Managing Stress among Healthcare Workers: Strategies and Implications Associated With Covid-19 Pandemic

Corona virus disease or Covid-19 has become a global pandemic. It was first reported in Wuhan, china. The disease has crossed all borders across the world and today the whole world is suffering from the pandemic now. So when Covid-19 started shaking the world with immense spreading of its first wave and second wave, the whole population is completely dependent on the healthcare sector. Since the healthcare workers are part of the service sector, they had to support and take care of the patients by risking their lives. The stress taken by the healthcare workers is beyond the imagination of a layman and is greater than normal work stress. Covid-19 made its entry abruptly, putting a high level of stress on the medical community. There has never has been such a catastrophic pandemic that has occurred in last five decades. The hospital infrastructure was never ready for such a huge pandemic and its implications. More patient load, high infectivity rate, increase in mortality rate, family getting infected, more serious infections, scarcity of medicines, anxiety of getting infected etc. all contributed to the increase in stress level of the healthcare workers. This study aims to understand the stress faced by the healthcare workers during the first and second wave of the pandemic and identifying the solutions to reduce stress and promote their mental health by listening to good music, having a good sleep, opening up to a counsellor, getting spiritual help etc., if a third wave occurs.


Introduction
The world has seen many pandemic outbreaks in the past. However, the last one hundred years has been the worst. The beginning of the 20 th century saw the emergence of the Spanish flu in 1918. The influenza strain H1N1 resulted in about 500 million cases and close to a 100 million casualties. The next big pandemic to hit the world was the Asian flu which originated from China in 1957. This was followed by the Hong Kong flu in 1968. The last deadly pandemic was the Swine flu breakout in 2009 originating from Mexico. After a gap of 10 years the world witnessed another deadly pandemic which is believed to have originated from Wuhan, china. The SARS-COV2 or corona virus called the COVID-19 began slowly in epidemic proportion and then spread to the whole world prompting the WHO to call it a pandemic. India was also a victim of the virus spreading to all parts of the country. The magnitude of the disease took the medical world by surprise. The health authorities, bureaucrats and the policy makers did not envision such a situation. The whole nation was in a state of shock. The health infrastructure in the country could not cater to look after so many corona infected patients at the same time. The biggest casualty was the health workers in India because of a weak health foundation. The health personnel including doctors were put to test in their attempts to salvage the lives of millions of COVID-19 victims who may otherwise succumb to the disease. Suddenly they were overburdened with work and extreme exposure to aversive circumstances. [1][2][3][4][5]. 2. Review of Literature Rachna Raj, Soujanya Koyalada, Amit Kumar, Stuti Kumari, Pooja Pani, Nishant Kishore Kumar Singh (2020) has done an observational study confirming that COVID-19 has a direct impact on creating psychological issues in medical and non-medical individuals and that it is on the higher side while they are getting adjusted to the current life style and anxiety of getting infected.
[1] Seshadri Sekhar Chatterjee , Madhushree Chakrabarty , Debanjan Banerjee , Sandeep Grover, Shiv Sekhar Chatterjee , Utpal Dan (2021) conducted a cross sectional study on the mental anguish among healthcare professionals of a tertiary care hospital in India during the outbreak of corona virus disease at the earliest stage. It has been found that doctors and nurses experience the greater level of stress compared to other medical professionals and that they were more likely the ones who was suffering insomnia. Several factors like age, educational level, marital status, urban habitat were seen to be the important categories that influenced their irritation, depression and anxiety [2]. William Wilson, Jeffrey Pradeep Raj, Seema Rao , Murtuza Ghiya (2020) conducted an observational study on the prevalence and predictors of factors causing stress among the frontline healthcare workers in India. Research stated the factors influencing and the symptoms of stress, depression and anxiety mentioned that female professionals were more likely to be an important predictor and that they were two times higher odds to suffer from these conditions compared to male professionals on the medical community [3]. Carolin Elizabeth George, Leeberk Raja Inbaraj, Shon Rajukutty, Luc P de Witte (2020) explains in detail about the issues they faced initially, mental stress and the adaptable solutions which helped the healthcare workers during the pandemic as they provided the service in one among the largest slums in India. This study ensures that the team could collectively design and could follow the adaptive involvement to care the people residing in slum with their positive cognitive reappraisal [4]. Maria Nicola, Zaid Alsafi, Catrin Sohrabi, Ahmed Kerwan, Ahmed Al-Jabir, Christos Iosifidis, Maliha Agha, Riaz Agha (2020). This is a review study derives the socio economic effects of COVID-19 on single traits of world economy. Review confirms that wide socioeconomic plan should be developed by including each and every sector and sector plans and that an ecosystem that motivates entrepreneurship should be made possible so that strong and sustainable models of business can prosper [5].

