Enhancing the Resilience of Health Care Warriors During COVID 19: A Mindfulness-

Based Program for Stress Management and Resilience Building

Dr.
Pooja Varma

Assistant Professor
Ms.
Ambeeka Kashyap
Ms.
Monica
Ms.
Sangeetha
 PG
Psychology
Jain
(Deemed to be University)

Bangalore

Abstract

The coronavirus disease 2019 (COVID-19) pandemic is presenting a unique set of

stressors and psychological trauma-related challenges to health care warriors (HCW)
who are the highest priority during this pandemic in India. These challenges include
uncertainty about the ultimate magnitude, duration, and effects of the crisis;
concerns about level of preparedness within individual health care organizations and
the public sector; lack of adequate personal protective equipment (PPE) and other
needed medical supplies; and potential threats to one’s own health and contagion
risks to loved ones and co-workers. In addition, the financial pressure created on
health care systems as a result of the COVID-19 pandemic is contributing significantly
to clinicians’ concerns and well-being. Uncertainty and the inability to be with their
loved ones to protect them from the virus has started taking an emotional toll on
healthcare workers and seems not dissimilar to what is seen during battlefield
conditions. The present study is designed to evaluate and execute the Stress
Management And Resilience Training (SMART), a mindful based intervention
program on depression, anxiety, stress, mindfulness, and resilience measures on
doctors and nurses. It has been hypothesised that interventions could be applied to
decrease levels of burnout in this professional population. Facilitating psychological
resilience for HCW that incorporates elements of the SMART resilience program in a
form of 8-weeks workshop mitigating psychological consequences for HCW who are
responding to pandemic that will include on-site meetings, self-directed learning
modules, and weekly text messages to support participants’ interest in learning self-
care and well-being methods for building resilience. Data analysis will include pre-
and post-DASS-21, resilience and mindfulness surveys and select demographic
variables. Outcomes will be assessed at baseline, end of intervention and after the
postintervention follow-up period.

Keywords. Pandemic, Health care warriors, Stress, Resilience, Mindfulness

The battle against the COVID-19 pandemic would be lost if it were not for our
frontline healthcare workers. However, these workers are rendering their services at
a great personal and emotional costs. Working in healthcare is already stressful, but
it is now compounded by the uncertainty of the future, fears of contracting and
passing on the virus, and being compelled into isolation to keep loved ones safe.
Apart from gruelling working hours in a high-pressure environment, being
surrounded by the coronavirus discourse has also been overwhelming. There is an
uncertainty about when things will improve and the time when pandemic will end.
As when there is an end in sight, a person can power through. Being a healthcare
worker as reported, has now become a thankless job. In many cases, loved ones or
neighbours may be upset that a health worker is interacting with or treating COVID-
19 patients instead of praising them. So the rewards are gone, and one can feel
demotivated to work.

Experts say that we could be looking at burnout and mental health issues among
healthcare workers if things are allowed to go on this way long term. This includes
exacerbation of existing conditions or symptoms if one has them like emotional
exhaustion, feeling drained out, irritation and aggression. It could also lead to
depersonalization – the inability to see patients as humans because they are seeing
the same misery and pain day in and day out with no respite. There will also be
impact on workers’ personal relationships and daily routines, which is not necessarily
a bad thing – doctors and nurses have to keep their emotions at bay to be able to
treat patients practically. However, when it becomes an unhealthy coping
mechanism, it can start to affect one’s work. 

Therefore, its observed that right from dealing with the risk of pathogen exposure,
working for long hours, and experiencing occupational distress, to enduring physical
violence, as well as social stigma, doctors and frontline health workers in the country
are not breathing easy. Ever since the surge in coronavirus cases, the very people
who are attempting to detect and treat the virus have been facing multiple
challenges.
The physiological, cognitive/emotional, and interpersonal response of a given individual to their
stressful situation determines resilience versus burnout. Items in green represent adaptive responses
while items in red may be maladaptive. Note that responses are interdependent (physiological
responses affect cognitive/emotional responses, etc) and that resilience and burnout lie at the
confluence of these dimensions (Figure 1).

Significance of the study

Because of the scarcity of research on the stress and resiliency of health care
employees es. in India, a desired intervention program based on resilience and
mindfulness (of Attention and Interpretation Therapy, AIT) will be designed to re-
examine the relationship of stress and resilience among health care workers.

