The median stress level among healthcare providers at the emergency department of HUSM, as measured by a visual analog scale (VAS), was higher during the 2009 H1N1 influenza outbreak (6.5) compared to before the outbreak (2.4). Years of experience in healthcare was significantly associated with higher stress levels during the outbreak. The study assessed stress levels in 62 healthcare providers before and during the outbreak, finding that long work hours, risk of infection, and feelings of being overworked and underappreciated contributed to increased job stress for emergency department workers during the H1N1 pandemic.

1. Level of Job stress among Health Care Providers at ED of HUSM during recent H1N1 Influenza Outbreak Assoc. Prof. Dr. Rashidi Ahmad Dept. of Emergency Medicine USM Health Campus

2. Introduction In the 21st century, the world is being challenged by few contagious and life threat infection such avian influenza and SARS. At current moment, no countries in the world are immune to an outbreak of a highly infectious disease. Luckily, Malaysia did not encounter both SARS and avian flu outbreak. We haven’t been challenged to the outbreak of deadly virus till now

3. Unfortunately, swine flu was disseminated rapidly throughout the world including Malaysia. As a result, there was a sudden influx of patients with influenza like illness (ILI) to the ED including HUSM . Longer shift hours, pressure to perform to meet rising expectations from public and administrators and scared for being infected created a lot of tensions among the ED HCPs at HUSM Cont…

4. Kathryn Wilkins. Work stress among health care providers Health Reports, Vol. 18, No. 4, November 2007 135,573 respondents. We are already in STRESS

7. Ping Wu, et al. The Psychological Impact of the SARS Epidemic on Hospital Employees in China: Exposure, Risk Perception, and Altruistic Acceptance of Risk. The Canadian Journal of Psychiatry, Vol 54, No 5, May 2009 6-point Likert scale

8. Objectives To determine the prevalence of job stress among HCPs in ED of HUSM during recent H1N1 influenza outbreak To determine the significance of their level of job stress prior to and during the outbreak To determine the association between the studied variables and stress level during the outbreak

9. Methodology The sample size was determined using a single proportion (n = log β/log p’) for a population of about 100 people with an expected prevalence of job stress of 10% and a 95% confidence level with a precision of 5%. The sample was obtained by non-probabilistic sampling. The researcher approached the respected staff and explained the aim and how to score their stress level using VAS.

10. Cont.. The study was undertaken from 20 to 30 August 2009. The considered variables were age, gender, race, co morbidities, marriage status and year of experiences. Data were collected into single form and entered into a SPSS+ (12.0) statistical package and analyzed.

11. Visual analog Stress Scale This scale consists of a 10 cm line drawn on a white paper that represents the variable to measure The patient is informed that one end of the line represents the absence of the variable and the other symbolizes the most intense manifestation the subject can imagine or the worst stress experience.

12. The patient scores the intensity of the expression of the variable marking the point between both ends that more accurately represents the strength of the variable he/ she is experimenting.

13. VAS The result is quantified measuring the distance from 0 to the point marked by the patient. Stress scores obtained from the VAS were arbitrarily grouped in four degrees: I (0 to 2.5 cm scored on the VAS), II (2.6 to 5 cm), III (5.1 to 7.5) and IV (7.6 to 10 cm). VAS > 7.5 cm was considered a high level of stress.

14. Results Variables n(%) Age median, range, IQR 31.0, 22 – 49, 5.5 < 30 28 (45.2) 30 and above 34 (54.8) Sex Male 29 (46.8) Female 33 (53.2) Total respondents: 62 out of 110 staffs (56%)

15. Variables n (%) Race Malay 56 (90.3) Non-Malay 6 (9.7) Marriage status Bachelor 23 (37.1) Married 39 (62.9) Years of experience Median, range, IQR 6, 1 – 24, 7 <5 20 (32.3) 5-9 25 (40.3) >10 years 16 (25.8)

16. Results Variables n (%) VAS before outbreak Median, range, IQR 2.4, 0 – 6.6, 2.0 Grade 1 35 (56.5) Grade 2 21 (33.9) Grade 3 6 (9.7) Grade 4 0 VAS during outbreak Median, range, IQR 6.5, 0 - 10, 3.6 Grade 1 4 (6.5) Grade 2 15 (24.5) Grade 3 22 (35.5) Grade 4 21 (33.9)

17. Significance mean difference between pre and during outbreak

18. Age and stress level during outbreak

19. Gender and stress level during outbreak

20. Experience and stress level during outbreak

21. Summary The median VAS score prior to the outbreak is 2.4 (grade 1) The median VAS score during the outbreak is 6.5 (grade 3) Significance mean difference between pre and during outbreak Significant association between years of experience in health services and the level of stress during the outbreak

22. Discussion STRESS is a biological term which refers to the consequences of the failure of a human to respond appropriately to emotional or physical threats. It includes a state of alarm and adrenaline production, short-term resistance as a coping mechanism, and exhaustion The Stress of Life , Hans Selye, New York: McGraw-Hill, 1956

23. Job stress is caused by conditions in the workplace that negatively affect an individual's performance and/or overall well-being of his body and mind. One or more of a host of physical and mental illnesses manifests job stress.

24. Signs of stress May be cognitive, emotional, physical or behavioral. Poor judgment A general negative outlook Excessive worrying Moodiness Irritability Agitation Inability to relax Feeling lonely or isolated Depressed Aches and pains Diarrhea or constipation Nausea Dizziness Chest pain Rapid heartbeat Eating too much Sleeping too much Withdrawing from others Neglecting responsibilities Using alcohol, cigarettes, or drugs to relax Nervous habits

25. Causes of work stress in government sectors High Demand for Performance - Increased workload, long working hours for the same pay, excessive travel and too much time away from family The expansion of technology Workplace Culture Personal or Family Problems Mental and physical harassment

26. Disadvantages of being ED HCW Daily contact with ILI patients Risk of infection and & quarantine Risk of death and hospitalization Over work Over stress Under appreciated Community avoidance

27. Conclusion and recommendations Infectious disease outbreak is a distressing event Preparedness and readiness are vital and it reduce tension Buddy system enhances quality of care and reduce stress level Involvement of occupational health experts, appropriate communication system, token of appreciation and counseling and follow up reduce stresses among HCWs

28. Thank You [email_address] Academic blog: www.drcd2009.wordpress.com