NicholasRula Spring2021

PROJECT
CALIFORNIA STATE UNIVERSITY SAN MARCOS
PROJECT SUB:MITTED IN PARTIAL FULFILUvlENT OF THE REQUIREtvlENTS FOR THE DEGREE
:tv1ASTER OF PUBLIC HEAL TH
TITLE: A Pilot Study to Assess Work-related Stress among Healthcare Professionals at a Community Clinic in North San
Diego County
AUTHOR(S): Rula Nicolas, Francisca Velazquez
DATE OF SUCCESSFUL DEFENSE: 04/27/2021
THE PROJECT HAS BEEN ACCEPTED BY THE PROJECT COJ\1MITTEE IN
PARTIAL FULFILLMENT OF THE REQUIRE11ENTS FOR THE DEGREE OF
:tv1ASTER OF PUBLIC HEAL TH
Emmanuel Iyiegbuniwe May 10, 2021

COJ\1MITTEE CHAIR SIGNATURE DATE
Diane Beach Diane Beac;h May 10, 2021

COJ\1MITTEE 11EMBER SIGNATURE DATE

A Pilot Study to Assess Work-related Stress among Healthcare Professionals at a
Community Clinic in North San Diego County
Francisca C Velazquez
Rula Nicolas
California State University San Marcos

WORK-RELATED STRESS ASSESSMENT 2
Abstract
Healthcare workers often suffer from occupational stress related to anxiety, lack
of skills, low social support at work, and uncertainty. All of these stressors may lead to
burnout, psychosomatic problems, poor quality of life, and services. Providing care to
others during the Coronavirus Disease 2019 (COVID-19) pandemic can lead to panic and
sometimes hopelessness. This pilot study was conducted to assess work-related stresses
among healthcare professionals at a community clinic in North San Diego County.
Survey questionnaires and consent forms previously approved by the Institutional Review
Board at California State University San Marcos were distributed anonymously via
Google Forms to different healthcare workers at a community clinic in North San Diego
County. The survey consisted of twenty-five questions designed to evaluate their self-
reported effects of stress. A total of nine responses were received and evaluated. The
preliminary results of this pilot study showed that six healthcare workers with higher
education levels self-reported that they were able to regulate work-related stress in a
healthier manner. However, six of the nine participants (66.6%) self-reported that they
were unable to avoid the observation of work-related stress and another six (66.6%)
expressed concerns over stressful and behavioral changes resulting from working under
pressure. The results of this pilot study suggest the importance of ongoing support from
management in reducing work-related stressors among healthcare professionals.
However, the results of this study cannot be generalized since it relied on self-
administered surveys from a very small sample size of nine participants at the same
community clinic in North County San Diego.
Keywords: Stress, Work-related stress, Healthcare professionals, Stress management and
coping strategies
Acknowledgments
On behalf of our Capstone group, we would like to thank our committee members Dr.
Emmanuel Iyiegbuniwe (chair) and Dr. Diane Darby Beach (member), for their
continuous support throughout this process of completing this project. We would also
like to acknowledge all MPH faculty members who supported us throughout this project
and guided us to finish strong. Lastly, we would like to thank both of our supportive
family members and friends who gave us strength, patience, and encouragement from the
bottom of their hearts. We know this capstone project would not have been possible
without all the special people who cheered us on to the end of our graduate studies.
TABLE OF CONTENTS
Abstract ........................................................................................................................... 2
Acknowledgments........................................................................................................... 3
List of Tables .................................................................................................................. 4
Table
Page ................................................................................................................................. 5
List of Figures ................................................................................................................. 6
Literature Review and Background ................................................................................ 7
Introduction ................................................................................................................. 7
Types of Stress ............................................................................................................ 8
COVID-19 Pandemic and Work-related Stress .......................................................... 9
Stress-Coping Strategies ........................................................................................... 10
Methods......................................................................................................................... 14
Survey Questionnaires .............................................................................................. 14
Study Design ............................................................................................................. 14
Data Analysis ............................................................................................................ 14
Results ........................................................................................................................... 16
Demographics Characteristics .................................................................................. 16
Work-related Stress................................................................................................... 16
Commonly Experienced Health-related Problems.................................................... 17
Discussion ..................................................................................................................... 19
Recommendations ..................................................................................................... 21
Limitations ................................................................................................................ 24
Conclusion .................................................................................................................... 25
References ..................................................................................................................... 26
Appendix A Consent Form .......................................................................................... 28
Informed Consent...................................................................................................... 28
Survey Questions ...................................................................................................... 33
Appendix B ................................................................................................................... 38
List of Tables
Table Page
1 The Demographics Characteristics of the Participants………………………………37

List of Figures
Figure Page
1 Participant’s feelings about the stress at work……………..……………………….....37
2 The current pandemic has increased the participants stress level at work…………….38
3 Participants’ support at work to overcome stress……………………………………..38
4 The Participants experienced Blurred vision related to stress……………...…………39
5 The participants experienced Restlessness……………………………………....……39

