Long-term stress can have a range of implications on your health and efficiency and that of your practice team
Stress is a term that has become a catch-all - like health and safety - encompassing an indiscriminate range of problems and feelings without being fully understood. Used as nature never intended, it has become a health hazard and those of us working in general practice should treat it accordingly.
As a society we may have arrived at the stage with stress that we reached with smoking or alcohol in the 1970. There was a vague awareness of the dangers but little focused effort on addressing them. Concerns were dismissed and life went on.
Unfortunately, stress can be as harmful as alcohol or smoking, not least because it too can have psychologically addictive qualities. Our abnormal lives have come to seem almost normal as we fight our way through insurmountable workloads, tackle remorseless deadlines and deal with frustrating inconsistencies and nonsensical demands. It becomes a challenge, in certain environments, to see who can be the most stressed out. Anyone who isn’t, it is implied, can’t be working hard enough. They are letting down the team.
Stress as a health hazard
The true concerns about stress, as with smoking and alcohol, are rooted in the damage hidden beneath the surface. Stress is potentially damaging to your health in a myriad of ways and its cumulative effects can prove fatal. However, because it doesn’t kill you instantly, as a fall from a high cliff edge might do, it is ignored or rationalised. This is unfortunate given the links to heart disease and a range of health problems but, as I suggested earlier, we have yet to fully accept the scale of the problem.
Stress is an automatic response to any stimulus which your system regards as threatening. We are designed so that we snatch our hands back when we touch something hot, leap back when we see a speeding car, feel alarmed and make a detour around a snarling dog tied up outside a shop. We have no control over that little jolt of alarm that results from a flood of hormones releasing adrenaline as our senses pre-empt our conscious responses and set systemic alarm bells ringing.
The adrenaline mobilises our bodies so that we can run for our lives. Digestion, growth and even some reproductive activities may be temporarily halted so that all resources are diverted to aid escape, explaining the phenomenon of executive heartburn. In severe cases, the system will, embarrassingly, jettison urine and faeces to enable a faster getaway.
System damage occurs when we don’t actually flee (or fight) and burn off the unnecessary turbo boost. Robert Sapolski, an eminent expert on stress, has written the entertaining and informative Why Zebras Don’t Get Ulcers, which explains this in everyday terms. The zebra’s life is one of high stress, with every clump of grass a hiding place for a stalking lioness. However, when the lioness erupts, the zebra runs and runs, either being captured or escaping. Once free of threat, their bodies having burnt off all the excess fuel, the survivors settle back to their continuous grazing and live ulcer-free lives.
If you’re not a zebra
We have no control over our responses to our lioness equivalents and, in most everyday situations, no means of venting the resulting involuntary output by either fleeing or fighting.
A near miss whilst driving leaves you trapped in your seat, heart pounding, hands shaking. If you could get out of the car at that point and run up and down the road, you could alleviate some of the aftermath and help your health (unless you got run over, of course).
Stress is pretty much unavoidable in terms of frights and it does keep us alive by propelling us out of danger. Small amounts are fine but continuous unresolved stressors are likely to do insidious damage over time.
There are some stressors that you can control. For example, if you jump every time your home phone rings, because you once took a dreadful call advising you of the unexpected death of a loved one, you can change the phone ring or get rid of your landline and switch to texts to minimise the association. It doesn’t help the pain of your loss but it does reduce the automatic response to the stimulus that fires up your system.
Stress at work
Stress affects the workplace in various ways. Someone who is unable to focus calmly on their work, responding to every new email, phone call, letter or approaching footsteps as though they were rustling grass that could harbour a lioness, is not able to devote themselves fully to their work. They may have disturbed sleep, digestive upsets, skin problems - the body has a myriad of ways of showing off its battle scars, even if many of these wounds are imaginary. Just as someone who has been burgled may sleep fitfully, another who finds the working day a series of alarming challenges will be unable to concentrate and do their best work.
A key determinant is the amount of control that we have over our stress levels. Put a zebra in a cage next to a lion and it could well die within days, unable to do anything to alleviate its naked terror. Put a human in a position where they are harassed and bullied and they are likely to become unwell in some way.
However, there are less obvious stressors than bullying and harassment. The Whitehall study, of civil servants, showed that having a stressful job per se is not necessarily stressful for individuals. A greater cause of stress is lack of control over your workload . Incessant demands, unrealistic timescales and sudden complaints could be termed a stress magnet, and we all know a workplace that corresponds to that description.
Managing stress without blowing the budget
In truth, if you have given up smoking, or wish to protect your health, you should be doing the same with stress. Sadly, giving up smoking saves you money whereas managing stress in the workplace is assumed to require more staff to share the workload.
So how do you tackle it pragmatically in the workplace and, more specifically, in general practice? Your team (your herd of zebras) is subject to constant and rising demand from patients and government paymasters, and the GP contract makes flight - although appealing at times - unrealistic. An overtly stressed manager will alarm the rest of the team, so the first task is to tackle your own stress levels. There are two starting points: how you act and what you do. We are all stressed so start by accepting that your situation is not unique. As a manager and, hopefully, a leader, it behoves you to act like one. Stop talking about your problems. They won’t go away but at least you won’t be dumping your stress on everyone else.
Set an example and, over time, use this example to encourage others to behave in the same way. Don’t be a jumpy zebra constantly upsetting the rest of the herd. In terms of what you do, it is difficult to argue with lists and plans. They may cause transient alarm by detailing all your stressors but they do stop unnecessary surprises. Plan your day realistically. If you can get an hour to tackle an important task you will be doing well. An open door policy is good but you need to teach the team that, unless it is fire, flood or a complaint, you are not to be disturbed at certain times. Get people used to your ‘concentration time’.
Triage your work
Another important point is not to allow people to give you verbal messages. Either carry something to record these or insist on emails or notes in your inbox. Periodically, transfer these messages to your to-do list, first ensuring that you triage it through the urgent/important sieve (see diagram – the internet has dozens of other examples).
This managerial triage is essential. In a nutshell, you deal with urgent and important items; diarise important but less urgent ones; delegate urgent but unimportant ones; and ignore those that are neither important nor urgent. Difficulties arise when you procrastinate over trivia or get bogged down in the critical activities, never managing to address the important goals. These then either become urgent or, neglected, result in a slow decline for both the practice and your career.
Constant, headless chicken busyness neither impresses nor fools your team members. You, and those around you, are paid for every hour that you work. You may not agree with the true hourly rate but it is your choice to work in general practice.
Effectiveness satisfies you and reassures those around you. Stop talking about stress and tackle it. As with dieting, don’t tell people what you are doing. Just as they would notice a sleeker outline in due course, so they will begin to recognise that you appear more in control, calmer, less frenetic.
Use your example to encourage and coach others into a more soothing and supportive environment, with lists instead of unreliable memories; brief, sensible protocols and procedures for everyday activities rather than errors and recriminations; and occasional time out with chocolate biscuits to remind everyone that there is light at the end of the tunnel. Rather than costly additional staff, you need to manage those that you have into more effective routines before you can assess the true needs of the practice.
Kathie Applebee is a practice management consultant who helps with the development of primary healthcare teams and works dealing with organisational problems in general practice.