Critical Values is the go-to resource for the entire laboratory team, providing insight and information on the latest research, information, and issues within pathology and laboratory medicine. The print and online magazine invites submissions on topics including, but not limited to, advocacy, education, technology, global health, workforce, workplace best practices, and leadership.
E. Blair Holladay, PhD, MASCP, SCT(ASCP)CM
Chief Executive Officer
Molly Strzelecki Editor
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Martin Tyminski Creative Director
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The first part of this two-part series looked at ways stress manifests and affects our physical and mental health, and how it has affected medical laboratory scientists throughout the COVID-19 pandemic. Read it here.
Managers who are able to identify where stress is coming from for an employee, or their own reaction to stress, may be able to address the situation before it becomes severe. Leaders who practice stress management and self-care demonstrate to employees that it is all right for them to do the same. This makes the organization better able to handle stressful situations and become healthier.1
While the health care environment is inherently stressful, there are ways to mitigate stress. Knowing your personality or that of your employees is helpful, and can help identify ways to handle stress. Questions to ask include are they a perfectionist? A martyr? Do they think negatively or personalize situations? Recognize the physical warning signs.
The work environment should be analyzed by performing a job analysis. At the peak of the pandemic many health care workers worked long hours, some without the appropriate breaks or time off. Workers should be allowed rest breaks and time off if requested. Managers should take a look at the work environment in order to make adjustments where needed, such as lighting, workspace ergonomics, noise levels, having supplies readily available where needed and checking for safety hazards. Allowing employees to bring personal items, such as photos, may enhance their work environment.
There are techniques that have been shown to reduce stress. These techniques can be incorporated into the work environment or can be done before or after work. Each person may have their own unique way to manage their stress but providing the tools is essential.
Laughter has a positive effect on the body. A person’s body temperature rises, making the body feel warmer, their pulse rate drops, breathing becomes deeper and muscle tension diminishes. Laughter can improve your immune system, relieve pain, improve personal satisfaction, and improve your mood.2 Purposeful laughter is a realistic, sustainable, and can enhance employees’ morale, resilience, and personal efficacy. In a study performed by Beckman, Reiger and Young, employees demonstrated a significant increase in several different aspects of self-efficacy, including self-regulation, optimism, positive emotions, and social identification, and maintained these gains at follow-up.3
Yoga breathing is an instant stress reducer. It can also aid asthma, reduce back pain, depression, multiple sclerosis, high blood pressure, heart disease and osteoarthritis. Relaxation techniques such as meditation, listening to music, relaxing in a sauna, hot tub, or bath, or spending time with a pet have been shown to calm a person. Massages have been shown to reduce the physiological effects of stress by lowering blood pressure, improving circulation, raising body temperature, reducing anxiety and raising a sense of well-being. A technique called laughter yoga developed by a medical doctor from India, has gained popularity and is practiced in companies and corporations, fitness centers, yoga studios, senior centers, and schools.4
The power of appreciation and knowing we have choices can reduce stress. We have choices to change our attitude. Being thankful, mindful, and keeping things in perspective are stress reducers. Learn to accept what you cannot change. Learning to say “no” can have a positive impact on your emotional wellbeing. Some people feel the pressure to always please. Self-empowerment and changing your attitude can beneficial.
Relying on spiritual connections, having a strong sense of self love, compassion, and acceptance and having a purpose in life enables one to view the stressors as opportunities to learn and grow from the experience.5 Social support is important. There are health benefits in connecting with others. There are risks to isolation therefore communication and keeping in contact with others is essential.
Stress makes you crave sugar and fat, directs fat to the abdomen, and can cause nutritional deficiencies. Reduce the amount of processed food, fast food, and eating too much. Stress depletes vitamin D in your body; therefore increase vitamin D-rich foods in your diet and reduce caffeine, which depletes your body of vitamin D. Eat more fruits and vegetables and drink herbal tea. Identify whether you are an emotional eater by examining and answering the question “Do you eat to cope?” Being conscious of your behavior can control your response when stress arises.
