Our Work
Our Work
Our Work
COVID-19 on Healthcare
Professionals’ Psychological
Adjustment Skills: Mediating
Role of Experiential
Avoidance and Psychological
Resilience
https://
www.frontiersin.org/
articles/10.3389/
fpsyg.2020.561536/full
İsmail Seçer ,
1*
Sümeyye Ulaş and
2
Zeynep Karaman-Özlü As the3
There are also some characteristics that strengthen or make the individual’s
position disadvantageous in the face of difficult living conditions. In this
context, experiential avoidance can be shown as an important determining
variable among the variables that shape the level of exposure of the individual
to challenging life events. Experiential avoidance is defined as reluctance to
experience emotions, thoughts, moments and physical feelings that are
considered negative and avoidance responses to reduce the frequency or effect
of these experiences (Hayes et al., 1996). It is also expressed as the rigid and
unchangeable attitude that the individual adopts in the face of negativities and
is associated with various psychological problems in this aspect (Ottenbreit
and Dobson, 2004). This concept, which includes both different experiences
avoided and different strategies used for avoidance, also covers the cognitive,
emotional and behavioral dimensions of avoidance. In this sense, it is thought
that experiential avoidance has important effects on the psychological
adjustment skills of the individual in the short- and long-term. That is, facing
negative situations, the individual often uses a number of ways such as paying
attention to another direction, denial and repression, but these ways can
prepare an environment for the effects of the negativity avoided in the long
run to continue and the problems associated with it to become widespread
(Briggs and Price, 2009; Hayes et al., 2012). Accordingly, it can be said that
the possible avoidance responses due to the fear of COVID-19 can play an
important role in the emergence and persistence of many psychological
problems. There are only a limited number of studies addressing the
psychological effects of the COVID-19 outbreak on individual and public
health, as the problem is still new. However, limited studies indicate that
individuals show severe signs of adjustment disorders (Ornell et al.,
2020; Shigemura et al., 2020). Individuals naturally will try to get rid of this
problem through effective coping strategies. However, the secondary effects
developing due to the pandemic may become chronic in individuals who show
avoidance reactions with the effect of various psycho-social factors. The data
related to the literature support this idea. For example, Santanello and
Gardner (2007) and Mahaffey et al. (2013) determined that individuals with
high experiential avoidance have intense anxiety disorders. Cribb et al.
(2006) and Briggs and Price (2009) determined that they have
depression. Rawal et al. (2010) determined that they have eating
disorders, Orcutt et al. (2005) determined post-traumatic stress disorders,
and Machell et al. (2015) determined that low level of subjective well-being.
Therefore, it can be argued that the healthcare professionals’ avoidance
responses, which we can define as the dysfunctional coping approaches, are a
risk factor that can disrupt psychological adjustment skills in the short- and
long-term.
In line with the information related to the literature given above, it is clear
that the fear of COVID-19 poses a significant risk for its potential to disrupt
healthcare professionals’ psychological adjustment skills. This risk can be
expected to deepen in healthcare professionals with experiential avoidance.
On the other hand, it is thought that psychological resilience can strengthen
the position of healthcare professional in dealing with the negativity caused by
the epidemic. Accordingly, in this research, the effect of fear of getting COVID-
19 on the psychological adjustment levels of healthcare professionals was
examined through the mediating role of experiential avoidance and
psychological resilience. The results of the research are expected to contribute
to the understanding of the nature and consequences of secondary health
problems likely to develop due to the COVID-19 in healthcare professionals as
well as to expand our perspective on understanding individual risks and
protective factors. It is possible that this broadening in our perspective will
have important consequences for the development and implementation of
preventive and rehabilitative practices for healthcare professionals after the
pandemic. In this direction, answers to the questions given below were sought
within the scope of the research.
Brief Resilience Scale is a four-point likert type (never, rarely, often, and
always) assessment tool developed by Smith et al. (2008) and adapted to
Turkish culture by Doğan (2015). The scale consists of six items, and the high
scores indicate a high level of psychological resilience. The scores that can be
obtained from the scale range from 6 to 24 (Sample items are: “It does not
take me a long time to come to myself after stressful situations and I will
survive difficult times with very little trouble”). In this research, the construct
validity of the scale was reviewed, and it was determined that the model fit
indices (χ2/SD = 1.96; REMSEA = 0.062, RMR = 0.063, SRMR = 0.067, CFI =
0.98) were at a good level and internal consistency coefficient Cronbach alpha
= 0.91 were determined to be sufficient.
Results
Three different models were tested for the purposes of the research. In this
context, the research hypothesis first constructed as Model 1 as “Fear of
COVID-19 directly predicts psychological adjustment skills in healthcare
professionals” was tested. In this model, fear of COVID-19 is expected to
negatively and directly predict psychological adjustment skills in healthcare
professionals.
Discussion
In this study, in which the effect of fear developed due to the COVID-19
pandemic in healthcare professionals on psychological adjustment skills was
dealt in the context of experiential avoidance and psychological resilience, are
discussed by considering the constructed models.
In this context, the first important finding reached within the context of the
objectives of the research is the predictive role of the fear of COVID-19 on
psychological adjustment skills in healthcare professionals. The fear
developed in connection with COVID-19 has come to the forefront as an
important pressure tool on depressive symptoms, anxiety and stress, which
form psychological adjustment skills. During the pandemic with a traumatic
nature, healthcare professionals are likely to be affected by the pandemic
process and the adverse conditions they face in patients, both as an individual
and as a professional (Greenberg et al., 2020; Schwartz and Graham,
2020). Banerjee (2020); Ornell et al. (2020), Shigemura et al. (2020),
and Seçer and Ulaş (2020b) stated that the pandemic process should be
considered as a traumatic difficult life process. In this regard, it can be
thought that COVID-19 may affect psychological adjustment skills negatively
in the short and long term by triggering intense stress, anxiety and depressive
symptoms in healthcare professionals.
Findings obtained from the research reveal that fear of COVID-19 poses a risk
for psychological resilience in healthcare professionals. In this sense, the high
level of resilience appears to be a quality that protects the psychological
adjustment skills of healthcare professionals while reducing the risk of
COVID-19 on healthcare professionals. Therefore, it seems possible to limit or
even prevent the negative impact of the fear and anxiety created by the
epidemic on healthcare professionals through experiential avoidance-like
features with the help of psychological resilience. In this sense, it is thought
that emergency measures to improve the psychological resilience of healthcare
professionals may contribute to the prevention of negative effects that may
occur in the short and long term due to the epidemic. This will also strengthen
the psychological adjustment skills of healthcare professionals and activate the
effects that will strengthen their quality of life, life satisfaction and
professional commitment.
Shevaun D. Neupert 2
Studies out of China have examined the experiences of HCPs during the height
of their COVID-19 outbreak. In a sample of 1,563 medical staff workers in
China working during the COVID-19 pandemic, 73.4% reported stress-related
symptoms, 50.7% reported symptoms of depression, 44.7% reported anxiety,
and 36.1% reported experiencing insomnia (Liu et al., 2020). Lai et al.
(2020) found evidence for higher rates of anxiety, depression, and distress
among HCPs in Wuhan compared to HCPs in other regions in China. Other
studies examined the need for and impact of services offered to healthcare
workers, such as adjusting shifts to allow time for rest (Chen et al.,
2020; Kang et al., 2020).
