate) was 8.4%
Source: Aiken et al 2002
168 PA Hospitals: Average Patient Load
Carried By Nurses on Last Shift Worked
8 or more
8%
4 or less
12%
7
17%
5
39%
6
24%
Source: Aiken et al 2002
Effect of Nurse Staffing on Mortality
 For every one patient-per-nurse increase
in nursing workloads in PA hospitals: 14%
increase in risk of death within 30 days for
an individual patient
 After controlling for all the hospital and
patient variables we have: 7% increase in
risk of death
Source: Aiken et al 2002
Translating the Results
 5 per 1000 fewer surgical patients of
the types studied expected to die in
hospitals with 4:1 versus 8:1 average
ratios
 ~ 4 M similar procedures/year in U.S.
hospitals: if all patients treated in
hospitals at 4:1 vs. 8:1 ratios … up to
20,000 fewer deaths
Source: Aiken at al 2002
Conclusions
(Aiken et al 2002):
In hospitals with high patientto-nurse-ratios, surgical patients
experience higher risk-adjusted
30-day mortality and failure-torescue rates, and nurses are
more likely to experience
burnout and job dissatisfaction.
Inpatient Mortality Rates in 118,803
English Surgical Patients From 30 Trusts
in Relation to Nurse Staffing Levels
2.8
2.6
2.4
2.2
2
1.8
1.6
1.4
1.2
1
2.7
2.4
2.2
2
Lowest Pt:Nurse
Ratios
Highest Pt:Nurse
Ratios
Education Levels of Hospital
Nurses and Patient Mortality
 Aiken, Clarke, Cheung, Sloane, & Silber
(September 24, 2003, Journal of the
American Medical Association)
 The proportion of hospital staff RNs holding
baccalaureate or higher degrees as their
highest (not initial) credential ranged from 0
to 77% across the hospitals.
Patient deaths after surgery are lowest in
hospitals where nurses care for fewer patients
on average and have higher levels of education
Deaths per 1000 patients
25
20
Patient-to-nurse ratios
15
High
Medium
10
Low
5
0
20
40
60
Source: Aiken et al 2003
% Bachelor’s-prepared
nurses
Relationship Between Nurse Staffing and
Selected Adverse Events Following Surgery
(Kovner & Gergen, 1998)
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Significant inverse relationship between RN staffing
levels and the following postoperative complications:
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urinary tract infections
pneumonia
thrombosis
pulmonary compromise
Estimated that one additional RN hour per patient
day was associated with a 9% decrease in UTI and
8% decrease in pneumonia
Kovner et al. (2002)—only pneumonia associated
with staffing
Blegen et al. (1998)
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Increasing a unit’s total hours of care (RN,
LPN, NA) is not associated with lower rates
of adverse outcomes
Increasing the proportion of RN hours of
care is associated with lower rates of
adverse outcomes:
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medication errors
pressure ulcers
patient complaints
patient falls
American Nurses Association
Sponsored Studies (1997, 2000)
 Two major studies on the relationship between
nurse staffing and patient outcomes “that [could]
reasonably be theorized to be preventable in
some patients by the amount and skill mix of
nursing provided.” (ANA, 2000, p. vii)
 Associations between higher staffing and higher
proportions of RNs and better outcomes across 9
states:
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shorter lengths of stay
lower risk of pressure ulcers
lower risk of pneumonia
lower risk of postoperative infections
lower risk of urinary tract infections
Nurse Staffing and Patient Outcomes in Hospitals
Needleman, Buerhaus, et al. (2001)
(Report available at www.hrsa.gov)
 Main analyses involved 1997 discharges from 799
hospitals across 11 states (AZ, CA, MA, MD, MI,
NV, NY, SC, VA, WI, WV)
 The study found statistically significant
relationships between nurse staffing variables and
the following patient outcomes in acute care :
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Medical Patients: urinary tract infection, pneumonia,
shock, upper gastrointestinal bleeding, length of stay
Patients Undergoing Major Surgery: urinary tract
infection, pneumonia, failure to rescue (defined as the
death rate among patients with sepsis, pneumonia,
shock, upper gastrointestinal bleeding, or deep vein
thrombosis)
Nurse Staffing and Patient Outcomes in Hospitals
Needleman, Buerhaus, et al. (2001). (Report available at www.hrsa.gov)
 High RN staffing associated with 3-12% decrease in
likelihood of events, high total nursing staffing associated
with 2-25% decrease
 No effects of staffing on mortality in either medical or
surgical patients
 Study conducted at Harvard and reported to HHS.
Published in New England Journal of Medicine in May 2002
Examples of Other Recent Staffing Research
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Cho, S.-H., et al.: The effects of nurse staffing on
adverse events, morbidity, mortality and medical
costs. Nursing Research. 2003; 52(2): 71-79.
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McGillis Hall L et al. Nurse staffing models as
predictors of patient outcomes. Med Care. 2003;
41(9):1096-1109.
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Person SD et al. Nurse staffing and mortality for
Medicare patients with acute myocardial infarction.
Medical Care. 2004; 42(1):4-12.
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Unruh L. Licensed nurse staffing and adverse events
in hospitals. Med Care. 2003 Jan;41(1):142-52.
Issues for Clinicians and Managers
(Clarke, Nursing Management, June 2003)
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Financial imperatives v patient needs
Burnout, job satisfaction issues in nursing
staff: potential for vicious cycles
Perceptions of staff and managers are the
most important tool right now in evaluating
the safety of staffing levels
Legal liability issues
Communicating staffing decisions to staff and
patients/families
Minimum Staffing Ratios:
The Goals
 Proponents hope to alleviate some
prominent concerns about patient safety
 Minimum staffing requirements will lead to
more manageable workloads, improve
nurse job satisfaction and retention and
ameliorate the hospital nurse shortage
 Half of all Americans believe that the quality of health
care is affected “a great deal” by a shortage of nurses
(Harris Poll, 1999)
 93% of Americans believe that the nursing shortage
jeopardizes the quality of health care (Penn, Shoen,&
Berland, 2001).
The size of the U.S. population older than 65 is projected
to double over the next 30 years, growing to 70 million
by 2030.
Those over age 85, who tend to require
more health care services than the young,
are the fastest growing segment of the population.
Source: U.S. Census Bureau, Decennial Census Data and Population Projections
 The Bureau of Labor Statistics reports that jobs for RNs will grow 23
percent by 2008. That's faster than the average for all other
occupations.
 About half of the RN workforce will reach retirement age in the next
15 years.
 The average age of new RN graduates is 31. They are entering the
profession at an older age and will have fewer years to work than
nurses traditionally have had.
 RN enrollments in schools of nursing are down. In fall 2000, entrylevel BSN enrollment fell by 2.1 percent, dropping for the sixth year in
a row, according to the American Association of Colleges of Nursing
3 Major Factors in Nurse Burnout
 Inadequate numbers of nurses
 Poor administrative support for nursing care
 Poor doctor-nurse relationships
The same factors that lead to nurse burnout are
identical to the ones that lead to poor patient
satisfaction with their care
Surveys of 820 Nurses and Interviews with 621
AIDS patients in an urban hospital environment
Source: Vahey DC, Aiken LH, Sloane DM, Clarke SP and Vargas D., “Nurse Burnout
and Patient Satisfaction,” Medical Care, 42(2): II-57-II-66, February 2004
The “Perfect Storm”
 Demographic trends in the profession
 Financial pressures within health care
 Demand for health care and demand for
nursing services within the health care
system
Source: Sean Clarke, RN, PhD, CRNP, CS
Assistant Professor, School of Nursing, University of Pennsylvania
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Work-Related Stress for Nurses
 Work in which the demands imposed
are threatening and not well-matched
to the knowledge, skills, and ability to
cope of the nurses involved
 Work which does not meet the needs of the nurses
involved
 Situations in which nurses have little control over
work
 Situations in which nurses receive little support at
or outside of work
Cox, T. and Griffiths, A. “Work-related stress in nursing: Controlling the risk to
health.” Working paper, International Labor Office, Geneva, Switzerland, 1996.
