Stress First Aid

Implementation Guide
for SFA COACHES
 Stress First Aid Model
This guide was designed to
to increase knowledge and
understanding of how to
implement the Stress First Aid
model. It was developed by
Patricia Watson of the National
Center for PTSD, and Richard
Seven C’s
1. Check
Westphal of the University
2. Coordinate
of Virginia.
3. Cover
4. Calm
For additional information on 5. Connect
Stress First Aid, you may also 6. Competence
review the Stress First Aid for 7. Confidence
Health Care Workers Manual,
by Patricia Watson, Ph.D., of
the National Center for PTSD,
and Richard Westphal of the
University of Virginia.

2 National Center for PTSD

 Stress First Aid Implementation Guide
for SFA COACHES
Stress First Aid (SFA) is a self-care and coworker support model developed for those in high-stress
occupations. It offers simple, practical actions to identify and address early stress reactions in
oneself and others in both an acute and ongoing way (not just after “critical incidents”). It allows
for differences in capacity for self-care or coworker support, as well as preferences as to what is
most helpful. SFA gives a framework to identify the actions which might be most indicated in
different circumstances. It also highlights the importance of organizations engaging in discussions
and problem-solving around work stress. This Guide offers steps for implementing SFA in your
organization or department, whereby SFA coaches can be identified who support SFA unit leads and
those who are implementing the SFA model within their departments/units/teams. This facilitates
scalable and sustainable support.

Step 1: Get Trained in Stress First Aid (SFA)

• Read the manual to familiarize yourself with SFA.
• Use the training resources and additional handouts on the NCPTSD website.

Step 2: Introduce the Model to Your Organization

• Use the 30-minute SFA briefing slide set and instructor’s manual on the NCPTSD website to
brief your organization on the model.
• Determine next steps for rolling out the model in your organization. There are a number
of ways to do this:
• Train everyone in the organization.
• Find a group of employees who can become coaches to roll the model out across the
organization or to interested teams. These individuals will ideally have protected time to
accomplish this process.
• Train existing peer support teams, mental health support staff, or EAP providers to roll the
model out to interested departments or teams.

Stress First Aid Implementation Guide for SFA Coaches 3

 Step 3: Introduce the Model to Selected Units or Teams
• During the first introduction:
• Make introductions and explain your background, credentials, and role.
• Explain why you are providing support with the SFA model.
• Give contact number and back-up name and number.
• Ask team members if they are familiar with the SFA model; if not provide them with the
30-minute overview of the model and distribute or send an email with resources (manual,
workbook, handouts).
• Make plans together on how often and how best to meet (for example, via video-based
meetings during the COVID-19 pandemic).
• Discuss your general availability for questions, consultation (e.g., how quickly you will be able
to return calls or emails; better times of day to talk).

Step 4: Provide Longer Trainings to SFA Unit Leads

• SFA coaches can train SFA unit leads to ensure that SFA is being implemented in teams based
on the team’s implementation plans.
• SFA unit leads will be those who are overseeing implementation of the SFA model within their
departments/units/teams
• SFA champions are those recruited by unit leads to foster conversations and activities related
to SFA within their teams.

• Use the 4-hour slide deck and instructor’s manual and distribute or send an email with
resources (manual, workbook, handouts).
• This model is akin to the “train-the-trainer” model. SFA coaches become trainers to their unit
leads, disseminating the model more widely throughout the organization.

4 National Center for PTSD

 • Support unit leads to roll out the SFA model in the organization. This can be done in different
ways, including:
• 15-30-minute briefing to departments as needed.
• Group discussions about the ways that the organization can move units or departments
towards the Green Zone if they are under stress as needed.
• Daily or weekly brief check-ins to identify stress zone indicators via stress continuum
questions, such as:
• “What does a green shift look like here?” “What does it feel like?”
• “What about a yellow shift?
• “How about an orange shift?
• Daily or weekly SFA tips or actions that support Green Zone functioning in staff
[Link] or monthly brown-bag lunches to discuss SFA actions or run
SFA scenarios.

Step 5: Provide Ongoing Support to SFA Unit Leads

• Weekly or monthly, during calls or check ins, discuss successes, challenges, concerns, and
questions that the SFA unit leads and champions have about implementation of the model.
• Listen empathically and help problem solve. You do not have to---and likely cannot---solve
their problems, but you can help them brainstorm solutions and consider alternatives.
• Convey that their ability to provide SFA support to their teams is very important, and that you
will check in regularly and offer support.
• Provide resources available to them within your workplace (e.g., EAP, occupational health,
support groups, webinars).
• Give information on hotlines and virtual resources, such as:
• SAMHSA Hotline
• National Suicide Prevention Lifeline
• Determine how staff can best share emotions, connect with each other, determine needs,
and instill hope if there is a critical incident during their shift. For example, a unit-based
group check-in or discussion might be appropriate.

Step 6: Sustain Stress First Aid Within Your Organization

1. Determine if it is reasonable for the organization to give SFA unit leads at least two hours a week of
protected time for SFA activities. Making this time available would both convey that the organization
values staff support and create space for unit leads to be most effective in implementing SFA.

