Stress of COVID-19: Coping Strategies for Healthcare WorkersPage 5 of 12

3. Coping with COVID-19: Emergency Stress, Secondary Trauma, and Self-Efficacy in Healthcare and Emergency Workers in Italy

Authors: Monia Vagni, Tiziana Maiorano, Valeria Giostra, and Daniela Pajardi

[This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). Front Psychol. 2020; 11: 566912. 2020 Sep 3. Doi: 10.3389/fpsyg.2020.566912]


One of the earliest studies was done in Italy, where the first epidemic outside of China arose. Not surprisingly, researchers found that professionals who were provided with the necessary knowledge and equipment were more resilient during the emergency response. They separated problem-focused strategies (to modify or solve a stressful situation through active intervention) from emotional coping (denial and avoidance). They note that low perceptions of self-efficacy have been found to be a predictor of PTSD in other studies.


Coping with the coronavirus disease (COVID-19) is a significant risk factor for the psychological distress of healthcare workers. 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.

*COVID-19 became epidemic in Italy before its appearance in the United States.

We study differences between healthcare and emergency (frontline) 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. For this purpose, we collected data from participants through the following online questionnaires: 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).

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 great 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.


The coronavirus disease (COVID-19), or the acute respiratory disease caused by SARS-CoV-2, began spreading in China at the end of 2019 and, to date, represents an international health emergency without precedent in terms of its health, economic, and organizational effects on people’s lives (WHO, 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 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): more than 150 doctors died and 25,000 other health workers were infected, in a general population of 30,000 deaths and 220,000 infections within a span of 11 weeks.

It was clear that the medical staff would experience serious psychological repercussions because of the working conditions as well as the difficulty of maintaining scientific guidelines 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; healthcare and emergency workers were subjected to serious psychological and physical stress.

The aim of this study, as with 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 workers 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 to the stress that they experience, the literature clearly explains that both 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 (psychosomatic disorders, sleep/wake cycle alterations, sense of tiredness);
  • Emotional (irritability, nervousness, agitation, anger, low self-esteem, guilt);
  • Cognitive (distractibility, sense of ineffectiveness, negative anticipation of events); and
  • Relational (increase in conflicts within emergency teams and/or with their organization/institution, and social withdrawal).
  • Reactions from secondary trauma. (Bellelli & Di Schiena, 2012; Walton et al., 2020; and others)

Faced with stressful events related to lack of previous experience and specific necessary knowledge, and which cause tension owing to the need for rapid decisions and a sense of responsibility, emergency workers may come to believe that their decisions are ineffective. In fact, emergency situations are characterized by high levels of decisional and operational uncertainty with associated regret and guilt (Del Missier et al., 2008).

We should note that several studies have highlighted that insufficient instructions and a lack of personal protective equipment (PPE) are important predictors of stress for healthcare and emergency workers in large-scale emergencies (Oh et al., 2017; Du et al., 2020; El-Hage et al., 2020; Walton et al., 2020).

Oh and colleagues (2017) noted that nurses involved in managing the Middle East respiratory syndrome (MERS) experienced lower levels of stress when the levels of PPE and training were higher. Some studies have indicated that frontline healthcare workers had lower secondary traumatization scores than both non–frontline health workers and the general public, in contrast to the findings on the SARS outbreak in the same area in Singapore (Chan & Huak, 2004).

According to Barleycorn (2019) and Tan and colleagues (2020), these results may be due to the dedicated training and psychological support given to healthcare workers after the SARS outbreak and demonstrate the validity of policy strategies for prevention of stress in the mental health field.

An analysis of 14 studies published from January to March 2020 aimed at investigating the stress experience of healthcare workers facing COVID-19 shows that they experienced symptoms of depression and anxiety. Moreover, the severity of their symptoms was influenced by their age, gender, role, specialization, type of activity performed, and exposure to patients with COVID-19; however, prevention, resilience, and social support mediated their response to stress (Bohlken et al., 2020).

In a review of the literature, Spoorthy (2020) underlined that sociodemographic variables, such as age, gender, profession, and workplace, and psychological variables, such as poor social support and self-efficacy, affect the stress level experienced by health workers. In addition, COVID-19 emerged as an independent factor for stress risk. Xiao and colleagues (2020) found that social support plays a role in reducing the anxiety levels in medical staff and increasing their sense of self-efficacy.