“Everyday the nurse confronts stark
suffering, grief, and death as few
other people do. Many nursing tasks
are mundane and unrewarding.
Many are, by normal standards,
distasteful and disgusting. Others
are often degrading; some are
simply frightening.”
Hingley, P. “The humane face of nursing,” Nursing Mirror, No. 159, 1984, pg 19-22.
7 Major Causes of Stress in Nursing
1. Dealing with death and dying.
2. Conflict with physicians.
3. Inadequate preparation to deal with the emotional
needs of patients and their families.
4. Lack of staff support.
5. Conflict with other nurses and supervisors.
6. Workload.
7. Uncertainty concerning treatment.
P. Gray-Toft and T.G. Anderson (1981a): “The nursing stress scale: Development of an
instrument,” Journal of Behavioural Assessment, vol. 3, 1981, pp 11-23; P. Gray-Toft
and T.G. Anderson (1981b): “Stress among hospital nursing staff: It’s causes and
effects,” Social Science and Medicine, vol. 15A, 1981, pp 539-647.
The 10 Domains:
Areas of Concern Demanding Action
1. Leadership and planning
2. Delivery Systems
3. Legislation/regulation/policy
4. Professional Nursing Culture
5. Recruitment/retention
6. Economic value
7. Work environment
8. Public relations/communication
9. Education
10. Diversity
“Without good and careful nursing many must suffer
greatly, and probably perish, that might have been
restored to health and comfort, and become useful
to themselves, their families, and the public, for
many years after.”
-- Benjamin Franklin (1751)
Stress
 Stress is a reaction to a physical or psychological
threat to the body. Some things will create stress in
everyone (e.g., being attacked by a wild tiger).
 Stress is also a personalized reaction because what
may be a threat to one person may or may not be to
another (e.g., speaking in front of groups).
 Stress is also a struggle to adjust to a life change.
 Stress is expressed physiologically, emotionally,
cognitively, and behaviorally.
The term "stress" is short for distress, a
word evolved from Latin that means "to
draw or pull apart."
Fight or Flight Response
 Innervated by the Sympathetic Nervous System
 Increased respiration rate
 Increased heart rate
 Changes in blood flow (increasing flow to the skeletal
muscles and decreasing to the periphery results in cold
hands and feet)
 Increased muscle tension
 Increased metabolism
 Increased perspiration/sweating
 Decreased digestion
 Changes in blood chemistry
The primary area of the brain that
deals with stress is its limbic system.
Because of its enormous influence on
emotions and memory, the limbic
system is often referred to as the
emotional brain. It is also called the
mammalian brain, because it emerged
with the evolution with our warmblooded relatives, and marked the
beginning of social cooperation in the
animal kingdom.
Whenever you perceive a threat, imminent or imagined,
your limbic system immediately responds via your
autonomic nervous system – the complex network of
endocrine glands that automatically regulates metabolism.
Your adrenal glands release adrenaline (also known as
epinephrine) and other hormones that increase
breathing, heart rate, and blood pressure. This moves
more oxygen-rich blood faster to the brain and to the
muscles needed for fighting or fleeing.
And, you have plenty of energy to do either, because
adrenaline causes a rapid release of glucose and fatty
acids into your bloodstream. Also, your senses become
keener, your memory sharper, and you are less
sensitive to pain.
Other hormones shut down functions unnecessary during the
emergency. Growth, reproduction, and the immune system all go on
hold. Blood flow to the skin is reduced. That's why chronic stress leads
to sexual dysfunction, increases your chances of getting sick, and often
manifests as skin ailments.
With your mind and body in this temporary state of metabolic overdrive,
you are now prepared to respond to a life-threatening situation.
Selye’s General Adaptation Syndrome (GAS)
Stage
Effect
Alarm
 “Fight or Flight” Response
 Intense ANS Arousal (e.g., heart rate, respiration rate, BP
increase, etc.)
Resistance
 Prolonged state of moderately high arousal
 Resistance saps energy and weakens immune system
Exhaustion
 Vulnerability to illness increases
 Physical illnesses become more common
Forms of Stress
Physical Stressors
(threats to health and safety)
Chronic Stressors
Acute Stressors
(Long lasting threats)
(Immediate threats)
Disease
Starvation
Poverty
Psychosocial Stressors Unemployment
(life role demands)
Divorce
Childcare
Predators
Combat
Crime
Work Deadlines
Arguments
Final Exams
Point: We are less well-evolved to cope with psychosocial stressors.
Using brain imaging, combat veterans were found to have an 8%
reduction in right hippocampal volume (i.e., the size of the
hippocampus), measured with magnetic resonance imaging (MRI),
while no differences were found in other areas of the brain.
This study also showed that diminished right hippocampal volume in
the PTSD patients was associated with short-term memory loss.
Similar results were found when researchers looked at PTSD sufferers
who were victims of childhood physical or sexual abuse.
Bremner, J. D. “The Invisible Epidemic: PTSD, Memory Loss and the Brain” Yale University,
School of Medicine. Grant by NIH, VA, and the National Center for PTSD Grant.
Note increased right basal ganglia:
28 year old woman with chronic anxiety, conflict avoidance
Note increased right basal ganglia:
44 year old man with chronic mild anxiety, conflict avoidance
Note increased right and left basal ganglia:
48 year old man with panic disorder
Source: Daniel G. Amen, M.D. SPECT Imaging
www.amenclinic.com
Stress as Demands & Resources
 Unpredictable/Uncontrollable events create demands
 Demands require an adaptive response
Increased resources to:
Attention narrows (focus on stressor)
Physical & emotional arousal (devoted to coping)
Immune system (increases in functioning)
Decreased resources to:
Sexual drive
Digestive system
Pain response
Stress = demands overwhelm resources
Primary Appraisal:
“How threatening is the event?”
Secondary Appraisal:
“Do I have the resources to cope with the event?”
Short-Term Effects of Stress
In the short-term, stress can be either a positive or
negative experience (distress v eustress).
It can keep us alert and ready to avoid danger.
Stress can increase our motivation to complete a task, improve
our performance, and add excitement to our lives. Many
recreational activities are stress producing and enjoyable
because of it.
Stress releases norepinephrine which helps create new
memories, improves mood, and encourages creative thinking.
But stress in the short term can be a negative experience when
we feel it too strongly. It can interrupt or interfere with our
desired performance. Too much stress in the short term can
cause us discomfort and create in us a desire to avoid or leave
certain situations.
Distress v Eustress
Simply stated, moderate levels of arousal
produce the best performances in most cases.
Long-Term Effects of Stress
When the stress reaction is repeatedly elicited or
occurs on a chronic basis, the long-term effects
can be serious, even deadly. Chronic stress can
result in both physical and emotional disorders
including:
 Fatigue
 Insomnia
 Headaches
 Backaches
 Muscle Pain
 Skin Disorders
 GI Dysfunctions
 Ulcers
 Increased Susceptibility to
Infectious Disease
 Sexual Dysfunction
 Increased probability of Accidents
 Psychiatric Disorders
 Hypertension
 Cardiovascular Disease
 Stroke
 Heart Attacks
 More Rapid Aging
 Cancer
Consequences of Chronic Stress
 Cognitive dysfunction
Impaired concentration, memory
Poor judgment/decision making
 Negative emotions
Hostility (Anger, Irritability, Frustration, etc.)
Anxiety
Depression
Fear
 Physical dysfunction
Immune system dysfunction
Insomnia
Cardiovascular system dysfunction
Pain (Neck Pain, Back Pain, Headaches)
Gastrointestinal problems (Ulcers, Irritable bowel)
 Behavioral consequences
Substance abuse
Role withdrawal
Role performance
STRESS and the High Cost of Caring
 Forty-three percent of all adults suffer adverse health
effects from stress.
 Seventy-five to 90% of all doctor's office visits are for
stress-related ailments and complaints.