Objectives
 To study the impact of COVID-19 on healthcare workers.  To find out the factors causing stress among healthcare workers during the first wave and second wave of COVID-19 pandemic.  To list out the overcoming strategies for stress management of medical community.

2.2Method of Study
Secondary data was collected for the detailed study on this topic. For data collection, information was collected from various newspapers, online news apps, broadcasted news on various television channels, YouTube, a number of journals and books. I have also utilized the data from the reports on COVID-19 published by numerous national and international agencies and other reliable websites.

Hit of Covid-19 on healthcare workers
Apart from the physical strain, the health workers were put into extreme mental stress which many of them could not handle. Long duty hours and working tirelessly without any break was one of the attributes to stress. Many health workers started getting irritated with the hospital attire including the nonstop use of PPE kits for long hours. Sometimes the hospital employees were victims of angry outbursts of the patients and their relatives. Many of them found disturbances in sleep. Some individuals started increased consumption of alcohol and nicotine. Many health workers lost their colleagues to the disease. The nature of work was suddenly taking a toll on their lives and health. They were forced to separate themselves from their loved ones. Many of them started witnessing grief and calamity at a young age.

Dealing with stress
Some of the sources of stress came from the socio demographic factors (gender, age and profession) and psychological variables (social support, selfefficacy). Some of the new stresses as a result of wide spread of pandemic added to the already burdened health community. career. One of the most common psychological stress was the anxiety of getting infected. To top it all, information overload or "infodemic" as it is called created confusion and panic among the general public. Breaking bad news to the patient"s relatives and friends caused more anxiety to the health workers. Many health personnel complained of financial difficulties. Some places reported stigma and even violence against doctors, nurses and hospitals in India. Many of them faced verbal abuse, phone threats and assault. The healthcare workers sometimes risked their own lives to save others. Warning indicators of stress can be divided into emotional, cognitive and behavioural compartments.
Lack of attention span and decision-making impairment affecting clinical practice was found common among doctors. A glimpse of what lies ahead clearly predicts increased depressed mood, insomnia, anxiety, irritability, memory impairment, fatigue, traumatic memories and sleep disorders. Medical community should be beware of unhelpful coping strategies -(Alcohol, tobacco etc.), which can easily become automatic ways to try and make them feel better at times of stress. However, these can have a negative impact on mental health, so it is a good idea to try and keep an eye on them. Dr. Richard Holt, a Bioethicist once said-"We are trained in treating one patient at a time, but in the worst of an epidemic, you have to think about the greatest good for the greatest number." Automatic thoughts or negative thinking patterns sometimes will set the tone for a prolonged mental battle. During COVID-19 stress, some of the potential psychiatric manifestations were anxiety disorders, depression, substance abuse, post-traumatic stress and burnout. Since this event is unprecedented, the psychological damages will be unprecedented too. Many health workers reported long time psychological problems. A survey of health workers revealed that more than half of the employees confirmed their mental health was negatively impacted by worry and stress due to COVID-19. It is believed this may give rise to a mental health epidemic in the future. Those with pre-existing psychiatric conditions got worse. [6][7][8][9][10].

Findings and Discussions
Numerous indicators have shown that India"s economy is already experiencing the stress of the currently deadly waves of corona virus disease. Even though this is influenced because of the local restrictions imposed by respective state governments, others are due to the reason that the citizens are staying indoors. Studies say that government has cautioned that there is no clear sign of dip in the Covid graph yet. Second wave or any wave that may rise in future cannot be prevented but can only be substantially contained. Second wave shows much greater impact in most of the countries and it is due to the reason that youth were affected in the second than the previous wave [10].By the end of May 2021, the count of patients is expected to be 1.5 lakhs per day and may come down to 20,000 per day. By July 2021, the second wave would diminish and third wave may occur within next six to eight months and can be expected by end of November of first week of December [11].  Figure 1 indicates the rise of new COVID-19 positive patients [13]. The rise in new Covid cases directly creates an impact on the stress level of frontline healthcare professionals of the country. Since there is a rise in reporting of new cases, it conveys that the positivity rate, spreading rate, infectivity rate and mortality rate would also mark a peak thereby creating more number of patients who may be hospitalized. A previous study demonstrated a high burden of depression and anxiety among young, unmarried Healthcare workers who were treating COVID-19 patients in highly impacted regions of India. Further, the researchers found that moderate to severe depression and anxiety among healthcare workers negatively impacted their overall quality of life during COVID-19 pandemic. Protecting the mental health of medical community is paramount to COVID-19 response and control efforts. Rapid development and implementation of interventions to prevent and treat mental health conditions are urgently needed to support the growing number of Healthcare Professionals caring for COVID-19 patients in India and worldwide [1].

