Stress management is important for healthcare workers during the COVID-19 pandemic. The pandemic has caused high levels of stress due to the unknown nature of the virus, lack of protective equipment, long work hours, and fear of infecting themselves or family. Stress leads to somatic symptoms like headaches and psychological issues like anxiety. At the individual level, stress can be managed through proper diet, exercise, sleep, spending time with family, and relaxing activities. Healthcare workers should acknowledge their stress and seek help from colleagues and professionals if needed. The government and community should support healthcare workers through ensuring security, pay, and removing stigma regarding the virus.

1. STRESS AND IT’S MANAGEMENT
IN HEALTH CARE PROVIDERS,
DURING TIMES OF COVID-19 PANDEMIC.
DR SULAKSHAN KUMAR TEWARI
M.D.(PSYCHIATRY)

2. What is stress ?
● Stress is response of our body and mind to a real or imagined threat,it is
a normal reaction to an abnormal situation
● It is a state of threatened homeostasis
● A lot depends on how one perceives it.
● It varies from person to person

3. COVID 19 Pandemic
● First case of COVID 19 was reported on nov. 17,2019 from Hubei province of china spreading
very quickly in china and then to other countries.
● WHO announced covid pandemic on march 11,2020 . till then 114 countries had been
affected
● With in 6 months it had spread its tentacles in 196 countries and territories infecting 14.5
million people and causing more than 6 lac deaths.
● Health care workers i,e doctors, nurses, paramedics and ward boys etc,being in forefront of
fight against corona started falling prey to corona.
● As per TOI report by aug 29,2020,more than 87000 HCWs infected and 573 dead
● In India ,according to IMA, 196 doctors succumbed fighting covid 19 by aug 8th.
● Till date ,more than 250 docs and 650 nurses have laid down their lives

4. Reasons for stress amongst healthcare workers
● As such it was totally a new challenge before the medical fraternity as nothing was known
about the pathophysiology,diagnostic tools or its management
● Lack of infrastructure,ppe,etc compounded the problem
● HCWs had no training to handle the pts.
● Fear of getting infected and then passing on the infection to families, friends or colleagues
● Pandemics and natural calamities are known to cause lot of stress among health care
providers
● Fear of reprisals from the relatives of the deceased
● Stigma and discrimination in community
● Lockdowns and curfews disrupting social, family and personal lives
● Interference from politicians and administrators in protocols and SOPs
● Financial reasons

5. Manifestations of stress
● During the times of stress the hypothalamus signals to pituitary gland
which in turn stimulates adrenals for increased cortisol production thereby
increasing the energy fuel available and it mobilizes glucose and fatty acids
from the liver. Increase in cortisol levels is important for regulating the
immune system thereby reducing inflammation.Stress upto certain level is
needed to enhance performance.
● Chronic stress mediates its ill effects through HPA axis and SNS causing
somatic symptoms, psychological symptoms(affecting emotions,behaviour,
cognition and biological rhythms) and psychosomatic disorders

6. Somatic manifestations
● Headache
● Painful neck muscles
● Back pain
● Tightness in chest
● Hair loss
● Acne
● Joint pains
● Tremors

7. Psychological manifestations
Emotional disturbances
● Anxiety
● Panic attacks
● Depression
● Guilt
● Compassion fatigue - you become numb dealing with distress
of pts. and their families

8. Behavioural
● Fits of anger
● Violence at home
● Shouting at kids
● Irritability
● Maladaptive behaviours : excessive smoking, heavy drinking

9. Cognitive
● Impaired
- concentration
-Attention
-Memory
-Recall

10. Biological
● Loss of sleep
● Loss of appetite
● Loss of of sexual drive
● Disturbed bowel and bladder activity
● Increase or decrease in blood pressure
● Diabetes mellitus
● Arthritis
● Precipitation of asthmatic attacks (in people with genetic predisposition)
● Psychosomatic disorders like gastric ulcers, IBS etc

11. How to manage stress
● No fixed or set formula , different people react differently to the same
stress
● A lot depends on how one perceives stress
● To manage stress we concentrate on three levels
Community level
Hospital level
Personal level

12. At government level
● Pandemic likely to stay longer.Invest in public health.
● Plan long term strategies instead of short term crisis response.
● Social security and health insurance for HCWs
● Prevent violence against health workers, check rumour mongers
● Stop obnoxious propaganda on social media with an iron hand
At community level
● Remove stigma and discrimination
● Educate masses for better compliance at ground level
● Community leaders and NGOs to help health deptt. teams
Community level

13. Hospital level
● Chief administrative or head of the department should lead from the front
● Adequate security
● Training and updating the knowledge of Healthcare providers
● Debriefing on daily basis
● New protocols or standard operating procedures to be discussed in virtual
meetings
● Rotate workers from higher stress roles to lower stress roles
Supporting the staff and their families
● Proper communication channel to be kept open
● Sharing and caring among co-workers

