Perceived stress, burnout, and resilience among healthcare workers in a multiple disaster-impacted setting during the COVID-19 pandemic




stress, burnout, resilience, healthcare workers, coronavirus disease 2019, Kashmir, conflict zone, disaster


Objective: Current literature on coronavirus disease 2019 (COVID-19) research presents gaps and opportunities to investigate the psychological experiences of healthcare workers (HCWs) serving in mass trauma situations. We aimed to measure perceived stress, burnout, and resilience in Kashmiri HCWs and explore the relationship of burnout with sociodemographic, work-related, and pandemic-related factors.

Design, setting, and participants: This was a cross-sectional descriptive study. Data were collected by circulating a web-based questionnaire among HCWs across primary, secondary, and tertiary healthcare levels in Kashmir, India. The questionnaire consisted of sections on personal, work-related, and pandemic-related variables as well as validated instruments to measure perceived stress, burnout, and resilience.

Results: A total of 514 valid responses were received. More than 80 percent of HCWs had moderate to high perceived stress. The prevalence of personal, work-related, and client-related burnouts was 68, 48.6, and 46 percent, respectively. Resilience was negatively correlated with stress and burnout. Younger (18-28 years), unmarried HCWs, especially junior residents and nurses, had higher burnout levels. Redeployment to deliver COVID-19 duties, unpredictability in work schedule, tested positive for COVID-19, and spending time in isolation/quarantine were also found to be significant risk factors for developing burnout.

Conclusions: Nearly half of the HCWs suffered from burnout, and more than half had moderate to high perceived stress. In addition to pre-existing risk factors of burnout, the pandemic seems to have introduced more occupational risk factors in this disaster-affected area. Lessons learnt from COVID-19 pandemic may help guide need-based intervention strategies designed for specific target population rather than a one size fits all approach.

Author Biographies

Bushra Syed Imtiyaz, MBBS, MD

Senior Resident, Department of Psychiatry, Government Medical College, Institute of Mental Health and Neurosciences, Kashmir, India

Mushtaq Ahmad Margoob, MBBS, MD

Department of Psychiatry, Government Medical College, Srinagar; SAWAB-Supporting Always Wholeheartedly All Broken-Hearted, Voluntary Medicare Society, Kashmir, India

Fazle Roub, MBBS, MD, DM

Lecturer, Department of Psychiatry, Government Medical College, Srinagar, India

Mehwish Imtiaz, MBBS, MD

Senior Resident, Department of Psychiatry, Government Medical College, Srinagar, India


WHO: Weekly epidemiological update on COVID-19—5 October 2022. Available at Accessed April 19, 2023.

Nicola M, Alsafi Z, Sohrabi C, et al.: The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int J Surg. 2020; 78: 185-193. DOI: 10.1016/j.ijsu.2020.04.018.

Hsieh KY, Kao WT, Li DJ, et al.: Mental health in biological disasters: From SARS to COVID-19. Int J Soc Psychiatry. 2021; 67(5): 576-586. DOI: 10.1177/0020764020944200.

Gupta S, Sahoo S: Pandemic and mental health of the front-line healthcare workers: A review and implications in the Indian context amidst COVID-19. Gen Psych. 2020; 33(5): e100284. DOI: 10.1136/gpsych-2020-100284.

Mahmud S, Hossain S, Muyeed A, et al.: The global prevalence of depression, anxiety, stress, and, insomnia and its changes among health professionals during COVID-19 pandemic: A rapid systematic review and meta-analysis. SSRN J. 2021. DOI: 10.2139/ssrn.3770223.

Galanis P, Vraka I, Fragkou D, et al.: Nurses’ burnout and associated risk factors during the COVID-19 pandemic: A systematic review and meta-analysis. J Adv Nurs. 2021; 77(8): 3286-3302. DOI: 10.1111/jan.14839.

