Spain was a front door country during the first weeks of the COVID-19 pandemic spread in Europe. As of 17 September 2020, more than 600,000 infected cases and more than 30,000 deaths (within a total population of 47 million people [1
]) have been reported in this country [2
]. The situation was especially hard in the period between March and May 2020, when the number of cases and deaths increased rapidly and, therefore, the Spanish Government mandated a national lockdown that started on March 15th. As is being increasingly reported, measures taken to control the COVID-19 pandemic such as the lockdown have caused a severe impact on mental health worldwide. Three studies conducted with the Spanish general population during this period [4
] revealed significant degrees of psychological impact, post-traumatic symptoms, anxiety, depression, and stress. These three studies reported that women, younger participants, students, and people with economic difficulties showed a higher symptomatology. During the aforementioned lockdown, the essential services providers continued working [7
] and had to deal with the consequences of the pandemic in their job. That is why essential workers are especially vulnerable to the psychological effects of the pandemic. In fact, Rodríguez-Rey et al. [6
] and González-Sanguino et al. [4
] found that people who worked on-site during the mandated lockdown showed higher distress levels than people who were teleworking.
During the COVID-19 pandemic, frontline workers bumped into a succession of first-hand, first-time seen traumatic images, such as empty main streets, the overcrowding of coffins, and war-like number of critic patients with a great scarcity of personal protection equipment, therefore risking their and their relatives’ lives [9
]. Understanding how this new scenario could have an impact on the psychological health of frontline workers is relevant to provide accurate post-crisis assistance, as well as to compile data that could be useful to prevent mental disorders in outbreaks or new pandemics. Therefore, the objective of the present study was to explore the psychological impact of the COVID-19 pandemic on frontline workers and to explore its association with multiple work-related variables, related concerns, and sociodemographic characteristics.
Following the Spanish legal disposals [8
], essential services can be divided into seven areas: health (e.g., health care personnel), provisioning and basic services (e.g., groceries, stores, and supermarkets), information and communication (e.g., journalists and mass-media personnel), security (e.g., army, police, and rescue services), transportation (e.g., fuel stations and public transportation), finances (e.g., banks), and miscellany (e.g., funeral parlors and tobacco shops). The consideration of essential workers encounters an international general agreement with few variations and always highlights the special relevance of frontline workers, namely those who cannot feasibly work from home and therefore are more exposed to contagions. Therefore, in accordance with both Spanish and international criteria, in this study, we considered frontline workers as healthcare workers, protective service workers, cashiers in grocery and general merchandise [11
], and journalists working during the Spanish lockdown period.
Healthcare workers normally experience higher burnout, depression, anxiety, and suicide risk than individuals with other occupations (e.g., [12
]). During the COVID-19 crisis, healthcare workers are facing extraordinary amounts of pressure, excessive workloads, uncertainty, emotional overburden, and high exposure to the virus [13
]. Intensive care units have surpassed their capacities so much that regular hospitals have had to occupy beds previously assigned to different services. Emergency field hospitals have been set up, and physicians with non-emergency specializations have had to move to assist COVID-19 patients [14
]. Additionally, healthcare workers have frequently lacked sufficient personal protective equipment and have felt inadequately protected against the virus [13
]. Therefore, burnout, depression, and anxiety levels have dramatically increased. According to a meta-analysis that included 13 studies carried out in Asian countries, anxiety and depression are currently present in more than 20% of the healthcare workers [17
]. In Spain, the situation is similar, with a very high psychological impact reported in different studies [18
]. Healthcare workers at respiratory medicine services, tertiary hospitals, regions with the highest incidence of COVID-19 [20
], as well as those with a presence of COVID-19 symptoms and virus contact history [19
], have shown the highest distress levels. Some other relevant variables associated with higher distress are the lack of previous crisis-management experience [21
], younger age [20
], female gender [17
], the prevalence of physical symptoms [25
], and factors that increase the risk of becoming infected such as being in direct contact with patients and shortages of personal protection [26
As for grocery workers, food purchasing patterns have changed dramatically during the pandemic, turning from regular visits to shop both perishable and non-perishable products to sporadic hoarding behaviors such as non-perishable stockpiling or panic buying [27
]. Thus, “food supply chains needed to adjust rapidly to demand-side shocks, as well as plan for any supply-side disruptions due to potential labor shortages and disruptions to transportation” [27
], (p. 171). Moreover, the shopping experience enormously changed during the lockdown period, with the occurrence of long queues, limited capacity restrictions, maintained distances, limited shopping times, and the mandatory use of masks and sometimes gloves [28
]. Furthermore, due to their lack of information on how to manage sanitary crises, to reduce their risk of infection and their level of uncertainty, grocery workers have faced an unprecedented scenario during the pandemic and consequently experienced high distress [29
Regarding protective service workers such as police, militaries, and public safety workers, they frequently face an enormous diversity of physical and psychological hazards [30
] that may cause severe negative psychological consequences. Indeed, a recent issue concluded that mental disorders are the second most common reason for medical discharge in some uniformed services [31
]. Concretely, among police workers, patrolling is the main source of anxiety [32
], but one-time severe crises may cause a myriad of psychological disorders. For instance, after the 11-M terrorist attack in Madrid in 2004, almost 4% of police workers involved in the rescue reported symptoms consistent with psychiatric disorders [33
]. During the COVID-19 pandemic, public safety and security workers in the occupational sectors have been the most affected by infections [34
]. Notably, as their work necessitates dealing with emotionally demanding situations, this sector scores high in resilience (probably due to cumulative emergency exposure [31