 Stress is linked to six of the leading causes of death:
heart disease, cancer, lung ailments, accidents, cirrhosis of
the liver, and suicide.
 The Occupational Safety and Health Administration
(OSHA) declared stress a hazard of the workplace. In terms
of lost hours due to absenteeism, reduced productivity and
workers' compensation benefits, stress costs American
industry more than $300 billion annually.
 The lifetime prevalence of an emotional disorder is more
than 50%, often due to chronic, untreated stress reactions.
Stress and the Immune System
Psychneuroimmunology (PNI)
Study of psychological influences on immune system functioning
Immune system
Body’s system of defenses against viral & bacterial agents
Lymphocytes = White blood cells
B Cells – neutralize “foreign agents”
T Cells – attack infections
Immunosuppression
Hypothalamic-pituitary-adrenal (HPA) axis produces cortisol in
response to stress
Cortisol energizes body for stress response (e.g., fight or flight)
Increased stress response =
decreased immune system response
S-O-R Model of Stress
Stress = Demand Exceeds Capacity
Stimulus
Organism
= Stressors
Response
“When the cards are dealt
and you pick up your hand, that is
determinism; there’s nothing you
can do except to play it out for
whatever it may be worth. And the
way you play your hand is free will.”
-- Jawaharlal Nehru
Stress!! What Can You Do?
Einstein on “Insanity”:
“Doing the same thing over and over again and
expecting different results.”
What do you choose to see?
Do you believe that there is nothing you can do or
do you believe that there are lots of things you
can do to ameliorate the high cost of caring?
A Short Film
You will see six people playing basketball – three are
wearing black shirts and three are wearing white
shirts. Each player can do one of three things:
1. Dribble
2. Pass the ball
3. Bounce-Pass the ball
CAREFULLY COUNT THE NUMBER OF TIMES
THAT PLAYERS IN WHITE SHIRTS BOUNCEPASS THE BALL.
Four-Stage Stress Management Model
Identify
(Physical, Cognitive, Behavioral)
Implement
Plan
Analyze
Develop Plan
Identify the Symptoms of Stress
 Physiological
 Cognitive
 Behavioral
Physiological Signs of Stress
 Increased heart rate
 Headache
 Pounding heart
 Vomiting
 Elevated blood pressure
 Sleep disturbances
 Sweaty palms
 Fatigue
 Tightness of the chest, neck,
jaw, and back muscles
 Shallow breathing
 Nausea
 Diarrhea
 Constipation
 Urinary hesitancy
 Trembling
 Twitching
 Stuttering and other speech
difficulties
 Dryness of the mouth or throat
 Susceptibility to minor illness
 Cold hands
 Itching
 Being easily startled
 Chronic pain
 Dysponesis
Cognitive Signs of Stress
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Forgetfulness
Preoccupation
Blocking
Blurred vision
Errors in judging distance
Diminished or exaggerated fantasy life
Reduced creativity
Lack of concentration
Lack of attention to detail
Orientation to the past
Decreased psychomotor reactivity and coordination
Attention deficit
Disorganization of thought
Negative self-esteem and Pessimism
Diminished sense of meaning in life
Lack of control/need for too much control
Negative self-statements and negative evaluation of experiences
Behavioral Signs of Stress
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Increased smoking
Aggressive behaviors (e.g., road rage)
Increased alcohol or drug use
Carelessness
Crying
Under-eating or Over-eating
Sleeplessness or want to sleep all the time
Withdrawal
Listlessness
Hostility
Accident-proneness
Nervous laughter
Compulsive behavior
Impatience
Diminished productivity
Self-injurious behaviors/suicide
Keep a stress diary for one week. Use a small 3x5 notebook to record stressful
situations and how your respond to them. By recording over time, you will come
to better understand your own personal stressors. Your individual stress pattern
is unique.
Note the physiological, behavioral, and cognitive signs of stress and assign a
“Stress Rating” by ranking them on a 10-point scale (where 10 is “extremely
stressful” and 1 is “not stressed at all). If you feel like you are “stressed all the
time,” then record 4 times a day: 1) before work, 2) mid-day (before lunch), 3)
after work, and 4) at bedtime.
 Date
 Time
 Where you were
 What you were doing
 Signs of Stress (physiological, behavioral, cognitive)
 Stress Rating (using 10-point scale)
Analyze the Sources of Stress
 Environmental/Social/Professional Sources
 Cognitive Sources
 Physical Sources
Different life crises have different impacts. In many cases, however, it may be
possible to anticipate crises and prepare for them. It may also be useful to
recognize the impact of crises that have occurred so that you can take account of
them appropriately.
Some very interesting work in this area has been done by Drs T H Holmes and R H
Rahe, with the Social Readjustment Scale. This allocates a number of 'Life Crisis
Units' (LCUs) to different events, so that you can evaluate them and take action
accordingly.
The idea behind this approach is to run down the LCU table, totaling the LCUs for
life crises that have occurred in the previous 2 years. As a rule of thumb, you may
anticipate some form of serious mental or physical effects of the crises according
to the following table:
Life Crisis Units (LCUs) and the Probability of Stress-Related Illness:
300 80%+
200-299 50%
150-199 33%
 Death of spouse 100
 Change in responsibilities at work 29
 Divorce 73
 Son or daughter leaving home 29
 Separation 65
 Trouble with in-laws 29
 Jail term 63
 Outstanding personal achievement 28
 Death of close family member 63
 Spouse begins or stops work 26
 Personal illness or injury 53
 Begin or end of school or college 26
 Marriage 50
 Change in living conditions 25
 Fired at work 47
 Change in personal habits 24
 Marital reconciliation 45
 Trouble with boss 23
 Retirement 45
 Change in work hours or conditions 20
 Change in health of family member 44
 Change in residence 20
 Pregnancy 40
 Change in school or college 20
 Sex difficulties 39
 Change in recreation 19
 Gain of new family member 39
 Change in church activities 19
 Business readjustment 38
 Change in social activities 18
 Change in financial state 38
 A moderate loan or mortgage 17
 Death of close friend 37
 Change in sleeping habits 16 C
 Change to a different line of work 36
 Change in number of family get-togethers 15
 Change in number of arguments with spouse 35
 Change in eating habits 15
 A large mortgage or loan 30
 Holiday 13 Christmas 12
 Foreclosure of mortgage or loan 30
 Minor violations of law 11
Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale.
Journal of Psychosomatic Research, 11, 213-218.
Environmental/Social/Professional Sources of Stress
Large-Scale Environmental Sources of Stress
 War
 Terrorism
 Possibility of natural disasters
 Environmental toxins
 Crowding
 Noise
 Disorganized environments
Environmental/Social/Professional Sources of Stress
Common Family Stressors
 Marital problems/Divorce
 Financial problems
 Health problems in family member
 “Sandwich Generation”
 Problems with behavior of a child
 Blended families
 Death of a family member
 Member of the family leaving home and other
significant life adjustments
 Difficulty with achieving family/work balance
(Dual role women)
 Change in family residence
 Isolation/loneliness
Environmental/Social/Professional Sources of Stress
Common Work Stressors
 Beginning a new job
 Retirement
 Work overload
 Time pressures
 Role ambiguity or uncertainty
 Lack of job security
 Poor relationships with supervisors or
colleagues
 Responsible for things you cannot control
Special Work Stressors for Nurses

Dealing with death and dying

Conflict with physicians

Inadequate preparation to deal with the emotional needs of
patients and their families

Lack of staff support

Conflict with other nurses and supervisors

Workload

Uncertainty concerning treatment

Inadequate financial and other rewards

Physical stresses and strains
Cognitive Sources of Stress
 Negative Self-Statements are converted into beliefs (generally,
irrational beliefs such as Perfectionism)
 Unrealistic expectations
 Pessimistic world view
 Imagining the worst outcomes
 Ruminative worry
 Illusions about change
 Significant life events and our reactions
 Victims of our autobiography
 Unrealistic expectations
 Black/White (“Either/Or”) v (“Both/And”) thinking
 Failure to stay in the Present
Common Irrational and
Self-Defeating Beliefs
 One should be liked, or approved of, by almost everyone.
