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REVIEW article

Front. Psychol., 10 December 2020
Sec. Psychology for Clinical Settings
This article is part of the Research Topic Coronavirus Disease (COVID-19): The Mental Health, Resilience, and Communication Resources for the Short- and Long-term Challenges Faced by Healthcare Workers View all 43 articles

Stress Reduction Techniques for Health Care Providers Dealing With Severe Coronavirus Infections (SARS, MERS, and COVID-19): A Rapid Review

  • 1Clinical Psychology Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy
  • 2Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
  • 3Nursing School, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

Objective: A rapid review was conducted to identify the most effective stress reduction techniques for health care providers dealing with patients infected with severe coronavirus (SARS, MERS, and COVID-19).

Methods: PubMed, PsychInfo, Embase, and CINAHL databases were searched to identify relevant studies. Searches were restricted by date (2000 until present). All empirical quantitative and qualitative studies in which relaxation techniques of various types implemented on health care providers caring for patients during severe coronavirus pandemics and articles that consider the implementation of mental health care services considered to be pertinent, such as commentaries, were included.

Results: Fourteen studies met the selection criteria, most of which were recommendations. Only one study described a digital intervention, and user satisfaction was measured. In the recommendations, both organizational and individual self-care interventions were suggested.

Conclusions: Further research is necessary to establish tailor-made effective stress reduction interventions for this population, during these challenging and particular times.


In the last 15 years, three global viral infectious diseases, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and coronavirus disease (COVID-19), have occurred worldwide, putting human lives at risk and challenging the health care providers working in the frontline. The SARS pandemic was declared as “contained” by the World Health Organization (WHO) in 2003 (World Health Organization, 2003).

It was reported by the Centers of Disease Control and Prevention that a total of 8,096 people in 29 countries were infected by it, out of whom 774 of them died (Centers for Disease Control and Prevention, 2016).

After the SARS pandemic occurred, population studies have shown that these kinds of events can cause anxiety, depression, stress, sleep disorders, and post-traumatic stress disorder (PTSD) (Hawryluck et al., 2004; Wu et al., 2005). Specifically, it is an experience of uncontrollable and excessive concern related to a number of situations or activities. Symptomatology includes restlessness, fatigue, and difficulty in concentrating, irritability, muscle tension, and sleep disturbances. It is not surprising that the health care workers who find themselves working in this situation encounter a lot of stress linked to both their personal safety and the safety of their families; this is an addition to the burden of dealing with patients who can experience severe psychological distress.

Concerns from health care workers and psychological distress during the previous SARS outbreak were linked to increased work stress, social isolation, and health fears. Factors related to the psychological distress of health professionals were physical and emotional exhaustion due to an overloaded health system, rapidly changing medical information and procedures, media control, nursing care, perception of self-risk, lifestyle affected by the epidemic, and subjective vulnerability (Maunder, 2004; Wong et al., 2005; Styra et al., 2008). In addition, when faced with the possibility of having to work in a pandemic, a significant proportion of health care workers did not go to work, despite having a strong sense of duty (Ives et al., 2009; Martinese et al., 2009).

During the SARS pandemic, health care workers reported significantly higher levels of distress, including burnout psychological stress and post-traumatic stress, hostility, and somatization (Chen et al., 2005; Maunder et al., 2006). It was suggested that healthcare workers should be screened when it comes to psychological distress, in order to provide psychological support (Chen et al., 2005). Prevention programs during SARS have been effective in diminishing anxiety and depression and improving sleep and quality of life (Chen et al., 2006).

In a cross-sectional study of 1,257 health care workers in 34 hospitals equipped with fever clinics or wards for patients with COVID-19 in multiple regions of China, a considerable proportion of health care workers reported experiencing symptoms of depression, anxiety, insomnia, and distress. It was suggested that, among Chinese health care workers exposed to COVID-19, women, nurses, those in Wuhan, and frontline health care workers had a high risk of developing unfavorable mental health outcomes and may need psychological support or interventions (Lai et al., 2020).

Among the health care providers, the frontline workers involved directly in handling COVID-19 patients are exposed at greater risk than others. Many reasons were found in adverse psychological outcomes ranging from excessive workload/work hours to inadequate personal protective equipment, over-enthusiastic media news, and feeling inadequately supported (Spoorthy et al., 2020).

Pervasive psychological problems have appeared among health care workers during the COVID-19 pandemic. The prevalence of symptoms of anxiety, depression, insomnia, and the overall psychological problems in health care workers during the COVID-19 pandemic in China was 46.04, 44.37, 28.75, and 56.59%, respectively (Que et al., 2020).

It has been demonstrated in various studies that relaxation techniques, such as the progressive muscular relaxation of Jacobson, the Mindfulness Based Stress Reduction techniques, and the relaxation techniques described by Benson, reduce stress, anxiety, and depression and improve quality of life in both patients and health care workers (Zinn, 1990; Botha et al., 2015; Carver and O’Malley, 2015; Greenlee et al., 2017; Tsitsi et al., 2017; Harorani et al., 2019; Ibrahim et al., 2019).

However, medical and nursing staff may be unable or reluctant to participate in psychological initiatives at the time of crisis (Chen et al., 2020). Initiatives such as staff training on psychological aspects in patient management and training in relaxation techniques (Chen et al., 2020) could therefore be useful, although the best approach during this pandemic is still unknown (Chen et al., 2020; Kang et al., 2020a; Xiang et al., 2020).