According to Walton and colleagues (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 protocols are absent and limited resources are available, health workers carry heavy responsibility as they are faced with making individual decisions 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 and colleagues (2020) showed that, for a sample of 534 healthcare professionals who worked closely with COVID-19 patients in Hubei, the most stressful factors were:

  • Lack of protocols for treating COVID-19
  • Scarcity of PPE
  • Exhausting work shifts
  • Concern about the risk of infection
  • Exposure to the suffering and death 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 and colleagues (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 loss of a social support network, which can be important to resilience, is another risk factor (Ozbay et al., 2007). In the COVID-19 emergency, both healthcare and emergency workers have often experienced a separation from their social supports, either because of the restrictions imposed by the lockdown or the fear of spreading the infection to family members. Also, although at first health workers received unanimous encouragement from the population, later they also experienced stigma and isolation. Some studies have shown that being able to resort to their own social support network is a significant protective factor for health workers dealing with this emergency (Cai et al., 2020).

As Favretto (2005) stated, when individuals experience situations that go beyond their coping strategies, their vulnerability to psychopathologic reactions increases. Studies conducted during previous epidemics (SARS, MERS, Ebola) converge in reporting that healthcare and emergency workers may experience extremely high levels of stress and even progress to traumatic stress or vicarious trauma. This trauma is defined as an experience of symptoms similar to those found in people with PTSD, such as in emergency nurses working with traumatized patients (Beck, 2011).

 Figley (1995) defined it as a form of stress that derives from the feelings of empathy experienced when helping traumatized people. The symptoms may include:

  • Intrusive recurring thoughts
  • Disturbed sleep
  • Fatigue
  • Physical symptoms
  • Hyperarousal
  • Increased stress response
  • Anxiety
  • Depression
  • Feeling emotional (Adriaenssens et al., 2012)

Wolf and colleagues (2016) described how nurses may feel “overwhelmed,” and this condition becomes a source of moral distress that triggers feelings of powerlessness, guilt, fear, anger, and frustration.

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 & Klopper, 2010; Mealer & Jones, 2013). Their frustration obviously intensifies upon 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).

As 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 and colleagues (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 and that the levels were higher for nurses than for doctors. Moreover, Li and colleagues (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 more severe symptomatology (Simione & Gnagnarella, 2020). This study also confirmed that females tend to have a greater perception of the risk of infection, which increases their risk for developing the symptoms of anxiety and distress.

Because of their long, intense exposure to various stressors, it is important to note the nature of the coping strategies used by these healthcare and emergency workers and their effectiveness in reducing and coping effectively with stress. Indeed, the effective management of stress levels in the acute/emergency phase could reduce the risk of developing long-term PTSD or other pathologies, such as anxiety and depression (Fullerton et al., 2004; Slottje et al., 2005; Argentero and Setti, 2011; Sakuma et al., 2015; Birinci and Erden, 2016; Li et al., 2017).

Coping may be defined as a series of cognitive and behavioral efforts to manage specific internal or external issues that test or exceed individual resources (Lazarus & Folkman, 1984). A distinction can be made between problem-focused and emotion-focused coping strategies. Problem-focused strategies are aimed at modifying and solving the stressful situation through active interventions. By contrast, emotion-focused coping is aimed at managing the emotions connected to the stressful event and regulating reactions to it; and managing the tension of response to stress, for example, by trying to avoid the threat (denial) or re-evaluating it (reappraisal).

The choice of coping strategies is influenced by the individual’s cognitive evaluation of the event, which involves estimating the resources available and the most effective strategies to deal with the situation (Lazarus & Folkman, 1984). A key element of this assessment is the extent to which the individual can maintain control over the outcome of the situation.

The literature indicates that individuals apply dysfunctional coping when they face an uncontrollable event by responding with a coping strategy focused on the problem; conversely, when they face a controllable situation they respond with coping strategies focused on emotions (Strentz & Auerbach, 1988; Vitaliano et al., 1990).

A coping strategy may be defined as adaptive when the controllability of the stressful event corresponds with the choice of coping strategy: in this case, the subject will experience fewer symptoms related to stress (Park et al., 2001). 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).

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 & 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).

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 and colleagues (2016) found in a group of emergency workers that avoidance as well as coping strategies focused on emotions were associated with the development of post-traumatic symptomatology.

Rodríguez-Rey and colleagues (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 and colleagues (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.