 To be worthwhile, one must be competent in all things.
 Things should always be the way we want them to be, and
it’s terrible when they aren’t.
 A person’s present and future behavior is irreversibly dependent upon
significant past events. People can never change.
 Every problem must have an ideal solution, and it’s really bad when this
solution is not found.
 Everything I do must automatically lead to an immediate payoff.
 Individuals have little internal control over their personal happiness or misery.
 If there is some possibility that something can go wrong, one should worry
about it.
 It is easier to avoid than to face difficulties and responsibilities inherent in
living.
 People can’t be trusted to make their own decisions.
Our History MAY Become Our Future
 Habits are formed through repetition
 Psychological and neurological “ruts”
(Synaptic pathways)
 Negative self-image, internal self-talk,
self-defeating beliefs
The Good News! People can change through insight and action!
The Structure of Emotional Responses
A
C
Activating Event
(e.g., Boss’s reprimand)
Feelings and Behavior
(e.g., upset, nervous, defensive)
This is the model that most people believe.
Albert Ellis: A-B-C Model
Between A (Activating Event) and C (Feelings and Behavior)
is B -- your thinking and your self-talk.
A
B
C
Activating Event
(e.g., Boss’s reprimand)
Your Thinking
(e.g., “I can’t do anything right” OR
“I made a mistake, but I’ll be more
careful next time.”)
Feelings and Behavior
(e.g., upset, nervous, defensive OR
disappointment, but kept in perspective)
Locus of Control
(A Continuum)
Internal
External
Locus of Control
Locus of Control
Free Will
Vs.
Destiny
Learned Helplessness – the failure to avoid or
escape from an unpleasant or aversive stimulus that
occurs as a result of previous exposure to unavoidable
painful stimuli.”
Learned Helplessness has been
observed in dogs, rats, mice, cats,
monkeys, and even Walleyed Pike!
On Elephants and
Fleas
Physical Sources of Stress
 Poor or unbalanced diet
 Lack of exercise
 Smoking
 Alcohol & Drug use (including the
inappropriate use of prescribed medication)
 Caffeine
 Poor sleep habits
 No time for relaxation
 Hormonal exacerbation of emotional states
Develop a Stress Management Plan:
Techniques
 Discover a Larger Perspective
 Change Your Point of View - Optimism
 Cognitive Restructuring
 Relaxation/Meditation/Prayer/Silence
 Change in Physical Health Habits
 Changing the Situation
 Self-Expression
 Humor
 Time Management
 Social Support and Connections
Discover a Larger Perspective
The Eagle Nebula – 7 Million Light Years Away
Some Ways of Discovering a Larger Perspective
 Become involved in a regular practice of prayer and
participate in a worship community
 Experience your faith
 Read about your own tradition
 Explore other religious & spiritual traditions
 Take classes in philosophy, metaphysics or other
disciplines that focus on meaning
 Investigate your family genealogy
 Look to nature
 Write down or sketch your thoughts and reflections
Optimism to Reduce Stress
Optimistic versus Pessimistic Cognitions During Hard
Times
Optimistic
Pessimistic
Temporary
Permanent
Specific
Pervasive
External
Personal
Source: Martin Seligman, Learned Optimism
 In a 23-year study done in a small town in Ohio by researchers
from Yale and Miami Universities, people over 50 who viewed aging
as a positive experience lived an average of 7.5 years longer than
those who did not -- a big gap. (The researchers controlled for such
possible confounding factors as race, gender, state of health, morale,
1/17/05
and loneliness.) People got more mileage out of optimism, in fact, than
from lowering blood cholesterol levels. And other things being equal, they
got more mileage out of their will to live than other psychological factors.
 Mayo Clinic researchers followed 447 people whose personal traits had
been evaluated 30 years earlier. Those classified as optimists had half the
risk of early death compared to those classified as pessimistic or "mixed."
The optimists had fewer problems as they aged--fewer limitations, less pain,
and more energy.
 In a study called "Is the Glass Half Empty or Half Full?" Harvard
researcher Dr. Laura Kubzansky found that optimism, as evaluated in the
way people explain events in their lives to themselves and others, was
protective against heart disease. Other studies have found that optimists
tend to recover faster after coronary bypass surgery than pessimists. Dr.
Kubzansky and other researchers believe that negative emotions and
chronic pessimism should be regarded as risk factors for heart disease.
BBC Interview with the Dalai Lama:
“Why would I give them my mind?”
“If the only prayer you said in
your whole life was ‘Thank you,’
it would be sufficient.”
-- Meister Eckhart
Cognitive Restructuring to Reduce Stress
1. Recognize
2. Challenge
3. Change
1. RECOGNIZE: Become more aware of your thoughts
and feelings that occur in response to stressful
situations. These Negative Automatic Thoughts (NATs)
often go under the radar – unconscious and knee-jerk.
Eavesdrop on this internal monologue by asking
yourself: “What were my thoughts and what was I
saying to myself about the situation that contributed to
my feelings of stress?”
2. CHALLENGE: Reframe with questions
 Is this thought really true?
 What is the worst thing that could happen?
 What is the likelihood of the worst happening?
 Am I overemphasizing a negative aspect of this situation?
 Is there anything that might be positive about this situation?
 Am I “catastrophizing” or “awfulizing,” jumping to conclusions, or assuming a
negative outcome?
 How do I know this situation will turn out this way?
 Is there another way to look at this situation?
 What difference will this make next week, month, year? Will I even remember this
a year from now?
 If I had one month to live, how important would this be?
 Have I done everything I can to change the situation for the better?
 Am I using words like “never,” “always,” “worst,” “terrible,” or “horrible,” to
describe the situation?
Good Luck? Bad Luck? Who Knows?
“Do you have the patience to wait
till your mud settles and the water is
clear? Can you remain unmoving till
the right action arises by itself?”
-- Tao te Ching
2. CHALLENGE: Cont’d.
 Use the “double-standard technique”:
Ask yourself: “Would I say this to a close
friend with a similar problem?
If not, what would I say to him/her?”
Give yourself the same encouraging, empathic
messages you would give
to a good friend.
 Reflect on past experience: “Has anything
like this happened to me in the past and, if
so, how did it turn out?”
3. CHANGE:
Replace Old Cognitions with New Ones
 Replace “awfulizing” with healthy,
realistic alternative cognitions. With
practice, you can learn to use
Cognitive Restructuring to turn off
the negative stress filter, catch and
reframe NATs and develop a greater
sense of control over your mental
responses to stress.
1. Identify the Self-Defeating Belief
2. Develop a realistic alternative
3. Systematically substitute the realistic
alternative for the Self-Defeating Belief
Self-Defeating Belief
Realistic Alternative
One should be liked, or approved of, by almost
everyone.
No one is liked by everyone. It’s unrealistic to
expect to be.
To be worthwhile, one must be competent in all
things.
One should not expect to be perfect in all
respects.
Things should always be the way we want them to be,
and it’s terrible when they aren’t.
Things are not always the way we want them to
be, but that’s not the end of the world.
A person’s present and future behavior is irreversibly
dependent upon significant past events. People can
never change.
People can and do change.
Every problem must have an ideal solution, and it’s
really bad when this solution is not found.
Many problems don’t have ideal solutions. It’s
unrealistic to expect them to.
Everything I do must automatically lead to an
immediate payoff.
Only a small proportion of what I do leads to an
immediate payoff.
Individuals have little internal control over their
personal happiness or misery.
We can exercise a great deal of control over our
own happiness or make our misery worse.
If there is some possibility that something can go
wrong, one should worry about it.
We should make reasonable preparations for
adversity, but excessive worrying won’t help.
It is easier to avoid than to face difficulties and
responsibilities inherent in living.
In the long run, it’s better to face difficulties and
accept responsibility.
People can’t be trusted to make their own decisions.