Amanullah S, Ramesh Shankar R: The impact of COVID-19 on physician burnout globally: A review. Healthcare (Basel). 2020; 8(4): 421. DOI: 10.3390/healthcare8040421.

Mousavi-Asl B, Firouzifar M, Noury L, et al.: Burnout among health care providers during COVID-19 outbreak. Acta Med Iran. 2021. DOI: 10.18502/acta.v59i2.5577.

Gualano MR, Sinigaglia T, Lo Moro G, et al.: The burden of burnout among healthcare professionals of intensive care units and emergency departments during the COVID-19 pandemic: A systematic review. Int J Environ Res Public Health. 2021; 18(15): 8172. DOI: 10.3390/ijerph18158172.

Hao Q, Wang D, Xie M, et al.: Prevalence and risk factors of mental health problems among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Front Psychiatry. 2021; 12: 567381. DOI: 10.3389/fpsyt.2021.567381.

Lu MY, Ahorsu DK, Kukreti S, et al.: The prevalence of post-traumatic stress disorder symptoms, sleep problems, and psychological distress among COVID-19 frontline healthcare workers in Taiwan. Front Psychiatry. 2021; 12: 705657. DOI: 10.3389/fpsyt.2021.705657.

Chew NWS, Ngiam JN, Tan BYQ, et al.: Asian-Pacific perspective on the psychological well-being of healthcare workers during the evolution of the COVID-19 pandemic. BJPsych Open. 2020; 6(6): e116. DOI: 10.1192/bjo.2020.98.

Khasne RW, Dhakulkar BS, Mahajan HC, et al.: Burnout among healthcare workers during COVID-19 pandemic in India: Results of a questionnaire-based survey. Indian J Crit Care Med. 2020; 24(8): 664-671. DOI: 10.5005/jp-journals-10071-23518.

Parthasarathy R, Jaisoorya T, Thennarasu K, et al.: Mental health issues among health care workers during the COVID-19 pandemic—A study from India. Asian J Psychiatr. 2021; 58(102626): 102626. DOI: 10.1016/j.ajp.2021.102626.

Thatrimontrichai A, Weber DJ, Apisarnthanarak A: Mental health among healthcare personnel during COVID-19 in Asia: A systematic review. J Formos Med Assoc. 2021; 120(6): 1296-1304. DOI: 10.1016/j.jfma.2021.01.023.

Li Y, Scherer N, Felix L, et al.: Prevalence of depression, anxiety and post-traumatic stress disorder in health care workers during the COVID-19 pandemic: A systematic review and meta-analysis. PLoS One. 2021; 16(3): e0246454. DOI: 10.1371/journal.pone.0246454.

Finstad GL, Giorgi G, Lulli LG, et al.: Resilience, coping strategies and post-traumatic growth in the workplace following COVID-19: A narrative review on the positive aspects of trauma. Int J Environ Res Public Health. 2021; 18(18): 9453. DOI: 10.3390/ijerph18189453.

Peters K: When disasters and conflicts collide: Improving links between disaster resilience and conflict prevention. ODI. Available at Accessed October 24, 2023.

Chadda RK, Malhotra A, Kaw N, et al.: Mental health problems following the 2005 earthquake in Kashmir: Findings of community-run clinics. Prehosp Disaster Med. 2007; 22(6): 541-545 [discussion 546]. DOI: 10.1017/s1049023x00005409.

Margoob MA, Khan AY, Firdosi MM, et al.: One year longitudinal study of snowstorm disaster survivors in Kashmir. JK Pract. 2006; 13(1): S29-S38.

de Jong K, Ford N, Kam SVD, et al.: Conflict in the Indian Kashmir valley I: Exposure to violence. Confl Health. 2008; 2(1): 10. DOI: 10.1186/1752-1505-2-10.

Margoob AM, Ahmad SA: Community prevalence of adult post traumatic stress disorder in South Asia: Experience from Kashmir. JK Pract. 2006; 13(1): S18-S25.

