key: cord-0682223-j35au6j6 authors: Domínguez‐Salas, Sara; Gómez‐Salgado, Juan; Guillén‐Gestoso, Carlos; Romero‐Martín, Macarena; Ortega‐Moreno, Mónica; Ruiz‐Frutos, Carlos title: Health care workers’ protection and psychological safety during the COVID‐19 pandemic in Spain date: 2021-04-26 journal: J Nurs Manag DOI: 10.1111/jonm.13331 sha: 05c5b0f7c8aa884896134593ac93f90c817d8608 doc_id: 682223 cord_uid: j35au6j6 AIMS: To analyse the relationship between work engagement, sense of coherence and psychological distress levels in Spanish health professionals who were active during the COVID‐19 pandemic lockdown. BACKGROUND: Work engagement and sense of coherence can help professionals to cope with work‐related psychological distress due to the harsh conditions of the COVID‐19 working environment. METHODS: Cross‐sectional observational study of 1,459 health care professionals. The Utrecht Work Engagement Scale, the Sense of Coherence Scale and Goldberg's General Health Questionnaire were distributed and analysed with descriptive and multiple linear regression methods. RESULTS: High levels of work engagement, especially in the dedication dimension, of sense of coherence, in particular in the meaningfulness dimension, and psychological distress were obtained. Significant correlations (p < .001) were identified between all the variables. CONCLUSIONS: Work engagement and sense of coherence correlated positively with each other and both negatively with psychological distress. So, health care professionals, despite presenting psychological distress, perceive their work satisfactorily and positively despite the severity of the situation and the harsh conditions. IMPLICATIONS FOR NURSING MANAGEMENT: Sense of coherence and work engagement are protective factors against psychological distress. Preventive measures for professionals should go through the dimensionalization of the problem and the adaptation of practical measures for daily management. The COVID-19 pandemic has triggered an unprecedented health crisis that has posed a difficult challenge for health systems. The absence of treatment, the ease and speed of contagion, the high figures of affected people, the severity of the disease and the limitations of resources have made the situation difficult to manage (Walton et al., 2020) . Health professionals are working in harsh conditions, under pressure, overloaded, and with a huge sense of vulnerability and lack of protection (Santarone et al., 2020) . The working environment has been perceived by workers as a threat due to constant exposure to the disease, fear of contagion and transmission of the virus to a family member . These conditions have a strong impact on the mental health of health workers, causing them anxiety, depression, insomnia (Pappa et al., 2020) , post-traumatic stress (Preti et al., 2020) , physical and mental exhaustion, as well as fear or emotional disorders . Maintaining the psycho-emotional well-being of frontline health workers and building up their resilience are crucial in addressing and containing COVID-19 . In this sense, Work Engagement (WE) and Sense of Coherence (SOC) are two competencies that can help professionals cope with work-related psychological distress (PD) and contribute to their well-being and health (Malagon-Aguilera et al., 2019) . Schaufeli et al. (2002) described WE as a positive and satisfying attitude related to work that is characterized by vigour, dedication and absorption. Vigour is characterized by high levels of energy, mental endurance, effort and persistence. Dedication refers to the importance, enthusiasm, inspiration, pride and challenge that work represents. Absorption is characterized by being totally concentrated and happily absorbed in work (García-Sierra et al., 2016) . The SOC is described as an ability to understand a situation, perceive it as manageable and mobilize resources to develop an effective response (Barańczuk, 2019) . The SOC is made up of three dimensions: comprehensibility, manageability and meaningfulness. Comprehensibility is the ability to understand and deal with situations. Manageability is the perception of available resources are adequation to the demands. Meaningfulness is the importance of experiences and motivation to fight against challenges (Kretowicz & Bieniaszewski, 2015) . For all of the above, this study aims to analyse the relationship between work engagement, sense of coherence and psychological distress levels in Spanish health professionals who were active during the COVID-19 pandemic lockdown. A cross-sectional descriptive and analytical study was conducted to obtain a quantitative approach of the concepts studied and explore possible relationships between them. The purpose of the descriptive study was to estimate the magnitude and distribution of the variables at a given time, in addition to measuring other characteristics of the population, such as epidemiological variables. In the analytical part, the variables of interest and potential risk factors were simultaneously collected in a defined population. The prevalence of the results in those exposed to each risk factor was then compared with the prevalence in those not exposed. In this study, an observational approach was followed, which means that the researcher only observed the concepts as described by the participants, without intervention (Grove & Gray, 2018) . The study was conducted in Spain, nationwide, including all regions. When data collection was completed, the total number of diagnosed cases of COVID-19 in Spain was 207.634 and 23.190 deaths (Department of Health of the Spanish Government, 2020). The established inclusion criteria were to be an active health care professional