Perhaps you know a physician colleague who has pulled back from hobbies. Who is not sleeping well. The physician who is usually gregarious and telling stories in the office or in the doctors’ lounge suddenly is mum. The easygoing person becomes cantankerous. Or maybe the quiet one becomes boisterous. Perhaps that doctor is you.

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These are likely the sign of a stress injury—a severe and persistent distress or loss of ability to function caused by damage after exposure to the overwhelming stressors of burnout, trauma, loss or moral injury.

Just like physical stress, psychological stress can injure a person’s mind and body. It can cause someone to lose control of their moods. In turn, that can be a precursor to medical errors, leaving the practice of medicine, depression or even suicide

An AMA STEPS Forward™ toolkit, “Stress First Aid for Health Care Professionals,” helps physicians and others in health care recognize and respond early to stress injuries, and manage them as one would any other injury. Stress first aid is a peer-support and self-care model that health systems can provide to improve organizational resilience and physician well-being. Based on years of research, it is practical, flexible and designed to be tailored to specific styles and needs of those working in high stress occupations.

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So, how can you recognize whether you or a colleague is suffering from a stress injury?

The toolkit has a color-coded visual tool—the stress continuum model—to help assess and identify different levels of stress reactions. With four zones, the continuum gives people a universal language to talk about what is going on, in turn normalizing and helping reduce the stigma of something that has often been taboo to talk about in the health care profession.

“Over the 10 years we have been doing this in health care, we’ve seen people start to use the language of ‘I’m in the orange zone’ or ‘I know I’m in the orange zone when I feel like I’m one sleep-deprived moment away from a bad decision.’ We’ve seen people’s increased ability to recognize when they’re significantly stressed, and they are far more likely to recognize the signs of a colleague experiencing a stress injury,” said Richard Westphal, PhD, director of Alliance for Compassionate Care at the University of Virginia School of Nursing in Charlottesville, a co-creator of the stress first aid toolkit.

The continuum’s four zones are:

  • Green. The ready zone. Someone is coping, functioning and is doing well.
  • Yellow. The reacting zone. The person is responding to multiple stressors at work and home. There is mild and transient distress or loss of function.
  • Orange. The injured zone. The person is responding to strong or multiple stressors, such as trauma, loss, moral injury and wear and tear. There is more severe or persistent distress or loss of function.
  • Red. The ill zone. There is unhealed orange zone stress and perhaps additional stress or risk factors. There are clinical mental disorders, such as PTSD, anxiety, depression or substance use disorders.

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Behaviors displayed in each zone

These are some outward signs you can look for in yourself or your colleagues to determine where you or they are on the continuum.

  • Green. This person is in control. They are calm and steady, getting their job done and motivated. They’re maintaining their humor and have ethical and moral behavior. They’re getting enough sleep.
  • Yellow. This person has changes in mood, they’re worrying, anxious, sad, irritable and/or angry. They’ve lost motivation and focus. You may see physical changes, such as poor sleep or aches and pains. They also may have social changes such as isolation, hyperactive activity or they may be loud or numb.
  • Orange. This person has lost control over their mood, social or physical reactions. That can present itself as panic, rage, guilt or shame. There may be social numbing or isolation, they can’t sleep and their moral compass has been affected. They no longer feel like their normal self.
  • Red. The symptoms persist and worsen for more than 30 days. This person is in severe distress and has functional impairment.

“If you can raise people’s awareness of stress reactions the orange zone, it prevents them from going into the red zone,” said Patricia Watson, PhD, a psychologist at the National Center for PTSD and a co-creator of the AMA toolkit. This means, people can be injured but avoid becoming impaired. The toolkit explains how to offer stress first aid to help people recover from stress injuries or illnesses.

Learn more from the AMA STEPS Forward™ webinar series, which focuses on physician well-being, practice redesign and implementing telehealth during COVID-19.

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