4.1Overcoming strategies
Managing COVID-19 stress is not easy. Getting adequate sleep, practicing breathing exercise and yoga, continuing other form of exercises and trying to socialize are some of the initial steps that can be taken to reduce stress. In fact, "Happiness can exist only in acceptance" [12]. The health workers should continue to take extra precautions to prevent COVID-19 infections by methods such as social distancing, wearing of face masks, washing hands regularly and finally getting themselves vaccinated at the earliest. Life style changes are definitely warranted as part of stress management. When traumatic event is experienced or witnessed, it is common for most people to have some reaction in response to these. Trauma affects body, mind and your sense of self. Common reactions can include re-experiencing of the event, avoidance of any reminders of the trauma, negative changes in mood and thought patterns, feeling constantly on edge, over-reactive and having trouble sleeping among others. These symptoms can subside shortly after the events or can be persistent and interfere with your day-today life. Should this happen it is important that the sufferer should reach out for aid. COVID-19 is here to stay for an unpredictable time now. Pandemics can have multiple waves. Hence, it"s advisable to adopt to a new way of life. It is always good to remember that life is a package. Therefore, the one who feels stressed and get negative thoughts should strictly follow theadaptive measures to overcome stress which are as follows:  Golden Five Rules -It constitutes good sleep, exercise, meditation, yoga and avoiding drugs for getting sleep. The future may augment increased screening for mental disorders in all settings. Healthcare workers may need to foster healthy coping mechanisms in the society in general, advocate physical health through physical activity and diet.Getting enough sleep can be a challenge at this time, but it is essential for their ability to make sound decisions.  Connect -Health personnel may find themselves somewhat excluded and isolated at this time because of work, restrictions, etc. It"s advisable to try to keep in touch with important people of their life as much as possible (without overdoing it!). Opening up of thoughts to mentor /colleagues and counsellor can also help in reducing stress.  Quality time -Spending some quality time with family can reduce stress to a certain extent  Self-care -Self-care is hardest when people need it most. A person may not feel like it is a priority when he/she has so much to do, but it is and cannot be negotiable at this time. Health personnel should ensure that they look after their basic physical and mental health needs or they won"t be able to look after others.  Hobbies -Pursuing passions and hobbies like listening to music or watching cartoons and movies can reduce stress to a certain extent and it is easily possible in this era of digital technology. . It is important to cultivate some hobbies of one"s choice.  Spiritual help -Prayers and meditation can also help in moving towards positivity and to reduce stress and makes feel relaxed.  Medication -This should be the last choice.
However, if the stress results in mental disorders beyond your reckoning, then consulting a psychiatrist should be considered.  Healthcare personnel should watch out for excessive stress, fatigue, and sudden exhaustion -Look out for stress levels worsening, feeling overwhelmed, feeling disconnected from their work and start finding looking after themselves harder as time goes on. Working on adrenaline for extended periods of time can also lead to a sudden onset of exhaustion. Healthcare workers should always remember not to blame themselves, as it is not their fault, rather reach out to their subordinates to get the support they need to get back on track.  Avoid negativity -The health personnel need to be vigilant and careful but don"t panic. They need to limit exposure to distressing news media and focus on positive thoughts.
Various measures can be implemented by the human resources department to help in reducing the stress of healthcare workers. [11][12][13][14][15]

Conclusion
Due to the impact of COVID-19 pandemic, everyone is experiencing a drastic change in their daily routine. New unwritten manual of do"s and don"ts in daily life caused by the pandemic maybe greater or smaller and can differ from person to person. But of doubt, the frontline healthcare workers who work in the battle field with COVID-19 are exposed to extraordinary stress in their working environment than a normal work stress they had before. The first wave and the second wave of the pandemic had hit the population so badly and has increased their work load and stress. The current study suggests that self-help and self-care would make the health care workers feel better. Also, a sound sleep, yoga, meditation, exercises, opening up to a person to share their thoughts would help in reducing the stress and anxiety etc., of the healthcare workers. Recruiting new staffs to share the increase in work load of the current staff, staff rotation, giving rewards, token of appreciations, extra benefits can also reduce the stress and increase the productivity of the medical community. This study recommends various measures to calm down the stress so that if a third wave of pandemic occurs, the frontline healthcare workers can manage the stress comparatively better than what they had experienced in the first two waves of the dreadful disease. However, further research may be needed to find out more effective ways for stress management so that it would help during a challenging time in future.