Housen T, Lenglet A, Shah S, et al.: Trauma in the Kashmir valley and the mediating effect of stressors of daily life on symptoms of posttraumatic stress disorder, depression and anxiety. Confl Health. 2019; 13(1): 58. DOI: 10.1186/s13031-019-0245-6.

Margoob MA: A study of present magnitude of psychiatric disorders and the existing treatment services in Kashmir (1990-1994). JK Pract. 1995; 2(3): 165-168.

Malla A, Margoob M, Iyer S, et al.: A model of mental health care involving trained lay health workers for treatment of major mental disorders among youth in a conflict-ridden, low-middle income environment: Part I adaptation and implementation. Can J Psychiatry. 2019; 64(9): 621-629. DOI: 10.1177/0706743719839318.

Shoib S, Yasir Arafat SM: Mental health in Kashmir: Conflict to COVID-19. Public Health. 2020; 187: 65-66. DOI: 10.1016/j.puhe.2020.07.034.

Maslach C, Schaufeli WB, Leiter MP: Job burnout. Annu Rev Psychol. 2001; 52(1): 397-422. DOI: 10.1146/annurev.psych.52.1.397.

World Health Organization: The International Statistical Classification of Diseases and Related Health Problems ICD-10. 10th ed. Geneva: World Health Organization, 2015.

Cordes CL, Dougherty TW: A review and an integration of research on job burnout. Acad Manag Rev. 1993; 18: 621-656.30.

Shanafelt TD, Bradley KA, Wipf JE, et al.: Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002; 136: 358-367.

Embriaco N, Papazian L, Kentish-Barnes N, et al.: Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007; 13(5): 482-488. DOI: 10.1097/MCC.0b013e3282efd28a.

Cohen S, Kamarck T, Mermelstein R: A global measure of perceived stress. J Health Soc Behav. 1983; 24(4): 385-396. DOI: 10.2307/2136404.

Piperac P, Todorovic J, Terzic-Supic Z, et al.: The validity and reliability of the Copenhagen burnout inventory for examination of burnout among preschool teachers in Serbia. Int J Environ Res Public Health. 2021; 18(13): 6805. DOI: 10.3390/ijerph18136805.

Campbell-Sills L, Stein MB: Psychometric analysis and refinement of the Connor-Davidson Resilience Scale (CD-RISC): Validation of a 10-item measure of resilience. J Traum Stress. 2007; 20(6): 1019-1028. DOI: 10.1002/jts.20271.

Nukui H, Midorikawa S, Murakami M, et al.: Mental health of nurses after the Fukushima complex disaster: A narrative review. J Radiat Res. 2018; 59(Suppl. 2): ii108-ii113. DOI: 10.1093/jrr/rry023.

Bhattacharyya R, Chatterjee S, Bhattacharyya S, et al.: Attitude, practice, behavior, and mental health impact of COVID-19 on doctors. Indian J Psychiatry. 2020; 62(3): 257. DOI: 10.4103/psychiatry.IndianJPsychiatry_333_20.

Sharma D, Mathur S, Solanki R, et al.: Stress-related disorders in health-care workers in COVID-19 pandemic: A cross-sectional study from India. Indian J Med Spec. 2020; 11(4): 180. DOI: 10.4103/injms.injms_77_20.

Wilson W, Raj JP, Rao S, et al.: Prevalence and predictors of stress, anxiety, and depression among healthcare workers managing COVID-19 pandemic in India: A nationwide observational study. Indian J Psychol Med. 2020; 42(4): 353-358. DOI: 10.1177/0253717620933992.

Margoob MA, Haji UA, Majid A, et al.: A study of burnout among clinicians as caregivers in a chronic mass trauma situation. JK Pract. 2006; 13(1): S94-S97.

Imtiyaz BS, Garratt EA, Cox JH, et al.: Telemedical education during national emergencies: Learning from Kashmir. Clin Teach. 2020; 17(4): 415-417. DOI: 10.1111/tct.13204.

