Chapter 2: When the Load Grows Heavy: Stress

A Letter from Amara

Dear Jiwoo, I am writing this at two in the morning, after a late shift, because I cannot sleep and I do not want to wake anyone. I have been a nurse on a busy hospital ward for six years. I chose this work, and most days I still love it. I love the moment when a frightened patient finally relaxes because I have explained what will happen next. I love the jokes we share at the nurses' station when the night is quiet.

But the nights are not often quiet anymore. We are short of staff, so each of us looks after more patients than we should. I run from bed to bed. The machines beep, the phone rings, a relative needs to talk, a doctor needs a form, and somebody always needs me five minutes ago. Some shifts I realize at the end that I have not had a drink of water since I arrived.

The strange thing is what happens after I leave. My shift ends, but my body does not seem to know it. My heart keeps racing on the bus home. My jaw aches because I have been clenching it, and I get headaches that last into my days off. Last week my younger brother asked me a simple question about dinner, and I snapped at him so sharply that he left the room. I felt terrible, because none of it was his fault.

When I mention any of this at work, my colleagues say, "That is the job." Perhaps they are right, since people who care for others have always worked hard. But I keep wondering about a few things. Is stress just the price of doing work that matters? When does ordinary pressure become too much? And what can I do about it when I cannot change the number of patients on my ward? With thanks, Amara

Dear Amara

Thank you for writing to me in the middle of the night, when the house was asleep and your mind was not. I am sorry that the ward has become so hard, and I am glad that you still feel the joy in your work. I could hear it in your description of the frightened patient who relaxes. Please hold on to that. It tells me that the problem is not that you have stopped caring. The problem is that caring has been asked to stretch further than any person can stretch for long.

I also want to say something about your brother. Snapping at someone we love when we are overloaded is one of the most common signs of stress that people describe, and it is not a sign that you are unkind. It is a sign that your reserves are empty. Later in this letter I will come back to him.

Your colleagues say, "That is the job." There is truth in that. Nursing, like many kinds of work, is demanding by nature. But "that is the job" can mean two different things. It can mean, "This work is hard, so let us help each other carry it." Or it can mean, "This work is hard, so do not complain."

The first meaning protects people. The second slowly wears them out. I hope that by the end of this letter you will feel free to choose the first.

What Stress Is, and Why the Body Reacts

Psychology textbooks usually describe stress as what happens when the demands on a person feel greater than the resources that person has to meet them. Resources here means anything that helps: time, skill, energy, information, equipment and the support of other people. The word "stress" is used for two things at once. It can mean the pressure itself, such as too many patients. And it can mean what happens inside us in response, such as a racing heart. In daily speech we mix the two together, which is one reason the subject can feel confusing.

The response inside us is very old. When the brain senses a challenge or a threat, it sets off an alarm that runs through the whole body. Stress hormones are released into the blood. The heart beats faster and the breath quickens, so that more oxygen reaches the muscles. The muscles tighten, ready to act, and digestion slows down, because it can wait. The senses sharpen and attention narrows onto the problem in front of us. Textbooks often call this the "fight or flight" response, because it prepared our distant ancestors either to fight a danger or to run from it.

On your ward, this alarm has surely helped you many times. When a patient suddenly becomes very ill, it is your stress response that makes you fast, focused and strong. You should not think of it as an enemy. It is a tool that the body lends us for emergencies.

The difficulty is in the word "emergencies." The alarm is designed to switch on, solve a short problem and then switch off again. After the danger passes, a second system in the body calms everything down. The heart slows, the muscles soften, digestion starts again and the person feels tired but settled.

What you describe, Amara, sounds like an alarm that rarely gets the chance to switch off. A whole shift of small emergencies, one after another, with no pause between them, keeps the body on alert. Then the bus ride home is too short for the calming system to catch up. Your racing heart, your clenched jaw and your headaches are what an alarm sounds like when it has been ringing for too long.

This is also the answer to the confusion that Daniel described in my last letter, when one article told him stress was good for him and another told him it was harmful. General explanations of research often describe the link between pressure and performance as a kind of curve. With very little pressure, people can feel bored and flat. With a moderate amount, many people feel alert and do their best work. But beyond a certain point, more pressure makes performance and health worse, not better.