Literature Review and Background

Introduction
Stress can be seen as a social tension that results from the surrounding
environment and often affects the nervous system (MedlinePlus, 2021). Pressure for the
short term is essential since it is necessary for humans to react to danger but may become
harmful to the body if sustained over a long period (Casarella, 2019). Employees with
stressful jobs have 2.2 times more cardiovascular mortality risks than those with low
work-related stress (American Heart Association, 2015). Being exposed to stress for too
long can lower a person's work performance and trigger negative consequences that can
affect their health or family and social life.
Stress can cause emotional problems, including diarrhea, constipation, pain,
headaches, lack of focus, tiredness, sexual problems, trouble sleeping, upset stomach,
alcohol use, drug abuse, and gain or loss of weight (MedlinePlus, 2021). When people
express stress over time, they will have a high chance of getting heart disease,
hypertension, obesity, diabetes, depression, menstrual problems, and skin problems like
eczema and acne (MedlinePlus, 2021).
Several factors contribute to stress; it might come from joyful events like a new
marriage, job promotion, new home, or unfortunate events, including illness, overwork,
or family problems (American Heart Association, 2015). It is common for some people to
stress more than others. Stress can be a significant factor and very hard to understand.
Several factors can play a significant role in someone's work environment. Some people
tend to have more confidence than others. Some build a better relationship with their
coworkers. Some might have a higher level of education and some know-how to manage
their stress.
Types of Stress
Stress can be confusing and often very hard to manage because there are different
types of stress, including acute stress, episodic acute stress, and chronic stress (APA,
2018). All these types of stress have their symptoms, duration, and approaches to
treatment. According to the Columbia River Mental Health Services, acute stress is a
more common form of stress (Columbia River Mental Health Services (CMHS), 2018).
Acute stress is only short-term and does not cause severe problems, and can be treatable
and manageable. Episodic stress is known to be suffered by those who have a more
frequent stressor in their life. People who are typically in a rush suffer from Episodic
stress (CRMHS, 2018).
Chronic or constant stress experienced over a prolonged period can lead to long-
term heart and blood vessel problems (American Psychological Association [APA],
2018). The ongoing increase in heart rate and the elevated levels of stress hormones and
blood pressure can affect the body. This type of stress can increase hypertension, heart
attack, or stroke (APA, 2018). In the past year, healthcare workers have had to work
under stressful conditions during the Coronavirus Disease 2019 COVID-19 pandemic.
This stress has almost become chronic. The stress that healthcare providers are
experiencing is more than their usual stress, making it chronic stress to their bodies and
minds.
Being a healthcare provider involving human contact, rapid decision making
(knowing the consequences) can impact a person's response to work stressors. Healthcare
professionals take a role where stress and demand are at their most challenging. Not all
healthcare workers have the same amount of stress or develop the same amount of
burnout. Several articles have looked at intensive care units where nurses and doctors
express death as one of the main stressors (Foxhall, Zimmerman, Stanley, & Bene, 1990).
In general, health professionals who work with a patient population are more prone to
stress because of their seriousness.
Occupational or work-related stress is a combination of ethical dilemmas and
patients' demands. Both triggers can become a burden in someone's professional
emotional state (Koinis, Giannou, Drantaki, Angelaina, Stratou, Saridi, 2015). A recent
study done by Health Psychology Research looked at how a healthcare worker's
environment impacts mental health. The study consisted of 200 healthcare professionals
ranging from 21-59 years old working in a 240-bed general hospital. (Koinis et al., 2015).
A standardized questionnaire was provided, which helped investigate coping strategies
during stressful times. They explained how various coping strategies could influence
health professionals' emotional health (Koinis et al., 2015). In this study, a significant
factor can be the lack of encouragement and motivation by other professionals. Hospitals
can offer a program for stress management; this would help reduce stress levels within
this workplace.
COVID-19 Pandemic and Work-related Stress
The COVID-19 emerged from Wuhan, China, and has led to the current pandemic
(World Health Organization, 2020). The virus spreads by respiratory droplets released
when someone with the virus coughs, sneezes, breathes, sings, or talks. These droplets
can be inhaled or land in the mouth, nose, or eyes of a person nearby.
On April 26th, 2020, a few months after the outbreak, more than 2,000,000 confirmed
cases and about 200,000 deaths were due to COVID-19 (WHO, 2020). A Major outbreak
like this poses a significant threat and demand to healthcare workers. During the year
2020, people working in hospitals and clinics experienced an extensive workload, a lack
of personal protective equipment, and lacking support. All healthcare workers worked
under overwhelming pressure and still had to find support for their personal lives.
According to the County of San Diego, 15276 residents were hospitalized due to
complications of COVID-19 (County of San Diego, 2021). North County counts for only
four hospitals and about 15 clinics to treat the infected populations.
COVID-19 continues to cause chaos across the world. Medical staff is one of the
prominent people mentally affected going through much psychological pressure. These
frontline workers were constantly in fear of being infected when treating ill patients.
Anxiety levels became high among all workers due to the media coverage and fake news.
Healthcare workers who were called upon to help with COVID-19 experience physical
strain, physical isolations, vigilance regarding infection control procedures, and pressure
to continue to follow clinic procedures (Cabatkapa, Nadjidai, Murgier, 2020).
Self-care for healthcare workers can be complex and challenging since they are in a role
where they might prioritize others' needs rather than their own (Cabatkapa et al., 2020).
Therefore, a coping strategy should be where providers do not feel unrealistically
responsible for patients' lives.
Stress-Coping Strategies
Coping is the ideas and behaviors that manage internal and external stressful
situations. It is used to understand and mobilize acts to reduce or tolerate stress (Algorani,
Gupta, 2020). Understanding coping mechanisms is essential to choose the best strategy
for everyone. We can classify coping into four major categories (Algorani, Gupta, 2020)
which are: First, problem-focused, which means to address the problem causing the
stress. Second, emotion-focused, which aims to reduce negative effects associated with
the problem. Third, meaning-focused aims to use suitable strategies to manage the
meaning of the problem that causes the stress. Finally, Social coping in which people can
reduce their stress by seeking emotional support from their surroundings.
For example, talking with the specialist to seek information and social support
was the most popular coping strategy in anxious surgical patients (Algorani, Gupta,
2020). Furthermore, using different coping scales to monitor people's coping strategies
can help evaluate the individual's psychological status and make improvements.
Stress as a Public Health Concern
It is essential to understand how much stress a healthcare provider can endure in
their work environment. Stress can negatively influence both the mental and physical
health of a person. According to the World Health Organization (WHO), depression is a
stress-related condition that happens to be the number one cause of disability (World
Health Organization (WHO), 2020). Healthcare providers are sometimes seen as heroes,
but in reality, they are human beings who also suffer from similar health problems like
their very own patients. Those healthcare workers who were dealing with much stress due
to the pandemic are experiencing symptoms of burnout.
After reviewing several articles regarding stress, we found that healthcare workers
are most impacted by stress. It is only ideal to understand and survey several healthcare
workers to understand their stress levels. This is what led the research, how a work
environment can create stress. Stress is part of the mental health sector, therefore being of
considerable importance to the Public Health community.

