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Coronavirus belongs to the Coronaviridae family, which is characterized by large, enveloped, single-stranded ribonucleic acid (RNA) viruses and is commonly found in some colds and diarrhea in humans. In December 2019, in Wuhan, a Chinese Hubei province, a novel betacoronavirus called severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2) emerged as a cause of severe respiratory infections in humans (Zhou et al., 2020). On March 11, 2020, the World Health Organization (WHO) classified the outbreak of the coronavirus disease 2019 (Covid-19) as a global pandemic, which increased the workload of healthcare workers (HCWs) and, consequently, caused a possible greater amount of stress. Its dissemination was fast, with the numbers of cases increasing daily in several countries, until the revision date of this paper, August 2021.
The impacts on public health caused by a virus of such a rapid and intense spread among the population were noteworthy, and it generated a sudden change in the medical routine. The overcrowding of healthcare units and the lack of hospital beds and healthcare equipment, such as mechanical respirators, were hindrances to the work organization, which affected the mental health of care teams in a pandemic situation, especially the frontline HCWs (Sun et al., 2021). In addition to these issues, it is extremely important to draw attention to the failures in protecting HCWs, which has been happening in several countries. With the rise of the pandemic, access to personal protective equipment (PPE) for HCWs has become a concern, due to the scarcity in places with high demand (Gallasch et al., 2020), which is not the only factor, but one of the factors that exposes HCWs to risk (World Health Organization [WHO], 2020a, 2020b).
As the coronavirus spread in different regions of the world, including Brazil, public health policies emphasized the need for contamination prevention measures and social isolation, which can cause a delay and/or reduction in the speed of spread of the disease (Barros-Delben et al., 2020). However, social distancing recommendation did not apply to essential workers, such as healthcare workers. The presence of these workers in their workplaces was necessary to ensure care related to several health problems, such as Covid-19.
It is important to highlight that a crisis is not only characterized by negative aspects (social limitations, probable illness, and loss of autonomy). A crisis is also a phenomenon that escapes normality and what is expected, either by its intensity or indefinite time, and that transforms those who experience it. One way of interpreting a crisis is to see it as an opportunity for necessary changes. On several fronts, individuals and public and private organizations had to learn to carry out daily and labor activities in a different way, which will probably represent a historic milestone for social organization (Barros-Delben et al., 2020).
In this context, the pandemic is a stressor per se, adding up to several other stressors, especially for HCWs, which were especially affected by this stress load, mainly those with more work experience over ten years) (Wang et al., 2021) and women, who were more at risk of developing several long-lasting psychological problems, as anxiety, depression, and insomnia, for example (Sun et al., 2021). These professionals demand attention, particularly women on the frontline because they are fundamental to carry out the work. Then, it is important to understand the relationship between stress and coping, as well as the development of psychoeducational materials, aiming to assist HCWs to cope better. This study focuses on the methodological process used to develop a psychoeducational booklet, which enables self-assessment and guides HCWs on how to deal with stressors from the Covid-19 pandemic. It is believed that, with this methodological description, it is possible to inspire other professionals to carry out rigorous scientific procedures for the progress of other psychoeducational materials.
To further understand how HCWs are coping with this stressful environment, the motivational theory of coping (MTC) was used as the theoretical framework for the development of the booklet. According to MTC, universal stressful events are situations interpreted as a challenge or a threat to the basic psychological needs of autonomy, competence, and relatedness (Skinner & Zimmer-Gembeck, 2016). These needs are explained by the basic psychological needs theory (BPNT), which is part of the self-determination theory (SDT) (Deci, 1984; Ryan & Deci, 2017). The satisfaction of the basic psychological needs (BPN) throughout life span is essential for personal growth and subjective well-being (Deci & Ryan, 2000), and it happens through the transactions between the individual and the environment.
The autonomy BPN is related to the ability of the individual to act in accordance with their personal values and beliefs and choose the activities in which they will engage. It also refers to doing things they feel like doing and not because they feel pressured or obliged by someone, some circumstance, or for other reason that does not correspond to their real values. The competence BPN refers to the need to interact efficiently with the environment, promoting self-efficacy. Finally, the relatedness BPN is about having meaningful bonds with other people, belonging, and acceptance. It is a need to feel connected and cared for (Ryan & Deci, 2017).
