Stress First Aid for Health Care ProfessionalsRecognize and Respond Early to Stress Injuries

Learning Objectives

1. Identify how to recognize stress injuries in health care professionals

2. Describe how to administer Stress First Aid (SFA) at the individual level

3. Describe SFA as a method of peer support at the organizational level

Quiz Ref IDSimilar to physical stress, psychological stress can cause injury to the mind and body. These injuries go beyond burnout: a stress injury is any severe and persistent distress or loss of ability to function caused by damage to the brain, mind, or spirit after exposure to the overwhelming stressors of fatigue (burnout), trauma, loss, or moral injury.¹ In particular, there is a significant risk of moral injury in high-stress, service-oriented professions where valued qualities such as selflessness, loyalty, a strong moral code, and excellence can also create vulnerabilities, such as prioritizing the needs of others above one's own needs.

Stress injuries can cause behavioral changes, including:

• Withdrawal from friends and family connections

• Irritability

• Decreased impulse control and other unprofessional behaviors, such as displays of anger in public or patient care areas

• Impaired judgment, for example, when making clinical decisions

• Working longer hours or becoming more rigid about following protocols

• Decreased self-care

Individual stress responses range from baseline to stress reactions such as feeling anxious or irritable, to stress injury where control of moods may be lost to stress illness that presents as severe distress or symptoms that last more than 30 days. Serious stress injuries can be a precursor to medical errors, exit from practice, or even depression or suicide.

The Stress Continuum Model (Figure 1) is a helpful, color-coded visual tool that¹:

• Creates a common language about stress reactions

• Differentiates between expected stress reactions and stress injuries, where help is needed

• Helps to reduce stigma by normalizing the language and understanding of stress reactions

• Facilitates recognition of when and what immediate and long-term actions would be most appropriate

Stress First Aid (SFA) is a framework for peer support and self-care for health care professionals. The SFA framework is parallel to how a clinician or first-responder approaches physical first aid—intervening when needed to remove the stressor, prevent further harm, and promote recovery for those who have been strongly affected by significant stress.¹Quiz Ref IDIndividuals may employ this framework when supporting peers or if they are aware of a potential injury in themselves, whereas organizations may train a team of health care professionals to administer SFA to their colleagues. SFA is usually administered to individuals experiencing a stress injury to stop progression to illness; however, as shown in Figure 1, SFA can be applied throughout the continuum.

The SFA framework is comprised of 5 essential needs that are related to increased resilience and recovery during a variety of adverse circumstances²:

1. A sense of safety

2. Calming

3. Social support

4. Occupational and coping competence

5. Confidence in oneself, others, and the future

These 5 essential needs, in turn, are the foundation for the 7 core functions of SFA (the 7 Cs) to improve self-care or to support a person whose behavior indicates that they may be experiencing stress injury (Figure 2).

1. Recognize a Stress Injury (Check & Coordinate)

2. Provide Primary Aid (Cover & Calm)

3. Provide Secondary Aid (Connect, Competence, & Confidence)

Recognizing a stress reaction or injury is an ongoing, continuous process that begins with the Check and Coordinate “Cs” of SFA. Whenever there is a change in behavior or change in risk for stress injury, consider performing these 2 Cs. The Stress First Aid Algorithm helps you determine the appropriate timing for the Check and Coordinate functions if you suspect a stress injury (Figure 3).

Check: Assess for Signs of Stress Injury

Be attuned to your coworkers—are they acting more withdrawn, or do they seem to have a shorter fuse than usual? Rather than look the other way or chalk it up to who they are or what they are going through, pause and think about checking in. Those who have a stress reaction or injury may not be aware that their behavior has changed. Reactive or injured individuals may also be unaware that they are at an increased risk of serious consequences such as depression, sleep disturbance, or post-traumatic stress disorder (PTSD). Health care professionals need to become skilled at checking in with their colleagues during times of crisis. This could be just the outreach a coworker needs during a rough time.

Fear of stigma can be an obstacle to asking for help. In addition, stress injuries may last a long time after the event or be triggered by a new experience. By cultivating a habit of attention to and checking-in with colleagues, you will be better able to observe patterns of behaviors that may indicate a stress injury and offer support. The Check function can be intimidating because we do not want to intrude into a peer's personal life, and yet, we are often in roles that require vigilance for patient and team member safety where we must act.

