|Year : 2021 | Volume
| Issue : 3 | Page : 85-94
The prevalence, causes, and management strategies for stress among health-care professionals of Delhi-National Capital Region
Rahul Mehrotra M.B,B.S, MD (Medicine) 1, Mayank Gupta M.B.B.S, MD (Medicine) 2, Mohit Bhagwati M.B,B.S, MD (Medicine), DNB (Cardiology) 3, Dinesh Jain M.B.B.S, MBA 4
1 Director and Head, Non-Invasive Cardiology, Max SuperSpecialty Hospital, India
2 DNB Senior Resident, Max Super Specialty Hospital, Saket, New Delhi, India
3 Associate Consultant, PSRI Heart Institute, India
4 Vice President, Clinical Data Analytics, Max Healthcare, New Delhi, India
|Date of Submission||20-Jan-2021|
|Date of Acceptance||13-Mar-2021|
|Date of Web Publication||23-Sep-2021|
Dr. Rahul Mehrotra
Director and Head, Non-Invasive Cardiology, Max SuperSpecialty Hospital
Source of Support: None, Conflict of Interest: None
Background: Stress at workplace has an adverse impact not only on the employees in terms of health, well being, and job dissatisfaction, but also affects the organization in terms of quality of output, absenteeism, and attrition which ultimately has detrimental financial implications. Health care professionals comprise of an important group that are majorly affected by workplace stress because of the nature of their work environment. Methods: The current study was undertaken to ascertain the presence of self perceived stress among healthcare workers in multispecialty hospitals of the National Capital Region of Delhi and to find the expected remedial measures that could be implemented to mitigate stress. In a questionnaire based study, a self administered questionnaire was used to assess stress and related factors using convenience-sampling technique. The response data were extracted and analyzed using Microsoft Excel, which was used for data analysis, tabulation, and graphical presentation. Results: Total 110 responses were received. Three quarter of the respondents identified significant stress in their life, with the highest stress reported by nursing staff at 98%, doctors at 67%, and administrative staff at 56%. The study shows a significant association of self reported stress with age of the respondents (P < 0.001). Respondents among age group of 15–25 years reported the highest prevalence of stress (P < 0.001). Women reported a higher level of stress than men, (P < 0.001), and nurses reported the highest level of stress followed by doctors and then administrative staff. Different methods to relieve stress were also discussed and it was found that two thirds (67%) of our study respondents would like to meditate at work. Conclusion: Stress is common among all categories of healthcare workers.Meditation can be a safe, effective, and feasible modality which can be offered at the workplace to safeguard the mental health of the health care workers and reduce their levels of stress.
Keywords: Meditation, stress, workplace
|How to cite this article:|
Mehrotra R, Gupta M, Bhagwati M, Jain D. The prevalence, causes, and management strategies for stress among health-care professionals of Delhi-National Capital Region. J Clin Prev Cardiol 2021;10:85-94
|How to cite this URL:|
Mehrotra R, Gupta M, Bhagwati M, Jain D. The prevalence, causes, and management strategies for stress among health-care professionals of Delhi-National Capital Region. J Clin Prev Cardiol [serial online] 2021 [cited 2021 Dec 3];10:85-94. Available from: https://www.jcpconline.org/text.asp?2021/10/3/85/326473
| Introduction|| |
Stress is a term commonly being used nowadays as stress seems to be ubiquitous. It is a multidimensional concept which, originally derived from the Latin word, “stringere,” (to draw tight), was meant to describe hardships and/or affliction. Being more of a subjective phenomenon, it is exceedingly difficult to have a single definition. The term “stress,” as it is currently used was coined by Hans Selye in 1936, who defined it as “the nonspecific response of the body to any demand for change.” Something that is difficult to define is almost impossible to measure! As such, there can be no diagnostic test for stress. Besides, it can be transient or permanent, healthy, or challenging for some, while distressful and unbearable for others. Owing to these problems with stress, a physician concluded in the 1951 issue of the British Medical Journal that, “Stress, in addition to being itself, was also the cause of itself, and the result of itself!”