According to MTC, coping can be defined as the struggle of the individual to “maintain, restore, replenish, and repair the fulfilment of basic psychological needs in the face of experienced assaults on those needs” (Skinner & Wellborn, 1994, p. 112). Ellen Skinner and collaborators structured MTC in a hierarchical process: the base of the system is composed of coping behaviors, which include action orientation and emotions. These behaviors are grouped according to their functionality into coping strategies. The strategies are grouped according to the adaptive process they refer to, into 12 coping families: six of them are more adaptive (when the stressor is perceived as a challenge to BPN), and six are maladaptive (when the stressor is perceived as a threat to BPN). Coping families are related to each BPN (Table 1).
Table 1 Coping families according to adaptive processes and basic psychological needs
| Stressor is perceived as a | To which BPN | Coping family | Definition/function in adaptive process | Adaptive process |
|---|---|---|---|---|
|
Challenge Adaptive coping strategies |
Relatedness | Self-reliance/self-comforting | Protecting available social resources using emotional and behavioral regulation, emotional expression, and closeness. | Coordinate reliance and social resources available. |
| Support seeking | Use of available social resources through proximity seeking, comfort-seeking, instrumental aid, spiritual support, emotional reassurance, and consolation. | |||
| Competence | Problem-solving | Figuring out what to do to, solving problems, adjusting actions to be effective, including planning and strategizing, and instrumental action. | Coordinate actions and contingencies in the environment. | |
| Information seeking | Finding additional contingencies by reading, observing, and asking others. | |||
| Autonomy | Accommodation | Flexibly adjusting preferences to available options through cognitive distraction or restructuring, minimization, and acceptance. | Coordinate reliance and social resources available. | |
| Negotiation | Finding new options using bargaining, persuasion, and priority-setting. | |||
|
Threat Maladaptive coping strategies |
Relatedness | Delegation | Finding limits in the use of resources through complaints, self-pity, maladaptive help-seeking, dependency, and whining. | Coordinate preferences and available options. |
| Isolation | Withdrawing from unsupportive social contexts through avoidance of others, dissimulation, “freezing”/paralyzing. | |||
| Competence | Helplessness | Finding limits to action through unclear thoughts, confusion, cognitive interference, cognitive exhaustion, panic, and random attempts to cope with the situation. | Coordinate reliance and social resources available. | |
| Escape | Escaping from non-contingent environments through mental distancing, denial, wishful thinking, and procrastination. | |||
| Autonomy | Submission | Giving up preferences through unresponsiveness, rumination, intrusive thoughts, and rigid perseverance. | Coordinate reliance and social resources available. | |
| Opposition | Removing constraints through aggression, blaming others, projection, challenging, anger, and revenge. |
Note. Based on Ramos et al. (2015), Skinner et al. (2003), Skinner and Zimmer-Gembeck (2007, 2009), Zimmer-Gembeck and Skinner (2008).
Considering the context and theoretical framework presented, the objective of this study is to describe the methodological process used for the development of a psychoeducational booklet, aimed at healthcare workers of hospitals, to help them cope with stressors related to the Covid-19 pandemic. It is expected that the booklet presents clear language and practical relevance to be used on a large scale.
Method
Development of the instrument and theoretical framework
The development of the booklet for HCWs was inspired by the Booklet for coping with stress in times of pandemic (Weide et al., 2020), developed by a group of Brazilian researchers who also created a task force (PsiCOVIDa) (Machado et al., 2020), with the mission of communicating scientific knowledge to enhance well-being during the pandemic. This booklet was distributed to all regions of Brazil, as well as to the United States, being translated into English, and to Colombia, being translated into Spanish. Both the booklets, the one mentioned and analyzed in this study, were based on the theoretical model of the MTC (Skinner & Wellborn, 1994; Skinner & Zimmer-Gembeck, 2016), which proposes coping with stress as a self-regulatory process. Besides maintaining the theoretical framework, the booklets are designed to have an adequate language for the target audience (Echer, 2005).