However, the literature does not offer unanimous results. Chamberlin and Green (2010) found that in a group of firefighters, all coping strategies actually correlated with high levels of stress: the authors explained this finding by suggesting that it is not the individual coping strategies that are maladaptive in themselves, but that greater effort is needed to adjust in stressful situations.

By contrast, Young and colleagues (2014) indicated that firefighters use problem-focused coping strategies more often at the beginning of the operation and emotion-focused coping strategies more commonly in the phase of breakdown and fatigue. However, after the incident, they use both strategies (Young et al., 2014).

A meta-analysis by Shin and colleagues (2014) highlighted that different coping strategies have different effects on work burnout: in particular, emotional stress and depersonalization are associated with the use of emotion-focused coping strategies, whereas professional ineffectiveness is associated with the use of problem-focused strategies.

Further, a few studies have investigated the coping strategies that emergency workers can use during health emergencies similar to COVID-19. Maunder and colleagues (2006) revealed that healthcare professionals who applied dysfunctional coping strategies, based on avoidance, hostile comparison, or self-blame, tended to develop higher stress levels. Wong and colleagues (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. and colleagues (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).

Methods and Materials


The main objective of this study is to identify the coping strategies activated by healthcare and emergency workers to deal with stress factors related to the COVID-19 emergency that may be associated with the risk of developing vicarious or secondary trauma. Few studies have considered both groups simultaneously when analyzing the strategies they have adopted to manage stress during the COVID-19 emergency.

In this study we are interested in detecting the similarities and differences in the approaches they adopted to manage their stress during the acute phase of the current pandemic According to Walton and colleagues (2020), the main acute stress reactions of emergency workers to emergency medical situations are emotional, cognitive, physical, and social; therefore, these factors were included in the questionnaire for the present study. Moreover, reactions linked to stress factors for difficulties due to ineffective decision-making and dealing with stress were also considered (Chesney et al., 2006). In addition, fears regarding contracting the virus and infecting their own families because of COVID-19 were specifically considered (Du et al., 2020; Huang J. Z. et al., 2020; Ornell et al., 2020; Walton et al., 2020).

Based on results found in the literature, the specific objectives of this study are as follows:

  • To examine the relationships between coping strategies, emergency stress, and secondary trauma in healthcare and emergency workers.
  • To identify significant differences in stress factors, coping strategies, and secondary trauma between two groups—health workers and emergency workers.
  • To analyze the predictive power of coping strategies on the various levels of stress.
  • To analyze the predictive power of stress factors on the levels of arousal and intrusion of secondary trauma.
  • To analyze the predictive power of coping strategies on the levels of arousal and intrusion of secondary trauma.


[For complete statistical data and analysis, refer to the original article at]


Participants were selected on a voluntary basis through cross-sectional sampling to look at the situation caused by the pandemic emergency. We used an internet platform to conduct the study and approached the participants using social media, dedicated mailing lists, and forums. Participants from all Italian regions completed the questionnaire online. The sample consists of 210 participants, 90 males and 120 females whose average age was 42.53 years. Further, 52.9% of the sample were married, 10.6% were separated, and the remaining 36.5% were single.

We selected professional figures who had directly worked in various sectors during the COVID-19 emergency and who could be divided into two main groups. The first, the Health Group, were healthcare workers: 57 doctors, 47 nurses, 9 psychologist, and 7 healthcare assistants. Their average age was 42.13 years, and their average years of active professional service was 14.60.

The second, the Emergency Group, consists of 89 participants: 48 emergency workers, 21 firefighters, and 20 Civil Protection staff, whose average age was 45.43 years and average years of service was 14.41. There was an age difference between the two groups), and the distribution of the gender variable differed between the two groups, with 41 males and 80 females in the Health Group and 49 males and 40 females in the Emergency Group. The study involved participants from the entire nation of Italy.


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.


We administered a series of questionnaires to evaluate the psychological stress and coping style of each participant. We included the following questionnaires.