14. Personal level
● Lot of uncertainty about when the pandemic will end-- May be 2 years.Have to live with it.
● When do I get infected- -High recovery rate and very low death rate
● If I transmit the virus to my family , friends or colleagues -- They will be taken care of
● How to come out of it-- There are people in community and hospital to help me
● If I get quarantined-- Time can be planned with positive attitude and healthy activity
Remember,you can”t control all that happens around you in hospital or in community but you have to be fully in control
of yourself. Use WBI-mobile app developed by Mayo clinic for seif-assessment.
" It is not the load that breaks you down ,it is the way you carry it"- Lou Holtz
While dealing with a problem there are two options
1 there is a solution-- work for it
2 there is no solution--- then why to worry
Avoiding the problem never helps

15. Main strategies to be adopted at personal level
● Care for yourself
● Ask yourself- "am i stressed"
● Acknowledge it, accept it
● Change your lifestyle
" If you cannot control what goes on outside , you can always control what goes on inside"
- -Wayne Dyer
● Exercise-- find 30 to 40 minutes for yourself and do some exercise
gym, jogging, skipping, aerobic exercise,
indoor games
All these activities help in establishing proper communication in hypothalamus pituitary adrenal axis

16. Main strategies to be adopted at personal level
Sleep
● Must maintain 7 to 8 hours of regular sleep
● Go to bed only when you are going to sleep
● Avoid tea or coffee 2-3 hours prior to your sleeping time
● No serials depicting violence or witchcraft
● No sensational news channels to be watched
● Dim light and light music help in inducing sleep
● Light massage on head or forehead helps in inducing sleep

17. Main strategies to be adopted at personal level
Diet
● Home cooked food only
● Avoid foods which don't suit your tummy
● Take advice from your mom or your wife as they know it better
● No junk food at all
● Take milk,curd,pulses,salads,seasonal fruit and vegetables
● Seeds,dry fruit, honey,ginger,turmeric and plenty of water

18. Main strategies to be adopted at personal level
Spend time with your family
● Share light moments with your spouse , kids and other family members
● Watch a comedy serial or a romantic movie
● Be with them. Discuss the routine family affairs with them
● Play with kids
● Spend time with your elders
Pursue hobbies
● Dancing, singing, music, painting, gardening, playing with pets, reading, cooking,pets

19. Main strategies to be adopted at personal level
Avoid maladaptive behaviours
● Avoid smoking, drinking or use of any non essential drugs
● All these aggravate stress
managing emotions
● Identify your abnormal emotions like irritability, anger, frustration, anxiety or depression
● Try to modulate your emotions, work on it and monitor regularly
● Deep breathing,
● Yoga and meditation
● Distancing yourself from anger provoking situations are persons
● Counting 10 to 1 backwards
● Distract yourself with the help of your favourite music or reading your pet topic
● Seek professional help in case your emotional, behavioral or thought process abnormalities persist
or aggravate

20. Main strategies to be adopted at personal level
Change the thinking process
● Tell yourself "i treat, he cures"
● You care, Nature Cures
● Deaths, complications and treatment failures occur in best of the hands in best of the hospitals
having best of the infrastructure
● Giving relief to 7-8 patients out of 10 is good enough score to feel happy about
Communication skills
● Verbal and nonverbal communication skills are important as much in Healthcare industry as in any
other field
● Empathy and polite words do magic

21. Main strategies to be adopted at personal level
Social media
● Be choosy about what to watch and what not to watch
● Avoid fake and sensational news
Learn to say no
● Be assertive if someone is violating your rights
● Work- life balance has to be maintained while working from home
● Know, when to switch off

22. Main strategies to be adopted at personal level
Let go
● Holding on to painful emotions damages you
● Forgive and forget . It decreases emotional turmoil and makes you feel better
Relaxation
● Simply sitting back and having deep breaths
● Watch some comedy clip
● Chat with your friend
Compassion fatigue
● Talk to your seniors, teachers and mentors who by virtue of their vast experience,are always able to to guide you

23. Main strategies to be adopted at personal level
Taking a break
● Plan a brief vacation with family or friends
● Spend time exclusively with yourself.
● Never to lose the chance to share lighter moments with your
buddies.
Enjoy what you do and do what you enjoy.

26. Conclusion
Covid 19 pandemic has infected millions of people globally. HCWs, while treating
corona patients, have been under great stress as nothing was known about its
pathogenesis and treatment. Poor infrastructure, unavailability of equipments,
long working hours, lack of training for handling the patients and equipment, fear
of infection or death to self or their families and fear of stigma and reprisals in
community further aggravate the stress which causes lot of somatic and
psychological effects. Government and community should ensure social and
physical security to corona warriors. However most important aspect of stress
management remains care of self. Taking good diet, proper sleep, proper rest and
relaxation are helpful in mitigating the distress. Take professional help if needed.

28. Thank you