The development process of the contents started with an integrative literature review of recent publications about stress in HCWs, as well as articles on specific stressors related to the Covid-19 pandemic. As inclusion criteria the descriptors “coping”, “psychology”, and “stressor” were used, filtering those articles that were evaluated with healthcare workers. The search was conducted on the following databases: PubMed, Microsoft Academic, and the publication database of the WHO, without limiting the period of publication of the articles. A search was also carried out on the Web of Science, Scopus, and ScienceDirect databases, using the descriptors “Covid” or “coronavirus” and the filter “from the last five years” (2016-2020). The articles were then uploaded to the software Rayyan, an open and free resource developed worldwide by Allen Institute for Al, which provides resources to upload complete articles, in addition to allowing the use of eligibility criteria (Figure 1).
Figure 1 Development process flowchart for the booklet: Coping with stress of Covid-19 for healthcare workers
Thereafter, a brief online survey with HCWs was conducted to identify: 1. their perception of the current main stressors and 2. coping strategies that these professionals deemed more effective to deal with them. The survey also included two questions about sociodemographic data (profession and gender) and two additional questions: 1. What are the main difficulties or challenges you are facing in terms of emotions and actions when dealing with the Covid-19 pandemic? and 2. What strategies have you used to deal with these situations in your daily life? The survey form in Portuguese was sent digitally to individuals from all regions of Brazil. It was translated into Spanish and sent to professionals in Colombia, Peru, and Argentina. The relevant results of the literature review and online survey were synthesized, and the final booklet was prepared (Figure 1). All participants agreed to participate in the research by signing the Informed Consent Form.
Judge evaluation of the booklet content
After the development of the booklet, 17 judges proceeded with an evaluation based on two criteria: language clearness and practical relevance. All judges agreed to participate in the research by signing the Informed Consent Form. After receiving the judges’ response sheets, the evaluation of the theoretical dimension of the instrument was calculated through the intraclass correlation coefficient (ICC) through the Statistical Package for the Social Sciences (SPSS) analysis software, version 23.0. This procedure was adopted considering the small number of judges. After these evaluations, the adjustments suggested by the judges were made. The booklet was then submitted for final analysis by the PsiCOVIDa task force scientific committee. Finally, a poster was prepared to be displayed in hospitals including the judges’ best evaluated coping strategies.
Results and discussion
The integrative review of literature
The database search resulted in 54,986 articles, but 13,566 of those were duplicated. After applying the exclusion criteria, 83 articles remained, with 21 articles specifically addressing HCWs, and, therefore, were read in full.
The articles presented as main stressors: exhaustion due to work overload, isolation (lack of contact with family), risk of being infected, lack of PPE, having to deal with the emotional reactions of patients, discrimination and stigmatization, dealing with a new disease, misleading definitions of each professional role in the hospital, and conflict between their professional duty and wanting to preserve one’s own lives (Brooks et al., 2020; Kang et al., 2020; Lee et al., 2005; Maunder et al., 2003). Some reactions to this stress process are quite frequent, such as changes in sleep and eating patterns and memory problems (Brooks et al., 2020; Dehkordi & Travakol, 2011; Lee et al., 2005; Sheraton et al., 2020; Su et al., 2007; Wu et al., 2008).
The literature review identified some common maladaptive strategies used by HCWs to cope with stress, such as 1. self-blame - asking themselves what did they do wrong to go through this; 2. helplessness and self-doubt - feeling unable to do the work; 3. escape - thinking about giving up the profession for being unable to deal with the situation; or 4. increased consumption of alcohol and smoking or other drugs to deal with emotions (Brooks et al., 2020; Dehkordi & Tavakol, 2011; Wu et al., 2008). According to MTC, maladaptive responses lead to negative outcomes, such as physical and mental health problems and, therefore, should be avoided (Ramos et al., 2015; Skinner & Zimmer-Gembeck, 2016).
