The Stress Continuum
I mentioned recently we had been reminded that medical care has always been a people business and the effect of the pandemic had severely impacted care-giver morale and well-being. These concerns were not new, of course, and several large healthcare systems had already established a chief welfare officer position. A number of them have recently reported their observations and learning from dealing with the effect of the pandemic. I will discuss their findings in a subsequent article, but here I want to focus on one of the frameworks they use to define their efforts—the stress continuum. This framework was developed by the U. S. Navy Medical Department and is now part of official policy. A report on the system is publicly available.
The stress continuum, and its management, is not a new project, having been started by the Marine Corps in 2007. There has been some discussion and criticism of the theoretical background, which I will not discuss. And, since it was developed by and for the military there are aspects of the program not easily translated into civilian contexts. For instance, much emphasis is placed on family support and function as elements in a sailor’s resiliency, and a military commander, particularly on a ship at sea, has a more encompassing relationship to his/her sailors than is typical in civilian life, but the principles seem applicable.
The continuum begins “green,” which is described as functioning normally, both at the individual and unit level, which is seen as essentially a command function. A “green” sailor is calm, confident, competent, maintains a sense of humor, sleeps and eats appropriately, avoids excessive alcohol intake, plays often, is socially active, at peace with him or herself, and healthy spiritually. The “yellow” zone is described as reacting to stress, showing distress, which is mild and temporary, anxious, sad, tense, or with physical and behavioral changes. The reacting sailor is grouchy, irritable, mean, short-tempered, has trouble sleeping, eats too much or too little, keeps to him or herself, and is negative and pessimistic. The “orange” zone is described as injured. Here the sailor is showing more severe or lasting distress and/or impairment, and may have lasting memories, reactions, and expectations. Individuals who have been injured experience loss of control, have difficulty sleeping, experience nightmares, have feelings of guilt and shame, may experience panic or rage attacks, can’t enjoy normal activities, experience disruption of moral values, and may experience suicidal or homicidal ideation. The red zone is described as ill, and manifests the symptoms associated with injury, but of more severe nature and lasting longer than 60 days. Maintaining the green state is seen mainly as a command responsibility. Dealing with the yellow and orange states is seen as a combination of individual, small group, and family responsibility, and red states are seen as medical issues that need referral to physicians.
Military psychiatrists taught me while I was on active duty that stress reactions and injury are normal responses to the abnormal stress of combat, and are best dealt with by peer support. This notion is embedded in the Navy document as “combat and operational stress first aid, (COSFA).” There are seven steps, all starting with the letter “C.” These are check, coordinate, cover, calm, connect, competence, and confidence.
As I reflect on my civilian experience, I think most of the physicians I interacted with were in a perpetual “yellow” state. I sat on a leadership committee that reviewed behavioral complaints about physicians. The vast majority could be seen as “grouchy, irritable, mean, short-tempered.” Certainly, I felt that way from time to time, but for some, it was a chronic issue. Although I did not survey staff as regularly, I suspect most of them operated from the yellow zone most of the time. Given this setpoint of chronic reacting, it is not surprising many people experienced injury (orange zone) during the pandemic.
What does the Navy recommend people in the yellow zone do to restore their psychic equilibrium? “Get more sleep and rest. Work out regularly, eat right, stay hydrated. Spend time with people you trust. Attend to your spiritual needs. Take your mind off worries you can’t fix. Have fun when you can. Encourage yourself and others.” They also recommend leaders take two specific steps: do positive after action reviews; recognize and reward accomplishments.
Obviously, all of these steps can be applied in the civilian world, but I there are a couple of cultural problems. First, physicians tend to think of themselves as “lone rangers.” They often lack the social supports at work available to others. Think about the virtual disappearance of the physicians’ lounge and dining room. Even if provided, most think they are “too busy” to avail themselves of it. The other challenge for physicians is the negative culture associated with perfectionism. All “errors” are seen as moments of shame and blame, not learning experiences. This is often embedded throughout clinical microsystems.
The challenge for administrators is recognizing turnover as a sign of a dysfunctional culture. There is a growing body of literature showing a link between low turnover and high clinical performance. Using the three part model of resilience, we have good measures of financial performance, mediocre measures of clinical performance, and almost no measures of human performance. As one administrator put it to me, “We can tell when the cart is in the ditch, but we can’t tell when it is headed that way.”
One way is for experience unit leaders to report on the stress level of their units along with patient and staff census and other operational measures. If any arbitrary yard stick is used consistently, the institution will be able to tell when conditions have gone from green to yellow. The stress continuum is one such yardstick. Right now, we are almost always at yellow, go into orange at least once a year, usually during flu season, now during the pandemic, and may go “red.”
Recovery from these conditions is much more difficult, expensive, and detrimental to patient care than the cost of instituting a measuring system and providing relief early. What works to provide relief is experiential. I once chaired a meeting of the nursing leadership where irritants were identified. One of the biggest: pulling staff to cover a short-staffed unit elsewhere. It turned out some people might get pulled two or three times in a single shift, which meant, of course, they produced almost no useful work and had a “yellow” day. Management worked to find other ways to provide “float” staffing to cover shortfalls. The stress continuum is a simple way of measuring where things are, both for individuals and for organizations. The challenge is to find ways to “be green.”
19 April 2021
 Brower KJ, Brazeau CMLR, Kiely SC, et. al. The Evolving Role of the Chief Wellness Officer in the Management of Crises by Health Care Systems: Lessons from the COVID-19 Pandemic. NEJM Catalyst 14 April 2021. Accessed https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0612.
 CNO. Operational Stress Control Awareness Brief. Accessed 18 April 2021. https://www.med.navy.mil/sites/nmcphc/Documents/health-promotion-wellness/psychological-emotional-wellbeing/operational-stress-control-awareness-brief.pdf.
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