Both articles were describing different parts of the same curve. A short, clear challenge that ends can be good for us. Heavy pressure that never lifts is not.

The sources I know agree on a few central points. Stress itself is not an illness, and some stress is a normal part of every life. But stress that is strong and lasts a long time can affect the health of both the body and the mind. Public health guides, psychology textbooks and international organizations that work on health all say this, each in their own words.

Demands, Control and Support

When researchers and workplace-safety agencies talk about stress at work, they often look at three things together. The first is demand: how much work there is, how fast it must be done and how emotionally heavy it is. The second is control: how much say a worker has over how, when and in what order the work is done. The third is support: how much help, information and kindness comes from colleagues and from the people in charge. General explanations of research describe the hardest mix as high demand, low control and little support. When demand is high but control and support are also strong, people often cope surprisingly well.

Your ward, as you describe it, has very high demand. You have little control over the number of patients or the moments when they need you. So the place where something might change most easily is support.

Let me show you what I mean with two other working days. In a valley where rice is grown, a group of neighbours are planting seedlings in a flooded field during a long, wet morning. The work is heavy, their backs ache and the rain does not stop. But the neighbours work in a line, side by side. They talk, they sing a little, they decide together when to stop for a meal, and the work moves forward as a shared task.

Now picture a dispatcher at a bus depot just before dawn. Three buses have broken down, two drivers have called in sick and the phone does not stop ringing. The dispatcher is alone in a small office, making every decision by herself, and nobody comes to ask how she is doing. The farmers and the dispatcher both have heavy days. But the dispatcher carries her load alone, and that is often what turns hard work into harmful stress.

Some textbooks add one more idea. They look at the balance between the effort a person gives and what comes back in return: fair pay, respect, recognition and a sense of security. When people give great effort for a long time and feel that little comes back, stress tends to grow. Many nurses, carers and teachers know this feeling well.

Here the sources begin to differ, and I think the difference is important for you. Self-help guides for the public are written for the person reading them, so they focus on what an individual can do: breathe, rest, talk, plan. International organizations that work on health and on work, and workplace-safety agencies in general, put much more weight on the workplace itself. They say that employers have a responsibility to look for the causes of stress at work and to reduce them, through fair workloads, enough staff, real breaks, clear roles and good support. In their view, teaching a tired nurse to breathe slowly is not enough if the ward is always short of hands.

Why do the sources differ here? I think it is because they are speaking to different people. A self-help guide speaks to someone who cannot rewrite the staff rota. An organization speaks to the people who can. Both are needed.

But please notice what this means for you, Amara. Your stress is not a personal failure to cope. Much of it comes from the way the work is arranged. If your ward has staff meetings, staff representatives or a person whose role is to listen to concerns, it may be worth raising the shortage together with your colleagues, calmly and with examples. One voice can be overlooked. Several voices describing the same problem are harder to ignore.

Signs That the Load Is Too Heavy

You asked when ordinary pressure becomes too much. There is no single line that is the same for everyone. But public mental health guides describe common signs that stress has gone on too long or grown too heavy. These signs tend to appear in four areas of life.

In the body, people often notice headaches, tight shoulders, a clenched jaw, an upset stomach, a racing heart, trouble sleeping and catching colds more often than before. In the mind, people describe racing thoughts, forgetting small things, finding it hard to make decisions and replaying the working day over and over at night. In the feelings, people notice that they become irritable, tearful, on edge or strangely numb. And in behaviour, people may stop eating proper meals, pull away from friends, give up activities they used to enjoy, or rely more and more on coffee, sugar or alcohol to get through the day.

Reading your letter, I recognize several of these signs: the racing heart on the bus, the headaches that last into your days off, the clenched jaw, the sleepless nights and the sharp words to your brother. I cannot tell you what they mean for your health. I can only tell you that, in the language of the guides, these are messages. Your body is not betraying you. It is telling you, as clearly as it can, that the load has grown heavier than it can carry without help.