However, despite the above difficulties, great strides have been made by modern science and systematic studies have been undertaken to study the effect of stress on the body. Psychosocial stress is now an established risk factor for wide ranging disorders from purely psychological in nature to as “solid” as gastric ulcers, acute myocardial infarction, stroke, diabetes, and cancer, to name a few.
Work-related stress or stress at workplace is an important type of stress increasingly being recognized in the contemporary work environment. The World Health Organization, while recognizing its importance has defined it as the response people may have when presented with work demands and pressures that are not matched to their knowledge and abilities, and which challenge their ability to cope. According to the National Institute of Occupational Safety and Health, occupational stress can be defined as the harmful, physical, and emotional responses that occur when job requirements do not match workers' capabilities, resources and needs. Work-related stress has an adverse impact not only on the employees in terms of health, well-being, and job dissatisfaction, but also affects the organization in terms of quality of output, absenteeism, and attrition rate which ultimately has detrimental financial implications.
In the United Kingdom, in 2011/12, work-related stress caused workers to lose 10.4 million working days, and workers were absent for on average 24 days. Other international studies show, for example, that about a fifth of staff turnover can be related to stress at work.
At a societal level, ill health associated with chronic work-related stress and prolonged exposure to psychosocial risks at work can strain national health services and reduce economic productivity, having a negative impact on a country's gross domestic product.
Health-care professionals comprise of an important group that are majorly affected by workplace stress because of the nature of their work environment. Numerous studies have shown high degrees of psychological distress among doctors, nurses, and other health-care professionals working in various situations. It not only affects the individual and the organization but also reflects on the quality of patient care, the ultimate benchmark for health-care industry. A study conducted at Mayo Clinic (Seattle, WA) revealed that 60% of American physicians at times suffered from symptoms of fatigue and depression, otherwise known as “burnout.” There are few systematic studies from India, but it appears that the situation is not different, if not worse. In a single-center study conducted among the intensive care unit staff of a tertiary care hospital in India, around 80% of the staffers suffered from burnout., According to another recent study from India, work-related stress among health-care workers was a cause for concern and was associated with decreased job satisfaction, days off work, anxiety, depression, sleeplessness, medical errors, and near misses. Several small scale studies have also highlighted the problem of stress among the healthcare workers in the country.,,
Despite the high prevalence of stress among health-care workers leading to a myriad of physical and mental health consequences, detrimental effects on patient care and loss to health-care organizations, little attention has been paid to identify the problem, address it and find suitable remedial measures.
The current study was undertaken to ascertain the presence of self-perceived stress among health-care workers in multispecialty hospitals of the National Capital Region (NCR) and find the expected remedial measures that can be implemented to mitigate stress.
Aims and objectives
The aim of the study was to identify the extent and sources of self-reported stress in large, multispecialty hospitals of NCR, among the administrative staff and clinical staff comprising of doctors and nurses.
The objectives of the study were
- To assess the existing stress levels among various work groups of health-care professionals
- To explore sources of stress among the workgroups of health-care professionals
- To explore factors causing work related stress as well as stress related to personal life
- To explore the different options utilized to relieve stress
- To explore the role of meditation in dealing with stress.
| Materials and Methods|| |
We collected anonymized responses using an online structured questionnaire survey [Google Forms – Annexure 1] from health-care workers among large hospitals (inpatient beds capacity >100 beds) within Delhi NCR. The questionnaire was designed to elicit the perception of stress in the life of health-care workers and the sources of such stress when present. A total of 110 responses were collected from health-care respondents, from May 20, 2019, to July 5, 2019.
The cross-sectional study was a questionnaire-based research study, where a self-administered questionnaire was used to assess stress and related factors. The study was conducted using convenience sampling technique to recruit respondents among the health-care workers. The responses were collected using Google Forms. The response data were extracted and analyzed using Microsoft Excel, which was used for data analysis, tabulation, and graphical presentation.
The questionnaire was designed in three sections. The first section covered questions related to existing stress in the respondent's life (questions 1–4). The second section covered questions related to methods for stress relief (questions 5–8). The third section consisted of socio-demographic factors such as age, gender, and work role [Annexure 1].
| Results|| |
Overall, 110 responses, complete in all respects, were received. Of all the respondents 66 were male and 44 were female, which included 43 doctors, 42 nurses, and 25 support staff (including patient care support staff and business support staff). Most number of respondents belonged to the age group of 26–45 years (63%) [Table 1].
