ASK THE EXPERT
Understanding Stress Injury and Stress First Aid
When It’s More Than Just a Bad Shift
Elaina Diaz, MSN, RN, NPD-BC, CMSRN
NPD Practitioner, Clinical Professional Development, RN Coordinator, Ascension Seton
NURSES ARE UNDER INCREASING AND UNPRECEDENTED LEVELS OF WORKPLACE STRESS, and for many, that stress can become chronic. Some stress is expected in our daily lives and professional practice, but at what point does it move beyond what we can handle, exerting a toll that over time becomes unmanageable, and at what cost? When we don’t recognize the signs early, stress can lead to long-term consequences for nurses and impact on the care we provide.
So, the real question becomes: what can we do when stress starts to pile up and how do we respond before it turns into something more serious? By understanding stress injury, recognizing where we fall on the stress continuum, and using tools like Stress First Aid, we can respond earlier, before stress becomes harder to recover from.
STRESS INJURY CONTINUUM
Stress injury is hurt, damage, or loss sustained by stress. First recognized by the military, the stress injury continuum was a model developed to categorize four levels of stress, including and beyond daily expected stressors, and into those that cause loss of function (see Figure 1) (Bellehsen et al., 2024; Ram et al., 2024). The stress injury continuum's first level, the ready state, is the optimal state of well-being and stress management in which coping strategies are effective (Bellehsen et al., 2024; Ram et al., 2024). The behaviors exemplified include engaging in activities that promote health and well-being, maintaining social relationships, and completing responsibilities (Ram et al., 2024). Stress naturally occurs in nursing and is balanced by effective coping strategies. This is where nurses can flourish in their practice.
The second level, the reacting zone, is engaged when an individual experiences undue stress with ineffective coping strategies, impacting functionality but is resolvable, and individuals can return to the ready state (Bellehsen et al., 2024; Ram et al., 2024). Individuals in this zone report difficulties with eating, sleeping, and anxiety, leading to loss of well-being, increasing cynicism, impacting social relationships, and the ability to fully complete responsibilities (Ram et al., 2024). In nursing, everyday situations such as short staffing or challenging patient care situations can place nurses in the reacting zone, but resolving these situations will allow the nurse to return to the ready state.
Progression to the third level, the injured zone, occurs when the individual experiences sustained stress beyond the ability to cope, resulting in injury that may have long-term damage or scarring if left untreated (Bellehsen et al., 2024; Ram et al., 2024). Chronic, unrelieved stress can lead to uncontrollable emotional responses, physical changes in sleep cycles, changes in behavior, and even thoughts of suicide (Ram et al., 2024). Nurses in this zone can become disengaged from their practice, going through the motions of providing care, expressing disdain for patients and peers, and overwhelming negative in their responses.
Finally, the fourth level of the continuum is the ill zone, in which the individual has lost the ability to function in their daily lives and needs professional intervention (Bellehsen et al., 2024; Ram et al., 2024). Identified mental disorders within this zone include anxiety, depression, panic attacks, and post-traumatic stress disorder (Ram et al., 2024). Managing and completing responsibilities no longer occurs, and unhealthy coping strategies such as drugs and alcohol may be utilized in lieu of seeking professional help (Ram et al., 2024). The consequences can be permanently detrimental to nursing practice and their daily lives. The stress injury continuum is expanding our understanding of stress among nurses to better articulate the perceptions of stress by nurses, recognize the impact of stress injury, and understand the need for interventional strategies to reduce stress injury.
Figure 1. Stress Injury Continuum. Watson, P., & Westphal, R.J. (2020). Stress First Aid for Health Care Workers. National Center for PTSD. Available on: www.ptsd.va.gov.
STRESS FIRST AID AS AN INTERVENTIONAL TOOL
The US Department of Veterans Affairs National Center for PTSD laid a foundation of the Stress First Aid (SFA) for Healthcare Workers framework to both identify stress injury and provide interventional strategies to alleviate stress injury and return to an optimal state of well-being (Watson & Westphal, 2020). SFA consists of seven core strategies, the seven C’s, geared for early recognition and individual and peer-supported implementation (see Figure 2) (Ganzel et al., 2020; Watson & Westphal, 2020). The National Center for PTSD defines the seven C’s as follows.
- Check is regular self- and peer-checking, to identify current stressors and levels of stress through reflection, observation and listening.
- Coordination is communicating, collaborating, and connecting individuals with appropriate resources.
- Cover is to ensure physical and psychological safety during times of stress
- Calm is often combined with cover to provide a quiet, soothing environment to regain composure and rest.
- Connect occurs when isolation is reduced through trusted relationships and peer support.
- Competence refers to building skills for stress management and professional confidence.