While there have been several well-written opinion pieces and commentaries
regarding the well-being of healthcare workers in the United States during this
pandemic (Godderis et al., 2020; Gold, 2020; Greenberg et al., 2020), we are
aware of only one descriptive study with data from New York City (Shechter et
al., 2020) that did not include a control group. There have been several meta-
analyses and reviews of the impact of this pandemic on HCPs internationally
(Chew et al., 2020; Pappa et al., 2020; Rajkumar, 2020), but no studies from
the United States were available to be included in these studies. Previous
studies have shown that the mental health challenges HCPs face during
pandemics often impact their ability to continue to be part of the frontlines
working to help treat and care for patients and their own families (Maunder et
al., 2006; Shechter et al., 2020). Further, enduring psychological effects could
negatively impact their ability to provide patient care in the future as well as
impacting their quality of life (Goulia et al., 2010). A crucial mission for
researchers during this time is enhancing our understanding of the
experiences of HCPs in order to plan for interventions and care both in the
short-term (now) and in the long-term (over the next couple of years). The
current study is designed to examine several critical outcomes such as
depressive symptoms, anxiety (current general anxiety as well as anxiety about
developing COVID-19), COVID-related stress, and health in HCPs during the
early months of the COVID-19 pandemic across the entire United States. In
addition, we also examine potentially beneficial indicators of resilience such as
control beliefs and proactive coping.
Methods
Participants
Amazon Mechanical Turk (mturk.com) was used to recruit participants for a
larger study on the impact of COVID-19. MTurk is an international online
crowdsourcing panel administered by Amazon and used here for collecting
data. Potential participants responded to the description: The purpose of this
study is to examine how people living across the United States are reacting to
the current COVID-19 pandemic. Select the link below to complete the 30-min
survey. Participant requirements for the current study were as follows: 18
years of age or older, living in the United States, native English-speakers and
free from a dementia diagnosis. Once recruited and consented (see section
“Procedure”), the participants completed the survey through the Qualtrics
platform which is an online survey tool. The sample for the larger study
consisted of 1,000 participants. Participants answered “Yes” or “No” to the
question, “Are you a HCP?” Participants for the current study included all
participants who answered “Yes” to this question as well as age-matched
controls drawn from the same dataset. Because of concerns regarding age
differences in our health indicators, we age-matched the controls. The final
sample included 90 HCPs and 90 age-matched controls (Mage = 34.72
years, SD = 9.84, range = 23–67) from 35 states across the United States.
Sample characteristics, including type of HCP, are reported in Table 1.
TABLE 1
Demographics
COVID-19 Anxiety
COVID-19 Stress
Depressive Symptoms
Current Anxiety
Ten state anxiety items from the State-Trait Anxiety Inventory (Spielberger et
al., 1983) were rated on a four-point scale ranging from 1 (not at all) to 4 (very
much so). Participants indicated how they were feeling in the current moment.
Example items include “I am tense” and “I feel frightened.” Five items were
reverse coded. A mean was calculated across the 10 items with higher scores
indicating more state anxiety (α = 0.88).
Health
Tiredness
Control beliefs were measured using the mastery (four items, α = 0.84) and
constraint (eight items, α = 0.95) scales from the Sense of Control Scales from
the Midlife Development Inventory (Lachman and Weaver, 1998a). On a 1
(strongly disagree) to 7 (strongly agree) scale, participants rated their
agreement with statements such as “What happens in my life is often beyond
my control” (constraint) and “I can do just about anything I really set my mind
to” (mastery).
Proactive Coping
The Proactive Coping Scale (Aspinwall et al., 2005) includes six items rated on
a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). An
example item includes, “I prepare for adverse events.” One item was reverse
coded. Higher scores indicate more proactive coping (α = 0.71).
Stress Appraisals
Results
There were no significant differences between HCPs and the control group on
gender [χ2 (1, N = 180) = 0.00, p = 1.00] or race [χ2 (5, N = 180) = 5.65, p =
0.34]. As expected, there were significant differences on education [χ 2 (8, N =
180) = 16.61, p = 0.03] such that HCPs had more education than non-HCPs.
Results from the MANOVA (Table 2) controlling for education show that
HCPs reported significantly higher levels of depressive symptoms, current
anxiety, concern about their health, tiredness, constraint, and past and future
appraisal of COVID-related stress, but lower levels of proactive coping
compared to non-HCPs (Pillai’s Trace = 0.28, F(12,160) = 5.29, p < 0.001, η2 =
0.28). Of note, there were also no significant group differences on COVID-
related stress or on the specific anxiety of developing COVID-19.
TABLE 2
Discussion
This study is a timely look into the experiences of HCPs across the United
States during the COVID-19 pandemic. Using an age-matched comparison
group, the HCPs were significantly more depressed and generally anxious than
the non-HCPs during the first months of the pandemic. In line with Shechter
et al. (2020) who documented high rates of lack of control and sleep
disturbances within HCPs in New York City, our results show that HCPs
across the United States had significantly higher rates of lack of control and
tiredness compared to controls. Additionally, the HCP group on average fell
into the clinically depressed range on the GDS (Guerin et al., 2018). While
some of the other findings (e.g., fatigue) may represent the nature of
professional differences sometimes seen between HCPs and other professions
in non-pandemic times (Dyrbye et al., 2014), meeting the criteria for
depressive disorder should not. We believe that the heightened level of
depressive symptoms in HCPs may be due to not just occupational differences
but occupational differences during a pandemic. Clearly, this is of concern not
just for understanding and, perhaps, helping the current situation but also to
look ahead to the potential lasting influence of this experience (see Maunder
et al., 2006; Lee et al., 2007). It is well-understood that the long-term
consequences of depression and anxiety can create enduring negative impacts
(Sareen et al., 2005; Musliner et al., 2016). Finding ways to intervene and
support HCPs, such as cognitive behavioral therapy or support groups, will be
an important goal to healthcare systems and workplaces now and in the
future.
Along these same lines, the HCPs showed lower proactive coping and fewer
resources to dedicate to adaptive coping behaviors. We know from past work
that proactive coping (Polk et al., 2020) and control beliefs (Neupert et al.,
2007) are key ingredients for resilient stress responses, representing potential
targets for intervention. For instance, Stauder et al. (2017, 2018) found that
using coping skills training with employees from work-environments that
were stressful, but unchanging, helped reduce stress and improve well-being.
Ethics Statement
This study involved human participants was reviewed and approved by
Georgia Institute of Technology Office Research Integrity Assurance –
Institutional Review Board (Protocol # H20141). Written informed consent for
participation was not required for this study in accordance with the national
legislation and the institutional requirements for exempt studies.
Author Contributions
AP designed the study and funded it out of her internal funds and a grant both
from Georgia Tech, as well as manuscript writing. MH managed the online
portion of the project and the data, wrote the methods, helped to prepare the
references, and helped with primary prose. ES helped with data analyses,
created the tables, helped to prepare the references, and helped with primary
prose. SN helped with study design, primary data analyses, as well as
manuscript writing. All authors contributed to the article and approved the
submitted version.
Funding
This work was supported by Georgia Institute of Technology’s Executive Vice
President for Research COVID-19 Rapid Response Seed Grant Program to AP.
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.
References
ORIGINAL RESEARCH ARTICLE
Front. Psychol., 03 September 2020 | https://doi.org/10.3389/fpsyg.2020.566912
Coping With COVID-19:
Emergency Stress, Secondary
Trauma and Self-Efficacy in
Healthcare and Emergency
Workers in Italy
Monia Vagni, Tiziana Maiorano, Valeria Giostra and Daniela
Pajardi *
As regards the stress that they experience, the literature clearly explains that
healthcare and emergency workers who intervene in emergency situations are
exposed to the risk of developing dysfunctional reactions that can be identified
at different levels—physical and/or physiological (e.g., psychosomatic
disorders, sleep/wake cycle alterations, and sense of tiredness); emotional
(e.g., irritability, nervousness, agitation, anger, low self-esteem, and guilt);
cognitive (e.g., distractibility, sense of ineffectiveness, and negative
anticipation of events); and relational (e.g., increase in conflicts within
emergency teams and/or with their organization/institution, and social
withdrawal)—and may also develop reactions from secondary trauma (Del
Missier et al., 2008; Sbattella, 2009; Argentero and Setti, 2011; Fraccaroli and
Balducci, 2011; Bellelli and Di Schiena, 2012; Walton et al., 2020). Faced with
stressful events regarding which they lack previous experience and specific,
necessary knowledge, and which cause tension owing to the need for rapid
decision timings and a sense of responsibility, emergency workers may
experience a sense of decision ineffectiveness. In fact, emergency situations
are characterized by high levels of decisional and operational uncertainty with
associated regret and guilt (Del Missier et al., 2008).