Given the remarkable adaptability of human beings, we believe that, by promoting

resilience, our diverse health care workforce can emerge from this monumental
challenge with new skills, closer relationships, and greater confidence in the power
of community.

The holistic approach to the concept of building resilience and well-being suggests
that stress management programs incorporate objectives and program content for
health care employees to include environmental, organizational, cultural, and
individual factors particular to the workplace and unique to the individual.

Review of Literature

Understanding the reflective levels in health care workers and the attributes which
contribute while also being influenced by it specially during the Covid times would
help look at the causal aspects of reflective awareness about their condition and
quality of life and focus on the enhancing their resilience as well.
Most of the literature on health care stress suggest a strong link among chronic illness,
increased stress, and increased family dysfunction. “Rising patient acuity, rapid
assessments and discharges, and increased service use by clients mean that HCW are
dealing with sicker people who are likely to have multiple conditions that may
complicate both the treatment and the recovery. These pressures can lead to work-role
overload and burnout.” The problems related to workplace adversity can be negative,
stressful, traumatic, resulting in difficult situations or episodes of hardship for them.
Despite all of these challenges, resilience enables them to cope with their work
environment and to maintain healthy and stable psychological functioning. Resilience
is the ability to bounce back or cope successfully despite substantial adversity.

The recent studies demonstrated that nurses and doctors are particularly vulnerable
to experiencing depression, anxiety, insomnia and distress in these work conditions
(Lai, 2019; Chatterjee et al., 2020; Santarone et al., 2020). Currently, the stress
extends outside of the realm of healthcare facilities. Physicians worrying about
infecting their families and contaminating their homes may choose to self-isolate or
face the guilt of potentially infecting a family member. Social isolation and subjective
feelings of solitude are known risk factors for suicide, and it is already established
that physicians have higher rates of suicide than the general population (Clark et al.,
2020; West et al., 2018).

Stress Management and Resiliency Training (SMART) program

SMART program was developed at our institution by a physician in the Division
of Complementary and Integrative Medicine who has extensive experience in the
field of resiliency training. The program is designed to help participants understand
the neuroscience and biology of stress. From that understanding, participants learn
skills to develop intentional attention and reframe life experiences using the 5 core
principles of gratitude, compassion, acceptance, forgiveness, and higher meaning.
This study aims to give insight on how resilience of health professionals might be
improved. The present study was designed to examine and help them to adapt the
Stress Management and Resiliency Training (SMART) program with each day on
stress, mindfulness, anxiety, and resilience measures on mental health workers.

▪ The Stress Management and Resiliency Training (SMART) program developed

by Mayo Clinic’s Dr. Amit Sood (2017) is mandatory for all physicians, nurses
and students across the Mayo Clinic enterprise.
▪ The 90-minute, mindfulness-based intervention has resulted in statistically
significant and clinically meaningful improvements in anxiety, stress, quality
of life and mindful attention in clinical trials in various populations of
caregivers, ranging from new nurses to seasoned physicians.
▪ Participants are trained in practices that allow them to reframe potentially
stressful situations more quickly. This helps care providers reconnect to the
 meaning of their work and boosts engagement, which in turn influences their
patients’ care experiences.

The structured program, which teaches self-care practices that build resiliency and
reduce participants’ emotional and physical vulnerability to daily stress. SMART is a
mindfulness-based intervention focusing on the intentional act of paying attention in
the present moment, without judgment. Unlike many mindfulness programs, which
require protracted training and practice time—a limiting consideration for busy
medical professionals—SMART can be delivered in a single 90-minute session, and
daily commitment to SMART practices can be as short as five minutes (Sood et al.,
2010).

The focus of this research study is on Attention and Interpretation Therapy (AIT) and
its impacts on helping professionals (social workers, counsellors, and psychologists).
AIT is a relatively new mindfulness-based approach based primarily on recent
developments in neuroscience (Sood et al,. 2010).