It is especially important to take into consideration the psychological care needs treatment preferences of the health care workers facing these kinds of situations. In one study, the impact on mental health care and perceptions of psychological care of the medical and nursing staff was explored in Wuhan (Kang et al., 2020b). The health care workers were divided into clusters according to their mental health disturbance: mild, moderate, and severe. When it comes to the interest in psychological care, the ones with subthreshold disturbances most wanted to obtain skills to help alleviate others’ psychological distress, whereas other medical and nursing staff most wanted to obtain self-help skills.

In the cluster where higher levels of mental health problems were reported, the medical and nursing staff showed more interest in skills for self-rescue and showed more urgent desires to seek help from psychotherapists and psychiatrists. Medical and nursing staff with subthreshold disturbances did not think they needed help from others. The other workers saw a greater need to obtain help from professionals than from close family and friends. Also, the modalities of obtaining services vary according to their levels of mental health problems. Medical and nursing staff with subthreshold and mild disturbances preferred to obtain such services from media sources, while staff with heavier burdens wanted to seek services directly from professionals (Kang et al., 2020b).

For this reason, it is important to identify what kind of interventions could be most effective in this population, also when it comes to self-help materials such as relaxation recordings, which can be delivered also without the health care workers having direct contact with the professionals.


This rapid review was aimed to identify the most effective stress reduction techniques for health care providers dealing with patients infected with severe coronavirus (SARS, MERS, and COVID-19).

In particular, there was a focus on the best practices and interventions that aimed at reducing psychological distress among health care professionals dealing with patients infected with severe coronavirus infections. Additionally, the delivery mechanisms of the identified interventions, the instruments used to test their efficacy, the determinants of their effectiveness, and their impact on specific psychological variables were investigated.

It was decided to focus only on severe coronaviruses because they have similar characteristics, and the objective of the review was to identify interventions that were specific to the health care providers who were facing similar situations.

The main question this rapid review aims to answer is:

• Which are the most effective stress reduction techniques for health care providers dealing with patients infected with severe coronavirus (SARS, MERS, and COVID-19)?

The secondary questions that we explored are:

• Which is the most effective manner of delivery considering the severe coronavirus characteristics?

• What instruments are utilized to measure stress reduction techniques’ efficacy?

• Which psychological variables are affected by stress reduction techniques?

• Which factors influence the effectiveness of stress reduction techniques’ application?

PubMed, PsychInfo, Embase, and CINAHL databases were searched to identify relevant studies. Searches were restricted by date (2000 until present). Searches were conducted by two authors independently between 3rd and 18th June 2020.

The keywords utilized in the various databases can be seen in the Supplementary Material (database search strings).

All studies and any systematic reviews identified during the screening process were reference checked to identify additional studies. During the preliminary screening of literature, two authors worked independently. Google Scholar was searched as other source.

The objectives were formulated according to the Cochrane Systematic Review indications (Thomas et al., 2019) and following the Cochrane indications and training materials for rapid reviews.

The eligibility criteria were referable to the type of participants; the studies had to concern health professionals, even if not exclusively; they had to indicate a technique, model, or recommendations for stress reduction; they had to relate to a problem or variable of psychological distress in health professionals during outbreaks of SARS, MERS, or COVID-19, and mental health outcomes.

All empirical quantitative and qualitative studies in which relaxation techniques of various types implemented on health care providers caring for patients during severe coronavirus pandemics and articles that consider the implementation of mental health care services considered to be pertinent, such as commentaries, were included. In addition, there was an exploration of any indicators of effectiveness in lowering psychological distress including anxiety, depression, PTSD, burnout, and others. Studies relating to the stress conditions of operators not related to epidemics and which did not propose interventions or recommendations were excluded. Information extracted from studies and reviewed included psychological distress variables, intervention, efficacy measurements, follow-up results, and country of study.

One reviewer screened all titles and abstracts (BB), considering the focus of the review and the inclusion and exclusion criteria. In the presence of uncertainties, the full text of the article was consulted. After that, two separate reviewers identified the definitive list by consulting the full texts of all the articles (EGB and EC). The quality evaluation of included literature was performed using the AGREE II-Global Rating Scale (AGREE II-GRS) Instrument (Brouwers et al., 2016); the GRADE approach was used to interpret the results (Langendam et al., 2013) and to create Table 1 (“Quality evaluation of the studies”).


Table 1. Quality evaluation of the studies.


The workflow of the article selections can be seen in Figure 1, and the pertinent articles are reported in Table 2.


Figure 1. Flow diagram of the selected studies.


Table 2. Summary of the selected studies.

The search for documents produced 67 records. Forty-one of them were excluded because they were considered irrelevant after an independent analysis of title and abstract. The remaining 26 were analyzed in full text independently among the authors to assess their adherence to the selection criteria and 16 were excluded. Fourteen met the selection criteria and, after quality appraisal, were included in the narrative review (see Table 2 for the selected studies).

One of the selected studies (Blake et al., 2020) is an intervention study, 1 is a case study (Sasangohar et al., 2020), 11 are opinions and recommendations (De Mei et al., 2020; Fessell and Cherniss, 2020; Galbraith et al., 2020; Hedderman et al., 2020; Kar et al., 2020; Maben and Bridges, 2020; Moazzami et al., 2020; Petzold et al., 2020; Shanafelt et al., 2020; Sultana et al., 2020; World Health Organization, 2020), and 1 is a letter to editor (Mukhtar, 2020). The quality of the studies was moderate to high. As reported by some of the authors, few of the reviewed considerations, recommendations, and suggestions have substantial evidence to support them. Some are based on direct requests from health care professionals and experience. All studies are written in English, except Petzold et al. (2020), which is written in German with abstracts in both languages, and De Mei et al. (2020), which is available in both English and Italian.