Exercise has been shown to relieve stress by lowering blood pressure, lowering fat in the blood, improving lung capacity, improving blood flow to the brain, and raising endorphins to name a few benefits.6 Turkington suggests walking instead of taking the car for short distances, taking the stairs instead of the elevator, or standing instead of sitting are all ways to incorporate exercise into your daily routine.6
Time management can reduce stress by simply organizing tasks in priority order. Making a list may help you realize you may not have to do everything at once. At work, other employees may be able to help, or working behind a closed door without interruption may allow you time to complete tasks.6
Organizations should ensure workload is adequate to the employee’s capabilities, clearly define the employee’s role, improve communication, and engage employees in discussion and decision making. In addition, changing the demands of work, by either the way the work is performed or the work environment can help prevent stress. Ensure employees have or acquire the appropriate knowledge and abilities to do their job. Improve employees’ control over the way they do their work (job sharing, flex time). Increase the amount of support given to employees. Improve managers, knowledge and understanding and attitudes toward workplace stress (training), Ensure equipment and physical working conditions are safe.
Managers should promote cooperation and minimize conflict. Conflict in most cases is inevitable, but preparing for it can make it manageable. Managers themselves should identify their body’s response to stress and ways to manage it in order to be an effective leader. Stress can impact a manager’s decision making, especially during a crisis where time pressures may impact their concentration and limit their creativity.
Most organizations have an inadequate emergency response plan—or no plan at all.7 Public health officials have expressed the need to prepare for a pandemic. According to Thompson et al, “Hospitals and healthcare organizations are relatively prepared for disasters that happen within their local service areas such as hurricanes, earthquakes, tornadoes, crashes, explosions, hazardous chemical releases and terrorists act.”8 A pandemic differs in that it quickly spreads throughout the world using necessary resources and taxing the workforce. Disaster planning is a necessity but is not enough for a pandemic. People need to understand how to protect themselves, their family, and how not to spread the virus.8
According to the Department of Health and Human Services it is important to allow some time off for workers who have experienced loss or personal trauma; counseling or educational services should be available in order to allow employees to put their experience into perspective.9 Managers should be ready to engage their employees and should be involved in the employee’s recovery by offering mechanisms for the employee to utilize such as employee assistance programs.
According to Pfefferbaum and North, “In the current pandemic [COVID-19], the home confinement of large swaths of the population for indefinite periods, differences among the stay-at-home orders issued by various jurisdictions, and conflicting messages from government and public health authorities will most likely intensify distress.”10 Essential workers have experienced crisis situations in the past. Learning from the past, organizations should have procedures in place such as a business continuity plan, a disaster recovery plan, and a critical incident plan. Most of these plans are put in place prior to their need; therefore reevaluating and updating the plan afterwards should be done. A study by Atuknda, Memiah, and Shumba, identified that 67 percent of facilities they studied did not have policies in place to deal with stress among health care workers. The facilities studied had a high incidence of burnout and stressed employees which lead to lower productivity, employees leaving the organization and low motivation.11 “Critical incident stress affects up to 87 percent of all emergency service workers at least once in their careers,” noted Kureczka.12
An employee’s stress response may be different after a crisis. Previous research shows employees may experience panic attacks, increased anxiety, depression, post-traumatic stress disorder, and increased suicide rates.13 During the COVID-19 pandemic employees identified what they expected from their employers which included: being heard, protected, prepared and cared for.14 Health care workers liked reassurance from their leaders, recognizing that their leaders did not have all the answers but were there to show support and express gratitude.14 Previous research showed health care workers may choose to be absent if a potential pandemic were to happen. Other health care workers—aware of the potential risk to themselves or family members—felt they had a professional obligation to treat patients during a pandemic.15 The COVID-19 pandemic has changed the life we once knew. The new normal of wearing a mask, socially distancing six feet apart, as well as the fear of this unknown virus and pandemic and isolation may increase stress for some individuals. “Knowing the facts about COVID-19 and stopping the spread of rumors can help reduce stress and stigma. Understanding the risk to yourself and people you care about can help you connect with others and make an outbreak less stressful,” writes the APA.1
As a manager or leader, it is important to promote a positive work environment. Managers face multiple challenges of bringing energy and passion to the workplace, of promoting a positive attitude, and creating an environment in which people feel connected to their work and colleagues.16 “Self-care for providers, including mental health care providers, involves being informed about the illness and risks, monitoring one’s own stress reactions, and seeking appropriate assistance with personal and professional responsibilities and concerns including professional mental health intervention if indicated,” notes Atuknda, Memiah, and Shumba.11