Stress First Aid Implementation Guide for SFA Coaches 5

 2. Determine how much training staff gets. For instance, all staff can get an initial awareness briefing;
on units where there is an active SFA unit lead and/or SFA champion there is a 20-minute SFA activity
once per week or month.

3. Determine what follow up is needed. For instance, at least twice a year you can have a 4-hour
workshop where SFA unit leads and/or SFA coaches come together to discuss and process their
experiences. This will give them the opportunity to discuss their challenges, frustrations and
rewards; share what it means to be an SFA unit lead or coach; and let you know where they need the
most help (e.g., training in conflict communication).

4. Consider requesting that at least one SFA coach has a cabinet-level position or is included in the
organizational leadership steering committee so that they can provide information to organizational
leadership about stress levels among staff and help lead discussions about what impact big
decisions have on the well-being of the entire workforce. They can also work with SFA unit leads and
champions to regularly get a pulse check of workforce stress trends. Incorporated into the leadership
structure in this way, SFA should create an improved ability for staff to identify issues, come together
as an organization, and problem solve solutions.

5. Determine metrics for success. The organization may already be using potentially valuable metrics,
such as an employee engagement survey. In units where SFA is rolled it out, engagement scores may
increase. Other metrics could include decreases in stress-related turnover or sick days. Other unique
data elements that have emerged in healthcare settings include using a stress continuum “pain-like
scale” on employee dashboards to record daily stress zone data across departments. Organizations
can also assess staff confidence about organizationally meaningful change priorities, such as
comfort having conversations regarding patient safety issues. Each organization should determine
the most relevant and feasible program evaluation metrics. Ultimately the model should improve
employees’ self-efficacy regarding self-care and coworker support, increase perceived organizational
support, and foster the ability of staff to look at and have input into systems issues.

6 National Center for PTSD

 S T R E S S F I R S T A I D I M P L E M E N TAT I O N W O R K S H E E T

SFA Team Development

• Who will be your most likely SFA Coaches?
• Who will be your most likely SFA Unit Leads?
• Who should be considered for the SFA Champions?
• When will your SFA Team begin meeting? Who will manage and schedule these meetings?

Organizational Support
• Will SFA best be implemented organization-wide or within specific departments or units?
• Based on the scale of implementation, which key stakeholders should be briefed on SFA?
• Which SFA coach(es) should brief key stakeholders?

Organizational Alignment
• Does SFA align with existing organization-specific language, mission, vision, or values?
• How can SFA language be adapted to fit with existing organization language, mission, vision,
or values? How can your organization’s language be adapted to fit with SFA?
• How will SFA complement existing peer support and staff well-being programs?

Employee Training
• How and when will SFA Unit Leads be trained on SFA?
• Which programs, departments, or teams should be trained on SFA?
• If you are planning an organization-wide roll out, are there programs, departments,
or teams that should be prioritized?
• How will new employees be trained in SFA?

Project Management
• What are next steps for:
• SFA team development
• Organizational support
• Employee training
• Outcome metrics
• What obstacles do you anticipate?
• What resources do you need to move forward?

Stress First Aid Implementation Guide for SFA Coaches 7

 E X A M P L E O F S T R E S S F I R S T A I D S Y S T E M L E V E L I M P L E M E N TAT I O N

In the first year of a Stress First Aid rollout in a hospital, the goal was to introduce the concept across the
entire facility in 15-minute briefings and to identify the names of people who wanted to become unit
leads or champions.

STRUCTURE

Organization-Wide
All staff participated in a 5-10 minute computer-based SFA awareness briefing. A television monitor
was set up to display rotating SFA-related posters, images and videos that kept SFA messages in staff
members’ minds. Plastic placards with simple SFA-related content were put on the break room tables so
staff could read them during meals.

Coaches
SFA Coaches with behavioral health experience were assigned to train, mentor and provide resources for SFA
unit leads and champions. At the organizational level, coaches performed the following actions as needed:
• Trained unit leads and champions in SFA skills
• Advised, consulted, and intervened when an escalated response was needed
• Guided and supported teams in implementation and maintenance
• Interfaced with hospital adminstrators, EAP, and wellness committees

Unit Leads and Champions

Most units had at least two SFA unit leads and/or champions, who were rotated after about two years.
Unit leads were first established in units that wanted SFA to enhance what they were already doing
to reduce [Link] were given at least two hours a week of protected time. This both affirmed that
the organization valued their roles and created space for them to do the [Link] two unit leads also
attended a four-hour SFA training.

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 Unit leads elicited volunteers (called “SFA champions”) to ensure that SFA was being sustained according
to the unit’s implementation plans. SFA unit leads and champions often became identified as someone
who unit staff could talk to if they were stressed.
At the departmental level, unit leads and champions performed the following activities:

DAILY:
• Embedded a brief SFA skill or technique for 2-5 minutes into unit meetings, to start with Green
Zone positive practices, such as a “thankful Thursday” with a gratitude focus.

