The science of stress first aid

When we are exposed to situations that drastically raise our stress levels, our mental health can be deeply impacted. We may even experience what is known as a stress reaction — a rise in mental distress that is often accompanied by physical symptoms such as increased heart rate, dizziness, and shaking.

Although rarely as apparent as a physical wound, the myriad negative effects of stress can be profound and long-lasting if left untreated. Stress First Aid (SFA) is an effective strategy developed to address these consequences, and while it can be self-administered to some degree, the success of SFA relies heavily on social support, especially by one’s peers and co-workers.

What is Stress First Aid?

SFA is a program designed to detect signs of stress and lessen its negative impacts in oneself and others. It is especially effective when implemented as part of a peer-driven stress management strategy as it leverages the power of the more informal and genuine relationships that occur naturally between co-workers. Applying SFA begins by adopting a routine of regularly assessing mental wellness and proactively designating resources to prevent or limit the severity of potential incidents. This is complemented by a series of steps to de-escalate, relieve, and process stress events if and when they arise. The components of SFA are applicable both during critical events and as ongoing care.

Several versions of SFA have been formed over the years for high-risk occupations and were influential on the adaptation for healthcare workers which was developed by Patricia Watson of the National Center for PTSD and Richard Westphal of the University of Virginia. This healthcare-focused version along with the others developed for military personnel, firemen, and law enforcement are freely available on the US Dept of Veterans Affairs website.

Incorporating SFA into standard practice can help to significantly improve the psychological well-being of workers — especially those working on frontlines or in dangerous conditions. With the onset of the COVID-19 global health crisis, interest in SFA accelerated. The extraordinary strain on the healthcare system as a whole provided ample opportunity to examine the effectiveness of SFA as a stress management strategy in a high-stakes, real-world scenario.

Kelley Rumsey, a pediatric trauma program manager at Children’s Hospital of Richmond at VCU, has long been a proponent of SFA in a healthcare setting. Previously, common stress control practice involved gathering as a group to discuss traumatic events. Burnout rates remained high, however, and given the potentially dangerous downstream effects of a stressed out, mentally traumatized healthcare staff, Rumsey began looking for a more effective system. In addition to her role at VCU, Rumsey also worked supporting emergency responders. This is where she first observed SFA in action and recognized its potential. Enlisting the help of Richard Westphal, she brought Stress First Aid to VCU in 2018 through a pilot program with a preliminary group of 20 PICU members. By 2021, training had begun across the health system.

In Rumsey’s words,

“SFA took on added momentum as pediatric nurses [who had been] deployed to other areas of the health system introduced the toolkit to their new teams, helping those teams better handle the stress of tending COVID-19 patients.”

The Stress Continuum

SFA works in tandem with a Stress Continuum model, which was originally developed by the US Marine Corps to help visualize and communicate the severity of stress and determine the appropriate remedy.

Green is the desired state for an individual, and it is the goal of preventative and training measures. As stress increases or accumulates, an individual’s state may progress from Yellow (transient state with mild effects) to Orange (persistent state with lasting effects) and finally to Red (a disabled state with loss of function). Understanding where on the continuum an individual is dictates the appropriate level of intervention. It is common and expected in high-pressure environments for an individual to move through each of these states and back again, sometimes rapidly. SFA is intended for application in the Yellow and Orange zones to help recover back to Green. It may also serve as a bridge to clinical care if an individual is found to be in the Red Zone.

In practice, this system provides an alternative terminology that allows conversations regarding mental state to occur more naturally between peers and co-workers by avoiding the stigma typically attached to admitting poor mental health.

From Rumsey again,

“It’s intended to be a natural conversation…It is not intended to look like a mental health intervention, because we know there is a lot of stigma around mental health. If someone thinks you are not ok, that could be the end of your career. SFA is really just a skillset for team members to begin that conversation.”