The purposes of the reviewed studies were to suggest interventions or recommendations and specific policy organizational recommendations, for the reduction of stress and psychological burden in health professionals during COVID-19 (De Mei et al., 2020; Fessell and Cherniss, 2020; Galbraith et al., 2020; Hedderman et al., 2020; Kar et al., 2020; Maben and Bridges, 2020; Moazzami et al., 2020; Petzold et al., 2020; Shanafelt et al., 2020; Sultana et al., 2020; World Health Organization, 2020) and to propose strategies and interventions such as mindfulness (Hedderman et al., 2020), telemedicine (Moazzami et al., 2020), and health model (Mukhtar, 2020). There are no differences between the recommendations referred to different populations and cultures. All studies are aimed at health professionals (De Mei et al., 2020; Petzold et al., 2020; Shanafelt et al., 2020; Sultana et al., 2020; World Health Organization, 2020), some at specific figures such as doctors (Fessell and Cherniss, 2020; Galbraith et al., 2020) or nurses (Maben and Bridges, 2020). Kar et al. (2020) include indications for the general population. None of the studies found discussed or proposed interventions or recommendations addressed to health care professionals involved in the SARS and MERS epidemics (Liu et al., 2020).

Relaxation Strategies During Pandemics

The study “Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19” was conducted on 51 patients who tested positive for COVID-19 and admitted to the general hospital of Hainan from January 01. As of February 16, 2020, progressive muscle relaxation (PRM) was seen to have a positive effect on improving sleep quality and reducing anxiety in COVID-19 patients. The cause of the decrease in anxiety in patients after PMR practice could be the balance between the anterior nucleus and the hypothalamic nucleus. In fact, it has been shown that by reducing the activity of the sympathetic nervous system, it is possible to prevent the side effects of stress and anxiety and increase physical and mental relaxation (Ferendiuk et al., 2019).

In an attempt to develop a clinical protocol aimed at reducing the negative effects of the current pandemic on the psychophysical health of health care personnel and patients, further characteristics of relaxation practices were evaluated and investigated.

Health care personnel are subjected to numerous stressful factors during sometimes prolonged work shifts: taking care of more or less serious COVID-19-positive patients, the worry of a possible infection from COVID-19, the fear of being able to infect loved ones, quickly adapting to the reorganization of Operational Units and consequently to quickly changing their duties, working alongside unknown colleagues or doctors from an operational point of view, sustaining much heavier work rates, etc. All these factors lead to the accumulation of stress, which, over time, risks becoming chronic. This condition leads to an inevitable relapse on both a psychological and physiological level such as “chest and non-diaphragmatic breathing, muscle tension more intense than normal, a rapid heartbeat, a condition of sympathetic tone, the appearance of negative fantasies or a chronic fear” (Rispoli, 1999).

Breathing, for example, has been evaluated as a fundamental element for the mindful meditation practices introduced by Kabat-Zinn, as it allows you to pay “non-judgmental attention to your cognitive, emotional and physical experiences, while reorienting your concentration. on respiratory sensations to promote cognitive and emotional regulation and progressively relaxed districts” (Azam et al., 2019).

The main findings of the 2011 “Targeting the restricted α-subunit repertoire of airway smooth muscle GABAA receptors augments airway smooth muscle relaxation” study refer to the fact that human airway smooth muscle possesses GABAA receptors (gamma-aminobutyric acid) with a limited (but conserved) α-subunit phenotype that can be pharmacologically targeted by selective agonists to generate electrophysiological changes and facilitate relaxation of pre-contracted smooth muscle. The activation of the receptor can directly and spontaneously relax the pre-contracted smooth muscle of the airways by a variety of procontractile agents (Gallos et al., 2012).

Furthermore, in a review of the scientific literature (Pavan and Palese, 2016), it was shown that GABA is one of the most important inhibitory neurotransmitters and influences mood and emotions. Low levels are associated with depression and sleep disturbances, conditions also found in people with PTSD, as well as in anxiety situations in which there is a reduction in GABA (Rispoli, 2016).

The scientific evidences cited so far show the importance of increasing the presence of GABA neurotransmitters in the body especially in this moment of COVID-19 emergency, both for patients with respiratory problems and for all those, including patients, doctors, health workers, and the civilian population, who experience a strong state of anxiety.

Another study highlighted the beneficial effects of relaxation techniques in asthmatic patients by measuring lung function. The results show that the use of relaxation as an auxiliary treatment appears to help asthma patients better manage stress and prevent further attacks, thus improving their quality of life (Pourdowlat et al., 2019). Lahmann et al. (2009) had previously obtained similar results by evaluating the impact of relaxation and guided imagery techniques on asthmatic patients.

A recent review of the literature (Tarsha et al., 2020) found that body-oriented psychological therapies were effective in reducing headaches caused by a state of tension, non-cardiac (non-specific) chest pain, psychosomatically influenced asthma diseases, and irritable bowel disease as demonstrated in other studies (Loew et al., 2001; Lahmann et al., 2008a,b, 2009). The importance of the body in psychological therapies has already been highlighted for some time by Rispoli (1999, 2004, 2016) who already in 1999 spoke about the unity of body and mind, overcoming this dichotomy. His theoretical approach focused on targeted interventions on the body to alleviate psychological pathologies, strictly connected to the physical and physiological level, and fits into this perspective of body and mind integration (Rispoli, 2016).