According to Walton et al. (2020), the specific stressors that health workers
face in the COVID-19 emergency are related to the organizational context. The
challenges for medical staff include not only an increased workload but also a
fear of infection, the need to work with new protocols that change frequently,
and the use of PPE. In uncontrollable situations such as a pandemic, when
specific action protocols are absent and limited resources are available, health
workers must make individual decisions with a heavy burden of responsibility
that may be contrary to their moral principles. For example, in the case of
COVID-19, they may have to choose which patients to save because only a few
places are available in intensive care. In this regard, Cai et al. (2020) showed
that for a sample of 534 healthcare professionals who worked closely with
COVID-19 patients in Hubei, the most stressful factors were the lack of
protocols for the treatment of COVID-19, the scarcity of PPE, the exhausting
work shifts, their concern about the risk of infection, and their exposure to the
death and suffering of their patients. They also found that the support of
superiors proved to be one of the most important motivational factors for
medical staff, and the presence of clear guidelines and effective safety
protocols were protective factors against the development of stress, in
particular, for females. Further, Walton et al. (2020) identified the
organizational stressors as the changes in work shifts, the prevalence of night
shifts, an excessive workload, staff roles, autonomy, the lack of support from
superiors, and the absence of adequate information and clear instructions. On
the basis of these stressors, they estimated that 10% of the medical staff
working on the front line of this pandemic are at risk of developing post-
traumatic stress disorder (PTSD). In addition, limited resources, longer shifts,
decreased hours of rest, and the occupational risks associated with COVID-19
exposure have increased the physical and mental fatigue, stress, anxiety, and
burnout of these staff members (Sasangohar et al., 2020).
The sense of frustration and impotence felt by nurses when they are unable to
treat and save a patient has been highlighted as a risk factor for secondary
traumatic stress in several studies (Missouridou, 2017). Avoidance and
emotional numbing can become tools for self-protection from intrusive
symptoms that exceed the personal tolerance level (Coetzee and Klopper,
2010; Mealer and Jones, 2013). Their frustration obviously intensifies on a
patient’s death. The onset of PTSD in the health workers involved in treating
MERS was also detected after the acute phase of the emergency was over,
highlighting a risk not only in the immediate period but also in the medium-
term period (Lee et al., 2018).
In reference to COVID-19, updated studies conducted on Chinese health
workers have already highlighted the strong impact of the epidemic on the
psychological health of doctors and nurses. Some studies have found that
healthcare workers have high levels of anxiety, depression, insomnia, and
distress (Lai et al., 2020; Li et al., 2020; Zhu et al., 2020). In particular,
female professionals with more than 10 years of experience and previous
psychiatric pathology present more risk factors of developing the symptoms of
stress, anxiety, and depression (Lai et al., 2020; Zhu et al., 2020). Huang J. Z.
et al. (2020) studied stress levels during the COVID-19 emergency in a sample
of medical staff. They found that females showed higher levels of anxiety and
PTSD than males did and that the levels were higher for nurses than for
doctors. Moreover, Li et al. (2020) found that nurses had developed higher
levels of vicarious trauma than those of the general population and that nurses
who did not work closely with COVID-19 patients showed a more severe
symptomatology, both physical and psychological, compared with their
colleagues working on the frontline emergency services. In Italy, a study
conducted on healthcare workers found that doctors and nurses developed
high levels of stress and anxiety, greater than those developed by the general
population, and that healthcare workers operating in the North, the area of
Italy most affected by the virus, showed a more severe symptomatology
(Simione and Gnagnarella, 2020). This study also confirmed that females tend
to have a greater perception of the risk of infection, which increases their risk
of developing the symptoms of anxiety and distress.
The strategies used to cope with trauma may differ among individuals, but
they can also vary according to the profession and the features of the
traumatic event (Nydegger et al., 2011). Individuals differ in their choice of
coping strategies (Connor-Smith and Flachsbart, 2007), and factors related to
the situation can also have a decisive influence on such choice (Brown et al.,
2002). A few studies have considered the ways in which gender influences the
perception of stress in emergency situations and the choice of coping strategy.
These studies highlight that females tend to perceive events as more negative
and uncontrollable and to resort more to coping strategies focused on
emotions and avoidance, whereas males tend to resort more to applying
problem-focused coping and to inhibiting emotions (Matud, 2004; Matud et
al., 2015; Matud and Garcia, 2019).
The literature on the relationship between coping strategies and the stress
levels of emergency workers has shown that the use of coping strategies
focused on the problem usually tends to correlate with lower stress levels, both
in healthcare workers (Watson et al., 2008; Howlett et al., 2015) and in other
emergency workers, such as firefighters (Brown et al., 2002). However, a
coping strategy frequently used by emergency workers is that of avoidance and
minimization, and this strategy is associated with higher levels of stress
(Brown et al., 2002; Chang et al., 2003; Kerai et al., 2017; Witt et al.,
2018; Theleritis et al., 2020). Loo et al. (2016) found that in a group of
emergency workers, avoidance as well as coping strategies focused on
emotions were associated with the development of post-traumatic
symptomatology. Rodríguez-Rey et al. (2019) revealed that among health
workers working in a pediatric emergency department, approximately 30% of
the variance in PTSD was explained by the frequent use of coping strategies
focused on emotions and the infrequent use of those focused on the problem.
In addition, Kucmin et al. (2018), who considered a sample of 440
paramedics, highlighted that the risk of developing PTSD symptoms was
predicted by the use of coping strategies focused on emotions.
Further, a few studies have investigated the coping strategies that emergency
workers can use during health emergencies similar to COVID-19. Maunder et
al. (2006) revealed that healthcare professionals who tended to apply
dysfunctional coping strategies, based on avoidance, hostile comparison, or
self-blame, tended to develop higher stress levels. Wong et al.
(2005) highlighted that during the SARS epidemic, doctors and nurses tended
to use different coping strategies. The doctors tended to turn more to action
planning, but this strategy did not affect their stress level. Instead, their stress
level was positively correlated with their use of coping strategies based on
emotional outlets. By contrast, the nursing staff tended to resort more to
behavioral disengagement and distraction strategies, which, however,
correlated with higher levels of stress among them.
In this regard, during the MERS epidemic, hospital staff tended to adopt
coping strategies related to the use of PPE and the adoption of all prevention
measures, as well as social support, whereas the coping strategy that they
adopted the least was that based on an emotional outlet (Khalid et al., 2016). A
recent study on healthcare workers in Hubei, China, during the COVID-19
epidemic (Cai et al., 2020), yielded similar results: to reduce stress, the
medical staff tended to rely on active coping strategies, such as using security
protocols, practicing social isolation measures, and seeking support from
family and friends, but they did not find it necessary to discuss their emotions
with a professional. Huang L. et al. (2020) found that a sample of nurses
working during the COVID-19 emergency presented greater emotional
reactions and turned more to problem-focused coping compared with
university nursing students. Emergency workers must have sufficient self-
efficacy in terms of their coping skills to be able to manage and cope with
stress levels. Self-efficacy in coping appears to be an effective protective factor
in relation to stress levels and maladaptive responses (Chesney et al., 2006).
Self-efficacy to cope with traumatic events has been effective in reducing the
risk of developing PTSD (Bosmans et al., 2015).
Based on results found in the literature, the specific objectives of this study are
as follows:
(1) To examine the relationships between coping strategies, emergency stress,
and secondary trauma in healthcare and emergency workers.
(2) To identify significant differences in stress factors, coping strategies, and
secondary trauma between two groups—health workers and emergency
workers.
(3) To analyze the predictive power of coping strategies on the various levels
of stress.
(4) To analyze the predictive power of stress factors on the levels of arousal
and intrusion of secondary trauma.