Study Objectives
The main objective of this pilot study was to conduct a survey of work-related
stress among a sample of healthcare professionals at a local community clinic in North
County, San Diego. The specific objectives were:
Objective 1: Develop and self-administer an online survey on work-related stress to
participants at a community clinic using Google Forms.
Objective 2: To determine the relationship between the level of educational attainment
and workplace stress among participants.
Objective 3: To propose recommendations regarding coping strategies and programs for
healthcare professionals potentially exposed to work-related stress.

Methods
Survey Questionnaires
We submitted and received CSUSM's Institutional Review Board (IRB) approval
for the application form, the consent form, and the survey questionnaire approved consent
form. The questionnaire was sent via email to eleven participants at the community clinic
using google forms. The survey responses were completely anonymous. Details of the
Consent Form and Survey Questionnaire used for this study are provided in Appendix A.
Study Design
The study relied on a questionnaire survey that incorporated three different
components: The first section comprised eight questions on background
information to assess participants' demographic variables, including age, sex,
degrees, and years of experience. The second section consisted of ten questions to
assess the self-reported effect of work stress on participants' health. The third
section had six questions to determine what health-related problems the
participants experienced during work, including excessive sweating, headache,
lack of confidence, and restlessness. The last part consists of one question to
provide additional information that they believe will be useful to the investigators.
Data Analysis
Qualitative data analysis of survey responses was conducted using the Excel
program and the International Business Machine Statistical Package for the Social
Sciences (IBM SPSS) Statistics 25 available through CSUSM's Cougar Apps. The data
from Google Forms was uploaded into IBM SPSS Statistics 25 and analyzed into two
categories; (1) Demographic Characteristics for close-ended questions and (2) the Excel
program for close-ended questions related to work stress questions and commonly
experienced health-related problems.