In their study, Blake et al. (2020) describe the development and evaluation of a digital package using the Agile methodology, in the United Kingdom. The study includes three phases: a content development phase, a peer review phase, and a package implementation and evaluation phase. The package includes an evidence-based guide to support the psychological well-being for all United Kingdom health workers. The package outlines the actions that team leaders can undertake to provide psychologically safe spaces for workers, to provide a guide to reduce social stigma, and to increase peer and family support, self-care strategies related to sleep and rest, shift work, fatigue, and healthy lifestyle behaviors; it also includes emotion management strategies such as guilt, pain, fear, anxiety, depression, burnout prevention, and psychological trauma.

Enhancing Awareness

The revised studies report to inform health care personnel about the professional stress risks associated with the emergency care. Awareness can reduce stigma to mental health conditions such as burnout and develop resilience in the health care provider by preventing burnout (Sultana et al., 2020). Adequate awareness of COVID-19 and regular updates about appropriate precautionary measures are recommended (Kar et al., 2020).

Self-Care Interventions

Positive mental health can prevent work-related stress and burnout and should be promoted among health professionals in COVID-19. Several strategies are recommended for reducing the workload, such as mindfulness and promoting self-care (Sultana et al., 2020).

Mindfulness training is recommended for health care professionals because it can promote self-care and well-being (Fessell and Cherniss, 2020; Sultana et al., 2020; World Health Organization, 2020). Mindfulness programs are also recommended because they can increase resilience to stress, quality of professional life, and self-compassion.

Compassion for both self and others in a clinical setting is a necessary component to facilitate a therapeutic environment. Self-compassionate people react to adversaries’ events in a more emotionally regulated model. Self-compassion is associated with a series of psychological strengths such as resilience, happiness, optimism, wisdom, curiosity, courage, exploration, and emotional intelligence (Hedderman et al., 2020).

Mindfulness-based interventions are particularly suitable for high-stress work contexts, can be practiced privately or in groups, in almost all environments, and can be conducted as briefly as possible (Galbraith et al., 2020). Mindfulness is recommended also for reducing work stress and suicidal ideation (Galbraith et al., 2020).

The promotion of self-care must start from the response to the essential needs of drinks, food, rest, and sleep (Maben and Bridges, 2020; Petzold et al., 2020; World Health Organization, 2020). It also includes indoor recreational activities and relaxation exercises to daily practice (Kar et al., 2020; World Health Organization, 2020). To protect self and take care of self, it is also recommended that professionals ignore fake news and reduce social media (Kar et al., 2020; World Health Organization, 2020).

Self-care micro practices such as diaphragmatic respiration has shown an improvement in stress reduction; it is believed that the mechanism acts by increasing parasympathetic activation and, given that diaphragmatic breathing is low cost, self-administered, non-pharmacological, and highly portable, the practice is recommended (Fessell and Cherniss, 2020). To improve self-care, it is also necessary to act on self-efficacy, and the promotion of self-efficacy is recommended both for medical staff and for public; strengthening self-efficacy beliefs is recommended as strengthening beliefs about the disease include its severity and susceptibility (Mukhtar, 2020).

Mental Health Services

Providing mental health services can be difficult during COVID-19, but such opportunities should be considered to prevent stress and burnout among professionals. Recommendations include building teams or multi-disciplinary teams of mental health experts who can provide mental health services or refer to appropriate resources if the health care worker shows signs of exhaustion (Sultana et al., 2020). Psychological counselors should be available in the staging areas of professionals to listen to staff difficulties and stories and provide support accordingly (Maben and Bridges, 2020; Shanafelt et al., 2020).

Group consultations or peer-support sessions are also recommended, which can allow specific topics to be dealt with in depth (Petzold et al., 2020; Sultana et al., 2020). Peer support and group support are particularly recommended among nurses for their “natural” tendency to take care of others and not themselves, which leads them to need others (colleagues and leaders) to remind them to think for themselves and to find ways to help new members feel safe, appreciated, and welcome as quickly as possible (Maben and Bridges, 2020).

Digital Technologies

The use of digital interventions to improve health services and care outcomes is also recommended during COVID-19. The push toward digital is twofold. On the one hand, the use of electronic medical records and telemedicine can reduce the overloaded work experience (Moazzami et al., 2020; Sultana et al., 2020) among the frontline health care workers in COVID-19.

Another approach is to provide mental health resources and interventions that use digital platforms such as mobile phones, apps, or Internet devices. This can positively affect working and mental life and health professionals (Sultana et al., 2020). Due to increased assistance demands, the professional engagement of the operators should be guaranteed by implementing and providing psychological support services by phone of via the web (De Mei et al., 2020).

Organizational Approaches

It is considered essential to improve organizational measures that affect the culture of work and stress in the workplace. Potential strategies include improving workflow management, organizing services focused on reducing workload, improving interoperability, organization of discussions and exchange of opinions, improvement of communication skills, providing adequate rest and exercise, and organizing seminars on coping skills (Sultana et al., 2020); such organizational support should include guarantees such as assistance to those doctors and nurses who fall ill, as well as medical and financial support for their families and protection from threats of neglect (Galbraith et al., 2020).

It is also recommended that the organization provide a resting place, guaranteed food and daily supplies, videos of their work to share with families to ease concerns, training to manage the patient’s psychological problems, and the provision of personal protective equipment (De Mei et al., 2020; Maben and Bridges, 2020; Shanafelt et al., 2020; World Health Organization, 2020). The recommendations regarding the implementation of all the necessary measures to protect the occupational safety suggest that the employer and the managers of the health structures must guarantee the adoption of preventive and protective measures, providing personal protective equipment in sufficient quantities for the health workers; this increases the sense of security and reduces stress (De Mei et al., 2020; Maben and Bridges, 2020; Petzold et al., 2020; World Health Organization, 2020).

