Stress is an interaction between individual perceptions, characteristics, and environmental or organizational factors.[1] It is the psychological and physical state that results when an individual perceives their resources as insufficient to cope with the demands and pressure of a situation.[1],[2],[3] Acute responses to stress involve feelings, behavior, and physical symptoms. Mild or moderate stress can improve productivity, fuel alertness, and creativity and lead to positive emotional states.[4] High and chronic levels of stress can have physical, psychological, social, behavioral, and health implications including depression, sleep deprivation, interpersonal conflict, alcohol and drug abuse, and increased cardiovascular risk.[5],[6],[7] Stress has been described as “the health epidemic of the 21st century” by the World Health Organization. Stress can adversely affect productivity, work quality, medical cost, and morale.[8] At an organizational level, stress can increase absenteeism and employee turnover.[9],[10] Stress can be a salient factor in the career of medical professionals.[11],[12],[13] High levels of stress among doctors contribute to job dissatisfaction, emotional burnout, and clinical depression, and can undermine the achievement of goals, both for individuals and for organizations.[14] Working conditions in the medical profession can be adverse with long working hours, night shifts, and high-risk situations.[15] However, stress responses toward the same working conditions may vary between individuals. Situations inducing stress in some individuals can be exhilarating and exciting, while unbearable to others. Research has shown the correlation between working hours, patient load, and stress levels to be weak or nonexistent.[16],[17] This implies that to a large extent, stress is an individual response rather than being driven directly by working conditions. Stress management focuses on the ability to alter perceptions of the person under stress. Strategies can be learned and contribute to life-long resilience. A meta-analysis identified four different types of stress-reducing interventions, of which three were individual-focused techniques and one was organization focused.[18] The individual techniques were found to be the most effective in managing stress. It is empowering to realize stress is largely the result of perceived ability to cope and that managing stress is largely achievable at the level of the individual. This article discusses different approaches to stress management starting with self-analysis and outlining two main groups of strategies that can be taken at an individual level. Reaction and perception of stress is modifiable, and techniques for stress management can be learned.[14] Self-Analysis To manage stress, its presence and causes must be analyzed. Symptoms and appraisals of stressful situations vary between individuals. Stress can manifest itself as psychological or physiological symptoms. Stressed individuals may be potentially be aggressive, anxious, develop low moods, mood swings, and have disturbed sleep.[19] Common stressors can be categorized as academic, financial, time related, health related, and self-imposed.[20],[21] Life factors can be a larger cause of stress than work problems.[22] Such examples include family life and having children.[23] An analysis can elucidate the source of stress allowing its management before the severity of symptoms increase.[14] Understanding the factors causing stress and awareness of its unique effects on individuals can be cathartic and helps initiate the most appropriate stress management techniques for each individual stressor[24] and leads to insights into how to avoid and reduce harmful stress in the future. Stressors can also be categorized between modifiable and nonmodifiable factors. Certain personalities are more prone to stress. Stress levels are positively correlated with personality traits such as “neuroticism” and “introversion”[25],[26] and negatively correlated with “agreeableness” and “conscientiousness.”[27],[28] Personalities are fixed factors that cannot be fundamentally changed, but can be modified by stress management techniques. The situations likely to cause stress are typically unpredictable, uncontrollable, uncertain, ambiguous, or unfamiliar. A useful model to better understand stressors is in Karasek's[29] model of work-related strain, where work environments are categorized according to “job demands” and “job control”. High-strain jobs, which place greatest risk on health, are most likely to arise when high job demands are combined with low decision latitude and low control over work. Jobs with high demand and with high decision latitude give opportunities for active learning and a sense of accomplishment. Decision latitude has been found to be more important than job demand in determining stress.[30] Strategies An individual plan can then be developed to minimize stresses using a number of strategies and focusing on the factors that are amenable to change. “Coping” is the intentional effort to minimize physical, psychological, or social harm caused by situations.[31] There are multiple frameworks for understanding coping mechanisms. Two of the most recognized strategies are emotion-focused coping and the problem-focused coping.[1],[32],[33] Individuals use both types of coping strategies to different degrees, often simultaneously and independent of the type of stressor.[1] Problem-focused coping strategies Problem-focused coping strategies actively resolve the source of stress and tend to be used when there is a feeling that something productive can be achieved.[1] Problem-focused coping mechanisms include the creation of action strategies to remove the stress, or the individual, from the stressful situation, to modify the stress, or to seek assistance in handling the stress.[31],[34] Practical skills to tackle stress include the development of effective communication skills and learning to be more assertive and confident in negotiating and discussing areas of conflict.[14] Other strategies revolve around improving skills such as time management and troubleshooting. Problem-focused strategies decrease stress, decrease role conflict,[32],[35] and reduce depression.