The first session of the science-based SMART programme concentrated on

understanding the neuroscience of the brain and behavioural aspects of human
experience with respect to stress and resilience. The second session featured a
follow-up presentation along with a question-and-answer session to reinforce
gratitude and mindfulness. The final session focused on practical approaches and
skill building with applications of kind attention and resilience thinking to change the
brain’s wiring and move past the tendency towards negativity and fear. Three to six
months of daily practice are generally needed to instil the principles and retrain our
emotions.

Purpose of the study

Supporting the mental wellbeing and resilience of frontline healthcare workers is

imperative to ensure global recovery from the COVID-19 pandemic.

The primary purpose of the study is to understand the perceptions of stress and
resilience of health care warriors (Nurses and Doctors) in different cities of India.
The secondary purpose is to develop an 8-week practicum using common domains of
wellness and self-care that might address those perceptions and improve a sense of
resilience in participants.

Information from this project contributes to the literature on understanding

perceptions of stress and developing resilience in health care warriors through skills
promoting self-understanding and reflective assessment of positive behavioural
patterns for improving the health of individuals and workplace environments.

Emphasis would be placed on individualized emotional support plans, as

psychological care is not one-size-fits-all. This includes the use of telemedicine, video
chats, or online forums to make appointments with psychologists and psychiatrists.
Support groups and reading materials pertaining to dealing with ongoing stressors
would be available.
The present study is designed to test the SMART program to enhance HCW’s
resilience and decrease depression, anxiety and stress among HCW working in COVID
hospital wings.

Methods

Research Questions

The research questions that would guide this study considered the following:

To what degrees does the Health Care Warriors (HCW) working in COVID wards
affected in times of pandemic on depression, anxiety and stress?

Do health care workers who engage in a resiliency training programme report a

change in their interrelationship with depression anxiety stress from pretraining to
post training?

Aims and objectives

● To investigate whether the Health Care Warriors (HCW) working in COVID

wards affected in terms of depression, anxiety, stress and resilience on a large
scale level.
● To implement the resiliency training programme (SMART Model) in gradual
phases to a small section of HCWs and reported change from pretraining to
post training.

Hypothesis

The following hypothesis are suggested for the present research:

There will be no difference in resilience-level to perceived levels of stress, anxiety,

and depression of Doctors.

There will be no difference on resilience-level interventions and its corresponding

effects on stress, anxiety and depression of Doctors.

There will be no difference in resilience-level to perceived levels of stress, anxiety,

and depression of Nurses.

There will be no difference on resilience-level interventions and its corresponding

effects on stress, anxiety and depression of Nurses.

Gender and age of the health care worker has no impact on resilience-level
interventions and the corresponding effects on stress and depression.
Sample and Procedure

A total of 200 nurses and doctors from six different hospitals (both government and
private) actively serving the COVID patients of various cities (Mumbai, Bangalore,
Delhi, U.P, and Odisha) in India. Participants meeting the inclusion criteria for the
study and those committing to attend sessions would be given the socio demographic
data sheet and the questionnaires to be filled through the online medium (e-mail) due
to the pandemic situation. Once the questionnaires are filled they would be scored and
statistically analysed for web based and offline mode interventions.
The resilience model would be maximized on the small number of participants based
on convenience sampling. Previous studies evaluating the effectiveness of resilience
training ranged from samples of 10 to 100 (Robertson et al., 2015; Van der Riet et al.,
2018). The informed consent form will be reviewed with all participants so they could
ask questions and review risks and benefits. Participants will have the right to enter
the study or decline involvement.
At the end of the 8-week online workshop, an additional survey will be given to each
participant to determine the value of the intervention in addition to answering open-
ended questions seeking anecdotal evidence of what worked well for the individual,
barriers encountered, and recommendations on how the project might be improved.
The small intervention group based on their willingness to participate will undergo a
90-minute session during which a study investigator and team members will present
a model of stress and resilience based on SMART Model (Sood et al., 2010;
Gullickson et al., 20012). Self-reported measures will be collected from both groups
at baseline and 8 weeks following the intervention.

Inclusion criteria

▪ HCW actively treating patients diagnosed with covid 19 on a regular basis and
▪ Being able and willing to participate.

Exclusion criteria

▪ Recent (within the past 6months) psychiatric illness/ trauma.

