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Communicating Under Stress

Practicing mindfulness activities helps you be more effective during difficult interactions

Do you sometimes lash out in anger at a patient or colleague, only to regret it later? Do you find yourself shutting down or tuning out in tense situations?

Practicing effective communication is no easy feat. Nurses need to be able to assess and manage complex, emotionally charged situations with patients, caregivers and colleagues — often in rapidly changing circumstances that require swift judgment calls.

The problem is that we tend to leave ourselves out of the assessment. We underestimate the degree to which our own thoughts, feelings and stress response can impair our ability to communicate in effective, appropriate ways.

Real-World Example: Take One

Consider the following scenario: Sarah is an RN who works nights on an orthopedic surgical unit of a large teaching hospital. At the end of her shift, she promised one of her patients, Mr. Smith, that she would make sure the day nurse would help to get his pain under control.

She recorded the patient’s complaints in his EMR and explained the situation during her verbal report to the oncoming nurse at shift change.

When Sarah arrives at work the following night and begins rounds, Mr. Smith yells at her, “You said you were going to take care of my pain and you didn’t!” Here are some of the things Sarah is thinking and feeling during this confrontation:

• Surprise and/or anger

Sarah thought she had set a pain management plan into motion. Why didn’t her colleague follow up? Was she not listening? How could the other nurse let Sarah down like this?

• Anxiety and/or fear

Given the patient’s angry demeanor, Sarah is a little worried that he could become violent. She considers what she can do to calm him down and deescalate the situation.

• Concern and/or uncertainty

Sarah is also concerned that the patient’s distress could be a sign of some other problem. Her mind races to recall what medications the patient is receiving, what procedures he has undergone, and what side effects or postoperative complications he might be experiencing.

• Impatience and/or nervous anticipation

Mr. Smith is probably not Sarah’s only patient, and she can’t help thinking of the long list of other urgent tasks awaiting her this shift.

As all these thoughts swirl around in Sarah’s head, her body responds with increased heart rate, respiration and blood pressure. To communicate effectively, Sarah needs to further investigate the patient’s complaint.

However, with her increasing stress, she may find it difficult to regain her composure and respond constructively to her patient. Instead, she may become defensive, overly apologetic or detached, none of which is helpful.

Emotional Intelligence

Situations like this emphasize the importance of emotional intelligence to effective communication, especially in a high-stress, high-stakes field like nursing.

Emotional intelligence includes skills like self-awareness, self-regulation, confidence, trust in yourself and others, empathy, the ability to correctly identify social cues, and the willingness to honor others’ perspectives.

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For nurses, emotional intelligence is an invaluable complement to clinical and technical proficiency.

Sarah may have competent clinical knowledge, but in the situation described, her most immediate priorities are to control her own stress response, identify the emotional tone and physical needs of her patient, and be open to explanations of why her colleague didn’t address the patient’s pain.

Only after surmounting those communication challenges can Sarah begin to use her clinical expertise.

Here are two exercises that can help.

ACTIVITY 1: Focusing on the Now

Getting in tune with the present can increase your self-awareness, a basic component of emotional intelligence. This first activity will help you access your own experience in the moment and consider how this awareness can make a difference in assessing and responding to a workplace scenario.

To get the full benefits of this exercise, we suggest that you read the following instructions and then set this article aside while you focus on the activity, which we recommend you do with your eyes closed. (You can also listen to an audio version on our website, www.korabektraining.com.)

Why take the time to do this? Because we can only perceive our experiences in the present moment. The past is a memory and the future is a projection or an expectation. The more we practice centering on the present throughout the day, the more self-aware we will be when we’re under stress.

Here are the instructions for the activity:

• Sit down and take a moment to close your eyes.

• Take a deep breath in and a slow breath out.

• Focus on the whole weight of your body resting on the chair or sofa.

• As best you can, let go of everything that has already happened today and everything you are anticipating for later today or the rest of this week. Turn your attention to what is happening in this present moment.

• Notice how your body feels right now. Is it comfortable, uncomfortable, tired, tense or relaxed? • Next, notice any emotions you are experiencing. Whatever feelings may arise are okay — everything is welcome.

• You may notice different thoughts. That’s okay too. Just try not to focus on them. Imagine them like clouds in the sky of your mind and let them pass by.

• Now, take a moment to notice the general sense of how you are right now, in body, heart and mind.

• See if you can soften and let go of any judgments you have about how you feel in the present moment. Allow yourself to be just as you are now, even if that is not the way you want to be.

• Try to extend a feeling of kindness toward yourself by placing your hand over your heart and feeling the warmth of that gesture. Once you have tried this yourself, move on to the second activity.

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Once you have tried this yourself, move on to the second activity.

ACTIVITY 2: Trusting Your Experience

The next exercise encourages you to trust your own experience and feelings.

Here are the instructions:

• First, answer this question: What is your favorite fruit? (You can’t get it wrong!)

• Second, consider how you came to your answer to that question. Did you imagine the tastes of different fruits? Recall pleasant associations from your past experience? Weigh your liking for one fruit over another?

The point of this activity is to illustrate the natural intelligence that comes from accepting our own individuality, our awareness and the complexity of our past experiences. Clearly, there is no one-size-fits-all answer when it comes to fruit preferences. Even different people who choose the same fruit may have different reasons. Yet, each preference is equally valid. This is an important lesson to remember when it comes to effective communication.

Building Your Skills

Doing activities like the ones on the previous page will gradually improve your emotional intelligence. Regular practice will prompt reflection and self-awareness while encouraging you to trust your own feelings and experience.

Real-World Example: Take Two

Let’s return to Sarah’s encounter with the agitated patient. This time, imagine that she is familiar with the above activities through regular practice. How would that affect her ability to communicate with her patient?

When Mr. Smith yells, “You said you were going to take care of my pain and you didn’t!” Sarah feels her stress levels rising, but she knows that if she tries to communicate from this place of overwhelm, it will adversely affect what she says and how she says it. Instead, she takes a slow, deep breath; focuses on her own experience in the moment; and acknowledges her feelings without dwelling on or dismissing them.

As she exhales slowly, she thinks to herself, “I am stressed, my patient is stressed and my colleague was probably stressed the previous day when she didn’t follow through on the pain management plan we discussed.”

Sarah makes eye contact with Mr. Smith and says in a kind and confident tone, “I’m sorry you’ve been in pain. Let’s figure out what is going on and what to do about it. I’m here to help.” Knowing she can address any communication problems with her colleague later, she sets about assessing her patient. Mr. Smith senses her calm and commitment, and he too exhales.

Happier at Work

Developing your emotional intelligence will better prepare you to respond effectively, respectfully and compassionately even in the most stressful scenarios. The skills these experiential activities teach require practice and patience. You’ll find yourself improving as you repeat them over and over again, in much in the same way that physical flexibility and strength can be developed over time through training and repetition.

As you become more proficient in these skills, they will pay dividends in safety, patient experience and career satisfaction.


BETH BOYNTON, RN, M.S., CP, is a nurse consultant specializing in teaching communication-related skills to healthcare professionals. She has written 3 books on communication in healthcare and co-authored one on leadership for nurses. She publishes two blogs including the award-winning, “Confident Voices in Healthcare.”  Beth is a pioneer in developing “Medical Improv” as an experiential teaching modality to help nurses and others speak up and listen effectively and respectfully. www.bethboynton.com

LIZ KORABEK-EMERSON, MFA, is a professor and coauthor of the book Designing and Leading Life-Changing Workshops. Learn more about her programs and listen to free guided meditations at www.korabektraining.com.


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