(5) To analyze the predictive power of coping strategies on the levels of
arousal and intrusion of secondary trauma.
Method
Participants
Procedure
This study used an online questionnaire and was conducted during the
lockdown period owing to the COVID-19 pandemic. The questionnaire had
three parts: one each to collect online informed consent and baseline
sociodemographic information, and one with an online series of
questionnaires, as described in the next section. Participants’ anonymity was
maintained in collecting the data. The institutional Ethics Committee
approved all the procedures.
Materials
We administered a series of questionnaires to evaluate the psychological stress
and coping style of each participant. We included the following
questionnaires.
Our analysis of the literature revealed that in situations in which they have to
cope with a pandemic, several factors may affect the stress of medical staff and
emergency healthcare workers and that COVID-19 represents an independent
specific stressor (Spoorthy, 2020). These stress factors have been identified as
frequently affecting healthcare and emergency workers in emergency
situations and leading to physical, emotional, cognitive, decision-making,
relational, and organizational stress (Del Missier et al., 2008; Sbattella,
2009; Argentero and Setti, 2011; Fraccaroli and Balducci, 2011; Bellelli and Di
Schiena, 2012; Du et al., 2020; Walton et al., 2020). Focusing on the
specificity of the COVID-19 epidemic, items have been constructed regarding
the fears of contracting the infection and of infecting colleagues or family
members (Walton et al., 2020), since COVID-19 represents a factor of
independent stress (Spoorthy, 2020) that has great impact (Huang J. Z. et al.,
2020). Consequently, we constructed the ESQ consisting of 33 items assessed
on a 5-point Likert scale, with scores ranging from 0 (not at all) to 4 (very
much), grouped into six scales. The participants were asked to indicate how
often they experienced certain emotions and thoughts while performing
intervention and emergency activities during the COVID-19 pandemic.
The ESQ demonstrated good internal consistency (α = 0.93) overall and for
each individual scale: Organizational–Relational Stress (α = 0.71), Physical
Stress (α = 0.82), Inefficacy Decisional Stress (α = 0.80), Emotional Stress (α
= 0.86), Cognitive stress (α = 0.72), and COVID-19 Stress (α = 0.80).
Statistical Strategy Explanation
First, we performed Pearson’s correlation analyses to identify the associations
between the variables for the two groups that we considered in this study.
Subsequently, we checked for significant differences between the two groups
as their stress levels, coping strategies, and secondary trauma. We used
hierarchical linear regression models to verify the predictive effect of the risk
factors (lack of adequate information and PPE) on the different stress levels
(in step 1). Then, we verified the protective effect of the coping strategies (in
step 2). The models were controlled for age, gender, and group. Lastly, we
used hierarchical regression models to verify the predictive effect of stress
factors on the components of secondary trauma. The models were controlled
for age, gender, and group.
Results
First, we conducted correlational analyses and comparisons of averages on the
reference sample. Table 1 shows the correlations between the scales of the ESQ
and the other instruments.
TABLE 1
To test the predictive effect of the coping strategies on various levels of stress,
hierarchical regression was conducted. Considering the Age and Gender
differences within the groups, we included these variables in all models
together with the Group variable (Health vs. Emergency) and the
“Instructions” and “Equipment” variables. The models generated by assuming
the ESQ scales as dependent variables are shown in Table 3. Regarding the
coping strategies, we observed an important effect of the Stop Unpleasant
Emotions and Thoughts Coping strategy on all the stress scales, except for
Physical Stress where the effect of the Focused Problem Coping strategy is
recorded.
TABLE 3
Discussion
The results of this study show that healthcare and emergency workers both
experienced high stressors during the COVID-19 epidemic, exposing them to
the risk of developing secondary trauma (Dominguez-Gomez and Rutledge,
2009; Argentero and Setti, 2011; Adriaenssens et al., 2012; Duffy et al.,
2015; Aisling et al., 2016; Morrison and Joy, 2016; Wolf et al., 2016; Roden-
Foreman et al., 2017; Lai et al., 2020; Li et al., 2020; Zhu et al., 2020). We
found significant differences between the two groups regarding their reactions
and their levels of organizational, physical, and relational stress, their sense of
decision-making, and their emotional and cognitive ineffectiveness. Compared
with emergency workers, healthcare workers had higher stress levels, leading
them to perceive more serious tensions and difficulties in teamwork, physical
fatigue, somatic illnesses, irritability, and difficulty in maintaining control
over the situation, in taking decisions, and in predicting the consequences of
their actions. Higher levels of stress have been reported related to the fears of
contracting COVID-19 and of infecting family members. In line with other
studies, we found that the COVID-19 emergency led health workers, in
particular, to perceive specific stress factors that affected the organizational
area, with consequences in terms of tension in teamwork and a sense of
ineffectiveness since they had to intervene without sufficient tools and
resources. They also experienced deep emotional reactions of anger,
powerlessness, and frustration with inevitable cognitive stress, in terms of
increased arousal levels. Many of the healthcare workers also developed
physical stress, due not only to the lack of sleep but also to the possible forms
of somatization of the psycho-emotional tension they perceived (Sasangohar
et al., 2020; Walton et al., 2020).
The differences recorded between the two groups in stress levels may be
explained by taking into account, for example, the fact that the Emergency
Group perceived their intervention with a greater sense of continuity in their
usual procedures compared with the Health Group. The former performed
their usual activities on the organizational, cognitive, and procedural levels,
although with greater levels of safety and self-protection and a greater
frequency of interventions. Conversely, the Health Group had to reorganize
aspects such as departments, teams, and shifts to cope with the emergency,
which thus involved making radical changes. In addition, the Health Group
helplessly witnessed a large number of deaths of their patients and had to
make decisions in conflict with their moral sense and in situations of
insecurity and unpredictability regarding the consequences of their actions
(Cai et al., 2020; Walton et al., 2020). However, in terms of physical stress,
there was no predictive effect of the group, which indicates that the Health
and Emergency Groups were both exposed to very similar physical stressors.
Above all, the lack of PPE affected the sense of making the right decisions, the
emotional sphere and, most importantly, the fear of contracting the virus or of
transmitting it to their families. These results converge with those of other
studies that have highlighted that the lack of adequate and specific
information and of equipment for healthcare staff in dealing with COVID-19
affected their self-efficacy and the factors protecting them from stress, thus
increasing their fear of contracting an infectious disease and causing them
greater emotional, decisional, and physical stress. Conversely, the
professionals who were provided with the necessary knowledge and
equipment were more resilient during the emergency response (Du et al.,
2020; Huang J. Z. et al., 2020; Ornell et al., 2020; Walton et al., 2020). The
lack of specific equipment and instruments in emergency situations along with
the risk of infection increases the feeling of poor control, leading to cognitive
and emotional stress and a sense of ineffectiveness (Placentino and Scarcella,
2001; Walton et al., 2020). Higher levels of stress were found in the Health
Group than in the Emergency Group because of the absence of PPE, the risk of
infection from the virus, and the lack of necessary instructions or prompt
information (Cai et al., 2020). The incidence of these variables is contained
and limited by the use of coping strategies.
The coping strategy that assumes a predictive effect, reducing stress levels, is
to block those negative or unpleasant emotions and thoughts associated with
the risk of developing secondary trauma. In fact, the use of the Stop
Unpleasant Emotions and Thoughts strategy reduces the Arousal and
Intrusion levels of the secondary trauma. The effectiveness of this strategy in
reducing the Arousal levels appeared to be greater in the Health Group.
As Fraccaroli and Balducci (2011) suggested, in situations of high emergency
stress, healthcare workers and emergency workers may have a deficit in the
cognitive process of emotions, thus failing to identify their emotional
reactions, which tends to be associated with maladaptive behaviors. The lack
of a complete recognition of one’s unpleasant emotions, which tends to be
denied and dismissed as a coping strategy, would explain the greater
predictive impact of cognitive stress and physical stress on post-traumatic
arousal compared with emotional stress.
