Stress and Coping During a Pandemic

Maunder RG, Leszcz M, Savage D, et al. Applying the lessons of SARS to pandemic influenza: an evidence-based approach to mitigating the stress experienced by healthcare workers. Can J Public Health. 2008;99(6):486-488.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5148615/pdf/41997_2008_Article_BF03403782.pdf

This article describes the distress clinicians experience during pandemics—stemming from legitimate worries specific to working in healthcare that many of us likely share —as well as evidence-based approaches to coping. – Stephanie Kukora, MD

Robert G. Maunder, MD is a psychiatrist at Mount Sinai Hospital in Toronto, whose research explores psychosocial aspects of health and disease, in particular the impact of interpersonal relationships on stress and illness. In this 2008 commentary, he and co-authors describe an evidence-based approach to supporting of healthcare workers’ resilience in preparation for the influenza pandemic that year, based on research investigating the stress associated with working in healthcare during the SARS outbreak several years earlier.

The authors describe that during the SARS outbreak, a third to half of healthcare workers in hospitals that treated SARS patients experienced clinically significant distress. Though these clinicians had significantly elevated rates of signs of chronic stress, including professional burnout, depressive/anxiety symptoms, or substance use/abuse disorders compared to workers in other similar hospitals two years later, rates of mental illness like depression and posttraumatic stress disorder were not elevated. This suggests that approaches to reducing pandemic-related stress should focus on coping, adaptation, and resilience in psychologically healthy people rather than intervention for mental health problems.

An infectious disease pandemic differs from other disasters in that it creates social isolation for healthcare workers; infection control procedures to reduce spread mandate quarantining and interpersonal distance, and clinicians in these situations are often assigned to unfamiliar work groups. Also, while healthcare workers usually turn to family support in times of stress, the perceived risk of infecting loved ones and concerns about caring for children if the parent is ill make creates additional stress in a pandemic. In addition to concerns for family health and social isolation, healthcare workers also worry about how they will be protected (PPE, vaccines, medications); themselves becoming ill; needing to treat their colleagues; stigma in the community (people fearing them because they could be contagious); ethical concerns and fairness in patient treatment; being able to get reliable and timely information; presence of leadership; and stresses of redeployment in unfamiliar settings.

To foster resilience and coping at the individual level, the authors note that Folkman and Green’s framework (https://onlinelibrary-wiley-com.proxy.lib.umich.edu/doi/abs/10.1002/%28SICI%291099-1611%28200001/02%299%3A1%3C11%3A%3AAID-PON424%3E3.0.CO%3B2-Z) for patients facing serious illness is applicable to the stresses experienced by healthcare workers in a pandemic. In this model, persons facing a change or a threatened change in the status of current goals and concerns begin with an appraisal, or the individual’s evaluation of the personal significance of the event including their perceived level of control. This appraisal is influenced by a person’s values and beliefs, and identifies harm or loss that has occurred or is threatened, as well as challenges where there is opportunity for mastery or gain. This then leads to coping processes, or the thoughts and behaviors used to regulate distress (emotion-focused coping), manage the problem causing distress (problem-focused coping), and maintain positive well-being (meaning-based coping). This sequential approach to coping mirrors the experience of healthcare workers during a pandemic: problem solving for events that are appraised to be within one’s control (e.g. reading the literature to better understand the virus and new treatments), emotion-based coping to enhance support and reduce isolation (e.g. video calling friends and extended family more often), and meaning-based coping for events that are unresolved and cause persistent distress after problem-focused efforts (e.g. pride in self/colleagues/profession for helping in this difficult time; thinking about how healthcare culture and practice may be changed for the better after this experience).

Resilience does not rest solely on individuals; healthcare organizations contribute to individual resilience by buffering workplace stressors before, during, and after a crisis. This depends on establishing reserves of both tangible resources (supplies, PPE) and non-tangible resources (flexibility in back-up planning, swift provision of information and training, etc) prior to crises. The authors recommend building anticipatory “relational reserves,” meaning supportive, collaborative, interdisciplinary relationships which can provide the basis for formal and informal support during a crisis. Healthcare organizations can also contribute to the meaning-based coping of individuals by fostering a shared sense of moral purpose, such dedication to caring for the sick. Effective leadership is also critical to the well-being of individuals in a healthcare organization. Regardless of goal specifics, persons facing crises cope more effectively when they have goals that they find meaningful, for which there is a plan of action, and for which there is a reasonable probability of success.