The sample of 181 frontline HCWs had a mean age of 37 years (range = 22 to 66 years) and were mostly women (71.8%), white (76.8%), married (45.9%), and professed some religious belief (90.1%). They worked as physicians (39.8%), nursing technicians (28.7%), nurses (15.5%), physical therapists (6.6%), hygiene assistants (2.8%), pharmacists (n = 1; 0.6%), others (5.5%), or did not answer (n = 1). The predominant level of education was complete higher education (12.7%), with specialization (31.5%), but 28.7% did not answer. Almost half of the sample had only one job (49.2%), and the rest had two (27.6%) and three or more jobs (22.1%). Only 8.8% of the sample were in psychotherapy (8,8%), and 2.2% were in psychiatric treatment at the time of data collection.

In hospital work, 86.2% of the sample were in direct contact with a patient diagnosed with COVID-19, and 85.6% were within one meter of the patient. In addition, 80.1% were in an environment where positively diagnosed patients were cared for and 61.3% of the HCWs were present in aerosol-generating procedures (considered to be greater transmitters of the virus). All these data reveal a high degree of exposure and high risk of infection of HCWs by the SARS-CoV-2 (WHO, 2020).

This risk can also be assessed by the results of the rapid immunochromatographic tests for IgG and IgM in blood to detect SARS-CoV-2 antibodies. These tests showed that 29.8% of the HCWs were IgG positive. For the RT-PCR molecular test, collected through nasal secretion, 17.1% of the samples were positive for COVID-19, even though they were asymptomatic, and were therefore taken out from work.

Despite the risks, most of these HCWs did not present work-related distress (89%), but 4.4% were referred for being at “risk of burnout”, and 6.6% with “probable burnout”, totaling 11.0% of the sample with indications of imbalance between demands and resources at work. Exhaustion and emotional impairment were the main symptoms presented. The mean of this sample was lower than the national mean in all dimensions, but within the SD, being compatible with the Brazilian sample (Table 1).

Most of the sample (59.4%) assessed the 12 events as “stressful” and “very stressful.” These HCWs presented a mean stress score of 2.9 points (SD = 0.5), a value close to the “stressful” classification. Family and illness-related stressors stood out in relation to work-related stressful events. In descending order, they indicated as main stressors the risks of transmitting the virus to family members and friends due to exposure at work, being separated from loved ones due to quarantine, and being hospitalized. In the work context, the stressors that stood out were the “risk of making a mistake while performing a procedure” (59.8% of the answers “almost always” and “always”) and having a “higher workload” (53.0%). Many of the HCWs (47.6%) perceived themselves as having some control over the situation, but a quarter of the sample felt they had no or little control (Table 2).

To deal with these stressors related to COVID-19, HCWs reported “always” using these coping strategies: (a) Information-seeking (43.4%) and Problem-Solving (38.6%), both strategies related to the perception of a challenge to the Competence BPN; (b) Negotiation (23.0%) and Accommodation (14.9%), both related to the perception of a challenge to Autonomy (Table 3). The data show a greater perception of threat to the Autonomy, reacting with anger and submission, in addition to feeling threatened in their Competence and wanting to escape from the situation (Table 3).

The main predictors of burnout were being a physician (p < 0.001), having maladaptive coping (p < 0.001), being in psychiatric care (p = 0.01), and having a religious belief (p = 0.05). HCWs with more than one job showed lower scores for burnout (p = 0.06) and adaptive coping, demonstrating an inverse correlation to the syndrome (p = 0.07). Therefore, the variables “having more than one job” and “adaptive coping” were identified as protective factors against burnout (Table 4).

The main predictors of COVID-19-related stress were having maladaptive coping (p < 0.001), being a woman (p = 0.01), having high-risk exposure (WHO score) (p = 0.04), and not having a specialization course or higher education degree (p = 0.07) (Table 4).

Analyzing 89 HCWs at higher risk of exposure (COVID-ICU; COVID-Ward), it was possible to identify conditional associations between psychological variables and Sars-CoV-2 diagnostic categories (Figure 1). The results of the network analysis suggest that the diagnosis of COVID-19 was more common in young men when controlling for other variables. Young men took more risks. They also show coping as a moderator. In this case, it decreases the strength of the association between stress and burnout. Furthermore, coping is more a predictor of burnout than of stress. Another variable of note is the perception of control, which correlated negatively with burnout and positively with coping. Positive correlations were observed between age and coping and between being a woman and stress (Figure 1).

The present study analyzed the stressful conditions and the ways of coping of 181 frontline HCWs in a hospital during the first wave of the COVID-19 pandemic. It was possible to identify the main stressors and describe the ways of coping presented by these HCWs in dealing with them at work. Some of the characteristics of this sample – women, married, white, mean age of 37 years, trained in Medicine and with a Specialization degree, working only one job, and professing a religion – are common to the HCWs identified in reviews on the topic (Pablo et al., 2020; Serrano-Ripoll et al., 2020). The women predominance, also observed in other studies with HCWs (Civantos et al., 2020; Elbay et al., 2020; Pablo et al., 2020; Serrano-Ripoll et al., 2020; Sun et al., 2021), points to the need to cater to this population, as women are also more vulnerable to developing stress, anxiety, and depression (Shreffler et al., 2020).

Despite having more social skills to cope with stress when compared to men, women are still the majority in requesting time off work, which can be caused by their work schedules, but also by the need to care for the home and family, and in some cases, suffer social stigmas and violence (Cai et al., 2020; Pinheiro et al., 2020).