who have worked in a clinical setting during the pandemic caused by coronavirus and over 18 years of age. This way, non-active health care professionals (retired, on leave or unemployed) or those who work from home (teachers, researchers or managers) were excluded. Through a convenience sampling system, a multidisciplinary sample consisting of physicians, nurses and other health care professionals was gathered. To determine the sample size, a 95% confidence, 2.6% precision and 15% adjustment for losses were considered, finally obtaining a sample of 1,459 professionals. The sociodemographic variables included were sex, age, marital status, level of studies, employment status, professional profile, level of care, type of work centre and years of experience. These variables were collected through a self-elaborated questionnaire designed for this purpose. The WE variable was assessed with the Utrecht Work Engagement Scale in its short version, UWES-9 (Schaufeli et al., 2006) . This is an assessment questionnaire designed to evaluate WE and consists of nine items that are assessed with a Likert scale from 0 to 6, in which 0 refers to never and 6 is the usual value (always/every day). The nine items were grouped into the three dimensions of WE: vigour, dedication and absorption. The UWES-9 is a validated instrument. For this study, Cronbach alpha of 0.924 was obtained considering the instrument as a whole, as well as internal consistency indexes of α = 0.843 for the vigour dimension, α = 0.861 for dedication and α = 0.794 for the absorption dimension. The SOC variable was assessed with the Sense of Coherence Scale SOC-13 in its Spanish version (Virués-Ortega et al., 2007) . It is an assessment instrument made up of thirteen items whose response range evaluates the frequency of certain experiences through a Likert scale of 1 to 7, in which 1 is less frequent and 7 is most common. The scale score range can vary from 13 to 91. Items are grouped into the three dimensions of the SOC: meaningfulness, comprehensibility and manageability. This study obtained Cronbach's alpha index of 0.824, considering the instrument as a whole. The internal consistency indexes presented by the different dimensions were α = 0.591 for meaningfulness, α = 0.690 for comprehensibility and α = 0.611 for manageability. The PD variable was assessed with Goldberg's General Health Questionnaire (GHQ-12) (Goldberg et al., 1997) . This is a selfmanaged scale made up of twelve items that evaluate the presence of PD. Each of the items consists of a Likert-type response scale of four options, scoring 0 the first two options and 1 point the remaining ones. The total score on the scale can range from 0 to 12 points, being a higher score indicative of a higher level of PD. The internal consistency index obtained in this study was α = 0.818. This study was carried out in the context of state of alarm and confinement decreed by the Spanish government as a contingency measure in the face of the spread of the virus. Due to this situation and so as to minimize interpersonal contact and consequent risks, data collection was carried out online through the Qualtrics plat-form®. Sample selection was carried out through non-probabilistic sampling. The dissemination of the survey was carried out through personal contacts and distribution lists of collaborating professional bodies. Data collection lasted from 26 March to 26 April 2020. A descriptive analysis of the variables was then carried out using frequency, mean, and standard deviation depending on the type of variable. In order to identify statistically significant differences, bivariate analyses were carried out including Student's t-test, analysis of variance (ANOVA) (with Bonferroni test for multiple comparisons), and correlations, depending on the type of variable. In addition, measures related to the size of effect were included: Cohen's d and partial eta-squared. To study the relationship between scales and its dimensions, Pearson's correlations were used. Finally, to analyse the role of WE and SOC as protective factors of PD, a multiple linear regression analysis (controlling by sex) using the Enter method was performed. Prior to the analysis, a diagnosis of collinearity was performed, obtaining values of variance inflation factor (VIF) < 3.5 and values of tolerance >0.2. For its part, the Durbin-Watson statistic provided a value of 1,936, being within the recommended range of values to assume the assumption of independence of errors. All statistical analyses were performed with the IBM SPSS 26.0 software. The development of this work complied with all the ethical principles set out in the Helsinki Declaration. Participants were previously informed and gave their consent to voluntarily participate. Participants received written information about the purpose and procedure of the study, as well as the voluntary nature of participating in the study and assured of their anonymity at all times. At the beginning of the questionnaire, potential participants were requested to answer two questions confirming they were within the acceptable age (18 years and above) to participate in the study and another tick to confirm they understood the aim and requirements of the study and that they were confirming their agreement to participate in the study. Subjects involved in the study were not exposed to any risk. This study has been approved by the Research Ethics Committee, Andalusian Regional Department of Health, reference number PI 036/20. The sample consisted of 80.9% of women and 19.1% of men. The average age of the participants stood at 41.03 years (SD = 11.21). Sociodemographic characteristics are summarized in Table 1 . Table 2 details