Of the study respondents around three quarter of the respondents identified significant stress in their life, with the highest stress reported by nursing staff at 98% [Figure 1]. Almost two-thirds of the doctors reported stress in their life [Figure 2], while among the administrative staff, the figure was 56%. The study shows a significant association of self-reported stress with age of the respondents (P < 0.001) where the age group of 15–25 years reported the highest prevalence of stress, gender (P < 0.001) where females reported a higher level of stress than males, work role (P < 0.001) where nurses reported the highest level of stress followed by doctors and then administrative staff.
Source of stress
In the questionnaire, respondents were asked about the main source of stress. Overall, more than half of the respondents exclusively identified their work life as the only source of stress while for 11% their personal life was the only source. However, 35% of the respondents identified both their professional as well as personal life as the source of stress. Significantly, work life was identified as a contributing source of stress in around 90% of the respondents across all the three roles in healthcare. While personal life was reported to contribute to stress in around 46% of the respondents [Figure 3].
This study shows a statistically significant association between the source of stress and age of the respondents (P = 0.032) where more respondents report both work and personal sources contributing to their stress as they age older in life. The younger respondents predominantly reported work life as the only contributing source of their stress.
Work role and stress
On segregating the source of stress according to different job profile, it was observed that among doctors, work-related stress was present among all the subjects and contribution of personal life to stress was reported by 42%. Among nurses, 60% and 19% were exclusively stressed because of work and personal life, respectively, while 21% nurses reported stress because of both the factors [Figure 4]. Among support staff, the source of stress pertaining exclusively to work and personal life were 36% and 16% respectively, while 46% respondents in this group were stressed because of both the factors.
Work role was also found to have a significant association with the source of stress (P = 0.003) where a majority of the clinical staff reported only work related stress, whereas for the administrative staff, it was related to both work and personal life.
Work life and causes of stress
We asked our study respondents, to identify the possible reasons of work-related stress. Behavior of other people towards them, was identified as the most common reason causing stress in our study respondents (97/110), which was followed by overwork (91/110), inability to achieve self-set goals (70/110), inability to meet others' expectations (68/110), and own behavioral problem (46/110) [Table 2].
The study did not find any statistically significant association between work roles and the work life-related causes of stress except for overwork (P = 0.014) where doctors (84%) and nurses (93%) overwhelmingly reported overburdened with work as the cause of stress.
Personal life and causes of stress
In our analysis of the responses regarding the possible reasons pertaining to personal life stress, a lack of personal time (84/110) was the most common reason followed by emotional problems (75/110), limitation of resources, for example, money or qualification (63/110), changes in personal life, for example., birth, death or sickness in family (62/110), own health issues (60/110), unfulfilled desires, for example, desire to start a family (54/110), and relationship problems (50/110) [Table 3].
The study has shown a significant association between limitation of resources as a personal cause of stress and age (P = 0.048) which reveals that the younger age groups suffer disproportionately from resource limitation (age groups 15–25 years – 73% and 46–65 years – 31%). For females, the health issues (P = 0.019), emotional problems (P < 0.001), and lack of time (P = 0.010) were found to be significantly higher personal causes of stress as compared to their male counterparts.
Similarly, the limitation of resources was found to have a significant association with work roles (P = 0.010) where administrative staff (72%) reported highest and doctors (40%) lowest, as the personal cause of stress.
Current methods to de-stress
In our study, the respondents were asked to select the techniques currently employed by them to relieve stress whenever possible. It was observed that entertainment like watching movies or TV was the most sought after and easily available mode of relieving stress with 60.9% respondents opting for it, followed by sleep (60%), spending time with family and friends (58.2%). meditation (25.5%), physical activity like sports (22.7%) and creative activity, for example, singing or dancing (17.3%) were found to be the least favorite [Figure 5].