  • Secondary Traumatic Stress Scale – Italian Version (STSS-I; Setti and Argentero, 2012)
  • The Coping Self-Efficacy Scale – Short Form (CSES-SF; Chesney et al., 2006)
  • An Original Questionnaire on Stressful Factors

We constructed an ad hoc 7-item questionnaire that included yes/no questions to detect stress factors identified by the literature, such as the availability of suitable equipment and the receipt of clear instructions during the COVID-19 coping experience. In this study, we present the results related to two of these items: “Instructions,” which refers to having received the necessary instructions to intervene, and “Equipment,” which refers to having PPE. Emergency Stress Questionnaire (ESQ; Vagni 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 results of this study show that Healthcare and Emergency groups both experienced high stressors during the COVID-19 epidemic, exposing them to the risk for developing secondary trauma (Roden-Foreman et al., 2017; Lai et al., 2020; Li et al., 2020; Zhu et al., 2020; and others).

We found significant differences between the two groups’ 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 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 the fact that the Emergency Group perceived their intervention to be more like 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 patient deaths  and had to make decisions in conflict with their moral sense (e.g., who gets the only bed) and in situations where they felt insecure about the consequences of their actions (Cai et al., 2020; Walton et al., 2020). However, Health and Emergency Groups were exposed to very similar physical stressors.

In earlier studies, the impact of the gender variable was significant. Females apparently tend to perceive events as more negative and uncontrollable, and thus suffer higher levels of stress. Further, females tend to resort to coping strategies focused on emotions, which were less effective in emergency situations (Matud, 2004; Matud et al., 2015; Matud and Garcia, 2019).

In the present study, however, these gender differences did show up. In fact, females and males perceived a similar sense of efficacy/ineffectiveness in dealing with stressful situations and had similar scores on the secondary trauma scale. For the Health Group, in particular, the lack of necessary instructions on how to conduct quick interventions affected almost all stressors, leading to tensions or conflicts within the team, difficulty in making decisions, irritability, anger, and frustration.

Above all, the lack of PPE affected the sense of making the right decisions, the emotional sphere and, most important, the fear of contracting the virus or of transmitting it to their families. These results converge with those of other studies.

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).

Moreover, the lack of equipment and instruments in emergency situations, along with the risk of infection, increase the feeling of poor control, leading to cognitive and emotional stress and a sense of ineffectiveness (Placentino & 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 needed instructions or prompt information (Cai et al., 2020). This stress was contained and limited by the use of coping strategies.

The coping strategy that is predictive in reducing stress levels is to block the negative emotions and thoughts about 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 fail to identify their emotional reactions, a failure that tends to be associated with maladaptive behaviors.

The lack of a complete recognition of one’s own unpleasant emotions, which tend 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, our results show that the “Stop Unpleasant Emotions and Thoughts” strategy has an inhibitory, and thus effective and highly significant, impact on the stress levels and the components of secondary trauma, unlike the problem-focused and social support strategies. Avoidant coping strategies tend to present themselves when healthcare and emergency workers experience fatigue and exhaustion, which 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 problem-focused coping in an emergency situation did not appear to be protective. This is likely 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 limited, especially in the first few weeks of the COVID-19 emergency in Italy, which meant that the level of protection afforded by problem-focused coping may have been lower than the stress levels.

In other words, emergency workers, although task-oriented, were faced with a problem that was not fully understood, and in the absence of PPE, felt somewhat helpless in terms of their ability to organize and make effective decisions. The strategy that ensured optimal levels of self-efficacy was the one that removed negative thoughts and emotions to be removed from consciousness, which was also found to have a protective function against the risk of developing traumatic symptoms.

The government lockdown 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 contact with corpses or the seriously ill. In this regard, the Health Group appears to have developed greater secondary trauma than the Emergency Group. By contrast, the latter appears to have developed more aspects of secondary or vicarious trauma than the Health Group.

The healthcare and emergency workers who participated in the present study do not appear to have developed a complete secondary trauma; however, these individuals were interviewed while the emergency was still in the acute phase; therefore, a followup study would be interesting. PTSD can take several months to fully emerge, and its stabilization can depend on both internal and external factors.

Because they blocked negative emotions and unpleasant memories, the healthcare and emergency workers’ arousal appears to be mainly cognitive, linked to the difficulty of focusing on and identifying the most appropriate intervention strategies; this led  them to experience regret, disappointment, and both physical and relational tension.

Health workers apparently blocked emotional aspects related to pain, impotence, and guilt, which allowed them to continue their work. In an emergency phase that is still active—only a few weeks after the start of the pandemic—it is possible to detect high arousal but lower intrusiveness of stressful or traumatic events. Low perceptions of self-efficacy have been found to be a predictor of PTSD in other studies (Benight and Harper, 2002; Bosmans et al., 2015).


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