The OSCAR communication strategy is one tool for conducting a check with a peer without making any assumptions about what the peer is feeling or thinking (Table 1).

Coordinate: Connect With Additional Support

If you have recognized significant stress in a colleague, the next automatic and complementary action is to ask:

1. Who else can help?

2. Who else needs to know about this individual's stress?

If you are a colleague, you may want to express your concern, offer your support, and ask if they would like to seek additional support from appropriate people within the organization. If you are a leader, you will have a greater responsibility and more resources to act. For example, marital discord that is impacting work behavior may be addressed with couples counseling through the organization's Employee Assistance Program (EAP). Supply chain quality improvement could address team member anger about poorly functioning equipment. A trusted mentor describing their own error experience may reduce the sense of isolation and guilt a person feels after a medical error.

When encountering an individual with an acute stress reaction or stress injury, your first step as a either a colleague or leader is to ensure physical and psychological safety. This is similar to physical first aid, where the primary survey is an assessment for airway, breathing, and circulation. Cover and Calm are the two Cs that make up primary stress first aid.

Cover: Protect From Impending Danger

When you witness a potentially dangerous reaction in a colleague, whether it is someone being uncharacteristically apathetic talking about wanting “it all to end” or someone overly sleep-deprived about to drive home, don't stay silent. Instead, use verbal and nonverbal tactics to create an authoritative presence that will prevent a potentially dangerous situation.

Examples of actions to take to address stress reactions or injuries before they become dangerous are shown in Table 2.

Calm: Promote Physical Stress Reduction

Along with Cover actions to protect from impending danger, it is important to also take action to calm yourself or others during situations that may trigger acute stress injuries (Table 3).

While the importance of primary aid may be apparent to clinicians, it is critical to go beyond promoting safety: long-term recovery depends on offering ongoing support via Connection and restoring Competence and Confidence in practice.

Connect: Engage Positive Social Supports

When you find yourself or a colleague in distress, ask yourself if there is a component of isolation and/or alienation contributing to the distress. The connection between individuals and team members builds a common identity through shared experiences, a common understanding of the meaning of events, shared responsibility, and reduced feelings of guilt, shame, or blame. The Connect “C” is vitally important when primary stressors are related to systems issues that require team-based solutions within the environment of care.

There are 3 general Connect actions as shown in Table 4.

Competence: Improve Social and Professional Skills

A “Stop, Back Up, and Move Forward” approach is one way to restore or enhance Competence after a stress injury (Table 5). The goal is to restore the individual's ability to function in occupational, personal, and social roles while cultivating new capabilities as needed.

Confidence: Build Self-Esteem and Hope for the Future

Restoring Confidence begins by engaging in a reflective process that wrestles with the question, “Who am I now, given the experiences that I have had?” Confidence actions are best accomplished through an empathic and authentic relationship that evolves over time.

The Confidence function builds realistic self-esteem and restores hope that was undermined in the aftermath of stress injury. The concepts of resilience, wisdom, and post-traumatic growth are grounded in the actions of reflection and a renewed belief in oneself. Trusted peers and leaders play a significant role in supporting someone with a stress injury who has experienced a loss of confidence. The Confidence function is particularly needed when there is despair, guilt, shame, emptiness, or thoughts of suicide.

Health care team members can be injured by the occupational stress of the work they do, and preserving the well-being of health care workers is one of the great challenges facing medicine today. Stress injuries are multifaceted and are the result of demands that exceed coping resources.³ The goals of SFA are to ensure safety, decrease stressors that are within the individual's or organization's ability to control, and facilitate recovery by employing additional resources. Figure 4 summarizes the process of SFA. Early recognition and intervention with SFA can reduce the risk of adverse outcomes or career harm.

Journal Articles and Other Publications

• Shanafelt T, Stolz S, Springer J, Murphy D, Bohman B, Trockel M. A blueprint for organizational strategies to promote the well-being of health care professionals. NEJM Catal. 2020;1(6). doi:10.1056/CAT.20.0266

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