The Anxious Nurse’s Guide to Thriving in a High-Pressure Environment

In the high-stakes world of healthcare, feelings of anxiety are not just common; they’re expected. Nursing is rewarding and incredibly demanding, especially in critical environments like the ICU or emergency department. It requires a balance of mental fortitude and compassion, often pushing nurses to their limits. If you consider yourself an anxious nurse, this guide is for you.

Understanding and managing anxiety is crucial, not just for our mental health but for the safety and well-being of our patients. Anxiety, when not addressed, can lead to medical errors, affect our decision-making abilities, and have significant impacts on our overall health. We can find ourselves dreading work and stress sleeping the night before.

After years of pursuing a nursing degree, it is disheartening to feel like this as an RN. However, just because you are an anxious nurse doesn’t mean that this is just how you are, and there is no hope to live a life less worrisome. It is possible to love and enjoy your nursing career while also actively managing your anxiety. So, both new graduate nurses and experienced nurses alike with or without existing mental health issues, let’s dig in!

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If you’d prefer to watch my video, Are You An Anxious Nurse? – click below!

Am I An Anxious Nurse, Or Am I Just Nervous?

First, it’s vital to differentiate between the typical feelings of nervousness that come with the job and diagnosable anxiety. Nervousness can be a normal and healthy response to new or challenging situations, often subsiding as familiarity and confidence grow.

The key 🔑 difference between anxiety and nervousness is that nervousness typically subsides once the triggering event is over. For example, you might be nervous whenever you have to call a physician but once the call is over, you feel balanced and calm again. Or, you might feel nervous about getting report at the beginning of a shift, but once you get through that, you feel ready to start the shift.

Also, with nervousness, the intensity lessens over time as repeated exposure to a situation lessens the unfamiliarity and fear surrounding it. Once confidence grows, the sting becomes dull, and what was once really scary is now NBD.

Being an anxious nurse is quite different. In contrast, anxiety is a persistent condition with physical symptoms such as restlessness and insomnia and psychological symptoms including constant worry and fear. When anxiety levels persist, intensify, or interfere with daily functions, it may indicate a more serious issue. Anxiety can manifest through physical symptoms such as palpitations, dizziness, or excessive sweating, impacting our ability to perform effectively.

Critical self-reflection question ➡️ Am I suffering from anxiety, or am I nervous about specific work-related situations?

If you feel like you are more likely nervous (even about multiple possible work situations), try to identify what specifically makes your heart race, breath quicken, and chest tighten up at work. List all of those situations. Externalizing emotions and specifically identifying situations makes experiencing and processing the feelings a more straightforward process. We don’t want to stuff or stifle; we want to acknowledge, process, and move forward.

If you notice there is a pattern, or if there are specific things you can do to lessen the nervousness about those situations, do it! Maybe you need to chat with your preceptor, get more attempts at starting IVs, a framework to speak with physicians, or just review some key aspects of your patient population’s most common issues so you can field patient questions better.

Regardless of the specifics, we’re taking a big and overwhelming emotion, externalizing it, and creating actionable steps to make it much more manageable!

As you can tell, being an anxious nurse will require a more intentional and supportive plan than nervousness. We want to get the current anxiety under control and then also get to a point where you are successfully managing it on a regular basis so that you can work with a clear head and calm heart.

Lower Your Baseline Level of Anxiety

Lowering your anxiety baseline is KEY. This reminds me of how we prevent secondary injury in our patients. Let’s say our patient came in with a myocardial infarction. We want their body to be focused on healing that issue, not overcoming secondary issues. This is why we aggressively monitor their hemodynamic status and electrolytes, replacing them proactively to prevent imbalances that lead to dysrhythmias. We also prevent injuries and other issues.

We want their body focused on one thing: Healing the MI. We need to mitigate other risks proactively to enable this to happen smoothly.

It’s the same with your anxiety. We want to be focused on healing issues related to anxiety, so we simultaneously need to address anything that we’re doing that may increase it and subsequently undermine our efforts.

Healing underlying issues likely takes deep inner work and chatting with a professional. In the meantime, let’s discuss practical ways you can reduce your overall baseline level of anxiety, which will make flare-ups much more manageable.