Wished for methods to de-stress
The study also asked the participants to select the most effective ways they wished for de-stressing, if given an option. It was observed that spending time with family was the most wished for way to relieve stress, if given a choice, which was voted by 64.5% of the respondents. This was followed by options for entertainment like movies or TV (50%), sleep (49.1%), and meditation (41.8%). Like previous observations, physical activity (31.8%) and creative activity (28.2%) were the least preferred [Figure 6]. Another interesting insight from the study is that, even though entertainment and sleep are the most common means employed by the healthcare workers to de-stress, but were less preferred if given a choice. In contrast, the other four options were wished more often for de-stressing.
Different option to deal with stress at work
Our study respondents were asked to rank 6 different options that may help them in dealing with stress at work, where rank 1 was most favored option and rank 6 the least favorite. It was observed that meditation at work (79/110) followed by physical activity at work, for example, gym (63/110) and entertainment at work, for example, TV room (60/110) were the most popular options, selected among the top three ranks. While taking short nap at work was the least favorite option, ranked in bottom three by 70 respondents, followed by creative activity at work (68/110) and behavioral training (64/110) [Table 4].
A significant association was observed between a preference for entertainment at work and age (P = 0.031) where younger age groups preferred the option more than the elder respondents (age groups 15–25 years – 77% vs. 46–65 years – 46%). Work roles also showed a significant association with the preference for entertainment at work (P < 0.001) with nurses (74%) in highest favor of the option followed by doctors (54%) and administrative staff (24%).
Meditation and stress
Finally, our study also found that if given an option, two-thirds (67%) of our study respondents would like to meditate at work.
| Discussion|| |
Our study attempted to assess the extent of stress among health-care workers of large hospitals in the Delhi NCR region, by studying the “source of stress,” “cause of stress,” and “coping mechanisms for stress,” through questionnaire-based responses. In this study, the prevalence of workplace stress among health-care workers (n = 110) (doctors, nurses, and other support staff) was 76%which was in line with the similar study by Salam et al. (66.2%), Kane (73.5%) and Birhanu et al. (68.2%). However, in the present study, the prevalence was higher than results reported from Visser et al. (55%), Nyssen et al. (40.4%) and Mosadeghrad (34.9%). The possible reasons for the difference might be due to differences in the tools used, study participants (previous studies included only one professional group), and the relatively small sample size of our study.
This study reports that nurses were the most stressed group, reporting stress in about 98% of respondents [Figure 1] followed by doctors (67%) [Figure 2] and other support staff (57%). There was a large difference noted in the level of stress reported among health-care workers who are first line care givers, in comparison to the support staff, with nurses being most severely affected. Similar observation was made in a study done by Halder and Mahato, i.e., nurses being on the higher band of level of stress and the reason could have been the nature of work which requires high vigilance and monitoring throughout their working hours. Nurses in comparison to doctors, technicians or paramedical staffs are often put into multiple responsibilities which also include dealing with the public. Previous study findings have suggested that, role ambiguity leads to stress in nurses.
Work-related stress was the major cause of stress in doctors and nurses while support staff reported major source stress as both professional and personal factor, which is consistent with the study by Al-Omar which reported that work-stress was higher among doctors (stress level = 4.04) and lower among hospital administrators (stress level = 3.69). In studies in Taiwan, doctors and nurses had a statistically elevated likelihood of work stress relative to other health - care providers, similar to what we noted in our study.
The major source of work-related stress [Table 2] reported in our study was other people's behavior or conduct, and 88% of our study respondents had to bear with it. About 83% of respondents were stressed because of excess work. Other prominent reasons for work-related stress observed were inability to achieve self-set goals (64%), and inability to meet other's expectations (62%). The study done by Blair and Littlewood emphasized that work relationships are potential stressors. Two sources of stress in this field are conflicts with co-workers and the lack of staff support. The study in Germany and Austria done by Sehlen et al. showed that the four greatest sources of work-related stress were “too much office work,” “time pressure,” “ill-defined responsibilities,” and “breaking off the conversation with the patient.” Similarly, a study done by Salam et al. showed those who worked more than 50 h per week were more stressed. The variation with the current study might be due to differences in setting and sample size.