I can facilitate other people’s decision making,
but I can’t decide for them.
Myths of the Perfect Nurse
 Cares deeply for all patients
 Has no life aside from serving mankind
 Considers herself the physician’s handmaiden
 Never makes an error*
 Is compulsively neat and perfect
 Is always calm
Strive for “perfection” in limited (and critical) areas
During Stress:
Refocus Your Thoughts, Reset Your Bearings
 What's my goal?
 I need to calm down.
 This situation isn't worth it.
 I'll take a few seconds here to relax.
 My body is telling me it isn't happy.
 What can I do to calm down? Ok, time for a warm bath!
Ok, time for a walk around the block.
 What's the best way out of here?
 I'm just human. So, I'll do the best I can, and let the rest go.
The Serenity Prayer
God grant me the serenity
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.
--Reinhold Niebuhr
Relaxation, Meditation, Prayer, Silence
to Reduce Stress
Relaxation Response
 Innervated by the Parasympathetic Nervous System
 Relaxation is not the same state as sleep, recreation, or
hypnosis
 Relaxation is a specific, integrated, innate, physiological
state of the body that includes:
 Decreased respiration rate
 Decreased heart rate
 Changes in blood flow (away from the skeletal
muscles – resulting in warm hands and feet)
 Decreased muscle tension
 Decreased metabolism
 Increased digestion
 Changes in blood chemistry
Stress v Relaxation:
What is the Message?
Short-Term Effects of Relaxation Response
 Alleviation of immediate stress
 Feelings of refreshment
 New outlook and improved creativity
Long-Term Effects of Relaxation Response
 Reduction of headaches, muscle aches, anxiety
 Reduction of the effects of long-term problems
associated with the chronic occurrence of the
stress reaction
 Vibrant health
Effects of Relaxation Response:
Research Results from MindBody Institute in Boston
 Patients with hypertension experienced significant decreases in blood pressure
and needed fewer or no medications over a three-year measurement period
(Eileen M. Stewart).
 Patients with chronic pain experienced less severity of pain, more activity, less
anxiety, less depression, less anger, and they visited the managed care facility
where they received care 36 percent less of- ten in the two years after completing
the program than they did prior to treatment (Margaret A. Caudill).
 Seventy-five percent of patients with sleep-onset insomnia were cured and
became normal sleepers. Sleeping also improved for the other 25 percent, and
most patients took significantly fewer sleep medications (Gregg D. Jacobs).
 Patients with complaints described by the admitting personnel as psychosomatic
and who were frequent users of a health maintenance organization reduced their
number of visits by 50 percent (Carolinej.C. Hellman).
Source: Herbert Benson, Timeless Healing, Scribner
Research on the Relaxation Response
 Patients who suffered from anxiety or mild or moderate depression were less anxious,
depressed, angry, and hostile (Herbert Benson).
 Women suffering from symptoms of premenstrual syndrome (PMS) experienced a 57
percent decrease in severity. The more severe the PMS, the more effective the relief with
the relaxation response (Irene L. Goodale).
 Patients undergoing painful X-ray procedures experienced less anxiety and pain and
needed one- third the amount of pain and anxiety medications usually required (Carol L.
Mandle).
 Patients who had open-heart surgery had fewer postoperative arrhythmias and less
anxiety following surgery (Jane Lesserman).
 Migraine and cluster headache sufferers found they had fewer and less severe
headaches (Herbert Benson).
 High school sophomores increased their self-esteem (Herbert Benson).
 Working people experienced reduced symptoms of depression, anxiety, and hostility
(Patricia Carrington).
 Working people had fewer medical symptoms, fewer illness days, improved
performance, and lower blood pressure (Ruanne K Peters).
Meditating nuns have increased activity
(red) in regions used for concentration
Source: Andrew Newberg, M.D. Director of Clinical Nuclear Medicine,
Director of NeuroPET Research, and Assistant Professor in the Department
of Radiology at the Hospital of the University of Pennsylvania
Meditating nuns have decreased activity (yellow) in
areas promoting a sense of self (e.g., ego)
Source: Andrew Newberg, M.D. Director of Clinical Nuclear Medicine,
Director of NeuroPET Research, and Assistant Professor in the Department
of Radiology at the Hospital of the University of Pennsylvania
Mind/Body Connection Well Documented:









Progress in psychoneuroimmunology
Stress and the immune system
Health behaviors and immune function
Stress and wound healing
Social support as a buffering factor
Cancer incidence and metastasis
Progress in cardiovascular physiology
Stress and cardiovascular function
Health behaviors and cardiovascular function
Do’s and Don’ts of Relaxation Techniques
Do
Don’t
Wear comfortable, loose clothing and
have proper back support
Put yourself in an awkward position or
one that will make it easy to fall asleep
Allow your mind to quiet down. Let
tense thoughts pass through like clouds
going across the sky
Think your way into tension – let
stressful thoughts pass through
Stay alert and conscious – focus on your
breathing and the feelings in your body
Allow yourself to become groggy or
sleepy – If you start to fall asleep, open
your eyes, sit up and return to relaxation
Go at your own pace and let go of your
muscles as your body decides to give up
tension
Expect yourself to relax all at once – You
must practice step by step
Give your body messages of appreciation
for relaxing
Get down on yourself or be impatient
Stay aware of your breathing
Smoke before, during or after relaxation
– let your body breathe
Two Popular Relaxation Techniques:
 Muscle-Tension Release
 Guided Imagery
1. Find a quiet place where you will not be interrupted.
2. Get comfortable – loose clothes, take off glasses, comfortable chair with
your head supported.
3. Stretch and take a deep breath
4. Close your eyes.
5. Repeat the word “calm” (or one of your choosing) each time you exhale.
6. Breathe in through your nose, hold your breath to a slow count of 5,
exhale through your mouth. Follow your breath with your mind.
7. Practice for about 15 minutes each day.
8. Begin to notice the difference in your body when it you are in a relaxed
state vs. stressed state.
Change Physical Health Habits to Reduce Stress
 Take 15-20 minutes each day to relax
 Get regular physical activity, such as walking or other exercise
(exercise is a very powerful stress buster)
 Eat healthy, well-balanced meals
 Pray or meditate to strengthen your religious or spiritual side
 Get enough sleep
 Bring pleasure into your life with things you enjoy, such as visiting with
friends, starting a hobby, reading, or listening to music
 Smoke – If you do, quit, even if it takes several attempts to succeed
 Drink too much alcohol -- Alcohol does not reduce the effects of stress
and may keep you from facing issues you should handle in better ways
 Drink too much coffee (or caffeine)—Coffee in small amounts seems
harmless, but too much can make you feel nervous and tense
 Overeat, especially between meals—Try to replace "nervous eating" with
a healthy habit such as relaxation, physical exercise, or pleasurable
activities
Steps to Changing Health-Related Behaviors
1. Record the current frequency and typical
circumstances of the behavior you want to
change.
2. Set a realistic behavioral goal for yourself.
3. Initiate a planned strategy for change.
4. Reward yourself for succeeding.
5. Don’t give up if you fail to meet your goal.
Change the Situation to Reduce Stress
1. Collective Efforts
2. Personal Efforts
Get Involved!
Individually and Collectively work toward the
implementation of the recommendations of
Nursing’s Agenda for the Future!
"Never doubt that a small group of thoughtful,
committed people can change the world.
Indeed, it is the only thing that ever has."
-- Margaret Mead
Get Involved!