Awareness and Deep Breathing 🫁

Deep breathing activities lower anxiety by engaging both the body and mind in a way that activates the parasympathetic nervous system, also known as the “rest-and-digest” system, which helps to counteract the body’s stress response or the “fight-or-flight” mechanism initiated by the sympathetic nervous system. When we’re stressed or anxious, our breathing tends to become irregular and shallow, limiting the amount of air that can flow into the body. Deep breathing encourages fuller, slower breaths that increase oxygen intake, slow down the heart rate, and lead to calmness.

By focusing on deep, diaphragmatic breathing rather than shallow chest breathing, you allow more air to flow into your body, calming your nerves and reducing stress and anxiety. This practice not only improves your attention span and lowers pain levels but also quiets the sympathetic nervous system, thereby reducing feelings of stress or anxiety. It’s a simple yet effective method to manage day-to-day anxiety as well as more pervasive issues like generalized anxiety disorder.

Practicing deep breathing can involve various techniques, such as taking slower, longer breaths from your stomach to counteract short, rapid breaths or trying different breathing patterns to find what feels most natural for you. It’s also beneficial to incorporate mindfulness into your practice by focusing on your breath and letting go of any thoughts without judgment.

Heads up ➡️ For those new to deep breathing, it might feel uncomfortable at first. You may get emotional or feel like it’s surprisingly difficult and want to give up. That’s okay and normal.

With regular practice, you’ll become better at using it to calm yourself during stressful times. It’s essential to approach deep breathing with self-compassion, recognizing that immediate results might not always be noticeable, but persistence will yield benefits over time.

Progressive Muscle Relaxation and Acceptance

Progressive Muscle Relaxation (PMR) is a technique involving the tension and relaxation of muscle groups, promoting relaxation and reducing anxiety. It’s beneficial for improving sleep, reducing stress, tension headaches, and enhancing athletic performance.

PMR can also help control the body’s response to anxiety, especially when paired with cognitive behavioral therapy. Regular practice increases awareness of bodily tension and the ability to release it, effectively managing stress in anxious situations.

When we are anxious about something, we are fixated on it. By focusing on something else intently, we cannot ruminate at the same time. Therefore, awareness can be a powerful tool. Even something as simple as focusing on the five senses (what can I see, feel, hear, touch, or taste) can pull you out of a negative thought cycle.

Physical Activity

Regular exercise has been shown to reduce stress, improve mood, and increase sleep quality, contributing to lower anxiety levels. Exercise releases endorphins, which enhance your sense of well-being. It is something you can focus on that organically pulls you out of rumination or a negative thought cycle.

Harvard Health outlines why exercise helps with anxiety:

• Exercise forces you to think about other things, not what you’re anxious about – we just mentioned this with awareness!
• Movement ⬇️ muscle tension – if your body isn’t as tense, it doesn’t feel as anxious.
• An increased heart rate alters brain chemistry, increasing the availability of critical anti-anxiety neurochemicals (serotonin, GABA, BDNF, endocannabinoid. (This book explains how this works very clearly. It’s fascinating!)
• Exercise activates frontal regions of the brain (the prefrontal cortex, or PFC for all of you fellow neuro nerds out there) and calms the reactivity of the amygdala (which drives the anxiety).
• Exercising regularly builds up resources that enable you to navigate challenging emotions.

If you’re working three 12-hour shift at the hospital, exercising the same day as work is likely a bit too much. You get quite a bit of movement walking around the unit all day! Make sure on your days off that you’re engaging in movement you enjoy.

It doesn’t have to be some intense workout class, a 6-mile run, or a lifting regimen. It needs to be something you will do and enjoy.

Wise Lifestyle Choices

Avoiding alcohol, recreational drugs, and caffeine can help reduce nurse anxiety.

Alcohol is tricky because you feel relaxed when you consume it initially, and it may feel like it’s helping you destress from a tough day. This is a sedative effect on the central nervous system, which can temporarily relieve feelings of fear and anxiety.

However, this is a short-lived relief. Once the effects of alcohol wear off, anxiety can return more intensely, creating a cycle where you might become dependent on alcohol for anxiety relief. This dependency can lead to withdrawal symptoms when not drinking, which can include increased anxiety among other symptoms like a rise in heart rate, sweating, trembling hands, and nausea.

Moreover, alcohol can also lead to poor food choices and dehydration, both of which can exacerbate feelings of anxiety. Additionally, the disinhibiting effects of alcohol might lead to risky decision-making and social embarrassment, adding to anxiety levels.