The reports also suggest that regular and honest communication from the leaders of the organization toward the frontline professionals is essential, as well as the visibility and guarantee of access to physiological and safety needs (De Mei et al., 2020; Maben and Bridges, 2020; Petzold et al., 2020; World Health Organization, 2020). It is recommended that the organization create a series of communication channels (listening groups, e-mail suggestion box, town halls, and managers visiting hospital units) and ensure that the voice of health workers is part of the decision-making process (Shanafelt et al., 2020; World Health Organization, 2020).

The organization can also support health care professionals in addressing the mental health stigma in the workplace; creating a culture that encourages open communication and seeks to reduce the stigmatization of psychological vulnerability is recommended (Galbraith et al., 2020; Shanafelt et al., 2020).

Evaluation of the Intervention

None of the 14 revised studies reported results of application of the intervention or recommendations.

Blake and others report the evaluation of the digital package tested. A total of 17,633 consultations of the tested package were carried out within 7 days of completion, and the evaluation (n. 55) indicated a high user satisfaction for content, usability, and utility (Blake et al., 2020).

Fessell and Cherniss (2020) recommended both physiologic bio-markers (blood pressure and salivary cortisol) and self-reported stress levels via the Depression Anxiety Stress Scales-21 as evaluation for diaphragmatic breathing.


Frontline health care providers during the COVID-19 pandemic were and are still being exposed to an enormous amount of stress for many reasons, such as lack of adequate protection, physical fatigue, exhausting shifts, and sometimes organizational difficulties, which can also include lack of human resources and being requested to operate out of one’s specialty out of necessity.

This rapid review was undertaken to assess the efficacy of stress reduction techniques for health care providers dealing with patients infected with severe coronavirus (SARS, MERS, and COVID-19). In particular, the authors were interested to identify what stress reduction techniques could be most effective in such particular circumstances.

Fourteen studies that fulfilled the selection criteria for this review were identified, 11 of which were recommendations. Only one intervention study met the quality appraisal criteria.

Only one intervention technique provided by a digital package using the Agile methodology (Blake et al., 2020) was described, and several recommended strategies based on individual, organizational, or team actions such as mindfulness, promotion of self-care, psychological counseling, digital platform information, and organizational support services were provided.

In the recommendations, it was specified that it is important to act on an organizational level. A lot of attention must be paid on communication, providing accurate updates in order to lower stress levels as much as possible, fostering a perception of control. All measures that guarantee the health care professionals’ safety and enhance their well-being must be put into place. In particular, attention to the organization of shifts, the creation of a safe place, and clear access to mental health services were outlined.

It was also specified that the interventions need to be tailor-made and safe; therefore, in the time of the peak of the pandemic, telehealth services must be provided. Some health care professionals seem to prefer not to have a direct contact with a mental health professional; therefore, resources, such as relaxation recordings and digital packaging, should be made available.

A number or self-care interventions were proposed, acting directly on essential needs, recreational activities, and specific stress reduction techniques, such as mindfulness-based interventions, diaphragmatic respiration, and acting on self-efficacy.

Even though these general indications were provided, no specific indications as to specific stress reduction techniques, which could be particularly effective during the COVID-19 pandemic, were provided. Further studies involving the health care providers themselves, and the measures of both satisfaction and effectiveness in reducing stress, with the use of patient-reported outcomes on anxiety, depression, PTSD, and insomnia are required.


Since a rapid review was conducted, there could bias as a consequence of streamlining the systematic review process. This bias could therefore have occurred during the selection of the studies, although three of the authors were involved in the selection in order to minimize this bias as much as possible.


Frontline health care professionals are indispensable during pandemics such as COVID-19; therefore, there should be an important investment in order to safeguard their mental health and to lower their stress as much as possible. Further research is necessary to establish tailor-made effective stress reduction interventions for this population during these challenging and particular times.

Author Contributions

EC proposed the study design and the idea, analyzed the literature and its development, and gave the final approval of the manuscript. BB and EB analyzed the literature and contributed to the preparation of the manuscript. VF and SP contributed to the shaping of the manuscript. ML revised and approved the final manuscript. All authors approved the submitted version.


This study was partially supported by Ricerca Corrente funding from the Italian Ministry of Health to IRCCS Policlinico San Donato.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at:


Azam, M. A., Latman, V. V., and Katz, J. (2019). Effects of a 12-minute smartphone-based mindful breathing task on heart rate variability for students with clinically relevant chronic pain, depression, and anxiety: protocol for a randomized controlled trial. JMIR Res. Protoc. 8:e14119. doi: 10.2196/14119

PubMed Abstract | CrossRef Full Text | Google Scholar

Blake, H., Bermingham, F., Johnson, G., and Tabner, A. (2020). Mitigating the psychological impact of COVID-19 on healthcare workers: a digital learning package. Intern. J. Environ. Res. Public Health 17:2997. doi: 10.3390/ijerph17092997

PubMed Abstract | CrossRef Full Text | Google Scholar

Botha, E., Gwin, T., and Purpora, C. (2015). The effectiveness of mindfulness based programs in reducing stress experienced by nurses in adult hospital settings: a systematic review of quantitative evidence protocol. JBI Database Syst. Rev. Implement. Rep. 13, 21–29. doi: 10.11124/jbisrir-2015-2380

PubMed Abstract | CrossRef Full Text | Google Scholar

Brouwers, M. C., Kerkvliet, K., Spithoff, K., and Consortium, A. N. S. (2016). The AGREE reporting checklist: a tool to improve reporting of clinical practice guidelines. BMJ 352:i1152. doi: 10.1136/bmj.i1152

PubMed Abstract | CrossRef Full Text | Google Scholar

Carver, M. L., and O’Malley, M. (2015). Progressive muscle relaxation to decrease anxiety in clinical simulations. Teach. Learn. Nurs. 10, 57–62. doi: 10.1016/j.teln.2015.01.002

CrossRef Full Text | Google Scholar

Centers for Disease Control and Prevention (2016). SARS (10 Years After). Available online at: (accessed October 8, 2020).