Shoib S, Arafat SMY: COVID-19 and the communication blackouts in Kashmir, India. Lancet Psychiatry. 2020; 7(9): 738. DOI: 10.1016/s2215-0366(20)30338-2.

Elhadi M, Msherghi A, Elgzairi M, et al.: Burnout syndrome among hospital healthcare workers during the COVID-19 pandemic and civil war: A cross-sectional study. Front Psychiatry. 2020; 11: 579563. DOI: 10.3389/fpsyt.2020.579563.

Youssef D, Abboud E, Abou-Abbas L, et al.: Prevalence and correlates of burnout among Lebanese health care workers during the COVID-19 pandemic: A national cross-sectional survey. J Pharm Policy Pract. 2022; 15(1): 102. DOI: 10.1186/s40545-022-00503-2.

Maraqa B, Nazzal Z, Zink T: Palestinian health care workers’ stress and stressors during COVID-19 pandemic: A cross-sectional study. J Prim Care Community Health. 2020; 11: 215013272095502. DOI: 10.1177/2150132720955026.

Alhaffar MBA, Alhaffar MAA, Kouchaji C, et al.: Psychological effects on healthcare workers in Syria during COVID-19. Res Square. 2021. DOI: 10.21203/

Alrubaiee GG, Al-Qadasi FA, Al-Qalah TAH, et al.: Psychological impacts among Yemeni healthcare workers during the COVID-19 pandemic: An electronic-based, cross-sectional analytical survey. Res Square. 2021. DOI: 10.21203/

Ghaleb Y, Lami F, Al Nsour M, et al.: Mental health impacts of COVID-19 on healthcare workers in the Eastern Mediterranean region: A multi-country study. J Public Health (Oxf). 2021; 43(Suppl. 3): iii34-iii42. DOI: 10.1093/pubmed/fdab321.

Denning M, Goh ET, Tan B, et al.: Determinants of burnout and other aspects of psychological well-being in healthcare workers during the COVID-19 pandemic: A multinational cross-sectional study. PLoS One. 2021; 16(4): e0238666. DOI: 10.1371/journal.pone.0238666.

Carod-Artal FJ, Vazquez-Cabrera C: Burnout syndrome in an international setting. In Burnout for Experts. Berlin: Springer, 2013: 15-35.

Blanch A, Aluja A: Social support (family and supervisor), work– family conflict, and burnout: Sex differences. Hum Relat. 2012; 65(7): 811-833. DOI: 10.1177/0018726712440471.

Houkes I, Winants Y, Twellaar M, et al.: Development of burnout over time and the causal order of the three dimensions of burnout among male and female GPs. A three-wave panel study. BMC Public Health. 2011; 11(1): 240. DOI: 10.1186/1471-2458-11-240.

Shanafelt TD: Enhancing meaning in work: A prescription for preventing physician burnout and promoting patient-centered care: A prescription for preventing physician burnout and promoting patient-centered care. JAMA. 2009; 302(12): 1338-1340. DOI: 10.1001/jama.2009.1385.

Huang Y, Zhao N: Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res. 2020; 288: 112954. DOI: 10.1016/j.psychres.2020.112954.

Zhang WR, Wang K, Yin L, et al.: Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychother Psychosom. 2020; 89(4): 242-250. DOI: 10.1159/000507639.

Wu Y, Wang J, Luo C, et al.: A comparison of burnout frequency among oncology physicians and nurses working on the frontline and usual wards during the COVID-19 epidemic in Wuhan, China. J Pain Symptom Manage. 2020; 60(1): e60-e65. DOI: 10.1016/j.jpainsymman.2020.04.008.

Zhou T, Xu C, Wang C, et al.: Burnout and well-being of healthcare workers in the post-pandemic period of COVID-19: A perspective from the job demands-resources model. BMC Health Serv Res. 2022; 22(1): 284. DOI: 10.1186/s12913-022-07608-z.