While caffeine can initially make you feel more alert and awake, it can also exacerbate anxiety symptoms in some people. This is because caffeine increases the activity in your brain and nervous system, which can lead to feelings of nervousness and jitteriness and can even mimic symptoms of anxiety.

In terms of recreational drugs – many increase anxiety! Self-medicating is a temporary fix. To work as a nurse for years to come, we need to look for long-term solutions.

Sleep 😴 is also a major factor in reducing your anxiety threshold. Good sleep will enhance your mental health and make anxiety easier to manage, while sleep deprivation will exacerbate it.

Individuals who experience severe sleep deprivation report heightened anxiety during tasks and a greater perception of catastrophic outcomes. (This can be even worse when you’re working with patients and dealing with death often.) Inadequate sleep acts as a chronic stressor, impairing brain function and overloading the body’s systems, leading to memory impairment, cognitive fog, and an inability to cope effectively with stress. It disrupts hormonal balance, increases adrenaline levels, and can intensify existing anxiety problems

Ensure you keep yourself hydrated and consume a nutritious diet. We want to give our body the best possible chance to weather emotional storms. We don’t want to be in a shack out in the middle of a field during a tornado 🌪️ . We want to be in a sturdy brick building with a basement to stand strong during high winds and flying debris. Avoiding booze and drugs, getting good sleep, and consuming foods that nourish our bodies are foundational aspects of this and are critical acts of self-care.

Social Support and Journaling

Socializing and not isolating yourself from loved ones or activities can provide a significant boost to your mental health and reduce nurse anxiety. Isolation amplifies suffering. Having social connection with people outside of work where we can tap into interests and topics that do not involve the stress of work are imperative. This will keep you from constantly being in “work mode” and enable you to build and maintain your identity outside of work.

Keeping a journal can help you external your emotions, which make them more manageable to process and work through. Future self journaling is my favorite framework to use, but you can always freeform it!

By integrating these methods into your daily life, you can effectively lower your baseline level of anxiety. However, it’s important to remember that managing anxiety is a continuous process that requires patience and practice.

Develop Routines To Outsmart Your Brain 🧠

Routines are helpful to cue your brain to gear up for something or calm down out of situations. Our brains have our innate fight or flight response, but in terms of transitions during the day, we need to be very intentional about moving from one activity to the next to maintain presence.

Have you ever finished a workout and couldn’t go to sleep? Or have you had to go out to dinner right after work and just couldn’t enjoy yourself? Or have your kids jumped on you immediately after walking in the door, and you’re just not ready to engage yet?

Working in healthcare with life and-death and other stressful situations (and just providing patient care, honestly!) in an intense environment requires more intention both before work and after.

A Pre-Shift Routine To Reduce Anxiety

Pre-shift anxiety is real (also referred to as anticipatory anxiety). Craft a customized routine that you go through beforehand to keep your nurse anxiety before work at bay. Your brain will get used to it, and you’ll be able to transition better mentally to go from your home mode to being focused for your intense job!

• Set out scrubs the night before
• Prep lunch and snacks, get coffee ready to go off in the morning
• Wake-up, 5 slow deep breaths
• Turn on your comfort show while you get ready
• Three yoga poses to stretch; put on scrubs
• Eat breakfast, head to work
• During the commute, listen to a specific podcast (I’ve been told our podcast is quite comforting before a shift!) or music that gets your head in the game
• Tell yourself, “I’m excited I get to do this,” even if you’re not (this tricks your brain a bit!)
• Walk into work, clock in and have a pre-shift prep routine
  • This will look very different depending on what unit you work on. Mine in med-surg was to put my stuff in my locker, look up my patients, fill up my water and get my computer set up, pre-fill out the top of my report sheets, double-check if anything was missed from the previous shift, and say hi to the people I was going to work with that day.

This routine tells your brain that you’re safe, you’re in charge, and you can handle what comes your way. It gets you in the mindset to do what you know, not ruminate on all of the possibilities of what could go wrong.

A Post-Shift Routine to Reduce Anxiety

Your crazy shift is over. You’ve finished charting and it’s time to clock out. Let’s soothe ourselves out of the all-consuming world of the hospital to our own reality at home. These routines will help reduce your nurse anxiety!