Further, the results of this study highlight that the Stop Unpleasant Emotions
and Thoughts strategy has an inhibitory and therefore effective and highly
significant impact on the stress levels and the components of secondary
trauma, unlike the problem-focused and social support strategies. The
literature points out that the avoidant matrix coping strategies tend to present
themselves when healthcare and emergency workers experience a condition of
fatigue and exhaustion, and this would explain the presence of the greater
acute stress responses in healthcare workers (Maunder et al., 2006; Young et
al., 2014).
The results of this study show that the problem-focused coping strategy (the
strategy most frequently used in the Health Group in line with the finding
of Huang L. et al., 2020) in this emergency situation did not appear to
demonstrate protective efficacy. This is likely to be because the workers were
dealing with an emergency that was not yet fully understood and the
therapeutic and treatment procedures were not fully known. Moreover, the
supply of PPE was scarce, especially in the first few weeks of the COVID-19
emergency in Italy, in all hospitals (e.g., a lack of respirators and insufficient
number of resuscitation beds), which meant that the level of protective
efficacy of this strategy may have been lower than the stress levels.
The government lockdown and the consequent restriction of visits outside the
working environment limited the use of coping strategies involving social
support, family, and friends, implying a greater use of emotional and cognitive
avoidance methods to deal with anguished thoughts, intrusive memories, and
the constant vision of corpses or the seriously ill. In this regard, the Health
Group appears to have developed a greater secondary trauma arousal than the
Emergency Group. By contrast, the latter appears to have developed more
aspects of intrusiveness related to secondary or vicarious trauma than the
Health Group (see Table 2).
Since they were interviewed during the COVID-19 emergency, the healthcare
and emergency workers who participated in the present study do not appear to
have developed a complete secondary trauma. This may explain the prediction
of the stress factors on arousal and not on intrusion. In other words, these
individuals were interviewed while the emergency was still in the acute phase
and before a structuring of answers in a psychopathological sense could be
performed. Therefore, performing a follow-up study would be interesting.
PTSD can take several months to fully emerge, and its stabilization can
depend on the individual’s internal as well as external factors.
Ethics Statement
The studies involving human participants were reviewed and approved by
Comitato Etico per la Sperimentazione Umana – CESU of the University of
Urbino. The patients/participants provided their written informed consent to
participate in this study.
Author Contributions
MV, TM, VG, and DP: conceptualization, writing – original draft preparation,
and writing – review and editing. MV, TM, and VG: methodology and
investigation. MV and TM: formal analysis and data curation. TM and VG:
visualization. MV, TM, and DP: project administration. All authors
contributed to the article and approved the submitted version.
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.
Acknowledgments
We would like to thank all the participants involved for the contribution they
made to this study during this serious emergency.
https://www.frontiersin.org/articles/10.3389/fpsyg.2020.566912/
fullORIGINAL RESEARCH ARTICLE
Front. Psychol., 03 September 2020 | https://doi.org/10.3389/fpsyg.2020.566912
risk factor for the psychological distress of health workers. Hence, this
study explores the relationship between coping strategies used by
healthcare and emergency workers in Italy to manage the stress
factors related to the COVID-19 emergency, which may result in the
risk of developing secondary trauma. We study differences between
healthcare (n = 121) and emergency workers (n = 89) in terms of their
coping strategies, emergency stress, and secondary trauma, as well as
the relationships of these differences to demographic variables and
other stress factors (Instructions and Equipment). For this purpose,
we collected data from participants through the following
questionnaires online: Secondary Traumatic Stress Scale – Italian
Version, The Coping Self-Efficacy Scale – Short Form, an original
questionnaire on stressors, and the Emergency Stress
Questionnaire (to assess organizational–relational, physical,
decisional inefficacy, emotional, cognitive, and COVID-19 stress). We
performed a t-test, correlational analysis, and hierarchical regression.
The analyses reveal that compared with the emergency worker group,
the health worker group has greater levels of emergency stress and
arousal and is more willing to use problem-focused coping. Healthcare
workers involved in the treatment of COVID-19 are exposed to a large
degree of stress and could experience secondary trauma; hence, it is
essential to plan prevention strategies for future pandemic situations.
Moreover, individual efficacy in stopping negative emotions and
thoughts could be a protective strategy against stress and secondary
trauma.
Introduction
The coronavirus disease (COVID-19), or the acute respiratory disease caused
by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), began
spreading in China at the end of 2019 and, to date, represents an international
health emergency without precedents in terms of its health, economic, and
organizational effects on people’s lives (World Health Organization, 2020).
After China, Italy was the first country to be affected by this epidemic, with the
first deaths on February 20, 2020, and a rapid increase in the spread of
infection and mortality. COVID-19 was first detected in Northern Italy, and it
then spread, although at different rates of incidence, to the other regions. It
was immediately evident that healthcare and emergency workers were at great
risk of contagion and that protection and intervention protocols needed to be
introduced in the absence of adequate points of reference because of the
exceptional nature of the epidemic, the rate of spread of the infection, the
seriousness of patients’ health condition, and the mortality index. The extreme
conditions in which health workers have had to work, especially in the most
affected regions in Northern Italy, are indicated by the following data from the
Italian National Institute of Health (2020): over 150 doctors died and 25,000
other health workers were infected within the general context of the
population of 30,000 deaths and 220,000 infections in a span of 11 weeks. It
was also clear that the medical staff would experience serious psychological
repercussions because of the working conditions as well as the difficulty of
having scientific points of reference on care and intervention procedures. To
this must be added the increase in workload, the extension of working hours
and, for health workers, the frequent exposure to the suffering and death of
their patients. Therefore, healthcare and emergency workers were subjected to
serious psychological as well as physical stress. Hence, the aim of this study,
which was also the aim of a previous study (Vagni et al., 2020), is to focus on
the similarities and the differences in the stress management of two
professional groups—healthcare and emergency workers—during the acute
phase of the pandemic. Both groups have had to deal with COVID patients as
frontline responders and have been exposed to the related risks of infection
and psychological consequences, which, to date, have not been examined in
detail through a comparative analysis.
As regards the stress that they experience, the literature clearly explains that
healthcare and emergency workers who intervene in emergency situations are
exposed to the risk of developing dysfunctional reactions that can be identified
at different levels—physical and/or physiological (e.g., psychosomatic
disorders, sleep/wake cycle alterations, and sense of tiredness); emotional
(e.g., irritability, nervousness, agitation, anger, low self-esteem, and guilt);
cognitive (e.g., distractibility, sense of ineffectiveness, and negative
anticipation of events); and relational (e.g., increase in conflicts within
emergency teams and/or with their organization/institution, and social
withdrawal)—and may also develop reactions from secondary trauma (Del
Missier et al., 2008; Sbattella, 2009; Argentero and Setti, 2011; Fraccaroli and
Balducci, 2011; Bellelli and Di Schiena, 2012; Walton et al., 2020). Faced with
stressful events regarding which they lack previous experience and specific,
necessary knowledge, and which cause tension owing to the need for rapid
decision timings and a sense of responsibility, emergency workers may
experience a sense of decision ineffectiveness. In fact, emergency situations
are characterized by high levels of decisional and operational uncertainty with
associated regret and guilt (Del Missier et al., 2008).