Care and concern for the family, reported within the studies, point out that the risk of transmitting the virus to family members, friends, and people on the work team was one of the factors most endorsed as stressful (Shechter et al., 2020; Silva et al., 2022; Sun et al., 2021). The same goes for the present research, which also identified the fear of getting infected and being hospitalized (Table 3). In addition, the review by Spoorthy et al. (2020) indicates that the greatest concern was related to illness and death of elderly contacts. The sample in the present study had a mean age of 37 years, confirming transmission as a stressful factor for this age group.

A recommended way to deal with the stressors in this context is psychotherapy, as it promotes the maintenance of well-being and quality of life during the pandemic, both for HCWs and for the general population. However, in this sample, only 8.8% reported undergoing this type of mental health care. Psychological care could lessen the negative psychological impact of this context by offering support and guidance for managing different challenges (Schmidt et al., 2020; Shechter et al., 2020).

This individual care for mental health seems important when considering the prevalence of burnout in the sample of this study, which was 11% (Table 2), considered high and worrisome because it compromises the quality of health care (Ferreira & Lucca, 2015). This percentage is close to that obtained by Civantos et al. (2020) with a sample of Brazilian physicians (14.7%) collected in the same period.

In the balance between personal and work demands and resources, to cope with these stressors, the HCWs reported the use of more adaptive coping, such as problem-solving and information-seeking, indicative of the perception of stressors as a challenge to the Competence, and negotiation with colleagues and superiors, related to the perception of a challenge to the Autonomy (Skinner et al., 2003; Skinner & Wellborn, 1994; Silva et al., 2022). Perceiving oneself as having some control of the situation, as close to half of the sample reported, helps in the management of stressful situations. In this attempt of gaining control, seeking support and information about the disease were the WC most reported by the HCWs, as also pointed out by Dullius et al. (2021) and Silva et al. (2022). In other words, in this first moment of the pandemic, the HCWs tried to improve their competence to deal with the challenges of the disease and the changes in family, personal, and work routines. However, these HCWs also perceived the situation as a threat to their Autonomy, reacting with anger and submission, which can be counterproductive in the work environment and in terms of mental health outcomes in the medium and long term (Skinner et al., 2003).

In the present research, professing a religious belief was pointed out as a risk factor for burnout (Table 4). It is possible that, in this context of a pandemic and deaths, the HCWs presented a negative religious/spiritual coping, which includes questioning the existence, love, and acts of God, feeling dissatisfied with God or the religious institution, or having interpersonal conflicts with members of the religious group (Stauner et al., 2016). Doubting God’s powers to interfere in the stressful situation, delegating to God the resolution of problems, or even believing in a punitive God (Foch et al., 2017) are ways of coping that can occur in the hospital setting and in the face of the health crisis and political scenario of that time, without vaccines. This is another area of intervention, as religious/spiritual practice is part of a set of coping, such as having a healthy lifestyle and engaging in leisure activities, as a way to avoid negative thoughts linked to the pandemic (Spoorthy et al., 2020).

Adaptive coping stood out in the present study, which showed coping as a moderator of the relationship between stress and burnout (Figure 1) so that the more and better coping the HCW presents, the less stress and burnout responses he/she has, highlighting that coping is a better predictor of burnout than stress itself. This shows the importance of identifying and strengthening the repertoire of adaptive and reducing maladaptive coping. The latter, in general, relates to negative affect (fear, anger, and sadness) and a perceived threat to their Relatedness, Competence, and Autonomy. Also important in this relationship is the fact that it shows the importance of identifying and intervening in stress responses earlier to prevent the occurrence of burnout.

Another relevant data is the negative correlation between the perception of control and burnout and the positive correlation with coping (Figure 1). These data suggest that promoting the perception that the HCW can handle the situation favors more adaptive coping, reducing the probability of burnout.

Given the positive correlation between age and coping, added to the fact that younger people are being more contaminated and are more exposed to the risk of contamination, it is important to have, as well, younger HCWs as a target population of intervention, as opposed to targeting only those in the risk range. Finally, special attention should be given to women because of their positive correlation with stress (Figure 1). The need to follow WHO recommendations to avoid contamination, especially among younger HCWs, should then be emphasized.

The present study has some limitations. The convenience sampling and the data collected refer to self-reports from HCWs during the first wave of COVID-19 in Brazil, in a pre-vaccine moment when the behavior of the disease was still poorly known. The fact that the data collection occurred right after the first COVID-19 tests performed by the HCWs may have contributed to aggravating the perception of stress. Added to this, the first phase of the disease provided an intense feeling of heroism from the HCWs, which dissipated throughout the long months as the number of cases did not decrease, associated with insecurity related to the conduct of the pandemic in the country. It should be considered that in the study by Messias et al. (2022), 63.1% considered it stressful to have conflicting news and information about the disease, its treatment, and isolation.

Was possible to conclude that, for 11% of this sample of 181 frontline HCWs, the high work demands in the hospital during the initial months of the COVID-19 pandemic generated burnout. Stress relates especially to events such as fear of contagion and separation from family members. Dealing with these stressors more adaptively, trying to problem-solving, information-seeking, social support, and negotiating can reduce burnout responses, increasing the perception of control of the situation and the sense of competence and autonomy. Thus, the importance of promoting adaptive coping for the reduction and prevention of contamination and burnout syndrome is highlighted.