the mean scores and typical deviations from participants' responses to the questions contained in the UWES-9, GHQ-12 and SOC-13 scales. In the same way, the total scores, as well as those relating to the dimensions that make up each of the instruments, are provided. The results of the bivariate analysis between the overall scores obtained on the scales and each of the sociodemographic variables are detailed in Table 3 . Significant differences were found in WE (t = 2.328; p < .005; d = 0. Spearman correlation analyses (Table 4 ) showed significant correlations across all scales (p < .001 in all cases). Thus, moderate and negative correlations were identified between the GHQ-12 and UWES-9 (r −0.412; p < .001) and between the GHQ-12 and SOC-13 (r −0.530; p < .001). Based on the relationship between the UWES-9 and SOC-13 dimensions with the GHQ-12, the results again showed significant correlations (p < .001) and negative in all cases. Table 5 presents The objective of this study was to describe the SOC, WE and PD of health care workers during the COVID-19 pandemic and the rela- associated with these professions. According to Xie et al. (2016) , it is expected that people with a strong vocation will be motivated to commit to their profession, since they perceive their personal mission more clearly and focus better on their objectives, with a clear sense of meaning and identity at work that encourages the development of WE (Hirschi, 2012) . In particular, Ziedelis (2019) The results of our study reveal a high level of SOC on the part of the participants, especially in the meaningfulness dimension, in reference to the degree to which one feels that life makes emotional sense (Kretowicz & Bieniaszewski, 2015) . This perception could reflect the highly significant interpersonal relationships that health care professionals establish with patients. According to Mudd et al. (2020) , it develops in a context of practical experience, sensitivity and close relationships which promotes the mental well-being of both professionals and patients. Söderlund (2013) This mutual transformation allows him to identify new meanings and leads them to spiritual growth and harmony (Turkel et al., 2018) . With regard to sociodemographic variables influencing study variables, it was identified that nurses had higher levels of PD, coinciding with the results of previous studies Yao et al., 2020) . Like Cao et al. (2020) suggested, this influence could be attributable to the variability of the tasks of these professionals and the high number of patients they can assist. In addition, the risk of infection is higher for nurses due to their close and frequent contact with patients , and they have expressed more negative feelings regarding the pandemic, including concern about their own exposure and contagion to their relatives (Cao TA B L E 4 Correlation coefficients between work engagement, psychological distress and sense of coherence , 2020) . Nursing professionals are more vulnerable to stress (Söderlund, 2013) , and their high level of commitment to providing quality care to critical patients has been a major challenge in the pandemic situation . According to Yao et al. (2020) , the higher prevalence of PD among nurses could be due to a lack of knowledge about COVID-19 and its routes of transmission and prevention measures. On the other hand, in this study, physicians showed a significantly higher level of SOC than other professionals. This result differs from the findings by Schäfer et al. (2018) who found no significant differences between the SOC of physicians and nurses of an intensive care unit. SOC among physicians has been associated with lower levels of burnout (Kawamura et al., 2018) and identified as a protective factor for well-being and life satisfaction (Buddeberg-Fischer et al., 2005) , mental health and against post-traumatic stress disorders (Schäfer et al., 2018) . With regard to the limitations of this study, some caution is recommended in the generalization of the results, as the sample selection procedure was not randomized. A possible bias associated with the uneven distribution of the sample with respect to sex is also recognized, with female participants predominating. Another limitation that should be acknowledged is the moderate Cronbach's alpha values for the dimensions of the SOC-13 scale obtained in this study. These results indicate a modest internal consistency, so caution is recommended in interpreting the results of SOC. All three variables were correlated: WE and SOC positively with each other and both negatively with respect to the PD. It could therefore be said that health care professionals, despite presenting PD, perceive their work satisfactorily and positively despite the severity of the situation and the harsh conditions. The participants expressed to be very involved in their work, conveying a feeling of importance, pride and challenge. Health care professionals also understand the magnitude of the pandemic and perceive it as manageable, finding meaning and using resources to develop effective coping strategies. SOC and WE were revealed as protective factors against the PD of health care staff working in the frontline during the COVID-19 pandemic. Although the identified levels of WE and SOC were high, as the pandemic situation worsens and extends in time, interventions by management teams aimed at maintaining these protective factors are recommended to fight against stress and burnout of workers. To face psychological distress in health workers caused by the health crisis, protection factors have been identified to be pro- The authors declare no conflicts of interest. 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