According to Walton et al. (2020), the specific stressors that health workers
face in the COVID-19 emergency are related to the organizational context. The
challenges for medical staff include not only an increased workload but also a
fear of infection, the need to work with new protocols that change frequently,
and the use of PPE. In uncontrollable situations such as a pandemic, when
specific action protocols are absent and limited resources are available, health
workers must make individual decisions with a heavy burden of responsibility
that may be contrary to their moral principles. For example, in the case of
COVID-19, they may have to choose which patients to save because only a few
places are available in intensive care. In this regard, Cai et al. (2020) showed
that for a sample of 534 healthcare professionals who worked closely with
COVID-19 patients in Hubei, the most stressful factors were the lack of
protocols for the treatment of COVID-19, the scarcity of PPE, the exhausting
work shifts, their concern about the risk of infection, and their exposure to the
death and suffering of their patients. They also found that the support of
superiors proved to be one of the most important motivational factors for
medical staff, and the presence of clear guidelines and effective safety
protocols were protective factors against the development of stress, in
particular, for females. Further, Walton et al. (2020) identified the
organizational stressors as the changes in work shifts, the prevalence of night
shifts, an excessive workload, staff roles, autonomy, the lack of support from
superiors, and the absence of adequate information and clear instructions. On
the basis of these stressors, they estimated that 10% of the medical staff
working on the front line of this pandemic are at risk of developing post-
traumatic stress disorder (PTSD). In addition, limited resources, longer shifts,
decreased hours of rest, and the occupational risks associated with COVID-19
exposure have increased the physical and mental fatigue, stress, anxiety, and
burnout of these staff members (Sasangohar et al., 2020).
The sense of frustration and impotence felt by nurses when they are unable to
treat and save a patient has been highlighted as a risk factor for secondary
traumatic stress in several studies (Missouridou, 2017). Avoidance and
emotional numbing can become tools for self-protection from intrusive
symptoms that exceed the personal tolerance level (Coetzee and Klopper,
2010; Mealer and Jones, 2013). Their frustration obviously intensifies on a
patient’s death. The onset of PTSD in the health workers involved in treating
MERS was also detected after the acute phase of the emergency was over,
highlighting a risk not only in the immediate period but also in the medium-
term period (Lee et al., 2018).
The strategies used to cope with trauma may differ among individuals, but
they can also vary according to the profession and the features of the
traumatic event (Nydegger et al., 2011). Individuals differ in their choice of
coping strategies (Connor-Smith and Flachsbart, 2007), and factors related to
the situation can also have a decisive influence on such choice (Brown et al.,
2002). A few studies have considered the ways in which gender influences the
perception of stress in emergency situations and the choice of coping strategy.
These studies highlight that females tend to perceive events as more negative
and uncontrollable and to resort more to coping strategies focused on
emotions and avoidance, whereas males tend to resort more to applying
problem-focused coping and to inhibiting emotions (Matud, 2004; Matud et
al., 2015; Matud and Garcia, 2019).
The literature on the relationship between coping strategies and the stress
levels of emergency workers has shown that the use of coping strategies
focused on the problem usually tends to correlate with lower stress levels, both
in healthcare workers (Watson et al., 2008; Howlett et al., 2015) and in other
emergency workers, such as firefighters (Brown et al., 2002). However, a
coping strategy frequently used by emergency workers is that of avoidance and
minimization, and this strategy is associated with higher levels of stress
(Brown et al., 2002; Chang et al., 2003; Kerai et al., 2017; Witt et al.,
2018; Theleritis et al., 2020). Loo et al. (2016) found that in a group of
emergency workers, avoidance as well as coping strategies focused on
emotions were associated with the development of post-traumatic
symptomatology. Rodríguez-Rey et al. (2019) revealed that among health
workers working in a pediatric emergency department, approximately 30% of
the variance in PTSD was explained by the frequent use of coping strategies
focused on emotions and the infrequent use of those focused on the problem.
In addition, Kucmin et al. (2018), who considered a sample of 440
paramedics, highlighted that the risk of developing PTSD symptoms was
predicted by the use of coping strategies focused on emotions.
Further, a few studies have investigated the coping strategies that emergency
workers can use during health emergencies similar to COVID-19. Maunder et
al. (2006) revealed that healthcare professionals who tended to apply
dysfunctional coping strategies, based on avoidance, hostile comparison, or
self-blame, tended to develop higher stress levels. Wong et al.
(2005) highlighted that during the SARS epidemic, doctors and nurses tended
to use different coping strategies. The doctors tended to turn more to action
planning, but this strategy did not affect their stress level. Instead, their stress
level was positively correlated with their use of coping strategies based on
emotional outlets. By contrast, the nursing staff tended to resort more to
behavioral disengagement and distraction strategies, which, however,
correlated with higher levels of stress among them.
In this regard, during the MERS epidemic, hospital staff tended to adopt
coping strategies related to the use of PPE and the adoption of all prevention
measures, as well as social support, whereas the coping strategy that they
adopted the least was that based on an emotional outlet (Khalid et al., 2016). A
recent study on healthcare workers in Hubei, China, during the COVID-19
epidemic (Cai et al., 2020), yielded similar results: to reduce stress, the
medical staff tended to rely on active coping strategies, such as using security
protocols, practicing social isolation measures, and seeking support from
family and friends, but they did not find it necessary to discuss their emotions
with a professional. Huang L. et al. (2020) found that a sample of nurses
working during the COVID-19 emergency presented greater emotional
reactions and turned more to problem-focused coping compared with
university nursing students. Emergency workers must have sufficient self-
efficacy in terms of their coping skills to be able to manage and cope with
stress levels. Self-efficacy in coping appears to be an effective protective factor
in relation to stress levels and maladaptive responses (Chesney et al., 2006).
Self-efficacy to cope with traumatic events has been effective in reducing the
risk of developing PTSD (Bosmans et al., 2015).
Based on results found in the literature, the specific objectives of this study are
as follows:
Participants
Procedure
This study used an online questionnaire and was conducted during the
lockdown period owing to the COVID-19 pandemic. The questionnaire had
three parts: one each to collect online informed consent and baseline
sociodemographic information, and one with an online series of
questionnaires, as described in the next section. Participants’ anonymity was
maintained in collecting the data. The institutional Ethics Committee
approved all the procedures.
Materials
We administered a series of questionnaires to evaluate the psychological stress
and coping style of each participant. We included the following
questionnaires.
Our analysis of the literature revealed that in situations in which they have to
cope with a pandemic, several factors may affect the stress of medical staff and
emergency healthcare workers and that COVID-19 represents an independent
specific stressor (Spoorthy, 2020). These stress factors have been identified as
frequently affecting healthcare and emergency workers in emergency
situations and leading to physical, emotional, cognitive, decision-making,
relational, and organizational stress (Del Missier et al., 2008; Sbattella,
2009; Argentero and Setti, 2011; Fraccaroli and Balducci, 2011; Bellelli and Di
Schiena, 2012; Du et al., 2020; Walton et al., 2020). Focusing on the
specificity of the COVID-19 epidemic, items have been constructed regarding
the fears of contracting the infection and of infecting colleagues or family
members (Walton et al., 2020), since COVID-19 represents a factor of
independent stress (Spoorthy, 2020) that has great impact (Huang J. Z. et al.,
2020). Consequently, we constructed the ESQ consisting of 33 items assessed
on a 5-point Likert scale, with scores ranging from 0 (not at all) to 4 (very
much), grouped into six scales. The participants were asked to indicate how
often they experienced certain emotions and thoughts while performing
intervention and emergency activities during the COVID-19 pandemic.
The ESQ demonstrated good internal consistency (α = 0.93) overall and for
each individual scale: Organizational–Relational Stress (α = 0.71), Physical
Stress (α = 0.82), Inefficacy Decisional Stress (α = 0.80), Emotional Stress (α
= 0.86), Cognitive stress (α = 0.72), and COVID-19 Stress (α = 0.80).
Statistical Strategy Explanation
First, we performed Pearson’s correlation analyses to identify the associations
between the variables for the two groups that we considered in this study.
Subsequently, we checked for significant differences between the two groups
as their stress levels, coping strategies, and secondary trauma. We used
hierarchical linear regression models to verify the predictive effect of the risk
factors (lack of adequate information and PPE) on the different stress levels
(in step 1). Then, we verified the protective effect of the coping strategies (in
step 2). The models were controlled for age, gender, and group. Lastly, we
used hierarchical regression models to verify the predictive effect of stress
factors on the components of secondary trauma. The models were controlled
for age, gender, and group.