Results
Demographics Characteristics
Eleven participants received the survey questionnaire, only nine responded and
completed them, resulting in a response rate of 81.8%. The survey results showed that
55.6% (n=5) of the participants were 35-44 years old, 11.1% (n=1) were 45-54 years old,
and 33.3% (n=3) were 25-34 years old. In addition, 88.9% (n=8) of the participants were
female, and only 11.1% (n=1) were male. 44.4% (n=4) were married, and the same
number were single. However, only 11.1% (n=1) of the participants were living with a
partner. The majority of them were White, 55.6% (n=5). Only 11.1% (n=1) was Middle
Eastern, and 33.3% (n=3) were Hispanic or Latino.
Approximately 66.7% (n=6) of the participants have a master’s degree, 11.1%
(n=1) have bachelor’s degrees, and the same percentage of participants have an associate
degree and/or high school diploma or GED. Of the 9 participants, 77.8% (n=7) have
eleven or more years of experience, and only 22.2% ( n=2) have 6-10 years of
experience. The results of the demographic characteristics of the participants are
summarized in Table 1, Appendix B.
Work-related Stress
Figures 1-3 demonstrate the results of the stress that is related to work.
Survey Question: I avoid expressing my true feelings and observations of stress at work.
The results show that no one strongly disagreed that they avoid expressing their true
feelings and observations of stress at work. However, almost half of them (n=4, 44.4%)
somewhat disagreed, and 22.2% (n=2) completely disagreed. Two of them (22.2%)
somewhat agreed and 11.1% (n=1) was neutral. Figure 1, Appendix B, illustrates this
result.
Survey Question: The current COVID-19 pandemic has increased my stress level
at work? Only 22.2% (n=2) of the participants strongly disagreed that the current
pandemic has increased their stress during work; however, 55.6% (n=5) somewhat
agreed. Only 11.1% (n=1) somewhat disagreed, and one opposed. Figure 2, Appendix B,
demonstrates the effect of COVID-19 on our participants.
Survey Question: During this pandemic, I have received minimal support at work
regarding coping with stress.Unfortunately, no one strongly agreed that they had received
minimal support at work regarding coping with stress during the pandemic, reflecting the
amount of job that needs to be done to support healthcare workers during this hard time.
Only two of them (22.2%) somewhat agreed and 11.1% (n=1) was neutral. However,
44.4% (n=4) somewhat disagreed, and 22.2% (n=2) of the participants completely
disagreed. Figure 3, Appendix B, illustrates our participants’ opinions about receiving
support at work to overcome work stress.
Commonly Experienced Health-related Problems
Figures 4-5 illustrate the self-reported experiences of various work -related stress by the
participants.
Survey question: Commonly experienced health-related problems: blurred vision – As
summarized in Figure 4, Appendix B, 77.8% (n=7) of the participants never got blurred
vision; only 22.2% (n=2) sometimes had this problem.

Survey Question: Commonly experienced health-related problems: Restlessness – As
shown in Figure 5, Appendix B, approximately 55.6% (n=5) of the participants have
expressed restlessness sometimes during work. One of them (11.1%) always had this
problem, and 33.3% (n=3) never had this problem.
The last question asked the participants to provide additional information on work-related
stress that they believe will be useful to the investigators. Only one of them responded as
follows: “my answers would have been different when referring to the pandemic last year
versus this year.”

Discussion
Our study showed that eight of our participants (88.9%) self-reported that they
performed their job duties and always took responsibilities when things go wrong, even
when it was not their fault. Almost half (n=4, 44.4%) of our participants somewhat
agreed that they negatively changed their behavior when under pressure to meet deadlines
at work. Changing the employee's behavior negatively affects their level of performance,
leading to adverse consequences like malpractice, which subjected them to more stressful
conditions and impacted their health in the long term. We did not determine the exact
percentage of each psychiatric problem including depression, insomnia, and anxiety
among our participants since this was outside the scope of the study. However, a previous
study among healthcare workers, physicians, nurses, and support staff by Preti et al.
(2020), reported depressive symptoms in 27.5-50.7%, insomnia symptoms in 34-36.1%,
and severe anxiety symptoms in 45%. The authors showed that general psychiatric
symptoms ranged from 17.3 and 75.3% during outbreaks, with high levels of stress
related to work in 18.1 to 80.1% (Preti, Mattei, Perego, Ferrari, Mazzetti, Taranto, Di
Pierro, Madeddu, & Calati, 2020). This study had similar findings to our pilot study with
limited results since individuals' characteristics, level of being in direct contact with
infected patients, level of education, and work support were considered important risk
factors.
Six of our participants (66.6%) disagreed or somewhat disagreed that they avoid
expressing their true feelings and observations of stress at work, which means they show
their emotions and describe stress and tension during the workplace. This type of
behavior affects people functioning and leads to unhealthy results. However, six
participants (66.6%) are still doing their hobbies and other activities besides their jobs.
People must leave some space to do what they like and enjoy their hobbies; it gives them
positive energy and renews their power to work and provide the best practice.
Additionally, only five of the participants (55.5%) strongly agreed or agreed that they
focus more on the positive aspects of their life than the negative ones. We can understand
that it is vital to increase outreach among workers to seek psychiatric assistance when
needed. Focusing on negative aspects affects their overall health.
Seven of our participants (77.8%) agreed that the current pandemic increased their
stress level at work. It is crucial to focus more on healthcare workers’ needs with a view
to helping them cope with and overcome stress during the pandemic since this may affect
their health for a prolonged period. It must be noted that the prevalence of post-traumatic
stress symptoms (range = 10-40%) have continued among healthcare workers after 1-3
years during outbreaks (Preti et al., 2020).
Eight of our participants (88.9%) are comfortable with experiencing new
situations and changes at work, indicating a high level of flexibility and experience doing
their job. Most of the participants never had blurred vision, excessive sweating, or
difficulty concentrating and breathing-related to work. However, almost all of them had
restlessness 66.7% (n=6), around 50% of them had headaches, and 37.5% (n=3)
sometimes lacked confidence. As a result, the participants have good experience focusing
on their jobs with minor health-related problems, including restlessness and headaches.
Stress is a very significant problem and is an ongoing public concern. The impact
of stress on our healthcare providers is very substantial (APA, 2018). Based on the
responses given to us by participants, it is apparent that stress at work exists. Stress is

