In 2017, Nursing Standard reported 10% of nurses in England who take sick leave do so because of anxiety, stress or depression. (1) In a 2016 investigation into the impact of perceived stress and ability to cope, 92% of nurses reported moderate-very high stress levels, with more than 60% having inadequate sleep, an unhealthy diet and no regular exercise. (2) RCN Scotland Director, Theresa Fyffe stated that rising patient demand, coupled with the highest yet nurse vacancy rate are taking its toll. 'Nurses are working longer than their contracted hours and through their breaks. All this means that nurses are burning out because of stress.' (3)

is it possible to survive the battleground of stress that seems to invariably come with the career of nursing?

Stress is a word tossed around us all the time. Our society appears to promote busyness and in many workplaces there is an underlying culture of competitive overworking. The Oxford English Dictionary defines stress as 'a state of mental or emotional strain or tension resulting from adverse or demanding circumstances'. (4) Burnout is perhaps harder to define but is understood by many as the state of exhaustion (emotional, mental or physical) from prolonged stress. It is a debilitating manifestation of 'tipping over the edge'. It is important for us to be aware of our own vulnerability in this area.

Experiments into stress show that our performance is directly correlated to the motivational demand put on us; i.e. we do not perform when there is little or no reason to. Thus 'stress', or motivational demand, is not in itself a bad thing. As pressure on us increases, so does our performance - as seen in elite athletes who attain personal bests when competing, which are unlikely to be achieved in training.

This can be illustrated by the 'Stress Responsive Curve' created by Robert Yerkes and John Dodson in 1908 and discussed in Zeal Without Burnout by Christopher Ash. (5) Stress hormones stimulate, energise and activate us — but these stress responses are designed for short bursts (the fight or flight response) and must be balanced by periods of rest and recovery. The pressure-performance curve has a limit at our optimum stress level; after this point, if pressure continues to build past the point at which we can cope, performance falls. Extended periods of high stress levels deplete our reserves and push us towards the 'tipping point', after which we are vulnerable to burnout. This tipping point is individual for each of us and as we recognise ourselves nearing it, we must be aware of our need to stop, step back, re-evaluate and rest.

what do we see in ourselves when we are beginning to burn out?

When stress begins to have a negative effect, this may manifest in irritability, reactive or defensive behaviour, short temperedness, feeling overloaded and an inability to cope. A stressed or exhausted limbic system produces a higher volume of irrational or frightening thoughts adding to anxiety. We often lose insight and feel exhausted or emotional. In turn, it also diminishes our ability to deal with stress.

As energy depletes, this stress response can develop into burnout and present as tearfulness, exhaustion, demotivation, inability to concentrate and perform, depression and time off sick. For nurses, this state can also be called 'compassion fatigue'.

why does working in healthcare put you at risk of burning out?

• High pressure environment; high expectations and frequent high emotions
• Responsibility for people: seeing directly the effect of your actions and decisions
• Long, irregular working hours making a healthy lifestyle challenging
• Stretched resources, increased workload and understaffing
• Constant noise, unpredictability and interruption to tasks
• Emotional situations such as death and dying
• Challenging characters and conflicts - amongst colleagues, patients and relatives, who are likely dealing with stress themselves and can take it out on you!

Perhaps we can conclude that working in healthcare often means working in a high stress environment and operating near to our peak ability with high energy demand for extended periods of time. We need to be self-aware to protect ourselves and to ensure we have appropriate amounts of rest and recuperation before we run out of reserves and forget why we wanted to care for people in the first place.

so how can we recognise these burnout symptoms before it's too late?

We need to know ourselves and let those who know us well help us recognise our symptoms. We are wired uniquely and each susceptible to burnout differently. It is wise to be deliberate in setting healthy habits (rest, exercise and sleep) to learn to manage our stress. To some extent our relationship with God shapes how we manage stress, but experiencing stress and burnout is certainly not spiritual weakness. We are all vulnerable to it, and different elements will be at play individually in each of us. We are not made to function in isolation but in community. In a world of social media, it's easy to have many Facebook friends but few deep friendships. It's valuable to be deliberate and to invest in a few close, accountable friends with whom we can share burdens and support.

Remember, there is hope. We can cast all our burdens on God (6) who showers us in his love and grace!

Esther Chevassut is a staff nurse and a CMF Associate Staff Worker for nurses and midwives on the south coast.

1. Jones-Berry S, Munn F. Exclusive: One in ten nurse sick days down to stress or depression. Nursing Standard 27 September 2017 bit.ly/2P71J47

2. Jordan TR, Khubchandani J, Wiblishauser M. The Impact of Perceived Stress and Coping Adequacy on the Health of Nurses: A Pilot Investigation. Nursing research and practice 2016: 5843256. bit.ly/2ShgX8I

3. Jones-Berry S, Munn F. Art cit

4. Definition of stress. English Oxford Living Dictionaries. bit.ly/2IQQN8O

5. Ash C. Zeal Without Burnout: Seven keys to lifelong ministry of sustainable sacrifice. Epsom: The Good Book Company, 2016

6. 1 Peter 5:7