However, adaptive coping behaviors were also mentioned, such as 1. information seeking and problem-solving - developing skills to solve problems, seeking information from more experienced professionals or other countries, and following preventive measures (such as the use of PPE), limiting the amount of exposure to news about the pandemic (Barbore et al., 2020; Dehkordi & Tavakol, 2011; Kang et al., 2020; Lee et al., 2005); 2. support seeking - religious or spiritual support; 3. accommodation and self-reliance - enhancing personal care through nutrition, physical exercises, psychotherapy, and relaxation techniques, such as deep breathing, yoga, and tai-chi; and 4. avoiding the lack of social contact through video calls. These strategies are considered adaptive as they lead to positive outcomes on physical and mental health and, therefore, should be encouraged (Ramos et al., 2015; Skinner & Zimmer-Gembeck, 2016).
Regarding working contexts - hospitals -, the literature suggests them to support the self-efficacy perception by providing more structure, such as clear guides for procedures and defining boundaries for each professional role, conducting regular training during the pandemic period and interdisciplinary meetings (Lee et al., 2005).
The online survey with HCWs obtained 141 responses: 96 responses to the Portuguese version and 45 to the Spanish one; 65% (n = 92) were female. The professions with the highest number of respondents were physicians (n = 46), nurses (n = 18), psychologists (n = 16), nursing technicians (n = 8), and nursing assistants (n = 8).
Considering the main stressors pointed out by the participants, 67% (n = 95) of the stressors were related to relatedness BPN, while 20% (n = 28) referred to the need for competence, and 13% (n = 18), to the need for autonomy. As for the coping strategies reported by the professionals, all of them mentioned adaptive coping strategies. The most prevalent response to stress was anxiety related to the risks of working (especially without adequate PPE or being part of a risk group) and being infected, in their routines (having to deal with family restructuring and/or the accumulation of tasks as caregivers of children or elderly people) and the difficulty filtering information.
The most used coping family was support seeking (34%, n = 48), which attempts to use available social resources to enhance relatedness. Participants also used information seeking (30%, n = 42), trying to find additional contingencies in the environment to be more effective in dealing with adversities. Another strategy reported by participants was self-reliance/self-comforting (20%, n = 28), trying to keep or recover the emotional and behavioral regulation. Problem-solving, attempting to adjust one’s actions to be more effective, was also reported (12%, n = 17). Agreeing with these data, recent literature points to social support as strongly associated with positive impacts on levels of anxiety, self-efficacy, stress, and sleep quality in HCWs working in the pandemic (Xiao et al., 2020).
As strategies to deal with stress, professionals reported mainly contact with spirituality and meditation techniques, seeking social support with family members (via video calls) or colleagues, restricted time to read and watch the news, and the strict application of hygiene routines for family self-protection, which was also found in the study by Barbore et al. (2020). Spiritual coping, often mentioned in the survey, is a personal resource for coping with crisis situations and can become a protective factor for the individual’s mental health by enabling the search for meaning, control, and comfort in the face of stressful situations related to disasters and catastrophes (Panzini & Bandeira, 2007; Polizzi et al., 2020). Some of the specific coping strategies reported by the respondents, especially those that appeared more frequently, such as those referring to spirituality, information filtering, and living with family members, were adapted and implemented in the final version of the booklet.
The evaluation of the judges
The results demonstrate an excellent agreement between the evaluators, being .98 for relevance of the content and .92 for clarity of language. According to Fleiss et al. (2003), these values are considered excellent (when above .75). The section with greater clarity was the list of stress-related signs or symptoms; and, regarding relevance, there was 100% agreement on the introduction and the sections describing difficulties related to the satisfaction of the three BPN.
The suggestions given by the judges were mainly regarding the language usage, so that it should be simpler and more understandable for all HCWs, as well as adapted to the hospital context. The suggestions were accepted and implemented.
The booklet
The last version of this psychoeducational booklet was named Covid-19’s booklet to coping with stress for healthcare workers, and it has 24 colorful pages with the results from the literature review, as well as from the online survey related to main stressors and how to deal with these situations (Araujo et al., 2020). It is organized into charts and checklists in which it is summarized how to recognize symptoms of stress and anxiety and cope with these symptoms and the difficulties feeling competent and exercising autonomy, besides problems in the relationships. This booklet also presents alternative communication boards for inpatients with no communication capacities. This content is linked to the MTC theoretical framework and summarized in Table 2.