 Improve workplace design and environmental conditions
 Clearly define nurses’ roles and responsibilities
 Ensure that the workload meets workers' capabilities and resources (e.g.,
adequate staffing)
 Design jobs to provide meaning, stimulation, and opportunities for workers to
use their skills
 Give staff opportunities to participate in decisions affecting their jobs
 Make sure there are good communications between all sectors of the workplace
 Put clear career development plans into place and address any uncertainties
about future employment prospects
 Implement flexi-hours and other strategies that will help
nurses balance work and home life
The Connection Between Processes and Structures and
Engagement with Work
Management Processes & Structures
Mission and Goals
Central Management
Supervision
Communication
Performance Appraisal
Health and Safety
Six Areas of Organizational Life
Workload
Control
Reward
Community
Fairness
Values
Engagement with Work
Energy
Involvement
Effectiveness
Source: Christina Maslach & Michael P. Leiter, “The Truth About Burnout,”
San Francisco: Jossey-Bass, 1997
Personal Approaches to
Changing the Stressful Situation
 Get clarification of your job responsibilities
 Delegate when possible
 Learn to say “no”
 Transfer to another department or another supervisor
 Suggest alternative solutions to your supervisor
 Find another job
 Find another profession
BRAINSTORM!
Personal Approaches to
Changing the Stressful Situation
A powerful source of stress for many
people – especially women – is the failure
to express one’s feelings and, instead hold
things in until they’re ready to pop.
This the “Volcano Syndrome.”
Assertiveness is the honest and clear expression of
thoughts, feelings, and opinions that is respectful and
does not violate the rights or dignity of another. In other
words, Assertiveness is about standing up for yourself,
believing in your opinions and your right to be heard and
getting your needs met. But it is also about respecting the
opinions and needs of others.
A Continuum
Assertiveness is a SKILL that can be learned and it
reduces stress by allowing you to have greater control
in interpersonal situations and set limits.
Comparison of Alternative Behavior Styles
Passive
Assertive
Aggressive
Characteristics
Allow others to choose
for you. Emotionally
dishonest. Indirect.
Inhibited.
Choose for self.
Appropriately honest.
Direct. Self-Respecting.
Choose for others.
Inappropriately honest
(tactless). Direct.
Your Feelings
Anxious. Ignored.
Helpless. Manipulated.
Confident. SelfRespecting. Valued.
Righteous. Superior.
Controlling.
Others’ Feelings
Guilty or superior.
Frustrated with you.
Valued. Respected.
Humiliated. Hurt.
Defensive. Resentful.
Others’ View of
You
Lack of respect.
Distrust. Do not know
where you stand.
Respect. Trust. Know
where you stand.
Vengeful. Angry.
Distrustful. Fearful.
Outcome
Others achieve their
goals at your expense.
Your rights are violated.
Outcome determined by
above-board
negotiation. Your and
others’ rights respected.
You achieve your goal
at others’ expense.
Your rights upheld;
others violated.
Underlying
Belief System
I should never make
anyone uncomfortable
or displeased…expect
myself.
I have a responsibility to
protect my own rights: I
respect others but not
necessarily their
behavior.
I have to put others
down to protect
myself.
Areas of Assertive Behavior
1. Setting limits (e.g., saying “no,” refusing requests)
2. Expressing negative feelings (e.g., delivery
criticism, expressing angry feelings)
3. Expressing positive feelings (e.g., expressing
compliments, expressing feelings of warmth or
appreciation)
4. Initiating activities or conversations
Very few people are either always assertive or always
non-assertive. There is a great deal of situational
specificity – most people find it easy to be assertive in
certain situations but not in other or all situations.
Components of Assertive Behavior
1. Verbal (what you are saying)
2. Non-Verbal (what your body is saying)
3. Affective (how you are feeling)
4. Cognitive (what you are thinking)
5. Listening (what are you hearing)
Assertiveness is not a series of short, unconnected
responses, but rather an interpersonal style that allows the
opportunity to express one’s own thoughts, feelings, and
needs openly and clearly to other people in a way that is
respectful. It results in clear, authentic communication as
well as increasing self-confidence and self-esteem.
Verbal Component of Assertive Behavior
 Empathy or Positive Statement (lets the
other person know you experience
empathy or note what they are doing right
– NOT a self-deprecating statement)
 Conflict Statement (what the problem is)
 Action Statement (what you would like
the other person to do)
Non-Verbal Component of Assertive Behavior
 Eye contact
 Posture
 Facial expression
 Voice characteristics (e.g., volume, tone, pitch)
 Touching
 Personal space
 Hand gestures
 Latency to respond (shorter = more assertive)
 Duration of response (longer = more assertive)
 Research shows that about 98% of what we communicate is non-verbal.
 Very strong cultural differences in non-verbal communication.
 We send confusing messages when there is a disconnect between verbal
and non-verbal components of our communications.
The Pan American smile, named after
the airline, is a perfunctory smile. It is
nothing but a courtesy smile as in the
case of a flight attendant responding
to a patron. It's an expression of
courtesy and politeness rather than
inner joy. Alas, the Pan Am airline is
dead but the smile will live forever.
The Duchenne smile, named after the researcher
Guillaume Duchenne, who first described it. It is
a genuine smile. The corners of the mouth curl
up and the skin around the eyes crinkles in
crow's feet like shape. The facial muscles
involved in this expression are difficult to control
voluntarily. Therefore, it's difficult to fake a
Duchenne smile unless your smile from within.
Affective Component of Assertive Behavior
 How are you feeling?
 When people hesitate to make an assertive
response, it is because of one of two reasons:
1) They don’t know what to do (skills deficit)
2) They feel uncomfortable doing so (anxiety inhibition)
 The majority of people resist behaving assertively
because they feel anxious or uncomfortable doing so,
not because they don’t know what they “should” do.
Cognitive Component of Assertive Behavior
 What are you thinking?
 People high in assertiveness expect more positive
outcomes.
 People low in assertiveness across a variety of
situations, often tell themselves all the negative things
that will result if they behave assertively (e.g., my boss
will fire me, my friend will dislike me).
 “The Myth of the Good Friend.”
 “The Myth of Modesty.”
Listening Component of Assertive Behavior
The active listener is reflective and empathic,
in order that the sender may feel accepted and
understood. The active listener is objective and
nonjudgemental, to avoid clouding the issue with
feelings of guilt and inferiority. By identifying the
feelings being transmitted, the active listener is
essentially telling the sender he/she is free to
express his/her emotions. By clarifying the
direction of these feelings, the active listener is
promoting the problem-solving process.
Express Yourself to Reduce Stress
 Talk about your stress with a friend or therapist
 Listen to others when they need an ear
 Express your suffering/stress through art or ritual
Process
and the
Story of the
Chinese Potter
Keep a Sense of Humor to Reduce Stress
“Humor is a prelude to faith and
laughter is the beginning of
prayer.”
-- Reinhold Niebuhr
Laughter Really Is the Best Medicine
 Through the “reverse exhalation” capacity of the lungs,
the physical contractions of laughter cause extra oxygen
to enter the body, moving stagnant air and increasing the
body’s blood oxygen level – This is aerobic, like “inner jogging.”
 The muscle movement of laughter increases peripheral circulation –
associated with the innervation of the parasympathetic nervous system
and the “relaxation response.”
 In many ways the breathing patterns of laughter are similar to those
that naturally occur during meditation.
 Laughter lowers serum cholesterol, reduces stress-related hormones,
and increases virus killer cells, B-cells, and activated T lymphocytes – all
of which improve immune system functioning and offset the
immunosuppressive effects of stress.
 Laughing releases endorphins – the body’s own natural opiates –
which diminish both physical and emotional pain.
Time Management to Reduce Stress
 Time management refers to actively structuring
your time so that you avoid stress and maximize
the likelihood of engaging in those activities that
you view as important.
 Organization is crucial.
 Designating time that honors and reflects your
priorities and values is critical.
 Drop low value jobs/tasks.
 Avoid distractions.
 Create more time.
Not Enough Time?
 Time-use studies show that leisure time
from 1965 to 1985 actually increased by 5
hours per week.
 The average American schedule has more
than 40 hours a week that could be used to
make deposits into our social capital account
and the important connections in our life.
 Question of priorities & values, not of time.
Make Values Personal
1. Identify Five (5) CORE VALUES that are both
personal and professional.
2. List at least two BEHAVIORS that exemplify
those values.
3. Close your eyes – meditate on the past two
weeks of your personal and professional life.
4. Honestly appraise how often you act on your
values.