[36] Time management is a form of active problem-focused coping.[34] Time management behaviors can facilitate higher productivity and alleviate stress.[37] Time management involves time assessment, clarification of goals, goal setting, and planning and development of appropriate strategies. Prioritizing tasks and monitoring completion of tasks are vital to ensure goal progression.[38],[39],[40] Time management must be realistic and must set aside time for social for socializing and hobbies to maintain the work-life balance, to prevent the onset of unmanageable stress. Time management is simple and cost-effective and an activity anyone can learn. It can help buffer the effects of multiple conflicting job and social demands. This leads to fewer physical symptoms of stress, lower levels of depression and anxiety, and less reported job-related strain.[38],[41],[42] Good time management can lead to higher job[38],[41],[42] and academic achievement[43] and greater job satisfaction.[38] Studies have shown that time management relieves stress more effectively than engaging in leisure activities.[44]The beneficial effects of time management are partially mediated by feelings of control over time, which is characterized by having sufficient time to finish work tasks, ability to keep to schedules and deadlines while minimizing procrastination.[39] This is analogous to the importance of control and decision latitude in buffering from work-related stress in the control demand model[29][Figure 1]. Figure 1: The job strain model Emotion-focused coping strategies Emotion-focused strategies for stress involve redirecting the focus from the actual problem and regulating emotions. These strategies are often used when individuals perceive the stressful situation as unchanging.[1] Examples of emotion-focused coping include seeking social support, positive re-interpretation of stressors, and ignoring or accepting stressors.[34] “While medicine is to be your vocation, or calling, see to it that you also have an avocation” Osler[45] Leisure is an intrinsically motivating and self-endorsed activity undertaken for enjoyment and pleasure[46] leading to “leisure satisfaction”. Leisure satisfaction is contentment and positively-toned emotion perceived as a result of meeting personal needs through leisure activities, which can restore hope or self-esteem and buffer the deleterious impacts of stress.[47] Leisure activities, unique to each individual, are categorized as active (involving physical exertion), passive, or social.[48] One passive activity is listening to music, a powerful modulator of emotions. Listening to uplifting music after stressful tasks can decrease depression and increase a sense of well-being.[49] Background music in the dissection laboratory can reduce levels of stress associated with dissection.[50]Active hobbies involve physical activity. Physical activity is gaining recognition for its beneficial effects on reducing stress. Employees who did not engage in physical activity report increased burnout and depression.[51] Aerobic exercise has protective effects on the harmful consequences on stress and enhances mental health.[52] In the short term, exercise can reduce anxiety.[53],[54],[55] Long-term regular exercise can attenuate physiological reactivity to psychological stress.[56],[57],[58] Exercise in animal models has been found to upregulate hippocampal neurogenesis[59] which is impaired by chronic stress.[60] Yoga was found to be a promising stress management technique in a randomized trial.[61] In terms of social activities, supportive social relationships have a well-recognized effect on buffering stress[62] perhaps through enhancing feelings of personal control and thereby engagement in positive health habits.[63],[64] Social relationships can also be a significant source of stress.[65] Poor quality relationships, including with a spouse, are associated with depression and can compromise the immune and endocrine function.[66] The extent to which a given individual feels supported by their significant other is the important factor in determining stress levels arising from work-family conflict.[67] “Nothing is miserable unless you think it so; and on the other hand, nothing brings happiness unless you are content with it.” Boethius Stress is subject to interpretation. Negative cognitive habits such as rumination, catastrophizing, and behavioral avoidance can exacerbate stress or future stress.[68] Positive reappraisal is an active, meaning-based cognitive technique that can be used to decrease stress.[69],[70]It involves productive reengagement and reinterpretation of stressful events, in more favorable ways (“benefit finding”). It may be practiced in simple steps, such as the five “freeze-frame” steps,[71] or in more formal cognitive–behavioral methods. Positive reappraisal reduces stress.[72] Cognitive behavior techniques have been found promising in stress management in a randomized control trial[61] and have long-lasting effects.[18] Positive reinterpretation is a more effective stress management technique than relaxation.[18] Mindfulness meditation-based interventions are also thought to be mediated by the positive reappraisal and reconstruction of stressful events as benign, beneficial, and/or meaningful opportunities for growth and actualization.[73],[74],[75] Mindfulness is becoming well regarded in the psychological and medical literatures for their therapeutic efficacy in reducing stress.[76],[77] Conclusion The highly demanding nature of the work in the health-care profession makes for an invigorating working environment but also one which can lead to significant levels of stress. Stress is an individual subjective experience not necessarily the result of a working environment. Individual stress management must begin with recognition of the specific stresses and reactions, both at work and at home, and identification of the potential areas for change. Effective stress management depends on individual characteristics and personal experience and involves both the modification of the stressors, with time management, and managing emotions associated with stress such as positive reinterpretation Source