WEEKLY:
• Gave 10 minutes of information on SFA skills at meetings

MONTHLY:
• Gave a 20-minute lunch and learns, SFA scenario discussions from the workbook, or an SFA
activity
• Assessed the unit’s overall stress levels, by asking questions such as, “what does a green shift
look or feel like here?” “What about a yellow shift or an orange shift?” “Where is this unit on the
stress continuum now?”
• Held team meetings to trouble shoot SFA implementation issues

AS NEEDED:
• Gave 30-minute awareness briefs for new team members
• Supported SFA implementation on the unit

The stress continuum was used in meetings to help examine resources, strategies and pressure points,
and start to shape a dialogue:
• For the Green Zone:
• Champions asked their teams in meetings, “What are the resources that currently exist
regarding building resilience and capacity?” They wanted to identify and promote a broad
range of these strategies.
• Leaders were advised that when their units were in the Green Zone they could send out a
green message such as: “I want to let everyone know that we know you’re working hard.
Obstetrics has had a significant increase in the number of live births, but there have been no
increases in the number of adverse events. You guys are doing a wonderful job.” Messages like
these publicly give praise and tell the workforce that leaders understand what’s going on in
that unit.

• For the Yellow Zone:

• Trainings were given about skills and strategies around navigating when work stress
is escalating.

Stress First Aid Implementation Guide for SFA Coaches 9

 • Leaders were advised to get out of their offices and go down to the unit with the message,
“I know your workload has gone up. The stress has been through the roof. What impact has
that had? Help me understand.”

• For the Orange Zone:

• EAP was given SFA training by SFA coaches, to be able to communicate in a common
language about stress and to become more aware of ways to intervene in cases of more
significant stress.
• Departments and units were trained in Orange Zone strategies, such as conflict resolution,
because Orange Zone stress contributed to interpersonal conflict.

• For the Red Zone:

• Trainings highlighted that if someone was concerned about more serious manifestations of
stress like suicidal ideation, anxiety and depressive disorders, or substance use, individuals
should be referred to EAP or other trained behavioral health professionals.
• The training included these messages:
• The earlier someone got connected to these resources, the more privacy could
be protected.
• Career harm comes from making bad decisions and acting poorly while under stress.
Don’t wait until there is behavior that is irreconcilable or that can’t be recovered. That is
what causes career harm.
• Going to behavioral health professionals or the EAP does not cause career harm.
At least two or three times a year SFA unit leads and champions came together for 4-hour workshops.
There, they could process their [Link] their challenges,frustrations, and rewards, discuss
what it means to be team member, and get needed help or resources.
The facility discovered that the most successful unit leads and champions were staff nurses or masters-
prepared nurses, as opposed to licensed independent practitioners. The latter had difficulty getting relief
from their other demands, which made it hard to fulfill the SFA unit lead or champion roles.

Steering committee
This facility had a leadership steering committee with representatives from all divisions that met daily
to oversee facility operations. This committee was responsible, for instance, for reviewing all mortality
incidents and risk factors in order to discuss opportunities for improvement. Two experienced SFA
coaches requested and were granted permission to participate in the steering committee to present
information related to unit or department well-being. They also prompted members of the steering
committee to consider the impact of policy decisions they made on workforce well-being. The coaches
used the stress continuum as a way to discuss structural organizational challenges and advocated for
measures to foster resilience within the organization.

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 S FA C R E AT E D A F R A M E W O R K F O R T H E O R G A N I Z AT I O N
The SFA model built an awareness and ability to have conversations about work stressors in a way that
was helpful for team members and for the organization. The biggest change was that staff very rapidly
started to infuse SFA concepts into how they worked. For instance:
• If something was going wrong on a unit, someone would say “orange huddle.” That meant
“Everyone take breath, we’re coming [Link]’s not blaming or shaming, … this is the shift
from hell, but we’ll make through.”
• One unit put up a dry erase board with space for Green, Yellow, or Orange Zones,. Each
person put their name in a category the Green Zone, it meant they were a good person to
talk to that day. Some staff members would erase their name or move it to a different zone as
the day went by.

SFA created an improved ability to identify issues, come together, and problem solve solutions.
Ultimately the model improved the ability of staff to look at systems [Link] stress continuum allowed
teams to more easily identify and discuss issues that “put them in the Orange Zone,” which initiated
problem-solving efforts about those issues. Steering committee representatives were then able to report
about those issues to the leadership steering committee (i.e., “Oncology is in orange because… The
hospital is in orange because…”).
It also helped when leadership took an SFA focus on work issues. For instance, if there were individuals
who were behaving in problematic way, the first step was to ask, “if someone is acting out, what is the
issue with the environment?”

O U TCO M E M E T R I C S
Some metrics that the organization was already using, such as staff satisfaction and engagement
surveys, were used to evaluate the impact of SFA in the organization. In units where SFA was rolled it out,
engagement scores went up. Additionally, units that embraced SFA had less stress-related turnover and
fewer employee absences, resulting in cost savings for the hospital.

Stress First Aid Implementation Guide for SFA Coaches 11

12 National Center for PTSD