different in every person depending on the situation. For example, during a stressful
event, heart rate increases, breathing becomes faster and shorter, and the body is in a
ready state to "fight" (Casarella, 2019). Depending on the person, there are several ways
to cope with the symptoms of stress.
When the pandemic started, people would be showing up with all possible
symptoms to clinics and hospitals. These healthcare providers had to move their patients
around to attend to all people waiting to get seen. Clinicians and all supporting staff
continued to work no matter what the outcome was. Mealtimes were missed due to the
influx of people needing medical attention. As the clinicians and staff took on the
pandemic, they started to experience stress and anxiety differently.
We can neither generalize the results of this study nor compare them to other
studies because of the small sample size. However, available evidence from previously
published studies has demonstrated that chronic stress, specific infection-related worries,
and work-related stress can and do impact healthcare professionals' work environment
(APA, 2018). While stress and ongoing worries may sometimes be very short term, we
are yet to see the potential long term effects of post-pandemic stress in the workplace.
Recommendations
Stress may be higher now more than ever because of the worldwide pandemic we
are going through. This is the time where clinics and other healthcare institutions should
focus on their employees' health. During the strain of work healthcare professionals are
not able to take time during work hours to join a connection session. It would be ideal for
each person to have this as a coping strategy during work hours.

Coping with stress is part of a healthcare worker's day. Having a connection
session or even a specific person to contact would be beneficial. An article published in
the U.S. The Department of Veterans Affairs website explains how healthcare workers
are accustomed to participating in frequent formal and informal pieces of training (U.S.
Department of Veteran Affairs, 2020). Additional organizational efforts during the
COVID-19 pandemic should be ongoing and can provide a measure of stress reduction
(U.S. Department of Veteran Affairs, 2020). There are specific areas healthcare providers
should be trained in, for example: managing limited resources, handling mass fatalities,
coping with high stress demands, conducting mental health screening, and enforcing
movement restrictions. Furthermore, it is essential to understand the surge-related triage
decision trees and to prepare for the needs of their families if workers are required to be
more engaged at work or quarantined. All those training will help improve their self-
efficacy during stressful times while at work. It is also recommended that healthcare
providers meet with their management or leaders to discuss the importance of stress
management.
Frontline health care professionals are also exposed to adverse mental health
effects as they attempt to balance the duty of caring for patients with anxieties about their
family and friends. Therefore, the American Medical Association (AMA) provided
recommendations to healthcare providers to overcome their stress during this difficult
time. Healthcare professionals need to take care of themselves first (AMA, 2021). No one
can save others before saving themselves. Healthcare professionals need to feel their
feelings with everything going around them, including shortages in supplies, equipment,
and the surge of people that need care. Without enough possibilities to provide the
necessary treatment, it is entirely fair to express their unacceptance. It does not represent
any unprofessional work or inability to complete their work (AMA, 2021). They need to
get enough rest when possible including during shifts.
Currently, the Behavioral Department (BH) for the clinic we collaborated to do
the survey has something called a "connection session." This consists of several staff
members from the BH coming together to discuss stressors due to COVID-19. The staff
consists of the BH department's clinic manager, a medical assistant, and 2 Licensed
Clinical Social workers. This session takes place once a month for 1 hour during
employees' lunchtime, 12:00 pm-1:00 pm. This session is open to anyone working for the
local community clinic. These sessions are virtual therefore allowing people to connect
on their phone. There is no specific agenda for these sessions; staff usually would have a
question or a specific topic they would like to talk about. This has been happening for
about ten months now; with about 50 staff members joining the ZOOM call, others would
instead take their lunch peacefully. Although these connection sessions are a great idea,
staff members must do it on their own time.
During this time, several community clinics were given a chance to join
connection sessions that allowed Behavioral Health personnel to connect and talk about
current stressors with staff. During staff mealtime, these efforts were made; therefore,
staff had to join as they ate lunch and talked about the clinic's issues. This was one of the
attempts to offer psychosocial support to all healthcare workers within the clinic. As
these efforts continue healthcare professionals will begin to feel relief while at work.
Limitations
We understand that a small sample size of (9) cannot represent an entire
community clinic. Having a small sample size means our study has less statistical power.
We had a small sample size because the clinic we studied only allowed a certain number
of people to be surveyed, no more than 15. People could not be reached during working
hours, therefore, limiting access to people. Due to COVID restriction, we were unable to
promote surveys within the clinic. If surveys were available for people, we can assume
we would have a better response rate.
Finally, did this survey fit every health professional working at this local clinic?
Not exactly generalizable since social desirability bias might have occurred. Even though
the consent form explained that the participants needed to answer their best of ability, we
knew some people might have answered other than that. All participants are working in
the same clinic; probably, people from different medical centers would have different
answers.
Generalizability limitations of our participants are mainly (n=5, 55.6%) white,
highly educated; (n=6, 66.7%) have master’s degrees, have long experience; (n=7,
77.8%) have 11 or more years of experience and are mainly (n=8, 88.9%) female. When
they have a high education level and long expertise, they tend to have more confidence
doing their job. They can manage their stress better than new employees with less
education level. Females usually manage their stress in different ways than males. People
with different ethnicities might manage their stress in several methods depending on their
background and their culture.