5. Write down typical examples of when you live
your values and when you don’t.
6. Discuss.
Values – Food for Thought:
Assertiveness
Balance
Caring
Courage
Courtesy
Commitment
Compassion
Confidence
Creativity
Consideration
Detachment
Determination
Enthusiasm
Excellence
Equality
Flexibility
Faithfulness
Forgiveness
Friendliness
Fairness
Gentleness
Generosity
Honor
Humility
Helpfulness
Honesty
Idealism
Innovation
Integrity
Independence
Inter-Dependence
Genuineness
Empathy
Joyfulness
Justice
Kindness
Love
Loyalty
Mercy
Moderation
Knowledge
Obedience
Orderliness
Modesty
Patience
Peacefulness
Prayerfulness
Purposefulness
Respect
Responsibility
Risk-Taking
Objectivity
Quality
Happiness
Security
Self-Discipline
Service
Steadfastness
Trust
Truthfulness
Tolerance
Harmony
Wisdom
Unity
Self-Knowledge
Self-Esteem
Wealth
Fame
Success
Intimacy
Beauty
Pleasure
Excitement
Contentment
Teamwork
EXAMPLE
Value = BALANCE
Behaviors = 1. Eat a healthy dinner with my
family at least four nights a week.
2. Play tennis twice a week.
Evaluate = The Past Two Weeks.
Television: Time Stealer
 Americans spend more hours alone in front of their TV sets (3-4
hours per day) than in any other activity except work & sleep
 TV watching accounts for more than ½ of all leisure time
activity
 Heavy television watchers are more likely to be pessimistic,
overestimate crime rates, and spend less time engaged with
others
 The only leisure time activity that is associated with decreased
(rather than increased) social capital and connections
 “The data suggest that most Americans would rather watch
Friends than have friends.” – Robert Putnam, Bowling Alon
 Longer work hours are associated with more (not less) civic
engagement and connections (e.g., report 30% less TV)
Stay Connected to Reduce Stress
In his book Love and Survival: The Scientific
Basis for the Healing Power of Intimacy,
physician Dean Ornish summarizes the power
of connections this way: “I am not aware of
any other factor in medicine – not diet, not
smoking, not exercise, not stress, not genetics,
not drugs, not surgery – that has a greater
impact on our quality of life, incidence of
illness, and premature death from all causes.”
The Dark Side of Connection:
Faulty Boundaries
 Armor
 Jell-O
 Semi-Permeable Membranes
Be Aware that “Compassion Fatigue” Affects
BodyMindSpirit
Some Symptoms of this “Care-Giving Shutdown”
 Fatigue
 Joylessness
 Pessimism
 Social Withdrawal
 Uninterested in intimacy or sex
 Concentration Difficulties
 Irritability
 Depression
 Physical Symptoms and Illness
 Feeling like you’re “just going through the motions” – lack of
passion or meaning
 Negative Coping Behaviors – Substance Abuse, “Soft Addictions”
“Illumined Selfishness” – Healthy Self-Care
 Nurture BodyMindSpirit
 Physical Regimen to Deal with Stress
 Quiet Time for Reflection, Prayer, Meditation, Solitude
 Creative Activities
 Social Support – Talk About It!
 Spiritual Support
 Optimism
 Humor
 Approach NOT Avoidance
 Cognitive Reframing
Caregivers often think we are the “Energizer Bunny” and can keep
going and going and going – This is a dangerous belief!
Balanced Wellness
Physical Health
Intellectual Health
Emotional/Social Health
Spiritual Health
Work environment factors leading to burnout include:





role conflict
ambiguity
autonomy
no opportunity to participate in decisions
lack of control of one's job
 giving too much and not taking self-care
Individual personality characteristics of people at risk
of suffering from burnout include:
 young idealistic professionals who have unrealistic expectations
about the work situation
 empathic people who pour too much of themselves into their job
 an individual's reaction to stress coupled with their stress-coping
mechanisms
The MBI-Human Services Survey (Maslach Burnout Inventory) measures
burnout as it manifests itself in staff members in human services
institutions and health care occupations such as nursing, social work,
psychology, and ministry.
“Burnout is the index of dislocation between what people are
and what they have to do, It represents an erosion in values,
dignity, spirit, and will – an erosion of the human soul.”
Subscales of Burnout Maslach
Burnout Inventory
Emotional Exhaustion
Depersonalization
Personal Accomplishment
MBI-HSS: Twenty-two items written as statements answered on a 7-point scale.
Emotional Exhaustion Subscale:
I feel emotionally drained from my work.
Working with people all day is really a strain for me.
Frequency Patterns:
High Burnout – several times a month or more
Low Burnout – several times a year or less
Depersonalization subscale:
I’ve become more callous toward people since I took
this job.
I worry that this job is hardening me emotionally.
Frequency Patterns:
High Burnout – once a month or more
Low Burnout – once or twice a year or less
Personal Accomplishment Subscale
(reverse scoring):
In my work, I deal with emotional problems very calmly.
I feel I’m positively influencing other people’s lives through
my work.
Frequency Patterns:
High Burnout – less than once a week
Low Burnout – several times a week or daily
Integration of Dualities
As in all dualities, the wise strive to
“hold the tension of the opposites”
to integrate and balance opposing
forces as we allow ourselves to
experience compassion for others
AND for ourselves.
Become a Lake
“We are here to awaken from the illusion of our separateness.”
-- Thich Nhat Hanh, Vietnamese Buddhist Monk
A Social Animal
“By our very natures, humans are prepared to be
social animals. We are biologically and
psychologically prepared for attachment and
bonding. Our need for connection is – from birth
and beyond – a fundamental survival need.”
-- Living a Connected Life
Maslow’s Hierarchy of Needs
The Roseto Effect – 1950s
A small town in Pennsylvania – A close-knit community of
Italian immigrants who lived longer lives than people in
neighboring towns and were virtually free of heart disease.
Had they found the alchemical Elixir Vitae?
No! They had high levels of social cohesion, trust, and
mutual respect. They were connected.
From 1979 to 1994, eight large-scale
community-based studies confirmed
what those early researchers found
in Roseto.
Scientific Studies
Five decades of medical and epidemiological research has
shown the powerful and positive effects of connections on:
 Heart and cardiovascular disease
 Stroke
 Respiratory Diseases
 Cancer
 Allergies, Colds, and other Infectious Diseases
 AIDS/HIV
 Depression, Stress and other Psychological Problems
Interesting Gender Difference
 When women are stressed – they move toward greater
connection with other (“Tend and Befriend” rather than
“Fight or Flight”)
 Men under stress tend to “hole up”
 Women respond to stress with a surge of brain chemicals
(such as oxytocin) that buffer the “fight or flight” response,
pushes them toward social contact, which releases more
oxytocin which calms them further. Estrogen (a female
hormone) has an enhancing effect on oxytocin whereas
testosterone (a male hormone) reduces it.
Klein, Laura & Taylor, Shelley (UCLA Stress Research Lab), 2002
A Thousand Words For Snow
Assumptions for the Model
1.
2.
Everyone needs a variety of people and relationships in their lives
Relationships are not static; they change, as do our lives and
needs.
3. Think of the “rings” in the model as semi-permeable membranes
4. It is the inner circle of relationships – those with whom we are
connected by the heart – that constitute our “tribe” or true safety
net. These are the containers that serve as our containers for
emotional and spiritual growth
5. With the possible exception of our biological family, most
relationships do not begin within this inner circle
6. Don’t mistake the “map” for the “territory” – life is really more
complex than any model can describe
The State of YOUR Safe Harbor
Know Thyself
 You can’t have a better relationship with anyone
else than the one you have with yourself
 What do you bring into your relationships?
 How well do you know yourself?
 The Persona and The Shadow
 Emotional Intelligence (EQ)
 “To know others is to be wise, to know oneself
is to be enlightened” – Tao Te Ching
“If we really want to love, we
must learn how to forgive.”