There is one thing I must say plainly. A racing heart and headaches can come from stress, but they can also come from other causes. Please do not simply assume that they are stress. Talk to a doctor and let the doctor check, especially if you ever have chest pain, trouble breathing or a feeling that your heart is beating in a strange way. You spend your days making sure that other people's symptoms are taken seriously. Your own symptoms deserve the same respect.

When stress goes on for a very long time and leaves behind a deep, heavy exhaustion and a growing distance from the work, people sometimes use the word "burnout." I will write about burnout properly in a later letter, because it needs space of its own. For now, it is enough to know that noticing the signs early, as you are doing, is one of the best ways to keep stress from going that far.

Small Ways to Lighten the Load

Now to your last question: what can you do when you cannot change the number of patients? I want to offer some small things, not because they will solve the staff shortage, but because small things, repeated often, can give your body chances to switch the alarm off.

The first is tiny pauses during the shift. You may not get a proper break, but you probably get many moments of a few seconds: washing your hands, walking down a corridor, waiting for a door to open. Public mental health guides often suggest using moments like these for a slow breath, with the breath out a little longer than the breath in. Breathing out slowly is one of the simplest signals that tells the calming system in the body it can begin its work. You could make hand washing your signal. Each time the water runs, let your shoulders drop and breathe out slowly once.

The second is the basics that busy people forget. Drink water. Eat something during the shift, even if it is small. These are such simple things that they can sound almost silly, but a body that is thirsty and hungry raises its own alarm on top of the alarm of the ward.

The third is a way of closing the working day. The bus ride is too short for your body to calm down on its own, so you might give it a little help. Some people who work in hospitals change their clothes before they leave, as if they are taking the shift off with the uniform. Others walk part of the way home, or sit for a few minutes before going inside, or say a quiet sentence to themselves, such as, "The shift is over, and I did what I could." It may sound too simple to help, but a small ritual like this tells the mind that one part of the day has ended and another has begun.

I think of a crane operator who works high above a building site in a small cabin. Her work demands complete concentration for hours, because every load she moves swings above other people. When she climbs down at the end of the day, she always does the same thing. She sits on a low wall near the gate, drinks a cup of tea from her flask and watches the sky for a few minutes before she goes home. Her colleagues tease her about it. She says those few quiet minutes are how she leaves the weight of the day up in the cabin.

The fourth is talking with colleagues. Many hospital teams find it helps to speak together after a hard shift, even briefly, about what happened and how it felt. The jokes at the nurses' station that you love are part of this too. Shared laughter is one of the oldest ways that people release tension together. If your team does not do this yet, perhaps you could suggest it.

The fifth is sorting what you can and cannot change. When everything feels urgent, it can help to write three short lists on a quiet day off: what you can control, what you can influence, and what you cannot change at all. You may find that the first list is short, but it is rarely empty. Many old traditions of thought share a similar idea: find the courage to change what can be changed, the calm to accept what cannot, and the wisdom to tell the difference. The textbooks I read say something similar in their own language. They describe how people cope better when they put their energy where it can make a difference, instead of spending it on what is out of their hands.

The sixth is your life outside the ward. Rest, sleep and time with people who make you laugh are not rewards for finishing your work. They are what makes the work possible. I will write about rest and sleep in my next letter, in reply to a delivery driver who has the same trouble switching off that you do.

And then there is your brother. You do not have to be perfect with the people you love. But you can repair. A simple apology and a short explanation, such as, "I am sorry I snapped. The shift was very hard, and you did nothing wrong," can turn a painful moment into a moment of trust. You might even tell him a little about how the ward has been. People who love us often want to help, but they cannot help with what they do not know.

You spend your days caring for others. I hope you will let some of that care come back to you. Until the next letter, Jiwoo

A Question to Think About

Here is the question I would like you, Amara, and every reader to think about: in your working day, where does your body's alarm switch on, and where, if anywhere, does it get the chance to switch off again? Try to answer from your own experience, not from what you think you ought to feel.

You might start by noticing your body at different moments: when you arrive, in the busiest hour, on the way home and on your first evening off. Where do you feel tension, and when does it ease? Which moments of your day, however short, could become small pauses?

You might also think about demand, control and support in your own work. Which of the three is strongest for you, and which is weakest? Is there one part of your load that you could share with someone else, instead of carrying it alone?