Conclusion
When healthcare workers are exposed to several stressors, medical errors can
happen. Even Though our pilot study had a small sample, we were able to see similarities
between participants. Our survey results showed how participants who have a higher
level of education could manage stress better. The main objective of this pilot study was
to conduct a survey of work-related stress among a sample of healthcare professionals at
a local community clinic in North County, San Diego. We aimed to determine the
relationship between educational attainment and workplace stress among participants and
find the best strategies for coping with the stress among healthcare professionals
potentially exposed to work-related stress. It is important to have recommendations for
healthcare professionals that are on different sides of stress. Some healthcare
professionals might benefit from one coping strategy more than the other, depending on
what they feel is right.
Through the studies, we have acknowledged that work-related stress is a public
health issue. People spend much of their time at work, and the work environment
substantially impacts their health. Stress can also contribute to other mental and physical
health problems; therefore, mental health is public health. The mental health burden of
work stressors and pandemics deserves as much attention as its physical toll.
In conclusion, through our survey, we can understand that depending on their job
title and education level, we can regulate and cope with stress differently. Ultimately, our
sample size was significantly small, and we could not generalize our results. We can
understand that healthcare workers can feel pressure in their work environment, and
several coping strategies can be implemented to reduce work-related stress.

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Cimmuto, A., & De Giusti, M. (2018, January). Association between work related
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Appendix A
Consent Form
Informed Consent
Title of Project: Assessment of Work-related Stress among Healthcare Professionals.
Invitation to Participate
Dear Participant:
Francisca Velazquez and Rula Nicolas are graduate students in the Master of Public
Health (MPH) program at California State University San Marcos (CSUSM). You are
invited to participate in a study on “Assessment of Work-related Stress among Healthcare
Professionals." You are being asked to join because you are a current healthcare
professional working in San Diego County. Before agreeing to participate in the study,
please read this Consent Form very carefully and ask any questions you may have
or need additional information. You must be at least 18 years of age to participate in this
study. The investigators will only use the information provided in the questionnaire to
gain insight on work-related stress among healthcare professionals, which is of
significant public health importance. Please note that the information provided will not be
used to identify any of the respondents. By signing this Consent Form, the participants
are giving their implied consent.
KEY INFORMATION ABOUT THIS QUESTIONNAIRE-BASED STUDY:
The following is a summary of this study's scope and is intended to help you decide
whether to participate or not. The purpose of this questionnaire-based study is to
understand work-related stress among a sample of healthcare professionals. We ask that

you answer each question to the best of your ability. We hope this survey will assist
future studies by providing insights on work-related stress and suggesting possible coping
mechanisms among healthcare professionals.
STUDY PURPOSE:
This study's primary purpose is to evaluate the effects of work-related stress among
healthcare professionals and evaluate the relationship between work-related stress and
health. Finally, we will look into which group of people are more vulnerable to work-
related stress.
NUMBER OF PARTICIPANTS:
We will be sending this survey to ten participants. Please ensure that you keep your
answers confidential during the survey. It will not affect your current or future relations
with CSUSM.
PROCEDURES FOR THE STUDY:
Before we begin with the survey, this consent form will be signed and returned via email.
When the consent form has been sent to you, you will have exactly five days to return the
consent form filled, signed, and dated. We will also like you to type the email you would
like this survey to be sent to (personal email). All of the information provided in this
Consent Form will remain confidential and will not be released to anyone. This survey
will be sent to each participant by a survey generator to allow each participant to stay
completely anonymous. This survey has 24 questions and should take no more than 15
minutes to complete. We ask for you to take your time to answer these questions to the
best of your ability.
RISKS AND INCONVENIENCES:

