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Identify how to recognize stress injuries in health care professionals
Describe how to administer Stress First Aid (SFA) at the individual level
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
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
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:
A sense of safety
Occupational and coping competence
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).
Recognize a Stress Injury (Check & Coordinate)
Provide Primary Aid (Cover & Calm)
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:
Who else can help?
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.
Why is peer support and outreach to colleagues so important in SFA?
One of the first things lost during a stress injury is self-awareness and the ability to recognize a stress injury in oneself. Therefore, while the principles of SFA can be applied to both self-care and peer support, the peer support component is often essential for early recognition and intervention.
When should I be concerned when performing a Check?
Recognition and intervention become essential when an individual is showing features of being injured, which is the orange zone shown in (Table 1). Stress injuries are identified by decreased ability to navigate daily life (loss of function), moral injury, and burnout/fatigue. To effectively mitigate stress injuries, individuals first have to be able to recognize them, then reduce stress in themselves or talk with the affected peer.
How do I recognize a moral injury or burnout in a colleague during Check?
Moral distress and ethical challenges, along with feelings of shame, self-blame, or a sense of betrayal by peers or leaders, can lead to moral injury. Words that may indicate the presence of moral injury are “could've,” “should've,” “ought've,” “if only.” Detecting moral injury can be challenging because individuals may feel ashamed or guilty and thus reluctant to talk about the experience. Importantly, individuals who bear a personal sense of shame or guilt because the moral injury is due to an act of omission (not taking action) or commission (taking action) may be at greater risk of suicide. For example, in an adverse event that resulted in patient harm, missing a critical detail in a patient condition would be an omission, while prescribing a medication or treatment that caused harm would be commission. Using the OSCAR communication method begins to break down the vow of silence that can accompany moral injury. For the injured person, being noticed in suffering can bring relief.
For cases of burnout/fatigue, the injury features tend to develop slowly over time and may look more like bullying, unprofessional behavior, or poor anger management. Because we do not see the stressor, there is a risk of blaming the individual for their behavior. This is why using the OSCAR communication during the Check step can be helpful. Initiate a conversation by saying “help me understand.” When you and the injured individual have shared knowledge about systems issues and other life stressors, there is opportunity for healing.
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.
How do stress injuries lead to loss of competence?
A stress injury not only negatively impacts a person's prior skills and abilities due to a decreased capacity to think clearly, but also prevents effective growth in social or professional skills. Competence is lost when existing occupational skills are no longer aligned with the demands that the person is facing. For example, this is commonly seen as someone advances in an organization where clinical skills may not be suited for leadership or administrative demands. Another example is the introduction of the electronic health record (EHR), which fundamentally changed patient–clinician interactions while creating new productivity demands that required new skills and knowledge.
Why is restoring competence after stress injury important?
Competence supports recovery, healing, and resilience by ensuring that needed skills are restored or obtained, then practiced. The general process for Competence is to:
Pause and identify core challenges
Develop or reinforce coping, social, and occupational skills
Re-engage with the challenge
It is important to note that if the person's stress injury behavior included conflict with team members, the entire team could benefit from Competence actions to prepare for integrating the person back into the team.
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.
Stress First Aid is an important tool for preventing and treating stress injuries
The Stress First Aid core functions—the 7Cs—can be effectively implemented with few resources
Stress First Aid can be integrated into existing peer support programs or used as a framework to establish a peer support program
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
Enjoy complimentary access to the full text of this article and learn more about this newest publication from NEJM Group.
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