Table 2 Summary of main stressors and related coping strategies according to Brazilian healthcare workers at the hospital
| BPN | Stressors - environmental conditions of the hospital | Examples of coping strategies to deal with these situations |
|---|---|---|
| Relatedness | - Difficulties dealing with the work teams1. - Emotional responses from users of healthcare services2. - Discrimination against me and my family because I work at a hospital1. |
• Nurturing positive emotions as a protective factor against physical and mental illnesses. • Trying to understand which feelings are associated with other people’s actions. Thus, one will be able to express oneself and act more effectively and appropriately to the situation. |
| - Lack of adequate and accessible emotional support2. | • Seeking support: looking for someone who can listen to them and listen to others, without judgment. • Counting on other people and supporting them. |
|
| - Not being present in my family’s daily routine1,2. | • Participating in your family’s daily life as much as possible, setting up each week’s routine with them. |
|
| - Social distancing1,2. | • Avoiding isolation, enabling your support network. | |
| Competence | - Increasing workload leaves me exhausted1,2. | • Planning: clearly defining tasks, establishing schedules and routines. |
| - Frequent changes in health policies1. | • Seeking information: searching for reliable sources of information and seeking to know the source of the news you receive, using official websites, such as WHO, Ministry of Health, and universities’. |
|
| - Insecurities related to my work, such as struggles with attention and fear of forgetting procedures1. |
• Avoiding helplessness and being too self-critical. • Rely on the skills you have developed thus far. |
|
| - Overwhelming duties with family care, which limits my work1,2. - Difficulty to recover my energy after a workday1,2. |
• Avoiding excess alcohol, self-medication, and other substances to escape from problems. | |
| - Lack of freedom1,2. - Unreasonable work schedules1,2. - Conflicts between my duty and my safety1,2. |
• Accepting one’s limitations, we all have them. • Accepting and trying to like oneself. Self-compassion helps to reduce stress. • Negotiating priorities at work. • Avoiding arguments and fights or blaming others. This tends to increase stress and decrease everyone’s collaboration • Feeling angry or having repetitive thoughts, with negative emotions, such as anger, fear, or sadness (e.g., remembering sorrow), is not an attitude that will help at this time. Identifying culprits can generate resentment and does not solve problems. • Proposing different and creative ways to solve old and new tasks. |
|
| - Thoughts such as having long-term effects of the disease, if infected1,2. - Difficulties keeping emotional control at work2. |
• Trying to think positively. Negative thoughts and pessimism do not help currently. |
According to Ornell et al. (2020), one effective measures in cases of pandemics to ensure people’s mental health could be the development of psychoeducational materials that are easily accessible to the population, precisely what was attempted with the elaboration of this booklet. The feedback from the judges was that the booklet should be made available to HCWs as soon as possible. It is worth noting that the booklet was published before the article due to the urgency of access by the HCWs at hospitals, who could benefit from support on how to deal with the adverse situations emerging during the Covid-19 pandemic. The booklet is available in Spanish and Portuguese1.
Final considerations
HCWs are more susceptible than the general population to the effects of the Covid-19 pandemic on their physical and mental health, due to their high exposure to the virus, overwhelming workload, and the need to cope with extreme adverse conditions. Thus, there must be special attention to their BPN. This study is a way to contribute to this with procedures for developing a self-assessment and through a health promotion booklet.
There is an urgent need for empirical research aiming to better understand and address the impacts on this population. It is necessary to work together - society, scientists, and institutions - on immediate measures and long-term strategic programs to address potential mental health-related issues. Therefore, mapping specific stressful situations related to work at hospitals during the pandemic and possible practical coping strategies to deal with them and enhance the satisfaction of BPN is a differential of this booklet.
In conclusion, the proposal of a booklet strongly anchored in scientific research shows the importance of providing applied scientific information to help understand the role of psychological variables on mental health problems. In addition, it is an asset to minimize the harmful impacts of the Covid-19 pandemic on HCWs during this period. We hope that this booklet can help support those who are taking care of everyone’s health.