▪ Clinically significant acute unstable neurological, psychiatric, hepatic, renal,
cardiovascular or respiratory disease that prevented participation in the study

Design

In the first phase, a cross-sectional survey design will be selected. The second phase
is a pretest-posttest research design for the examining the change in scores in
measures through the intervention model.
Measures

The following measures were used before and 8 weeks after the training program.

● Expanded Nursing Stress Scale (ENSS) will be used to measure nurses job

related stressors. The ENSS is an expanded and updated revision of the
classic Nursing Stress Scale (NSS) developed by Gray- Toft& Anderson
(1981). The NSS was the first instrument to target nursing stress rather than
general job stress.

● The DASS-21 is a set of three self-reported scales of depression, anxiety, and

stress. Each scale, consisting of seven items, is divided into subscales with
similar content and is based on the dimensional concept of psychological
disorder versus a discrete diagnostic category.
▪ The characteristics of the depression scale assess hopelessness, inability to
experience joy, lack of interest or involvement, and generalized dissatisfaction
with life. The anxiety scale evaluates behaviours of apprehension, worry over
performance (situational anxiety), and awareness of autonomic nervous
system or unconscious stimulation of fear, exhibited as the pounding of the
heart, breathing difficulties, or palmar sweat. The stress scale is used to
identify behaviours where the individual has trouble relaxing, becomes easily
upset, and may be overreactive exhibiting tension, irritability, and intolerance
of interruption.

● Connor-Davidson Resilience Scale (CD-RISC). The CD-RISC is a brief,

self-rated measure of resilience that has sound psychometric properties. By
using the CD-RISC, the findings of this study demonstrate the following:
resilience is quantifiable and influenced by health status (i.e., individuals with
mental illness have lower levels of resilience than the general population);
resilience is modifiable and can improve with treatment; and greater
improvement in resilience corresponds to higher levels of global improvement.
The CD-RISC could have potential utility in both clinical practice and
research.

▪ Mindful Attention Awareness Scale (MAAS). The trait MAAS is a 15-item

scale designed to assess a core characteristic of mindfulness, namely, a
receptive state of mind in which attention, informed by a sensitive awareness
of what is occurring in the present, simply observes what is taking place.

Analysis
 ▪ The variables of resilience, depression, anxiety, and stress scores with
demographic characteristics and job characteristics (income per month, ratio
of patients to nurses, shift work and professional rank) will be examined the
main predictors of depression, anxiety, and stress of doctors and nurses
dealing with pandemic.
▪ In Pretest and posttest assessments, the valid, reliable questionnaires for the
first workshop (pretest) and after the 8- week intervention approximately
(posttest). The last week will be designated for using an evaluation survey
providing participants an opportunity to respond both to quantitative and
qualitatively designed questions about their experience. Descriptive statistics
will be used to examine the data obtained (percentages, frequencies, means
and standard deviations). The primary outcomes of interest included changes
in the scores from baseline, preintervention and postintervention (at week 8)
between groups using the two-sample t-test.

Expected outcome

In the first phase, the level of depression, anxiety, stress and resilience level of
doctors and nurses will be evaluated.

In the second phase, a 8 week programme of stress management and resilience

intervention (bases on SMART model) for meaningful improvement in happiness,
satisfaction with life, and gratitude in health care workers will be introduced.

Social and clinical Implications

Improving resilience with SMART model is needed to relieve the Health care
warriors’ (HCW) burnout, reduce workplace stress and increase productivity. There is
enough literature on HCW’s problems at individual, institutional and societal level but
interventions to enhance their resilience are negligible in India. There is need to
explore this area and use these scientific steps to enhance health care services by
improving the resilience of health workers and systems of care.

Expected Budget

a. Relevant Books and Journals.

 ▪ Book based on A Two Step Program to Enhance Attention; Decrease Stress
(Sood, A. 2010).
▪ Training modules, handouts based on SMART Resilience Training model
(Sood, A. 2010) for circulation to health care professionals.
▪ Access to ACADEMIA, SCOPUS, SAGE for articles in the area.

b. Hiring services.
▪ Teaming up with psychologists’ hiring their expertise (during the intervention
phase) and services for technical assistance (i.e., sample analysis, developing
web-based audio video training programs with reference to the protocol for
promotion in various medical institutions and maintaining data base via
telephonic interviewing for screening and follow up regularly).
c. Field Work (for data collection post COVID times).

d. Contingency (telephone calls, internet, fax, computation, promotion aids and

printing needed for the project).