When you work in a hospital and focus intently on various tasks for an extended period of time, you can almost forget there is an outside world. While it’s phenomenal to be so focused (I personally loved getting in the zone!) it can detach you from your own reality. We need to step out of the world of our patients and the hospital and back into our roles at home.

• Clock out, head to your car
• Put your stuff in the same spot every time
• Turn on something comforting that you really enjoy (show, podcast, music) or call someone (like your mom) to debrief the day a bit
• Drive the same route home
• Take a shower as soon as you get home, visualizing the stressors of the day flowing down the drain
• If you’ve got any pretty big or intense feelings, identify them while you’re alone and decompressing
  • After you name them, remind yourself that other nurses have felt similar emotions after a shift, and give yourself a little warmth (this process of naming an emotion, acknowledging the common humanity you have with other nurses, and giving yourself comfort is called self-compassion).
• Spend time with whomever you live with, eat a meal, watch a show, or do something you enjoy
• Read a relaxing fiction book (getting lost in a world that isn’t real can help us cope when our jobs are a little too real)

These steps are customized to your needs and transition your brain out of work mode and into home mode. This sense of predictability is beneficial in anxiety reduction because anxiety is all about worrying about the unknown ahead. These routines will help mitigate pre-shift anxiety and post-shift detachment.

Work Anxiety Flares 🔥 or Freeze 🧊 Responses

An anxiety flare or a freeze response during a critical moment can be daunting. In the hospital, we are regularly exposed to situations that naturally signal DANGER ⚠️ DANGER to our brains. It is a very human response to freeze. It can be as intense as a code, or it can be something like the mean charge nurse made you look stupid at the nurse’s station – and just about everything in between!

The key is to recognize it early and implement coping strategies immediately. Grounding techniques, such as the 5-4-3-2-1 method, can help divert your mind from panic and refocus on the present.

Remember ➡️ You are not dumb. You are just panicking.

Let’s regulate the panic so that your prefrontal cortex, the part of your brain responsible for executive function and critical thinking, can come back online. Then, you can access all of that lovely knowledge in your brain that is temporarily blocked due to panic!

If it’s a code situation, we can think back to the basics of ensuring someone is on the chest. (As long as someone is giving good chest compressions STAT, we can take a moment to get everything else in order.) If it’s more of a social interaction situation, we may need to pause to collect ourselves.

• I’m not sure. Let me find the answer and get back to you.
• Let me look that up and circle back.
• Hang tight, let me find out because I’m not sure.

This would be a good time to head to the bathroom and do 3 minutes of slow, deep belly breaths to pull you out of that panic response and regain your capabilities higher level of thinking.

Simply having the awareness that you’re panicking a bit and need to pull back and reset is pretty powerful. We can feel a lot of shame for not being able to immediately respond like a hero the moment we’re asked a tough question or see a complex clinical situation unfold in a matter of seconds and not know what to do. Give yourself grace and a moment to recalibrate and you’ll find that you’ll be back in the game before you know it!

Encouragement ➡️ With repeated exposure to things like codes, your brain will start to de-emphasize the danger of the situation. You’ll get used to it and what to do when it happens. Your brain will no longer think you’re in danger, it will just get into go-mode and you’ll know what to do! So give your brain some time to acclimate and re-categorize these work emergencies from a red alert to a doable challenge. This is why those code team nurses look so cool – they’re able to access the PFC in their brain immediately because their brains now they are safe and it’s a cue to lean into higher lever thinking, not protect itself.

Recognize When to Seek Professional Help

While self-management strategies can be effective, there are times when professional help is necessary. If anxiety becomes overwhelming, persistent, and impacts your quality of life or your ability to perform your duties, seeking the guidance of a mental health professional is a step of strength, not weakness. Therapists can offer tailored strategies to manage anxiety, including cognitive-behavioral therapy (CBT) and, if needed, medication.

If you work for a major health system, you likely have access to something called an Employee Assistance Program, which may provide free therapy! You can call to set up an appointment. All you need to tell them is something like, “I’m noticing increased anxiety related to work and would like to explore coping mechanism to manage it better.” It doesn’t need to be more complicated than that!

Encouraging Quotes From One Anxious Nurse To Another

These are all from messages I received directly from bedside care providers, and I thought they would be helpful and encouraging.

“Don’t let people minimize your anxiety. It is real, and it is something we anxious people have to deal with…but you can overcome it, it doesn’t have to define you.”

