Peggy Soderstrom has witnessed life and death in her career as a nurse. But she can remember one incident with particular clarity-an emergency department shooting that happened 20 years ago. "There were several deaths and some horrible outcomes. The S.W.A.T. team was there," she said.

Soderstrom, Ph.D., RN, said she can still picture the two other nurses working with her at the time, and a hospital psychiatrist who tried to intervene shortly after the event. "I will never forget the nurse who was next to me," she said. "She just ripped into him because she was really stressed. It was an awful time. We had no time to downshift."

Although a shooting in the emergency department is unusually traumatic, nurses are subject to stress every day. Any nurse is susceptible to a particularly debilitating form of stress called critical incident stress.

According to the Emergency Nurses Association, critical incidents are acute stressors-situations that cause unusually strong emotions and interfere in the ability to function during or after the event. Some examples are mass casualties, disaster or the death of a child or peer.

"We had a nurse who was killed in a car accident and there was quite an emotional drain and it was traumatic for the staff. One unit was grief-stricken and shocked," said Bert McQueen, executive director of the Alaska Police Chaplains' Ministries, who counsels hospital and emergency service personnel.

McQueen has been specially trained by the International Critical Incident Stress Foundation to recognize the emotional aftershocks that someone might experience after dealing with a particularly troubling case.

"You don't know when you'll have a significant reaction," McQueen said. "Some people say nobody's "kidproof." It usually bothers nurses that kids are involved, especially in abuse situations or neglect of a child."

Signs of stress

The signs of critical incident stress can show up immediately, or sometimes days or weeks after the event. Physical symptoms include sweaty palms, shaking, fatigue, nausea and headaches. Someone under stress may have poor attention or disturbed thinking, nightmares or depression.

"Maybe the nurse is becoming overwhelmed and looking like she's going to tear up or start crying," McQueen said. "Sometimes, they just get so overwhelmed by stress that they react by throwing something or storming out."

Soderstrom is now an assistant professor at Johns Hopkins University School of Nursing in Baltimore and a stress specialist. She was called to New York after the Sept. 11 attacks. "I do believe a lot of people, including nurses, may not recognize they are under stress," she said.

"What I saw [in New York] was that people kept overworking and overfunctioning, and when the quiet moments came, there was a lot of pensiveness and weeping."

A certain amount of stress can be appropriate, McQueen said. "But if you see somebody who is not functioning and not able to get something to work, then I'd be concerned that it's something we need to pay attention to."

Talk therapy

If a critical incident has touched the lives of several people, hospital managers might call for a formal "debriefing." McQueen is one of the counselors trained to conduct those sessions, each lasting about three hours. He guides nurses and other professionals in recounting the stressful event and supporting each other. After the nurse was killed in a car accident, McQueen met with the unit to help with the grieving process.

Debriefings aren't always available to nurses suffering from critical incident stress, but talk is. "Most often, I promote one-on-one peer support," McQueen said. "If you see your fellow nurse having a reaction and know a particular case is bothering them, offer a listening ear," he said. "Talking is what seems to help fix it."

When you talk about a stressful event, "there's a certain kind of unburdening that happens," said JoAnne Herman, Ph.D., RN, a certified stress management educator at the University of South Carolina. "You don't feel that you are the only one that's having these same experiences. It validates your feelings of being normal and OK."

Herman experienced this unburdening firsthand when she witnessed a suicide. "I was at a friend's house and we were watching the Super Bowl. She lived on a lake," Herman said. A neighbor drove his car into the lake, intent on killing himself. When the people in Herman's group dived in to help, the man just shook his head.

"All of us, after that happened, just had to keep recounting the incident over and over again. That went on for about three weeks," Herman said. "Talking about it was almost this irresistible urge. It was a very strange sensation. That was just sort of the coping thing that we went through."

Stress debriefings usually occur within 24 hours after the incident, but Soderstrom said some people might need up to a week before they feel like talking. "There's this point in time immediately after the incident where feelings are raw and there's some resistance to someone coming into that pain and wanting to fix it immediately," she said.

Changing perception

After a stressful incident, you can help yourself by trying to change your perception of the event. Herman said that you can think about it as "a very bad thing that happened to me. It's part of my professional role and the kind of things I'm going to expect will occur."

"You can still have great sadness, revulsion, angst, fear and trepidation-and you need to recognize those feelings," she said. "But then you start problem-solving. 'How am I going to find a way to make sense of this?' Go to a counseling session. Talk to a friend. Write in a journal about it."

Nick Hall, Ph.D., who directs stress seminars for health professionals at the Wellness Center at Saddlebrook Resort in Tampa, Fla., said, "The key is not to try to reduce stress or even manage it. The key is to introduce appropriate recovery."

"It doesn't matter what the stress is, as long as you are able to counterbalance it, you're going to be all right," he said. "One of the techniques that I always recommend nurses do is complete this statement three times in the context of whatever is happening: 'I'm glad I'm not ____."

Hall recommends thinking things through and trying to pinpoint what's really worrying you. For example, "I've just seen this hurt child. I'm terribly upset. It could have been my own child."

Understanding the physical symptoms you are feeling also can aid recovery. "When you wake up in the middle of the night having a nightmare, when your heart starts to race, it's a perfectly normal response. Your brain is simply processing information that, hopefully, you will learn from," he said.

According to Hall, our bodies react to stress with the fight-or-flight response. "The body's default mode is to overreact because that will save your life," he said.
Stressbusters
"It's important to tame the physiology because it will feed back to the brain," Hall said. Deep breathing, progressive muscle relaxation, exercise and massage are ways to calm the body. If you have a Type A personality, a more active recovery-such as a noncompetitive round of golf or tennis-might feel more relaxing than a massage.

The International Critical Incident Stress Foundation also offers recommendations:

• Within the first 24 to 48 hours, alternate periods of strenuous physical exercise with relaxation to alleviate some of the physical reactions to the stress.
  
• Structure your time and keep busy.
  
• Spend time with others.
  
• Keep a journal.
  
• Make as many daily decisions as possible to give you a feeling of control in your life. If someone asks you what you want to eat, answer them, even if you're not sure.
  
• Eat well-balanced and regular meals.
  
• Get plenty of rest.

"Be careful with self-medication. That is a tendency if we hurt," McQueen said. "Drink lots of fluids, but not alcohol."

McQueen encourages nurses and other health care workers to talk to their families about traumatic events, but to spare them the details. "Make sure they know you've been through something awful and you just need a little distance," he said.

While it may be hard to put yourself first, Hall said, "what nurses so desperately need is to realize that it's OK to nurture yourself. So at the end of the day when they're not in the ER, but at home, it's OK to get a massage and go for a walk, to say no and not do favors, when you need to introduce that recovery."

According to the stress foundation, the signs and symptoms of a stress reaction may last a few days, a few weeks or even months, depending on the severity of the traumatic event. Occasionally, an event is so painful, ongoing help from a professional counselor is needed.

Whether you have success managing stress on your own or need help from others, the most important thing is to recognize the stress and take time to heal.

Contact Beth Berk at berk2@prodigy.net.