Family and personal factors contribute to stress among nonhealth-care workers and health-care workers alike. Lack of personal time and emotional issues are the two most important stressors observed in our study [Table 3]. Similarly, the study by Sehlen et al. showed that the greatest stress factors among health care worker especially nurses were “underpayment” and “lack of stability at home.” In the study of senior employees in a major US corporation, which used a similar design, both stress at home and at work were significantly and independently associated with depressive disorder. Similarly, study done by Weinberg A et al. provided clear evidence that aspects of the work environment as well as domestic stresses lead to, or perpetuate, depressive and anxiety disorders in healthcare professionals and hospital staff.
The American psychological Association survey, 2014 revealed the top stress management techniques used by nearly 2000 US adults were - listening to music (48%), exercising or walking (43%), surfing the internet/going online (42%), watching television or movies for more than two hours per day (40%), reading (39%), and praying (30%). Health-care workers are no different, as in our study, we observed that entertainment like watching movies was the chief mode of cooling off, followed by sleep, and spending time with family [Figure 5]. However, according to our study respondents, they preferred spending time with family if they were given a choice followed by watching movies for entertainment as the second most favored option [Figure 6].
Meditation has long been proven to be a simple, safe, and effective intervention for dealing with stress. Meditation quiets the mind, allows the person to disengage the senses and “go beyond” the mind. The relaxation response results in decreases in oxygen consumption, carbon dioxide elimination, respiratory rate and volume, heart rate, heart rate variability, blood pressure, and muscle tension., There are elegant studies demonstrating the positive psychological impact of meditation in terms of reduction of negative emotions (anger, cynicism, fear, and burn out) and increase in positive emotions (joy, calmness, harmony, tolerance, etc.,) in health-care workers. As such, meditation is increasingly been utilized as a stress management tool in the healthcare setting. Besides, large numbers of corporations are offering meditation at the workplace, as an effective stress management tool for their employees. In our study too, we observed that around 67% of the health-care worker would like to meditate, if give an option. This clearly means that though it does not come to mind as a tool for stress management, for most employees, if given an option, it will be accepted by the majority of workforce. It has also been shown that workplace meditation program not only improves the psychosocial well-being of the employees, it also increases their productivity at workplace.
| Conclusions|| |
Most of the health-care professionals significantly experienced workplace stress, and roles dealing with direct patient care, are more severely affected by stress. Being over burdened with work was significantly associated with workplace stress. Health policy makers and hospital managers should be aware of the extent of workplace stress and should work toward reducing stress at the workplace. Meditation at workplace can be a safe, effective, and feasible modality which can be offered at the workplace to safeguard the physical as well as mental health of the healthcare workers, reduce their levels of stress and improve their efficiency. Further large-scale studies should be done in different parts of the country to provide strong evidence regarding the determinants of workplace stress among health care professionals and study the role of meditation as an important intervention to deal with workplace stress.
This was a questionnaire-based survey with random convenient sampling without any control group. The sample size of this study was small, and sampling was limited to few big corporate hospitals of Delhi-National Capital Area. A larger study with a greater number of samples from various geographical and different sectors (public and private) of hospitals will give us a clearer picture of stress burden among the healthcare workers. Furthermore, systematic studies are needed in due course to study the impact of meditation on stress levels subjectively and objectively to ensure that health-care workers can remain stress free at workplace.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cooper CL, Cartwright S. An intervention strategy for workplace stress. J Psychosom Res 1997;43:7-16.
Konstantinos N, Christina O. Factors influencing stress and job satisfaction of nurses working in psychiatric units: a research review. Health Science Journal 2008;2:183-95.
Salilih SZ, Abajobir AA. Work-related stress and associated factors among nurses working in public hospitals of Addis Ababa, Ethiopia: A cross-sectional study. Workplace Health Saf 2014;62:326-32.
Béjean S, Sultan-Taïeb H. Modeling the economic burden of diseases imputable to stress at work. Eur J Health Econ 2005;6:16-23.
Pisljar T, van der Lippe T, den Dulk L. Health among hospital employees in Europe: A cross-national study of the impact of work stress and work control. Soc Sci Med 2011;72:899-906.
Pearson C. New Study Shows High Rate of Stress among Doctors. Washington (DC): VOA News; 2009.
Kushal A, Gupta SK, Mehta ME. A systemic review. Int J Res Foundation Hosp Healthc Adm 2018;6:6-11.