Education and training should be provided to health care leaders, first responders, and health care professionals regarding psychosocial issues.11 According to DeFraia, “such training would increase manager awareness of how symptoms of traumatic stress express themselves in the workplace as performance issues.”17 Critical Incident Stress Debriefing (CISD) is a technique to manage stress after a critical incident such as COVID-19. It is used with emotionally healthy people who experience an acute stress reaction to a traumatic event with the goal of mitigating the impact of the event and to speed up the recovery process.18 The main idea of the debriefing is to focus on the stress caused by the traumatic event. According to Mitchell, Sakraida, and Kameig, “CISD was not designed to be a stand-alone intervention, but rather a part of the broader CISM intervention that includes being prepared for a crisis, pre-crisis education, training, appropriate follow-up, and/or referral when necessary.”18 Not all clinicians believe there is a benefit to CISD but there is evidence-based research that indicates it does reduce recovery time and lessen the impact the traumatic event has had on family members.19-21 Devilly, Gist, and Cotton found that overall debriefed parties generally appreciated the gesture. After a crisis, it may be best for health care managers to perform debriefing strategies to get an overall assessment of their employee’s mental health and possible interventions needed.22
A recent practice put in place by Northwell Health Systems is tranquility tents. The tents are designed for their staff to find peace, use for reflection, and to recharge. The tents provide resources for the employees in all types of support, and include activities such as message of hope boards, gratitude rock gardens, name tag making, and color-by-number art.23 The Office of Patient & Customer Experience at Northwell realized leaders play a vital role, and there were twice-weekly meetings to discuss best practices, guest speakers, and patient stories and provide peer support.24 Northwell also has a “Team Lavender,” a Care for the Caregiver program and an Emotional Resource Call center for service jointly between their Employee Assistance Program and behavioral health service focusing on the well-being of employee as a top priority. They even provided, through their cafeterias, items for purchase for outside the workplace such as ready-to-go meals and household items.23
Dewey, Hingle, Goelz, and Linzer suggest, “developing an evidence-based menu of interventions, to be carefully selected from, and tailored to various workplace settings. For larger health systems, wellness committees and employee assistance programs are the logical resources to organize these interventions. In smaller settings, appointing a wellness champion could help to elucidate colleagues’ needs and implement solutions. Surveys to assess stress points, fears, and concerns can inform leaders and provide insight into areas requiring attention. We also suggest developing plans to back up, cross-train, and rotate leadership to avoid leader burnout.”25
The World Health Organization (WHO) published recommendations for the public, health care workers and team leaders and managers during COVID-19. For team leaders and managers, they state: “Keeping all staff protected from chronic stress and poor mental health during this response means that they will have a better capacity to fulfil their roles.” They discuss the fact that the pandemic will not disappear anytime soon and the focus should be on good communication, accurate information, the need to update employees, and make available all information on mental health support services that are offered.26
Leaders and managers are not immune to stress. The APA recently updated their website to include information for leaders during the COVID-19 pandemic. According to the APA, there are ways to cope with and lead through a crisis. Techniques offered by psychologists to help leaders while managing high-pressure situations include recognizing the warning signs, think and pause before you make decisions or announcements, prioritize self-care get enough sleep, take breaks during the workday and have employees that are capable of taking on responsibilities.9
Health care facilities in recent months have seen an unprecedented number of patients seeking care in their facility, increasing stress in the workplace. Policies and procedures should be in place to identify ways to cope. Managers should be aware that all employees—including themselves—may be experiencing stress in different ways. Health care employees in particular during this crisis have experienced demands placed upon them like no other time. With the prospect of multiple waves of this pandemic manifesting itself, managers must be aware of the signs, symptoms, and methods to minimize stress. Managers and employees need to balance work and leisure. Many laboratory professionals feel stressed under normal work conditions. Acknowledging the increase in stress among during the pandemic and finding ways to lessen stress now is critical.
Organizations should assess their overall response to the pandemic. Reviewing the policies and procedures in place currently, what worked, what didn’t work and how to accommodate employees during this crisis will better prepare the organization for the future. Anticipate stress and have a plan to minimize organizational stress and the stress of individual employees. Recognizing stress is the start of the journey in managing it.
1. American Psychological Association. Stress Management for Leaders Responding to a Crisis. Retrieved from https://www.apa.org/topics/covid-19/stress-management-crisis.pdf
2. Mayo Clinic Staff. Stress Management. Retrieved from:https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-relief/art-20044456 on July 22, 2020.
3. Beckman, H., Regier, N. & Young, J. Effect of Workplace Laughter Groups on Personal Efficacy Beliefs. Journal of Primary Prevention, (2007).