Results
First, we conducted correlational analyses and comparisons of averages on the
reference sample. Table 1 shows the correlations between the scales of the ESQ
and the other instruments.
TABLE 1
To test the predictive effect of the coping strategies on various levels of stress,
hierarchical regression was conducted. Considering the Age and Gender
differences within the groups, we included these variables in all models
together with the Group variable (Health vs. Emergency) and the
“Instructions” and “Equipment” variables. The models generated by assuming
the ESQ scales as dependent variables are shown in Table 3. Regarding the
coping strategies, we observed an important effect of the Stop Unpleasant
Emotions and Thoughts Coping strategy on all the stress scales, except for
Physical Stress where the effect of the Focused Problem Coping strategy is
recorded.
TABLE 3
Discussion
The results of this study show that healthcare and emergency workers both
experienced high stressors during the COVID-19 epidemic, exposing them to
the risk of developing secondary trauma (Dominguez-Gomez and Rutledge,
2009; Argentero and Setti, 2011; Adriaenssens et al., 2012; Duffy et al.,
2015; Aisling et al., 2016; Morrison and Joy, 2016; Wolf et al., 2016; Roden-
Foreman et al., 2017; Lai et al., 2020; Li et al., 2020; Zhu et al., 2020). We
found significant differences between the two groups regarding their reactions
and their levels of organizational, physical, and relational stress, their sense of
decision-making, and their emotional and cognitive ineffectiveness. Compared
with emergency workers, healthcare workers had higher stress levels, leading
them to perceive more serious tensions and difficulties in teamwork, physical
fatigue, somatic illnesses, irritability, and difficulty in maintaining control
over the situation, in taking decisions, and in predicting the consequences of
their actions. Higher levels of stress have been reported related to the fears of
contracting COVID-19 and of infecting family members. In line with other
studies, we found that the COVID-19 emergency led health workers, in
particular, to perceive specific stress factors that affected the organizational
area, with consequences in terms of tension in teamwork and a sense of
ineffectiveness since they had to intervene without sufficient tools and
resources. They also experienced deep emotional reactions of anger,
powerlessness, and frustration with inevitable cognitive stress, in terms of
increased arousal levels. Many of the healthcare workers also developed
physical stress, due not only to the lack of sleep but also to the possible forms
of somatization of the psycho-emotional tension they perceived (Sasangohar
et al., 2020; Walton et al., 2020).
The differences recorded between the two groups in stress levels may be
explained by taking into account, for example, the fact that the Emergency
Group perceived their intervention with a greater sense of continuity in their
usual procedures compared with the Health Group. The former performed
their usual activities on the organizational, cognitive, and procedural levels,
although with greater levels of safety and self-protection and a greater
frequency of interventions. Conversely, the Health Group had to reorganize
aspects such as departments, teams, and shifts to cope with the emergency,
which thus involved making radical changes. In addition, the Health Group
helplessly witnessed a large number of deaths of their patients and had to
make decisions in conflict with their moral sense and in situations of
insecurity and unpredictability regarding the consequences of their actions
(Cai et al., 2020; Walton et al., 2020). However, in terms of physical stress,
there was no predictive effect of the group, which indicates that the Health
and Emergency Groups were both exposed to very similar physical stressors.
Above all, the lack of PPE affected the sense of making the right decisions, the
emotional sphere and, most importantly, the fear of contracting the virus or of
transmitting it to their families. These results converge with those of other
studies that have highlighted that the lack of adequate and specific
information and of equipment for healthcare staff in dealing with COVID-19
affected their self-efficacy and the factors protecting them from stress, thus
increasing their fear of contracting an infectious disease and causing them
greater emotional, decisional, and physical stress. Conversely, the
professionals who were provided with the necessary knowledge and
equipment were more resilient during the emergency response (Du et al.,
2020; Huang J. Z. et al., 2020; Ornell et al., 2020; Walton et al., 2020). The
lack of specific equipment and instruments in emergency situations along with
the risk of infection increases the feeling of poor control, leading to cognitive
and emotional stress and a sense of ineffectiveness (Placentino and Scarcella,
2001; Walton et al., 2020). Higher levels of stress were found in the Health
Group than in the Emergency Group because of the absence of PPE, the risk of
infection from the virus, and the lack of necessary instructions or prompt
information (Cai et al., 2020). The incidence of these variables is contained
and limited by the use of coping strategies.
The coping strategy that assumes a predictive effect, reducing stress levels, is
to block those negative or unpleasant emotions and thoughts associated with
the risk of developing secondary trauma. In fact, the use of the Stop
Unpleasant Emotions and Thoughts strategy reduces the Arousal and
Intrusion levels of the secondary trauma. The effectiveness of this strategy in
reducing the Arousal levels appeared to be greater in the Health Group.
As Fraccaroli and Balducci (2011) suggested, in situations of high emergency
stress, healthcare workers and emergency workers may have a deficit in the
cognitive process of emotions, thus failing to identify their emotional
reactions, which tends to be associated with maladaptive behaviors. The lack
of a complete recognition of one’s unpleasant emotions, which tends to be
denied and dismissed as a coping strategy, would explain the greater
predictive impact of cognitive stress and physical stress on post-traumatic
arousal compared with emotional stress.
Further, the results of this study highlight that the Stop Unpleasant Emotions
and Thoughts strategy has an inhibitory and therefore effective and highly
significant impact on the stress levels and the components of secondary
trauma, unlike the problem-focused and social support strategies. The
literature points out that the avoidant matrix coping strategies tend to present
themselves when healthcare and emergency workers experience a condition of
fatigue and exhaustion, and this would explain the presence of the greater
acute stress responses in healthcare workers (Maunder et al., 2006; Young et
al., 2014).
The results of this study show that the problem-focused coping strategy (the
strategy most frequently used in the Health Group in line with the finding
of Huang L. et al., 2020) in this emergency situation did not appear to
demonstrate protective efficacy. This is likely to be because the workers were
dealing with an emergency that was not yet fully understood and the
therapeutic and treatment procedures were not fully known. Moreover, the
supply of PPE was scarce, especially in the first few weeks of the COVID-19
emergency in Italy, in all hospitals (e.g., a lack of respirators and insufficient
number of resuscitation beds), which meant that the level of protective
efficacy of this strategy may have been lower than the stress levels.
The government lockdown and the consequent restriction of visits outside the
working environment limited the use of coping strategies involving social
support, family, and friends, implying a greater use of emotional and cognitive
avoidance methods to deal with anguished thoughts, intrusive memories, and
the constant vision of corpses or the seriously ill. In this regard, the Health
Group appears to have developed a greater secondary trauma arousal than the
Emergency Group. By contrast, the latter appears to have developed more
aspects of intrusiveness related to secondary or vicarious trauma than the
Health Group (see Table 2).
Since they were interviewed during the COVID-19 emergency, the healthcare
and emergency workers who participated in the present study do not appear to
have developed a complete secondary trauma. This may explain the prediction
of the stress factors on arousal and not on intrusion. In other words, these
individuals were interviewed while the emergency was still in the acute phase
and before a structuring of answers in a psychopathological sense could be
performed. Therefore, performing a follow-up study would be interesting.
PTSD can take several months to fully emerge, and its stabilization can
depend on the individual’s internal as well as external factors.
Ethics Statement
The studies involving human participants were reviewed and approved by
Comitato Etico per la Sperimentazione Umana – CESU of the University of
Urbino. The patients/participants provided their written informed consent to
participate in this study.
Author Contributions
MV, TM, VG, and DP: conceptualization, writing – original draft preparation,
and writing – review and editing. MV, TM, and VG: methodology and
investigation. MV and TM: formal analysis and data curation. TM and VG:
visualization. MV, TM, and DP: project administration. All authors
contributed to the article and approved the submitted version.
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.