The Stress First Aid Model

If an individual recognizes their teammate to be suffering from stress, they have the power to implement SFA and help bring that person back to a green state. This may mean referring them to a more formalized treatment if it is determined that SFA alone will not suffice, but in many instances, SFA can halt the worsening of a stress reaction before this becomes necessary. Besides the advantages that come with a peer-driven intervention strategy, one of the primary features of SFA is the latitude given on the specific methods used to restore mental wellness. Rather than a predetermined treatment plan, SFA instead provides a logical progression of critical objectives to meet when aiding a person’s mental health recovery from a stressful event. Determining the specific tactics used to achieve those objectives relies on familiarity and a caring relationship between the administering and affected individual(s).

The lack of specificity in approach provided by the SFA model is intentional and necessary. Due to the wide variety and deeply personal nature of mass trauma events, there is currently no evidence-based consensus on effective interventions for the immediate to mid-term periods following these events. Therefore, these interventions are characterized as “evidence-informed.” The SFA protocol is based on the psychosocial interventions used in trauma and disaster recovery thoroughly discussed in Five Essential Elements of Immediate and Mid–Term Mass Trauma Intervention: Empirical Evidence.

The SFA model incorporates these interventions into its seven core actions, referred to as the ‘Seven Cs.’ The first two are meant to be more of a proactive effort to protect and maintain green zone status. If a stress reaction is detected, the interventions are implemented to recover green zone status and minimize the likelihood of lasting mental injury. If an injury occurs that is beyond the scope of SFA, SFA can serve as a bridge to more intensive care.

1. Check: This is a screening step to ascertain an individual’s current status and determine if any intervention is necessary. Stated plainly, it means getting to know someone well enough that changes in their behavior can be recognized. This requires rapport and trust — elements which are crucial to the success of SFA.

2. Coordinate: Efforts to help someone recover often benefit from additional help, and allocating resources in advance makes for a speedy and effective response. Mentors, friends, professionally designated support personnel — these are just a few of the types of people who may be well-suited to aid in the recovery. Others who might be affected should be identified and informed as necessary, such as managers or co-workers. All of this is best done with the consent and collaboration of the individual in need.

3. Cover: Upon the event of a stress reaction, the first step is to secure the physical safety of both the individual and others using the least intrusive means possible. Restoring perceived safety in those feeling threatened is essential to regaining control and beginning recovery.

4. Calm: Once a feeling of safety has been established, the next phase is to help them regain their sense of composure. This may be as simple as employing breathing techniques or it may require an extended period of rest and removal from triggering environments.

5. Connection: Social ties are often eroded as a secondary effect of severe stress, leading to feelings of isolation. Efforts should be focused on being with the person and helping to rehabilitate their social support system. This helps to reaffirm their sense of self-worth and stability.

6. Competence: Sometimes ability is diminished as a result of stress, and sometimes stress is due to a lack of training or resources. Whichever the case, it is necessary to correct this gap in order to enable the individual to meet and overcome future challenges.

7. Confidence: SFA culminates in this final stage, the goal of which is to help them feel more optimistic and hopeful of good outcomes as future challenges emerge. Ideally, the individual would be able to frame the event as a lesson learned and build on the experience in order to bolster a realistic sense of self and their abilities.

Final Thoughts: The Effectiveness of SFA in a Health Care Setting

Perhaps the greatest testimony to the viability of SFA as a stress mitigation strategy is the variety of crucial industries which have adopted it and developed their own iterations. Originating in the military and spreading to first-responders, law enforcement, and now to health care, SFA has proven its value in several high-stakes arenas.

Back at VCU, the results are encouraging. Since Rumsey’s original SFA pilot program in 2018, data shows improvements in retention and decreases in burnout and absenteeism. Beyond the numbers, team members can actually feel the difference.

According to Rumsey,

“We heard from the team members, and we heard from staff that the culture has shifted…It is a much more caring and supportive environment.”

Taking a step back, perhaps the success of SFA is unsurprising. The simplicity of its premise, which is essentially that we need attentive, caring friends, belies the complexity of the issue. We have multiple populations in various fields whose safety nets of social support by friends and family have been disrupted en masse and yet prioritization of mental wellness is still heavily stigmatized. This formal packaging of our basic and instinctive need for social support during hardship might seem to be merely a statement of the obvious, but just so, it is a profound admonishment of the systems which necessitated its development.

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