Mengist B, Amha H, Ayenew T, et al.: Occupational stress and burnout among health care workers in Ethiopia: A systematic review and meta-analysis. Arch Rehabil Res Clin Transl. 2021; 3(2): 100125. DOI: 10.1016/j.arrct.2021.100125.

Margraf J, Lavallee K, Zhang X, et al.: Social rhythm and mental health: A cross-cultural comparison. PLoS One. 2016; 11(3): e0150312. DOI: 10.1371/journal.pone.0150312.

Ripp JA, Bellini L, Fallar R, et al.: The impact of duty hours restrictions on job burnout in internal medicine residents: A three-institution comparison study: A three-institution comparison study. Acad Med. 2015; 90(4): 494-499. DOI: 10.1097/ACM.0000000000000641.

Gopal R, Glasheen JJ, Miyoshi TJ, et al.: Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005; 165(22): 2595-2600. DOI: 10.1001/archinte.165.22.2595.

Goitein L, Shanafelt TD, Wipf JE, et al.: The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005; 165(22): 2601-2606. DOI: 10.1001/archinte.165.22.2601.

Sirois FM, Owens J: Factors associated with psychological distress in health-care workers during an infectious disease outbreak: A rapid systematic review of the evidence. Front Psychiatry. 2021; 11: 589545. DOI: 10.3389/fpsyt.2020.589545.

AlJhani S, AlHarbi H, AlJameli S, et al.: Burnout and coping among healthcare providers working in Saudi Arabia during the COVID-19 pandemic. Middle East Curr Psychiatr. 2021; 28(1). DOI: 10.1186/s43045-021-00108-6.

Roslan NS, Yusoff MSB, Razak AA, et al.: Burnout prevalence and its associated factors among Malaysian healthcare workers during COVID-19 pandemic: An embedded mixed-method study. Healthcare (Basel). 2021; 9(1): 90. DOI: 10.3390/healthcare9010090.

De Kock JH, Latham HA, Leslie SJ, et al.: A rapid review of the impact of COVID-19 on the mental health of healthcare workers: Implications for supporting psychological well-being. BMC Public Health. 2021; 21(1): 104. DOI: 10.1186/s12889-020-10070-3.

Nyasulu JC, Chirwa MD, Kumwenda J, et al.: Health systems’ resilience during the COVID-19 pandemic public health emergency: The role of existing community health structures in rural Malawi. Am J Disaster Med. 2022; 17(3): 207-217. DOI: 10.5055/ajdm.2022.0435.

Epstein RM, Krasner MS: Physician resilience: What it means, why it matters, and how to promote it. Acad Med. 2013; 88(3): 301-303. DOI: 10.1097/ACM.0b013e318280cff0.

Zwack J, Schweitzer J: If every fifth physician is affected by burnout, what about the other four? Resilience strategies of experienced physicians. Acad Med. 2013; 88(3): 382-389. DOI: 10.1097/ACM.0b013e318281696b.

Smith GD, Ng F, Ho Cheung Li W: COVID-19: Emerging compassion, courage and resilience in the face of misinformation and adversity. J Clin Nurs. 2020; 29(9-10): 1425-1428. DOI: 10.1111/jocn.15231.

Fairley R, Mace SE, Lehman-Huskamp K, et al.: Interventions to improve the psychological well-being of healthcare workers in disasters, pandemics, and mass casualty events. Am J Disaster Med. 2022; 17(3): 189-195. DOI: 10.5055/ajdm.2022.043.



How to Cite

Imtiyaz, B. S., M. A. Margoob, F. Roub, and M. Imtiaz. “Perceived Stress, Burnout, and Resilience Among Healthcare Workers in a Multiple Disaster-Impacted Setting During the COVID-19 Pandemic”. American Journal of Disaster Medicine, vol. 19, no. 1, Feb. 2024, pp. 59-70, doi:10.5055/ajdm.0452.