- Mother Theresa
Forgiveness: A Special Opportunity for Healing and Health
 Those who have studied it can tell you without qualification that
forgiveness is a sign of strength. Not only is it a very human quality, displays
of forgiveness and reconciliation are common among monkeys, apes and
other primates, and suggest this behavior has been around for over thirty
million years. And research conducted at the University of Wisconsin in 1997
indicates forgiveness can be taught and with positive results.
 On January 2, 1998, ABC News reported "studies show that letting go of
anger and resentment can reduce the severity of heart disease and, in some
cases, even prolong the lives of cancer patients."
 Dr. Frederick DiBlasio of the University of Maryland is one of many family
therapists successfully using forgiveness as a tool to reconcile couples when
other techniques have proved ineffective.
 Everett Worthington, Jr. who is a professor of Clinical Psychology at
Virginia Commonwealth University and a pioneer in forgiveness research,
has found that people who won't forgive the wrongs committed against
them tend to have negative indicators of health and well-being: more
stress-related disorders, lower immune-system function, and worse
rates of cardiovascular disease than the population as a whole.
www.forgiving.org
 Charlotte vanOyen Witvliet, PhD (assistant professor of psychology at Hope
College in Holland, MI) is investigated the physiological effects of forgiveness
and unforgiveness. Results demonstrated that unforgiving thoughts increase
sympathetic nervous system arousal, heart rate, and blood pressure.
 Porter Storey, MD, (medical director of the Hospice at the Texas Medical
Center and a pain and symptom management consultant at the M.D.
Anderson Cancer Center in Houston). “Forgiveness can dramatically improve
a lot of parameters in patients much more effectively than expensive
medications, and it has essentially no bad side effects." His focus is on
forgiveness among terminally ill cancer patients. In the 20 years Dr. Storey
has been caring for dying patients, he has noticed that those who are able to
let go of past anger and hurt experience a dramatic reduction in anxiety and
distress. This observation led him to begin investigating the ability of a
counseling intervention to increase forgiveness as well as patients' sense of
hope and overall quality of life.
 Forgiveness has been shown to predict both physical and emotional health.
This research confirms that association with self-reports of physical
symptoms, number of medications used, quality of sleep, and several indices
of psychological well-being (Kathleen Lawler, Ph.D.).
Forgiveness is something virtually all
Americans aspire to -- 94% surveyed in a
nationwide Gallup poll said it was
important to forgive -- but it is not
something we frequently offer. (In the
same survey, only 48% said they usually
tried to forgive others.)
"Everyone thinks forgiveness is a lovely
idea, until they have something to forgive.”
– C.S. Lewis
Three kinds of forgiveness, all interrelated:
 Self-forgiveness, which enables us to
release our guilt and perfectionism.
 Forgiveness we extend to others and
receive from them, intimates and enemies
alike.
 Forgiveness of God that assures us of
our worth and strengthens us for this
practice.
Awakening to the Ordinary Grace that Surrounds Us
 It all depends upon how you start out!
 Believing is Seeing.
 What do you believe about the nature
of humankind and grace itself?
 What is your worldview?
Our Culture and Media Tend to Focus
on What is Wrong with Humankind
 “Good news is no news.”
 “If it bleeds, it leads.”
Center for Media and Public Affairs – 2003 Year in Review of Top Television
News Stories – Based on 11,834 stories broadcast on ABC, NBC, CBS
Good-Natured
Binti-Jua and the Brookfield Zoo (IL)
August 16, 1996
Binti-Jua is Swahili for “Daughter of Sunshine”
Bonobos and Compassion
(Robert Yerkes, Frans de Waal, etc.)
Humans share 98.4% of our DNA with chimpanzees.
Is Empathy/Compassion Inborn in Human Beings?
Martin Hoffman’s (NYU) research shows that even
day-old infants show remarkable empathy and will
cry at the sound of another infants’ crying.
Psychologist Carolyn Zahn-Waxler, Ph.D.,
et al (NIMH) observed children whose
parents were hurt somehow - either
physically (e.g., father had a bad
headache) or emotionally (e.g., mother
received bad news and was crying). They
discovered that even very young children
had a very well-developed sense of
empathy. They reacted with concern,
wanting to help or "fix" the problem, and
they offered comfort and compassion to
the parent who was hurt.
Rescuing Hug
Brielle and Kyrie Jackson – born 10/17/95 twelve weeks
ahead of due date. Preemies were placed in separate
incubators to reduce the risk of infection at The Medical
Center of Central Massachusetts in Worcester.
Kyrie (born 2 pounds, 3 ounces) was doing well but Brielle
(born 2 pounds) was failing. A compassionate and quick-thinking
nurse, Gayle Kasparian. remembered that a common procedure in
Europe was for double-bedding of multiple-birth babies. With the
parents’ blessing, she placed Brielle in the incubator with Kyrie.
As soon as the door closed, Brielle snuggled up to Kyrie and calmed
down. Within minutes Brielle’s blood-oxygen readings were the best
they had been since her birth. As they dozed, Kyrie wrapped her tiny
arm around her smaller sibling.
Sooner than expected, the twins went home from the hospital!
Empathy is a neurological phenomenon, says
Thomas Lewis, M.D. (co-author A General
Theory of Love). “Watching one in pain fires the
same neurons fired when the one watching
undergoes the same type of pain,” he said. This
means that the brain empathizes with another
by generating an internal model of that other.
To put it simply, empathy at least partly relies
upon neural modeling.
Love and Medicine
There are few professions that require expressions of love
like the healthcare profession does. Medical caregivers
possess immense potential for expressing love.
Unfortunately, says Harvard University psychiatrist
Gregory Fricchione, “physicians take very little time to
express love through listening and spending time with
patients.” Patients who face the challenges brought by
separation from friends, family and familiarity need the
love of those in the medical fields, he said.
Fricchione pointed to research related to the role that the
brain’s amygdala plays in patient stress and worry. “The
amygdala continually sends signals related to fear and
anxiety when the patient is told of their illness and its
possible affects,” he said. However, he added, the nurture,
compassion and social attachment provided by caregivers
can significantly reduce the amygdala’s power to paralyze
patients through fear.
What We Believe Sets the Stage for Our Experience
We Determine What We Tune In To
 Original Sin v Original Blessing (Matthew Fox)
 “We are born originally pure.” (Dalai Lama)
 “We have been loved since the beginning.”
(Julian of Norwich – 15th Century Christian mystic)
 “Among all the strange things that men have
forgotten, the most universal and catastrophic lapse
of memory is that by which they have forgotten that
they are living on a star.” (G.K. Chesterton)
Good and Evil
 Are good and evil opposites or two sides of the same
human coin?
 The banality of evil (Hannah Arendt on Adolf Eichmann)
 “There is a capacity of virtue in us, and there is a capacity
of vice to make your blood creep.” (Ralph Waldo Emerson)
 What does it mean to be human?
Amazing Grace Surrounds Us
As Close as Our Next Breath
John Newton was the captain of a slave ship.
On May 10, 1748 on a homeward voyage, while he was attempting to
steer his ship through a violent storm, he experienced what he was
to refer to later as his “great deliverance.” He recorded in his journal
that when all seemed lost and the ship would surely sink, he
exclaimed, “Lord, have mercy upon us.” Later in his cabin he
reflected on what he had said and began to believe that God had
addressed him through the storm and that grace had begun to work
for him.
He returned to England, decided to become a
minister, and applied to the Archbishop of York for
ordination. He wrote hundreds of hymns, the best
known of which is “Amazing Grace.”
John Newton 1725-1807
What is it about some people who see
‘compassion’ as a verb?
 All kinds of people demonstrated ordinary grace
 Felt connections (never pity or sentimentality)
 Faith in the goodness of others
 To help others is a privilege, a blessing
 Humor
 Humbleness
 Impulse to do good is immediate
 Negatives into positives
Thank you for coming and
Godspeed on your journey.
www.fullpotentialliving.com
252-473-4004
Kelly
Kathleen and co-author Dorothy