There are very minimal risks and inconveniences in participating in this study. These
include participants may be uncomfortable answering the survey or interview questions.
The time participants spend participating in the study might be considered an
inconvenience.
SAFEGUARDS:
The following measures will be taken to minimize these risks and inconveniences:
Participants can skip any questions that they feel uncomfortable answering while taking
the survey. The participant will complete the study at their convenient time and place.
CONFIDENTIALITY:
All of the responses to this survey will remain anonymous. The study results may be used
in reports, presentations, or publications. However, your names will not be included, and
the results will only be shared as aggregate data. The data will be stored in a password-
protected computer. This research team will only have access to the data, which will be
retained up to one year after the survey is completed, and then the digital files will be
erased.
VOLUNTARY PARTICIPATION:
Taking part in this study is voluntary. You may choose not to take part or may leave the
review at any time. Leaving the study will not result in any penalty. Your decision to
participate in this study will not affect your current or future relations with CSUSM.
BENEFITS OF TAKING PART IN THE STUDY:
There are no direct benefits to participation in this study. However, this study highlights
the effect of stress on work and productivity. Besides, the study's results will be presented
to faculty from CSUSM. They may allow future studies to help implement a successful
program on work-related stress at similar health related workplaces.
PAYMENT OR INCENTIVE:
You will not receive any payment for taking part in this study.
STUDY-RELATED INJURIES:
Not applicable.
CONTACT INFORMATION:
If you have questions about the study, please call us at 951-322-2216, 858-716-7819, or
email us at velaz014@cougats.csusm.edu or nicol047@cougars.csusm.edu. You can also
contact our Thesis Committee Chair, Professor Emmanuel Iyiegbuniwe, at
eiyiegbuniwe@csusm.edu. You will be given a copy of this form for your records. If you
have any questions about your rights as a participant in this research or if you feel you
have been placed at risk, you can contact the IRB Office at irb@csusm.edu or (760) 750-
4029.
PARTICIPANT'S CONSENT:
This document has been approved by the Institutional Review Board at California State
University San Marcos.
● I have read and understood the provided information and have had the opportunity to
ask questions.
● I understand that my participation is voluntary and that I am free to withdraw at any
time without giving any reason and without cost, and that I will be given a copy of this
consent form.
● I voluntarily agree to take part in this study (please check the option that applies to you
and sign):
☐ I give permission to complete this survey questionnaire.
☐ I do not give permission to complete this survey questionnaire.
Printed Name _______________________ Participant’s Signature
___________________
Date________________ Email:______________________________________________
Survey Questions
Assessment of Work-related Stress among Healthcare Professionals
Investigators: Francisca Velazquez and Rula Nicolas

Instructions: Please answer the following survey questions to the best of your
knowledge. Please note that all responses to these questions will be strictly treated as
anonymous and confidential.
Section 1: Demographic Questions

1. Which category below includes your age?
□ 18-24
□ 25-34
□ 35-44
□ 45-54
□ 55 or older
2. What is your gender?

□ Male
□ Female
□ Non-binary/ third gender
3. What is your marital status?

□ Single
□ Married
□ Living with a partner
□ Widowed
□ Divorced
4. What is your race or ethnicity? (please check all that apply)

□ American Indian or Alaskan Native
□ Asian
□ Black or African American
□ Hispanic or Latino
□ Native Hawaiian or other Pacific Islander
□ White
□ Two or more ethnicity (please specify) __________________
5. What is your highest level of education?

□ High School Diploma or GED
□ Associates Degree
□ Bachelor’s Degree
□ Master’s Degree
□ Doctoral Degree
□ Other (please specify) __________________
6. What is your job title?

□ Clinician (Doctor, Nurse, Nurse Practitioner, Physician’s Assistant)
□ Licensed Clinical Social Worker
□ Medical Assistant
□ Clinical Manager
□ Supervisor
□ Other (please specify) __________________
7. How long have you been working at Vista Community Clinic?

□ Less than 5 years
□ 5-10 years
□ 10-15 years
□ 15-20 years
□ 20+ years
8. How many years of work experience do you have?

□ 1-5 years
□ 6-10 years
□ 11 or more years
Section 2: Work Stress Questions

9. When carrying out my job duties, I always take responsibility when things go
wrong,
even if it is not my fault.
□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Somewhat Disagree
□ Disagree
10. I carry the burden of my problems in a healthy manner.

□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
11. I avoid expressing my true feelings and observations of stress at work.

□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
12. I do observe negative changes in my behavioral patterns when I am under

pressure to meet deadlines at work.
□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
13. My participation in hobbies and other activities of interest have declined

because my work takes up most of my time.
□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
14. I tend to focus more on the positive aspects of my life than the negative.
□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
15. I have to keep up-to-date with my work schedule even when I feel
overworked.
□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
16. The current COVID-19 pandemic has increased my stress level at work.
□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
17. During this pandemic, I have received minimal support at work regarding
coping with stress.
□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
18. I am comfortable with experiencing new situations and changes at work.