Total expected budget: 10,000 INR/-

References

Chatterjee, P., Anand, T., Singh, J., Rasaily, R., Singh, R., Santasabui, D., Singh, H.,

Praharaj, I., Gangakhedkar, R., Bhargava, B. and Panda, S. (2020). Healthcare

workers & SARS-CoV-2 Infection in India: A Case-control investigation in the time

of COVID-19. Indian Journal of Medical Research. Vol. 151 (5), 459-467.

Clark, L., Stephens, A.F. Liao, S. Byrne, T.J., Gregory, S.D. (2020). Coping with

COVID-19: ventilator splitting with differential driving pressure using standard

hospital equipment. Anaesthesia. doi: 10.1111/anae.15078. 

Gothard, S. (2019). Developing Resilence Training for Health care employess in a

rural medical center. Retrieved from

https://digitalcommons.acu.edu/cgi/viewcontent.cgi?article=1168&context=etd
Gullickson, A. M., Graham, M. A., Amundson, K.A., Smyth, K. T., Sood A. (2012).

A Mindfulness and Neuroscience Based Intervention: Stress Management and

Resilience in the Workplace. Poster session at the meeting of the International

Symposia of Contemplative Studies, Denver, Colorado.

Lai J. (2020). Factors associated with mental health outcomes among health care

workers exposed to coronavirus disease 2019. JAMA Netw Open. 3(3).

Mistretta, E.G. and Davis, M. (2018). Resilience Training for Work-related stress

Among Health Care Workers, Retrieved from:

https://journals.lww.com/joem/Fulltext/2018/06000/Resilience_Training_for_Work_

Related_Stress_Among.11.aspx

Santarone, K., McKenney, M. and Elkbuli, A. (2020). Am J Emerg Med. Jul; 38(7):

1530–1531. Published online 2020 Apr 15. doi: 10.1016/j.ajem.2020.04.030

Screiber, M., Catest, D. M. (2019). Maximizing the Resilience of Healthcare Workers

in Multi- hazard Events: Lessons from the 2014-2015. Ebola Response in Africa,

Retrieved from https://academic.oup.com/milmed/article-

abstract/184/Supplement_1/114/5418686.

Sood, A. (2010).  “Train Your Brain, Engage Your Heart, Transform Your Life: A

Two Step Program to Enhance Attention; Decrease Stress; Cultivate Peace, Joy and

Resilience; and Practice Presence with Love—A Course in Attention & Interpretation

Therapy (AIT)” Rochester, MN: Morning Dew Publications.

Sood, A., Prasad, K., Schroeder, D., Varkey, P. (2011). Stress management and

resilience training among Department of Medicine faculty: a pilot randomized clinical

trial. J Gen Intern Med. (8):858-61.

Soodetal.“StressManagementandResiliencyTraining(SMART)ProgramamongDepart

mentofRadiologyFaculty:APilotRandomizedClinicalTrial.”Explore(NY).2014Nov–

Dec;10(6):358–363. https://www.thenewsminute.com/article/burnout-and-covid-

anxieties-are-pushing-india-s-healthcare-workers-brink-126963

https://mumbaimirror.indiatimes.com/coronavirus/news/mental-health-needs-of-

healthcare-workers-due-to-covid-19-pandemic/articleshow/75831611.cms?

utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst

https://www.deccanherald.com/opinion/panorama/respect-our-healthcare-workers-

855644.html

https://www.pressganey.com/docs/default-source/industry-edge/issue-15---

april/mayo-clinic-uses-smart-approach-to-enhance-caregiver-resiliency.pdf?sfvrsn=2

Van der Riet, P., Rossiter, R., Kirby, D., Dluzewska, T., Harmon, C. (2015). Piloting

a stress management and mindfulness program for undergraduate nursing students:

student feedback and lessons learned. Nurse Educ Today. 35(1): 44‐ 49.

Yılmaz, E.B. (2017). Resilience as a strategy forstruggling against challenges related

to the nursing profession. Chin Nurs Res., 4: 9e13.

http://dx.doi.org/10.1016/j.cnre.2017.03.004E.B. Yılmaz / Chinese Nursing Research

4 (2017) 9e1313