Acknowledgments
We would like to thank all the participants involved for the contribution they
made to this study during this serious emergency.
https://www.frontiersin.org/articles/10.3389/fpsyg.2020.01684/
fullORIGINAL RESEARCH ARTICLE
Front. Psychol., 10 July 2020 | https://doi.org/10.3389/fpsyg.2020.01684
As of the first half of May, 2020, Italy was one of the most affected countries
during this outbreak, counting over 223,000 individuals infected by COVID-
19 and more than 31,000 casualties (World Health Organization, 2020a). The
high prevalence of the disease in the Northern regions of the country led to a
national reorganization of the hospital network and caused sudden changes in
the personal and professional lives of healthcare professionals.
Recent scientometric analysis found that the most common research topics
include emergency care and surgical, viral pathogenesis, and global responses
in the COVID-19 pandemic but there is a lack of mental health research and
only few studies addressed the impact of the COVID-19 pandemic on
healthcare professionals' well-being (Tran et al., 2020). Therefore, the main
objective of this study is to identify the prevalence of burnout and
psychological distress in health professionals during the early phases of the
pandemic. The secondary objective of this study is to assess the demographic,
psychological, and work-related predictors of burnout.
We used 10-fold repeated (10 times) cross-validation to train and tune our
model over a grid of α and λ hyperparameters on half of the sample, which
constituted the training dataset. The model was refit on the training dataset
with the best performing hyperparameters to calculate the final penalized β
coefficients. The model was then applied to the other half of the sample, which
constituted the testing dataset, to calculate model performance. The above
procedure was repeated for each of the three dependent outcome variables.
Elastic net regression was performed using the R (version 3.5.1)
packages caret (Kuhn, 2015) and glmnet (Friedman et al., 2010).
Results
Description of the Sample and Prevalence of
Psychological Symptoms
Three hundred and thirty out of the about 800 health professionals working in
the Institution participated to the online survey. Table 1 reports the
demographic, work-related and psychological characteristics of the
participants of this research.
TABLE 1
Table 1. Demographic, work-related, and psychological characteristics of the
study participants.
Discussion
The main aims of this study were to assess the prevalence of burnout among
health professionals during the COVID-19 pandemic and to evaluate its
predictors. Results show that severe levels of burnout and psychopathological
symptoms had high prevalence, and that the work-related and psychological
factors associated with the necessity to cope with the COVID-19 emergency
increase the risks of negative psychological consequences.
The regression models clearly show that the increased workload, the constant
contact with COVID-19 patients and the psychological aspects related to their
care are related to the levels of burnout. On the one hand, this calls for
political and organizational decisions. Although the main focus of health care
systems is on minimizing transmission, treating the infection, and saving
lives, attention should be made to reduce the work-related burden on health
professionals. Attention should be focused on promoting positive and
protective strategies to cope with the emergency developed with the support of
a dedicated psychologist.
On the other hand, these results show that presence of previous psychological
comorbidities, fear of infection and feelings of isolation due to perceived lack
of support from friends should be taken into account by interventions aimed
at preventing the development of burnout in health professionals.
The main limitation of this study is the heterogeneity of the sample. Although
the inclusion of health professionals with different occupations and working in
different wards allowed to provide a more complete picture of the impact of
the pandemic, the variety of the respondents' characteristics. In addition,
similarly to other studies performed during epidemics (Maunder et al.,
2006; Lee et al., 2007), the respondent rate was low, indicating the risk of the
auto-selection of the sample. Moreover, the cross-sectional nature of this
study limits our understanding of the risk factors of burnout and suggests that
longitudinal studies are needed for this purpose. Finally, the assessment of
burnout, psychological distress and post-traumatic symptoms was performed
using self-reported instruments which were not confirmed by medical records
or specialistic evaluations.
In conclusion, this study shows that health professionals have a high risk of
incurring in burnout or psychological conditions due to the COVID-19
pandemic. Continuous monitoring and timely treatment of these conditions is
needed to preserve the professionals' health and to enhance the healthcare
systems preparedness to face the medium- and long-term consequences of the
outbreak.
Ethics Statement
The studies involving human participants were reviewed and approved by
Comitato Etico dell'Istituto Auxologico Italiano. The participants provided
their electronic informed consent to participate in this study.
Author Contributions
EG, EP, CS, and CM were responsible for drafting the manuscript. All authors
critically revised it for important intellectual content, gave final approval to
the finished manuscript, and agreed to be accountable for all aspects of the
work.
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.
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.
Acknowledgments
We would like to express our deepest appreciation to all the health
professionals who kindly participated in this study for donating their effort
and time in a period of global emergency to help scientific research to
continue.
Model 1 Model 2
Variable
B SE p B SE
Infected Relatives or
0.03 0.02
Friends (0 = No 1 = Yes)
F 98.14 124.34
P <0.001 <0.001
R2 0.11 0.21
R2 Change
Table 4. Main and interaction effects on anxiety.
Model 1 Mode
Variables
B SE p B SE
F 50.87 207.56
P <0.001 <0.001
R2 0.06 0.31
R2 Change 0.25
able 5. Main and Interaction Effects on Stress.
Model 1 Mode
Variable
B SE p B SE
F 107.71 137.41
P <0.001 <0.001
R2 0.12 0.23
R2 Change 0.11
Hypothesis 2 suggested that having an infected or dead family member, relative, or friend moderates the
effect of COVID-19 fear, which can cause (i) depression, (ii) anxiety, and (iii) stress. Hypothesis 3
suggested that having an underlying illness moderates the effect of COVID-19 fear, which can cause (i)
depression, (ii) anxiety, and (iii) stress. In order to test hypothesis 2 and 3, the effects of the interaction
terms on the dependent variables (depression, anxiety, and stress) are shown in Model 3, see Table
3, Table 4, and Table 5. Moderation variables (underlying illness, infected relatives or friends) were both
added to the existing variables in each Model 3. Model 3 in Table 3 (F = 100.96, R2 = 0.22, ΔR2 =
0.01, p < 0.001), Table 4, (F = 174.94, R2 = 33, ΔR2 = 0.02, p <.001), and Table 5 (F = 110.26, R2 = 0.23,
ΔR2 = 0.01, p < 0.001) were found to be statistically significant. The interaction effect of the COVID-19
fear variable and the variable of infected or dead relatives or friends on depression, anxiety, and stress (B
= 0.05, p < 0.01; B = 0.05, p < 0.001; B = 0.06, p < 0.001, respectively) was statistically significant. The
interaction effect of the COVID-19 fear variable and underlying illness variables on depression, anxiety,
and stress (B = 0.09, p < 0.001; B = 0.10, p < 0.001; B = 0.06, p < 0.05, respectively) was statistically
significant. Therefore, hypothesis 2 and hypothesis 3 were accepted. Figure 2, Figure 3 and Figure
4 are shown in two groups as moderation effects a and b. The moderation effect of individuals’ underlying
illness situations on the effect of COVID-19 fear, and its effect on depression, anxiety, and stress, is
demonstrated by (a). The moderation effect of having an infected or dead family member, relative, or
friend of individuals on COVID-19 fear, and its effect on depression, anxiety, and stress is demonstrated
by (b). The results are illustrated in Figure 2, Figure 3, and Figure 4. Figure 2. Interaction effects on
depression. Moderators of underlying sickness is depicted in (a), having infected relatives or friends is
depicted in (b).
Figure 2. Interaction effects on depression. Moderators of underlying sickness is depicted in (a),
having infected relatives or friends is depicted in (b). Figure 3. Interaction effects on anxiety.
Moderators of underlying sickness is depicted in (a), having infected relatives or friends is depicted in (b).
Figure 4. Interaction effects on stress. Moderators of underlying sickness is depicted in (a), having
18, 1836 9 of 15 Figures 2–4 are shown in two groups as moderation effects a and
b. The moderation effect of individuals’ underlying illness situations on the effect
of COVID-19 fear, and its effect on depression, anxiety, and stress, is
demonstrated by (a). The moderation effect of having an infected or dead family
member, relative, or friend of individuals on COVID-19 fear, and its effect on
depression, anxiety, and stress is demonstrated.