Saravanabavan L, Sivakumar MN, Hisham M. Stress and burnout among intensive care unit healthcare professionals in an Indian tertiary care hospital. Indian J Crit Care Med 2019;23:462-6.
Dasgupta H, Kumar S. Role stress among doctors working in a government hospital in Shimla (India). Eur J Soc Sci 2009;9:356-70.
Adshead G. Healing ourselves: Ethical issues in the care of sick doctors. Adv Psychiatr Treat 2005;11:330-7.
Mokhtar K, Shikieri A E, Taha EM, ryan A. The Relationship between Occupational Stressors and Performance amongst Nurses Working in Pediatric and Intensive Care Units. American Journal of Nursing Research. 2016;4:34-40.
Kane PP. Stress causing psychosomatic illness among nurses. Indian J Occup Environ Med 2009;13:28-32.
] [Full text]
Birhanu M, Gebrekidan B, Tesefa G, Tareke M. Workload Determines Workplace Stress among Health Professionals Working in Felege-Hiwot Referral Hospital, Bahir Dar, Northwest Ethiopia. Journal of Environmental and Public Health. 2018; 2018: 6286010. pmid:30598668.
Visser MR, Smets EM, Oort FJ, De Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. CMAJ 2003;168:271-5.
Nyssen AS, Hansez I, Baele P, Lamy M, De Keyser V. Occupational stress and burnout in anaesthesia. Br J Anaesth 2003;90:333-7.
Mosadeghrad AM. Occupational stress and turnover intention: Implications for nursing management. Int J Health Policy Manag 2013;1:169-76.
Halder S, Mahato AK. Stress and psychological well-being status among health care professionals. Int J Occup Saf Health 2013;3:32-5.
Moustaka E, Constantinidis TC. Sources and effects of work related stress in nursing. Health Sci J 2010;4:210-6.
Al-Omar BA. Sources of work-stress among hospital-staff at the Saudi MOH. J King Abdul Aziz Univ Econ Adm 2003;17:3-1.
Lee WL, Tsai SH, Tsai CW, Lee CY. A study on work stress, stress coping strategies and health promoting lifestyle among district hospital nurses in Taiwan. J Occup Health 2011;53:377-83.
Blair A, Littlewood M. Sources of stress. J Community Nurs 1995;40:38-9.
Sehlen S, Vordermark D, Schäfer C, Herschbach P, Bayerl A, Pigorsch S, et al
. Job stress and job satisfaction of physicians, radiographers, nurses and physicists working in radiotherapy: A multicenter analysis by the DEGRO Quality of Life Work Group. Radiat Oncol 2009;4:6.
Phelan J, Schwartz JE, Bromet EJ, Dew MA, Parkinson DK, Schulberg HC, et al.
Work stress, family stress and depression in professional and managerial employees. Psychol Med 1991;21:999-1012.
Weinberg A, Creed F. Stress and psychiatric disorder in healthcare professionals and hospital staff. Lancet 2000;355:533-7.
American Psychological Association (APA). Stress in America™: Are Teens Adopting Adults' Stress Habits? Washington, DC: APA; 2014.
Goyal M, Singh S, Sibinga EM, Gould NF, Rowland-Seymour A, Sharma R, et al.
Meditation programs for psychological stress and well-being: A systematic review and meta-analysis. JAMA Intern Med 2014;174:357-68.
Savel RH, Munro CL. Quiet the Mind: Mindfulness, Meditation, and the Search for Inner Peace. Am J Crit Care. 2017;26:433-6.
Arya NK, Singh K, Malik A, Mehrotra R. Effect of Heartfulness cleaning and meditation on heart rate variability. Indian Heart J 2018;70 Suppl 3:S50-5.
Thimmapuram J, Pargament R, Sibliss K, Grim R, Risques R, Toorens E. Effect of heartfulness meditation on burnout, emotional wellness, and telomere length in health care professionals. J Community Hosp Intern Med Perspect 2017;7:21-7.
Kersemaekers W, Rupprecht S, Wittmann M, Tamdjidi C, Falke P, Donders R, et al.
A workplace mindfulness intervention may be associated with improved psychological well-being and productivity. A preliminary field study in a company setting. Front Psychol 2018;9:195.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]