Google Scholar

Chen, C.-S., Wu, H.-Y., Yang, P., and Yen, C.-F. (2005). Psychological distress of nurses in Taiwan who worked during the outbreak of SARS. Psychiatr. Serv. 56, 76–79. doi: 10.1176/

PubMed Abstract | CrossRef Full Text | Google Scholar

Chen, Q., Liang, M., Li, Y., Guo, J., Fei, D., Wang, L., et al. (2020). Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatr. 7, e15–e16.

Google Scholar

Chen, R., Chou, K.-R., Huang, Y.-J., Wang, T.-S., Liu, S.-Y., and Ho, L.-Y. (2006). Effects of a SARS prevention programme in Taiwan on nursing staff’s anxiety, depression and sleep quality: a longitudinal survey. Intern. J. Nurs. Stud. 43, 215–225. doi: 10.1016/j.ijnurstu.2005.03.006

PubMed Abstract | CrossRef Full Text | Google Scholar

De Mei, B., Lega, I., Sampaolo, L., and Valli, M. (2020). COVID-19: Stress Management Among Healthcare Workers - Centro Nazionale per la Prevenzione delle Malattie e la Promozione Della Salute. Available online at: (accessed October 8, 2020).

Google Scholar

Ferendiuk, E., Biegańska, J. M., Kazana, P., and Pihut, M. (2019). Progressive muscle relaxation according to Jacobson in treatment of the patients with temporomandibular joint disorders. Folia Med. Cracovien. 59, 113–122.

Google Scholar

Fessell, D., and Cherniss, C. (2020). Coronavirus disease 2019 (COVID-19) and beyond: micropractices for burnout prevention and emotional wellness. J. Am. Coll. Radiol. 17, 746–748. doi: 10.1016/j.jacr.2020.03.013

PubMed Abstract | CrossRef Full Text | Google Scholar

Galbraith, N., Boyda, D., McFeeters, D., and Hassan, T. (2020). The mental health of doctors during the Covid-19 pandemic. BJPsych. Bull. 1–4.

Google Scholar

Gallos, G., Yim, P., Chang, S., Zhang, Y., Xu, D., Cook, J. M., et al. (2012). Targeting the restricted α-subunit repertoire of airway smooth muscle GABAA receptors augments airway smooth muscle relaxation. Am. J. Physiol. Lung Cell. Mol. Physiol. 302, L248–L256.

Google Scholar

Greenlee, H., DuPont-Reyes, M. J., Balneaves, L. G., Carlson, L. E., Cohen, M. R., Deng, G., et al. (2017). Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J. Clin. 67, 194–232. doi: 10.3322/caac.21397

PubMed Abstract | CrossRef Full Text | Google Scholar

Harorani, M., Davodabady, F., Masmouei, B., and Barati, N. (2019). The effect of progressive muscle relaxation on anxiety and sleep quality in burn patients: a randomized clinical trial. Burns 46, 1107–1113. doi: 10.1016/j.burns.2019.11.021

PubMed Abstract | CrossRef Full Text | Google Scholar

Hawryluck, L., Gold, W. L., Robinson, S., Pogorski, S., Galea, S., and Styra, R. (2004). SARS control and psychological effects of quarantine, Toronto, Canada. Emerg. Infect. Dis. 10:1206. doi: 10.3201/eid1007.030703

PubMed Abstract | CrossRef Full Text | Google Scholar

Hedderman, E., O’Doherty, V., and O’Connor, S. (2020). Mindfulness moments for clinicians in the midst of a pandemic. Ir. J. Psychol. Med. 1–4. doi: 10.1017/ipm.2020.59

CrossRef Full Text | Google Scholar

Ibrahim, A., Koyuncu, G., Koyuncu, N., Suzer, N. E., Cakir, O. D., and Karcioglu, O. (2019). The effect of Benson relaxation method on anxiety in the emergency care. Medicine 98:e15452. doi: 10.1097/MD.0000000000015452

PubMed Abstract | CrossRef Full Text | Google Scholar

Ives, J., Greenfield, S., Parry, J. M., Draper, H., Gratus, C., Petts, J. I., et al. (2009). Healthcare workers’ attitudes to working during pandemic influenza: a qualitative study. BMC Public Health 9:56. doi: 10.1186/1471-2458-9-56

PubMed Abstract | CrossRef Full Text | Google Scholar

Kang, L., Li, Y., Hu, S., Chen, M., Yang, C., Yang, B. X., et al. (2020a). The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus. Lancet Psychiatry 7:e14. doi: 10.1016/s2215-0366(20)30047-x

CrossRef Full Text | Google Scholar

Kang, L., Ma, S., Chen, M., Yang, J., Wang, Y., Li, R., et al. (2020b). Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional study. Brain Behav. Immun. 87, 11–17. doi: 10.1016/j.bbi.2020.03.028

PubMed Abstract | CrossRef Full Text | Google Scholar

Kar, S. K., Arafat, S. Y., Kabir, R., Sharma, P., and Saxena, S. K. (2020). “Coping with Mental Health Challenges During COVID-19,” in Coronavirus Disease 2019 (COVID-19). Medical Virology: From Pathogenesis to Disease Control, ed. S. Saxena (Singapore: Springer), 199–213. doi: 10.1007/978-981-15-4814-7_16