“Anxiety isn’t going to stop you from being a great nurse. If you love what you do, you will find ways to be the best nurse you can be…and passion overcomes anxiety. Your patients will see you care before they see that you are anxious. Just breathe.”

“Don’t feel ashamed of your anxiety. Yes, there are people who won’t get it who will judge you. They aren’t nice and they aren’t worthy of your time. Try to ignore them and turn to someone you trust that accepts your problems. I find it easier to have someone I trust that knows about my struggles. It makes me feel safer and that will make my anxiety easier to handle.”

“Dealing with the life and death situations we see as nurses can really help us put our own lives in proper perspective. I know it has helped me a lot in realizing that a lot of the things that used to give me anxiety (and still sometimes do) are truly not worth worrying about.”

“When I was a new grad nurse, I really worried for a while that even though I loved my new career the anxiety might “do me in” in the long run but it’s actually turned out to be quite the opposite. I think being a nurse has actually encouraged me to become a less anxious person. Or maybe I’ve just better learned to handle it.”

A Personal Story From A Previously Anxious Nurse

The below story was submitted to FreshRN from Thomas Floyd, RN to encourage those of you who also struggle with anxiety.

“I’ve had problems on and off with anxiety since high school but totally hit the peak in nursing school. I honestly can’t pin point the biggest cause whether it was bills, family or school itself but there were so many moments sitting in class feeling like I couldn’t breathe or I might pass out for no reason as at all. I think the perfect example for the current student in question [of whether they can be a nurse even though they struggle with anxiety] is when I walked out of my cardiac lecture in school because of a panic attack.

For whatever reason, I couldn’t center myself and just felt the anxiety building and ended up leaving in the middle of the lecture.

However, now six months post grad I am working as a cardiac step down nurse in a prominent teaching hospital. All is possible! I think so many people have anxiety and some don’t even really recognize that “feeling” as anxiety itself. I still get anxiety but being able to recognize it and tell myself “this will pass. You’ve felt this before and it’s not something that will hurt you” helps immensely… that and my dog. Hope this helps someone!

The first time I did a clinical rotation in the ER I was terrified. All day I kept wondering if I was doing things wrong. Then late in the afternoon a little girl came in with a dislocated kneecap. As I stood by watching the doctor at her feet, her mother at her head, boyfriend by her side, and the nurse I was following trying to start an IV, I felt useless and afraid because I didn’t know how to help her.

After a minute I realized that the nurse was having a hard time starting the IV because the girl was shaking too hard. She was crying and so afraid, and in so much pain. So I reached around the nurse and took the girl’s hand. She squeezed (hard), and after another minute she stopped shaking.

The nurse got the IV started and we got her some pain meds, and the situation progressed normally from there. I went around to the other side of the bed and tried to catch her attention so the doctor could reset the kneecap. I told her a joke and she laughed, and then she realized the doctor was done and she didn’t feel any pain, and she wasn’t scared anymore.

She turned to me and said “Thank you.” That felt so awesome. That was the first time I had made a decision that was entirely my own, based on what I thought I could do for a patient. That was the first time I knew what it felt like to be a nurse instead of just a student.

Now I know we don’t do what we do for the thank yous, but from then on every time I got stressed over a test, angry at one of my instructors, afraid at a new clinical site, or frustrated and ready to give up, I thought of that little girl squeezing my hand and thanking me, and suddenly it was all worth it, and whatever anxiety I was feeling would melt away.

Find your moment. That was mine.”

Final Thoughts For The Anxious Nurse

The journey of a nurse is fraught with challenges that test our limits. Yet, the nursing profession offers unmatched fulfillment. Understanding, acknowledging, and managing feelings of anxiety is not only a personal investment in our well-being but a professional responsibility to those we care for.

Remember, it’s okay to ask for help, and taking care of your mental health is just as important as the care you provide to your patients. Let’s embrace the challenges with strength, support each other, and thrive in the high-pressure environment that we worked so hard to be in!

More Resources For The Anxious Nurse

• Empathy’s Toll: The Reality of Nurses and Secondary Trauma
• For the Overwhelmed New Grad Nurse: I See You
• How to Be a Better Nurse: 4 Essential Tips
• “I’m Not Drowning Anymore” – A Professional Development Plan For Nurses
• Why We Freeze When a Patient Codes
• Best Jobs For Nurses With Anxiety