Stress Management

Abdus Salam Khan, MD FACP
March, 2019

Stress is a daily routine in emergency departments all around the world. People who work in emergency department are exposed to various degrees of stress all along their duty timings. Let us delve into this subject and try to create some understanding about stress and practical ways to deal with its effects and ultimately the recommendations to make the work place healthy for the people.

Stress in its basic form is the force that causes all responses. It can also be seen as the body’s response to any challenge or demand. So, at this basic level stress is a good thing which makes us do the job required. It also results in high level performance, creates healthy competition and so on and so forth.

So when is the stress a bad thing? It is, when it is more than anyone can take it, or for a sustained period of time. So if anyone is exposed to any excessively traumatic event, that person will show the effects of that event in the behavior and the state of mind. Similarly when a normal or acceptable level of stress gets prolonged beyond certain the person’s capabilities, then that person will also show the effects of the sustained stress.

Emergency department by its design and working has both types of stresses, and the people that work in ED are prone to get exposed to both type of stress.

While I was looking at the literature it was interesting to note that very insignificant amount of work has been done to quantify the problem, as it is hard for the people to talk openly about it. Mostly because they feel it will be seen at weakness and may result in far reaching consequences.

In Pakistan the culture of pretending that we should be strong and macho results in no one admitting that they have problem dealing with stress. It then causes issues both at personal level and also on the working and safety of the department that those people are working for.

The burnout is a term that is used quite constantly now when the constant stress on a person makes then have emotional and physical exhaustion. It’s the end of the spectrum for the person in dealing with the stress and can result in people committing suicide or going into extreme depression. These people also are prone to make more mistakes and have low self esteem and improper communication with the patients and colleagues. Dealing with the burnout is important but preventing it is rather more effective strategy for the department.

Looking at the model of response to a disaster, we can stipulate that stress when excessive or prolonged can result in different phases manifesting the individual who is exposed to the high level of stress. Sometimes these phases overlap and sometimes one phase may skip, but it is still worthwhile to understand the dynamics.

Impact Phase:

It is short lived and starts immediately after exposure to stress. It can resolve in 1-7 days depending upon the cause and magnitude of the stress. The example of stress may be a wide spectrum ranging from a difficult colleague to an unexpected death of a patient especially young.

Its manifestations include disbelief, numbness, fear and possible confusion.

Crisis Phase:

• It lasts a variable period but not very prolonged.
• Patients show sign /symptoms in this phase which stem from the feeling of denial or hyper arousal.

Patient may feel: Fatigued, dizzy, headache, nausea, irritability, apathy, social withdrawal and also being angry at colleagues.

Resolution Phase:

It can last up to almost a year.
It results in grief, gilt and depression

Reconstruction Phase:

People who go through effective resolution of the stress are the ones who are able to successfully reconstruct their life for themselves.

They learn and successfully integrate event into their new self-content, and develop skills to deal with the stress better.

How do we deal with stress?

The medical community is now thinking beyond treating people exposed to stress and now they are inventing ways to either

• Prevent stress
• Make physicians resilient to minimize the impact on them.

It is important that we took into stress and stress related issues as early as possible. So early identification is the key to tackle with the stress issues in any department and especially in the emergency department.

1. Prevent Stress:
It is utmost important to develop the system that prevent excessive stress, as it protects the people working in the department. The department has to have a system of support for all the people to feel safe while working, and ultimately people will also be safe when they interact. The department should:

1. Provide educational support
2. Provide administrative support
3. Provide supervisory support
4. Have a system of fair reporting and audit.
5. Have a balanced system of tackling of error done by staff.

2. Resiliency Culture:

The work in emergency department can never be stress free or error proof, so the people working in emergency department have to work on themselves to guard against becoming victim of stress. How one can develop themselves to become resilient?

1. Being self-critical.
2. Work on your relationships.
3. Know your work system well.
4. Give yourself time off.

The most important defense against stress related burnout in emergency department is a person who knows the strength and weakness of self and the system and work within it. If you know when to ask for help and your system is quick in providing it then you won’t see increased burnout in your department.

More on the topic later. You can reach me at

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