□ Strongly Agree
□ Somewhat Agree
□ Neutral
□ Disagree
Section 3: Commonly Experienced Health-related Problems

19. Blurred Vision
□ Never
□ Sometimes
□ Always
20. Excessive Sweating

□ Never
□ Sometimes
□ Always
21. Headaches
□ Never
□ Sometimes
□ Always
22. Restlessness
□ Never
□ Sometimes
□ Always
23. Lack of Confidence

□ Never
□ Sometimes
□ Always
24. Difficulty Concentrating and Breathing

□ Never
□ Sometimes
□ Always
25. Please provide additional information that you believe will be useful to the
investigators, but may not have been included in the above questions.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________
Thank You!
Appendix B
Table 1: The demographic characteristics of the participants
Age Gender Ethnicity / Marital Education Work

(18-55+) (Male, race Status Level Experience
Count (%) female, Non- Count (%) (Single, Count (%) Count (%)
Binary) Married,
Count (%) With
partner
Count (%)
25-34 Female Hispanic Single Associates 6-10 years

3 (33.3) 8 (88.9) 3 (33.3) 4 (44.4) degree 2 (22.2)
1 (11.1)
35-44 Male Middle Married Bachelor’s 11 or more

5 (55.6) 1 (11.1) Eastern 4 (44.4) 1 (11.1) 7 (77.8)
1 (11.1)
45-54 Non-Binary White Living with High School

1 (11.1) 0 (0) 5 (55.6) partner 1 (11.1)
1 (11.1)
Master’s
6 (66.7)
Figure 1. Participants' feelings about the stress at work

Figure 2. The current pandemic has increased the participants’ stress level at work
Figure 3. Participants’ support at work to overcome the stress

Figure 4, The participants experienced blurred vision related to stress
Figure 5. The participants experienced restlessness

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PROJECT

CALIFORNIA STATE UNIVERSITY SAN MARCOS

PROJECT SUB:MITTED IN PARTIAL FULFILUvlENT OF THE REQUIREtvlENTS FOR THE DEGREE

:tv1ASTER OF PUBLIC HEAL TH

AUTHOR(S): Rula Nicolas, Francisca Velazquez

DATE OF SUCCESSFUL DEFENSE: 04/27/2021

THE PROJECT HAS BEEN ACCEPTED BY THE PROJECT COJ\1MITTEE IN

PARTIAL FULFILLMENT OF THE REQUIRE11ENTS FOR THE DEGREE OF

:tv1ASTER OF PUBLIC HEAL TH

Emmanuel Iyiegbuniwe May 10, 2021

Diane Beach Diane Beac;h May 10, 2021

COJ\1MITTEE 11EMBER SIGNATURE DATE

COJ\1MITTEE 11EMBER SIGNATURE DATE

Community Clinic in North San Diego County

California State University San Marcos

among healthcare professionals at a community clinic in North San Diego County.

management in reducing work-related stressors among healthcare professionals.

community clinic in North County San Diego.

Keywords: Stress, Work-related stress, Healthcare professionals, Stress management and

1 The Demographics Characteristics of the Participants………………………………37

1 Participant’s feelings about the stress at work……………..……………………….....37

3 Participants’ support at work to overcome stress……………………………………..38

4 The Participants experienced Blurred vision related to stress……………...…………39

5 The participants experienced Restlessness……………………………………....……39

Literature Review and Background

affect their health or family and social life.

Stress can cause emotional problems, including diarrhea, constipation, pain,

eczema and acne (MedlinePlus, 2021).

stress (CRMHS, 2018).

Being a healthcare provider involving human contact, rapid decision making

stress because of their seriousness.

Occupational or work-related stress is a combination of ethical dilemmas and

patients' demands. Both triggers can become a burden in someone's professional

study done by Health Psychology Research looked at how a healthcare worker's

A standardized questionnaire was provided, which helped investigate coping strategies

COVID-19 Pandemic and Work-related Stress

can be inhaled or land in the mouth, nose, or eyes of a person nearby.

four hospitals and about 15 clinics to treat the infected populations.

to continue to follow clinic procedures (Cabatkapa, Nadjidai, Murgier, 2020).

Therefore, a coping strategy should be where providers do not feel unrealistically

responsible for patients' lives.

reduce their stress by seeking emotional support from their surroundings.

Stress as a Public Health Concern

It is essential to understand how much stress a healthcare provider can endure in

health of a person. According to the World Health Organization (WHO), depression is a

to the pandemic are experiencing symptoms of burnout.

considerable importance to the Public Health community.

stress among a sample of healthcare professionals at a local community clinic in North

County, San Diego. The specific objectives were:

Objective 1: Develop and self-administer an online survey on work-related stress to

participants at a community clinic using Google Forms.

Objective 2: To determine the relationship between the level of educational attainment

and workplace stress among participants.

Objective 3: To propose recommendations regarding coping strategies and programs for

healthcare professionals potentially exposed to work-related stress.

We submitted and received CSUSM's Institutional Review Board (IRB) approval

The study relied on a questionnaire survey that incorporated three different

components: The first section comprised eight questions on background

information to assess participants' demographic variables, including age, sex,

section had six questions to determine what health-related problems the

participants experienced during work, including excessive sweating, headache,

experienced health-related problems.

Eastern, and 33.3% (n=3) were Hispanic or Latino.