CrossRef Full Text | Google Scholar

Lahmann, C., Loew, T. H., Tritt, K., and Nickel, M. (2008a). Efficacy of functional relaxation and patient education in the treatment of somatoform heart disorders: a randomized, controlled clinical investigation. Psychosomatics 49, 378–385. doi: 10.1176/appi.psy.49.5.378

PubMed Abstract | CrossRef Full Text | Google Scholar

Lahmann, C., Schoen, R., Henningsen, P., Ronel, J., Muehlbacher, M., Loew, T., et al. (2008b). Brief relaxation versus music distraction in the treatment of dental anxiety: a randomized controlled clinical trial. J. A. Dental Assoc. 139, 317–324. doi: 10.14219/jada.archive.2008.0161

PubMed Abstract | CrossRef Full Text | Google Scholar

Lahmann, C., Nickel, M., Schuster, T., Sauer, N., Ronel, J., Noll-Hussong, M., et al. (2009). Functional relaxation and guided imagery as complementary therapy in asthma: a randomized controlled clinical trial. Psychother. Psychosomat. 78, 233–239. doi: 10.1159/000214445

PubMed Abstract | CrossRef Full Text | Google Scholar

Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., et al. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw. Open 3:e203976. doi: 10.1001/jamanetworkopen.2020.3976

CrossRef Full Text | Google Scholar

Langendam, M. W., Akl, E. A., Dahm, P., Glasziou, P., Guyatt, G., and Schünemann, H. J. (2013). Assessing and presenting summaries of evidence in cochrane reviews. Syst. Rev. 2, 1–9.

Google Scholar

Liu, K., Chen, Y., Wu, D., Lin, R., Wang, Z., and Pan, L. (2020). Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complement. Ther. Clin. Pract. 39:101132. doi: 10.1016/j.ctcp.2020.101132

PubMed Abstract | CrossRef Full Text | Google Scholar

Loew, T., Tritt, K., Siegfried, W., Bohmann, H., Martus, P., and Hahn, E. (2001). Efficacy of ‘functional relaxation’in comparison to terbutaline and a ‘Placebo relaxation’method in patients with acute asthma. Psychother. Psychosomat. 70, 151–157. doi: 10.1159/000056241

PubMed Abstract | CrossRef Full Text | Google Scholar

Maben, J., and Bridges, J. (2020). Covid-19: supporting nurses’ psychological and mental health. J. Clin. Nurs. 29, 2742–2750. doi: 10.1111/jocn.15307

PubMed Abstract | CrossRef Full Text | Google Scholar

Martinese, F., Keijzers, G., Grant, S., and Lind, J. (2009). How would Australian hospital staff react to an avian influenza admission, or an influenza pandemic? Emerg. Med. Austr. 21, 12–24. doi: 10.1111/j.1742-6723.2008.01143.x

PubMed Abstract | CrossRef Full Text | Google Scholar

Maunder, R. (2004). The experience of the 2003 SARS outbreak as a traumatic stress among frontline healthcare workers in Toronto: lessons learned. Philos. Trans. R. Soc. Lond. Ser. B Biol. Sci. 359, 1117–1125. doi: 10.1098/rstb.2004.1483

PubMed Abstract | CrossRef Full Text | Google Scholar

Maunder, R. G., Lancee, W. J., Balderson, K. E., Bennett, J. P., Borgundvaag, B., Evans, S., et al. (2006). Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg. Infect. Dis. 12:1924. doi: 10.3201/eid1212.060584

PubMed Abstract | CrossRef Full Text | Google Scholar

Moazzami, B., Razavi-Khorasani, N., Moghadam, A. D., Farokhi, E., and Rezaei, N. (2020). COVID-19 and telemedicine: immediate action required for maintaining healthcare providers well-being. J. Clin. Virol. 126:104345. doi: 10.1016/j.jcv.2020.104345

PubMed Abstract | CrossRef Full Text | Google Scholar

Mukhtar, S. (2020). Mental health and emotional impact of COVID-19: applying health belief model for medical staff to general public of Pakistan. Brain Behav. Immun. 87, 28–29. doi: 10.1016/j.bbi.2020.04.012

PubMed Abstract | CrossRef Full Text | Google Scholar

Pavan, A., and Palese, A. (2016). Disturbo da stress post traumatico nei pazienti adulti: revisione integrativa sui fattori biologici/Post traumatic stress disorders affecting adult patients: an integrative review on biological factors. Scenario 33:4.

Google Scholar

Petzold, M. B., Plag, J., and Ströhle, A. (2020). Umgang mit psychischer belastung bei gesundheitsfachkräften im rahmen der Covid-19-pandemie. Der. Nervenarzt. doi: 10.1007/s00115-020-00905-0 [Epub ahead of print],

CrossRef Full Text | PubMed Abstract | Google Scholar

Pourdowlat, G., Hejrati, R., and Lookzadeh, S. (2019). The effectiveness of relaxation training in the quality of life and anxiety of patients with asthma. Adv. Respirat. Med. 87, 146–151. doi: 10.5603/arm.2019.0024

PubMed Abstract | CrossRef Full Text | Google Scholar

Que, J., Le Shi, J. D., Liu, J., Zhang, L., Wu, S., Gong, Y., et al. (2020). Psychological impact of the COVID-19 pandemic on healthcare workers: a cross-sectional study in China. Gen. Psychiatry 33:e100259. doi: 10.1136/gpsych-2020-100259

PubMed Abstract | CrossRef Full Text | Google Scholar

Rispoli, L. (1999). La Valutazione Integrata Dello Stress. Milano: Franco Angeli.

