28 September 2022

Stress has become a standard feature of our lives. Information overload and multiple demands can cause a heavy mental load, increasing our sense of being out of control. We are more available than ever before due to technology. Due to our constant connectivity, it seems harder for us to take time out and participate in activities which help to relieve stress. However not all stress is bad and we do need a certain level to keep us activated and enhance our performance. Getting the balance right is challenging and we do need to protect our wellbeing by reducing stress and safeguard our health.

Finding a clear definition of stress is challenging. It can be described as a form of psychological pain. We know the physiological response to a stressor is the release of adrenaline and cortisone. When we experience a perceived danger, our amygdala takes over to produce the flight or fight response through signals to the hypothalamus with activation of the sympathetic nervous system with adrenaline release and the pituitary and adrenal glands releasing cortisone.

In an acute situation, our frontal lobe may be impacted and our capacity for reasoning and problem solving can be impaired. This is known as amygdala hijack which is a basic survival response to danger. This can be responsible for emotional outbursts, poor memory recall and an inability to think clearly in an acutely stressful situation such as when we are dealing with an aggressive patient. In addition, stress increases our pulse, blood pressure, blood glucose and our respiratory rate in response to adrenaline and cortisone release. While this is necessary in an acute situation, when stress is chronic the continued activation of the hypothalamic pituitary axis contributes to health problems. Other symptoms of stress include rapid heartbeat, muscular tension, headaches, gastrointestinal upset, and insomnia.

Persistent adrenaline surges cause hypertension and in the longer-term elevated cortisone will result in both increased appetite and increased fat storage - both of which contribute to a range of health problems, in particular causing cardiovascular disease and inflammation. Longstanding, unresolved stress can also result in burnout. Typical behavioral characteristics displaying stress can include isolation, introversion, rumination, procrastination, anger, crying easily, self-depreciation, excessive caution, lack of enthusiasm, reluctance to ask for help, inflexibility, difficulty in taking rest breaks, difficulty in concentration, irritability, change in appetite and a sense of fatigue with decreased motivation. We may try to relieve stress in unhealthy ways such as with alcohol or drugs or by eating food for comfort. When we are feeling fatigued due to chronic stress, we are more inclined to eat fatty and sugary food and drink beverages containing caffeine to increase our energy levels. To protect our health is it essential to turn off the chronic stress response through means which assist us to relax and counter the harmful impact of stress.

A certain amount of stress is necessary to perform well and respond to everyday challenges. Many doctors and other healthcare professionals thrive and perform well in times of stress in the emergency department, during surgery and during resuscitation. A stress response to danger is also essential to save us and those around us in times of danger. But when stress becomes chronic and we experience an over-reaction to small stressors, this is a sign that stress is impacting our emotions, cognition, and physical health in a negative way. While we cannot banish stress from our lives and do not want to eliminate it entirely, we can learn how to reduce chronic stress and we can learn coping strategies to reduce its negative impact on us.

We can counter the stress response by using a combination of approaches that elicit the relaxation response. These include deep abdominal breathing, focusing on a soothing word (such as peace or calm), listening to calming music, visualising tranquil scenes, prayer, yoga, and tai chi. Also getting seven to nine hours of sleep a night is essential.

Exercise, such as taking a brisk walk shortly after feeling stressed, not only deepens breathing but also helps relieve muscle tension. Movement therapies such as yoga, tai chi, and qi gong combine fluid movements with deep breathing and mental focus, all of which can induce calm. Even the act of squeezing a stress ball can be helpful to release muscle tension.

When we are experiencing stress, it is important to enhance our diet with fresh whole foods such as fibre-rich fruits and veggies, fish, nuts, and even dark chocolate. Mediterranean-style diet (fruits and vegetables, whole grains, and lean protein) is an excellent option. Avoid too much caffeine and sugar, especially if tachycardia is a symptom of stress.

In times of chronic stress in the workplace, having outside interests, particularly an activity which takes our full concentration and focus, is a good way to set aside the stress and relax. Being proactive in our learning will increase confidence and self-esteem which will counter stress. This is especially important if new skills reduce our stress about performing certain tasks or dealing with situations. Training and education which increases self-confidence will reduce stress.

Social connection and support is also important. The buffering theory holds that people who enjoy close relationships with family and friends receive emotional support that indirectly helps to sustain them at times of chronic stress and crisis. Supporting each other and helping others are great antidotes to stress and provide a sense of purpose and satisfaction.

Setting boundaries and saying no to excessive demands is vital. However, in healthcare there may be times when we cannot control extrinsic factors in relation to our workload or a situation such as a patient who is critically unwell. When there is a crisis, we need to focus on good teamwork and supporting each other. When experiencing a stressful situation, self-reflection and self-awareness are fundamental to coping.

A lot of stressors are outside our control. Managing stress as a doctor or healthcare professional is important to reduce errors, improve patient safety and enhance productivity. Acknowledging stress and taking action to minimise the impact on our wellbeing through a range of strategies will benefit us and those we care for.

Kay Dunkley
AMA Victoria doctor wellbeing and mentoring
 

Further reading

• Why Stress Happens and How to Manage It | Everyday Health
• Stress management in Medicine Stress management in Medicine | SciELO - Brazil
• Doing What Matters in Times of Stress | WHO
• Understanding the stress response | Harvard Health