- Confidence is achieved during the restoration of hope, meaning, self-worth, and trust.
Stress First Aid works best when it is embedded into everyday practice, not reserved for only formal programs or crisis situations. Early recognition combined with peer-to-peer support reinforces the idea that nurses do not have to manage stress injury alone.
As more nurses learn the language of the Stress Injury Continuum and practice Stress First Aid in real time, it becomes easier to speak up, check in on one another, and take action early, before stress progresses into something that causes long-term consequences.
ADOPTING STRESS FIRST AID STRATEGIES
The reality is that many nurses practice elements of Stress First Aid, even if they don’t use the language or terminology. It shows up in everyday moments of teamwork: Checking on a coworker after a difficult shift, a coworker who notices you are quieter than usual, a charge nurse who quietly rearranges assignments after a tough situation, or a colleague who asks if you okay and waits for the answer.
Applying the seven C’s into nursing practice may look a little different in different workplace settings but there are easy ways to adopt them into everyday practice. For example, “Check” might sound like: “You seem off today, how are you doing?” “Calm” might be as simple as stepping away for two minutes, taking a few slow breaths, and getting a drink of water before walking into the next room. “Connect” might look like sending a quick text to a trusted coworker after work: “That shift got to me. Can we talk tomorrow?” These small actions don’t erase what happened, but they can reduce isolation and help nurses recover instead of carrying stress forward.
Stress First Aid is crucial when stress starts to affect safety and performance. “Cover” may mean creating a pause before a nurse returns to a high-risk task, calling for help during escalating situations, or making sure someone isn’t left alone after a traumatic event. “Coordinate” can include looping in a charge nurse, supervisor, nurse leader. There may be services like employee assistance, when stress is no longer manageable with informal support alone that can be coordinated for support.
Over time, the goal is to rebuild competence and confidence through realistic and meaningful support. That may include debriefing after difficult events, accessing education on stress injury and coping strategies, and building routines that support recovery between shifts. Nurses at every level, regardless of role or years of experience, can use these strategies to support themselves and each other.
Healthcare organizations can strengthen this work by normalizing conversations about stress injury, offering education and peer support resources, and making help easy to find and access. Practical tools and training materials are available through the National Center for PTSD, and ongoing research continues to explore how the Stress Injury Continuum and Stress First Aid can support healthcare workers. The more we understand stress injury, and the sooner we respond, the more likely we are to prevent stress from progressing into something that causes lasting harm.The US Department of Veterans Affairs National Center for PTSD laid a foundation of the Stress First Aid (SFA) for Healthcare Workers framework to both identify stress injury and provide interventional strategies to alleviate stress injury and return to an optimal state of well-being (Watson & Westphal, 2020). SFA consists of seven core strategies, the seven C’s, geared for early recognition and individual and peer-supported implementation (see Figure 2) (Ganzel et al., 2020; Watson & Westphal, 2020). The National Center for PTSD defines the seven C’s as follows.
- Check is regular self- and peer-checking, to identify current stressors and levels of stress through reflection, observation and listening.
- Coordination is communicating, collaborating, and connecting individuals with appropriate resources.
- Cover is to ensure physical and psychological safety during times of stress
- Calm is often combined with cover to provide a quiet, soothing environment to regain composure and rest.
- Connect occurs when isolation is reduced through trusted relationships and peer support.
- Competence refers to building skills for stress management and professional confidence.
- Confidence is achieved during the restoration of hope, meaning, self-worth, and trust.
Stress First Aid works best when it is embedded into everyday practice, not reserved for only formal programs or crisis situations. Early recognition combined with peer-to-peer support reinforces the idea that nurses do not have to manage stress injury alone.
Figure 2. Stress First Aid Model. Watson, P., & Westphal, R.J. (2020). Stress First Aid for Health Care Workers. National Center for PTSD. Available on: www.ptsd.va.gov.
MOVING FROM AWARENESS TO ACTION
Stress will always be apart of nursing, but lasting harm does not have to be. By understanding stress injury, recognizing where we fall along the stress continuum, and responding early through Stress First Aid, nurses can support one another before stress becomes illness. The good news is that nursing, and other healthcare disciplines, are continuing to build the evidence around stress injury and Stress First Aid, strengthening the tools and strategies available to support the workforce. As more nurses learn the language of the Stress Injury Continuum and practice Stress First Aid in real time, it becomes easier to speak up, check in on one another, and take action early, before stress progresses into something that causes long-term consequences. The goal is not resilience at all costs. The goal is shared responsibility, early intervention, and sustainable support. Stress First Aid reminds us that we don’t have to carry hard shifts alone. Sometimes the most powerful intervention is simply noticing, checking in, and staying connected. TN
REFERENCES