Google Scholar

Rispoli, L. (2004). Esperienze di Base e Sviluppo del sé: L’evolutiva Nella Psicoterapia Funzionale. Milan: FrancoAngeli.

Google Scholar

Rispoli, L. (2016). Il Corpo in Psicoterapia Oggi. Neo-Funzionalismo e Sistemi Integrati: Neo-Funzionalismo e Sistemi Integrati. Milan: FrancoAngeli.

Google Scholar

Sasangohar, F., Jones, S. L., Masud, F. N., Vahidy, F. S., and Kash, B. A. (2020). Provider burnout and fatigue during the COVID-19 pandemic: lessons learned from a high-volume intensive care unit. Anesthes. Analges.

Google Scholar

Shanafelt, T., Ripp, J., and Trockel, M. (2020). Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 323, 2133–2134. doi: 10.1001/jama.2020.5893

PubMed Abstract | CrossRef Full Text | Google Scholar

Spoorthy, M. S., Pratapa, S. K., and Mahant, S. (2020). Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review. Asian J. Psychiatry 51:102119. doi: 10.1016/j.ajp.2020.102119

PubMed Abstract | CrossRef Full Text | Google Scholar

Styra, R., Hawryluck, L., Robinson, S., Kasapinovic, S., Fones, C., and Gold, W. L. (2008). Impact on health care workers employed in high-risk areas during the Toronto SARS outbreak. J. Psychosom. Res. 64, 177–183. doi: 10.1016/j.jpsychores.2007.07.015

PubMed Abstract | CrossRef Full Text | Google Scholar

Sultana, A., Sharma, R., Hossain, M., Bhattacharya, S., and Purohit, N. (2020). Burnout among healthcare providers during COVID-19: challenges and evidence based interventions. Indian J. Med. Ethics 4:73.

Google Scholar

Tarsha, M. S., Park, S., and Tortora, S. (2020). Body-centered interventions for psychopathological conditions: a review. Front. Psychol. 10:2907. doi: 10.3389/fpsyg.2019.02907

PubMed Abstract | CrossRef Full Text | Google Scholar

Thomas, J., Kneale, D., McKenzie, J. E., Brennan, S. E., and Bhaumik, S. (2019). “Determining the scope of the review and the questions it will address,” in Cochrane Handbook for Systematic Reviews of Interventions, eds J. P. T. Higgins, J. Thomas, J. Chandler, M. Cumpston, T. Li, M. J. Page, et al. (New York, NY: Wiley), 13–31. doi: 10.1002/9781119536604.ch2

CrossRef Full Text | Google Scholar

Tsitsi, T., Charalambous, A., Papastavrou, E., and Raftopoulos, V. (2017). Effectiveness of a relaxation intervention (progressive muscle relaxation and guided imagery techniques) to reduce anxiety and improve mood of parents of hospitalized children with malignancies: a randomized controlled trial in Republic of Cyprus and Greece. Eur. J. Oncol. Nurs. 26, 9–18. doi: 10.1016/j.ejon.2016.10.007

PubMed Abstract | CrossRef Full Text | Google Scholar

Wong, T. W., Yau, J. K., Chan, C. L., Kwong, R. S., Ho, S. M., Lau, C. C., et al. (2005). The psychological impact of severe acute respiratory syndrome outbreak on healthcare workers in emergency departments and how they cope. Eur. J. Emerg. Med. 12, 13–18. doi: 10.1097/00063110-200502000-00005

PubMed Abstract | CrossRef Full Text | Google Scholar

World Health Organization (2003). SARS Outbreak Contained Worldwide. Available online at: (accessed October 8, 2020).

Google Scholar

World Health Organization (2020). Mental Health and Psychosocial Considerations During the COVID-19 Outbreak, 18 March 2020. Geneva: World Health Organization.

Google Scholar

Wu, K. K., Chan, S. K., and Ma, T. M. (2005). Posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (SARS). J. Traum. Stress 18, 39–42. doi: 10.1002/jts.20004

PubMed Abstract | CrossRef Full Text | Google Scholar

Xiang, Y.-T., Yang, Y., Li, W., Zhang, L., Zhang, Q., Cheung, T., et al. (2020). Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 7, 228–229. doi: 10.1016/s2215-0366(20)30046-8

CrossRef Full Text | Google Scholar

Zinn, J. K. (1990). Full Catastrophe Living. New York, NY: DELTA Publishing.

Google Scholar

Keywords: COVID-19, coronavirus, health care workers, psychological intervention, stress reduction techniques, review

Citation: Callus E, Bassola B, Fiolo V, Bertoldo EG, Pagliuca S and Lusignani M (2020) Stress Reduction Techniques for Health Care Providers Dealing With Severe Coronavirus Infections (SARS, MERS, and COVID-19): A Rapid Review. Front. Psychol. 11:589698. doi: 10.3389/fpsyg.2020.589698

Received: 31 July 2020; Accepted: 04 November 2020;
Published: 10 December 2020.

Edited by:

Andrew E. P. Mitchell, University of Chester, United Kingdom

Reviewed by:

Jianjian Wang, Lanzhou University, China
Rachit Sharma, GRID Council Delhi NCR, India
Ruoyu Wang, University of Edinburgh, United Kingdom
Xianzhuo Zhang, Lanzhou University, China

Copyright © 2020 Callus, Bassola, Fiolo, Bertoldo, Pagliuca and Lusignani. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Edward Callus,

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