4. Laughter Yoga Health Craze Sweeping the World. Laughteryoga.org. 28, 167–182
5. Leyden-Rubenstein, L.A. The Stress Management Handbook. Keats Publishing Inc. New Canaan, Ct, 1998.
6. Turkington, C. Stress Management for Busy People. McGraw Hill Publishing; New York, NY. 1998.
7. Gardiner, K. Looking after No.1: when an organisation experiences a huge crisis, who looks after those looking after the business during this difficult time? The Safety and Health Practitioner. Vol. 28, Issue 4, 2010.
8. Thompson N. A., Van Gorder C. D. Healthcare executives’ role in preparing for the pandemic influenza ‘gap’: A new paradigm for disaster planning? Journal of Healthcare Management, 52(2), 2007, pp.87–93. Retrieved from: https://journals.lww.com/jhmonline/Citation/2007/03000/Healthcare_Executives__Role_in_Preparing_for_the.5.aspx
9. U.S. Department of Health and Human Services (DHHS). A Guide to Managing Stress in Crisis Response Professions. DHHS Pub. No. SMA 4113. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2005.
10. Pfefferbaum, B. and North, C. Mental Health and COVID-19.New England Journal of Medicine. Published online April 13, 2020. P. 1-3 Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJMp2008017#article_references
11. Atuknda, R., Memiah, P., & Shumba, C. S. Care for the caregiver: Stress relief and burnout among health workers in HIV care. Global Journal of Medicine and Public Health. Volume 2, Number 1, 2013, pp.1-7.
12. Kureczka, A. W. ‘Critical incident stress in law enforcement’. FBI Law Enforcement Bulletin, Vol. 65, Issue 2/3, 1996, pp.10-15.
13. Shranks, Jeremy. Stress at Work. Burlington, MA. Elsevier Butterworth-HeinemannLinacre House.2005.
14. Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA. Published online April 07, 2020. doi:10.1001/jama.
15. Ehrenstein,B., Hanses,F.., & Salzberger,,B. Influenza pandemic and professional duty: family or patients first? A survey of hospital employees. BMC Public Health, 6:311. 2006.
16. Lundin, S. C., Paul, H., & Christensen, J. Fish! New York: Hyperion. 2000.
17. Defraia,G. S. EAP-Based Critical Incident Stress Management: Utilization of a Practice–Based Assessment of Incident Severity Level in Responding to Workplace Terror. International Journal of Emergency mental Health and Resilience, Vol. 15, No. 2, 2013, pp. 105 – 122.
18. Mitchell, A., Sakraida, T., and Kameig, K. Critical Incident Stress Debriefing: Implications for Best Practice. Disaster Management and Response. Vol 1, No.2. , 2003, pp. 46-51.
19. Mitchell JT, Everly GS. Critical incident stress debriefing (CISD): an operations manual for the prevention of traumatic stress among emergency services and disaster workers. 2nd ed. Ellicott City (MD): Chevron Publishing; 1996.
20. Everly GS, Boyle SH. Critical incident debriefing (CISD): a meta-analysis. International Journal of Emergency Mental Health; 3, 1999, pp.165-8.
21. Lane P. Critical incident stress debriefing for health care workers. Omega 1993-1994; 28:301-15.
22. Devilly,G., Gist,R. & Cotton, P. Ready Fire Aim! The Status of Psychological Debriefing and Therapeutic Interventions: In the Workplace and after Disasters. Review of General Psychology.Vol.10, No.4. 2006, pp. 318-345.
23. Northwell.edu. Delivering moments of peace on the front line with Tranquility Tents. northwell.edu/blog/2020/05/21/delivering-moments-of-peace-on-the-front-line-with-tranquility-tents (No Author)
24. Gierlinger, S., Barden,A., and Giammarinaro,N. Turned Upside Down: The Role of New York Patient Experience Leaders During COVID-19. Journal of Patient Experience. 7(3): 287–290. Published online 2020 Jun 24. doi: 10.1177/237437352093620
25. Dewey,C., Hingle,S., Goelz, E. and LinzerMSupporting Clinicians During the COVID-19 Pandemic. Annals of Internal Medicine. Published online at https://doi.org/10.7326/M20-1033,2020.
26. World Health Organization (WHO). Mental health and psychosocial considerations during the COVID-19 outbreak. Mental health considerations 2020-02-14e_en_19MARCH2020_marissa.docx