]). However, presenteeism (attending work when lacking health) is a common thread due to their usual reluctance to admit distress [35
Finally, media professionals rarely appear as frontline workers in the literature except when in conflicts and war periods (e.g., [36
]). In those cases, it has been largely reported that conflict journalists suffer more from psychological distress than local journalists (e.g., [37
])—they end up “depleted and broken, their personal lives often in shambles, their sleep plagued by images of death” [38
], (p. 9). Concretely, it has been found that the amount of previous crisis-related assignments, rather than a protective factor, become a risk factor for higher levels of post-traumatic symptoms [39
]. During the whole COVID-19 pandemic, news on television and radio has continued broadcasting, and newspapers have continued being printed and published online. Thus, mass-media professionals, including not only visible faces (i.e., correspondents, presenters, and journalists) but also technicians (e.g., camera and sound technicians), have played a critical role given that they must clearly, sensitively, and regularly provide accurate and constantly updated information. Indeed, media professionals have acquired some societal responsibility since this information could contribute to reducing people’s uncertainty and fear [40
] and fighting misinformation [41
]. Moreover, the work of media professionals during the pandemic has entailed being constantly updated and coping with a constant flow of data that implies rapid fact-checking through very different simultaneous and varying sources to keep the population constantly informed, therefore being unable to disconnect digitally or to balance family and work. To our knowledge, there has been no study covering how the pandemic has affected the psychological health of media professionals. However, this overwhelming information management is relevant given that information overload has been found to be associated with poorer mental health outcomes in the general population [6
Hence, once all the peculiarities of working during the COVID-19 pandemics in each frontline group of workers are stated, we present a study in which we aimed to explore their psychological symptomatic response to working during the COVID-19 pandemic and the potential demographic and work-related factors that may be associated with their symptoms. Additionally, such psychological symptomatic responses were compared across the four groups and with the data obtained from the Spanish general population in the study by Rodríguez-Rey et al. [6
]. By presenting this knowledge, we hope to be more capable of taking care of those who are taking care of us.
To our knowledge, this has been the first study in Spain that evaluated the psychological impact (and the demographic and work-related associated factors) of working during the COVID-19 pandemic in four groups of frontline workers: healthcare, grocery, mass media, and protective professionals. Our main finding is that all four groups evaluated the pandemic situation as severe or very severe, reported feeling sadness, and showed mild to severe psychological impact, with health care and grocery professionals being, by far, the most affected groups and protective professionals being the least negatively affected. The course of this impact, although not significant, seemed to gradually increase as the pandemics progressed, except for the grocery workers, who showed a reverse pattern. It is also worth noting that, despite this general distress, most of the sample reported not having received psychological support.
As a previous study evaluated the psychological impact of the Spanish general population with the same instrument (IES-R) at the beginning of the lockdown [6
], we can also report that all frontline workers except the protective service workers showed significantly more psychological impact symptoms than the general population. The protective service professionals’ lower results (that were still high because their scores indicated mild psychological impact) might have been due to the high profile of working-related resilience and hardiness [50
] or to some assumption of self-imposed stoicism and permanent availability for duty [52
]. The worsening labor scenario as time progressed (e.g., more exposure to the virus and accumulative and varying knowledge) might have accounted for the relation between time and higher psychological impact in the professional groups that had to provide individual assistance or handle information, whereas the reverse pattern found in grocery markets might be explained by an initial shock that was replaced by a progressive normalization of their new working functions as restrictions were gradually lifted. In this sense, occupational health during crisis periods would benefit from longitudinal studies with bigger samples to explore the temporal evolution of the workers’ psychological impact.
The demographic and work-related variables that correlated with higher psychological impacts were lower educational level, female gender, considering the crisis as very severe, a lack of sufficient individual protection equipment, being afraid of infecting or becoming infected with COVID-19, uncertainty about the future, and subjective feelings within the work environment such as overworking, a low recognition of the work done, and not being emotionally prepared to cope with such a working scenario. Interestingly, previous working experience in critical situations did not appear to be a protective factor against psychological impact, which contradicts results from previous studies [21
Some of the variables mentioned above may have accounted for the high psychological impact found in healthcare and grocery professionals. First, grocery workers had a lower educational level than the other groups and recognized not having the training needed to face this crisis, which may have increased their uncertainty and distress to face such a new shift [21
]. Other COVID-19 studies have also found lower educational levels to correlate with higher psychological symptoms (e.g., [46
]). Second, both grocery and healthcare workers are highly feminized professions, and evidence has exposed a clear gender gap in the number of contagions (76% women, [54
]). Third, being female has repeatedly proved to be a risk factor for developing mental disorders when facing the COVID-19 crisis, both in the general population [6
] and in healthcare professionals [24
]. Lastly, the extremely reduced nurse/patient ratio in Spain [55
] would have forced these female professionals to overwork.
Indeed, many professionals considered that they were overworking during the pandemic (more than 38% of healthcare and grocery workers, 60% of media professionals, and 21.7% of protective service workers). Coherently, all the groups reported an average of more than six extra working hours the previous week, with the healthcare group showing the highest mean (M
= 11.64). The perception of overworking was associated with higher psychological impact in all frontline workers’ mental health, except for protective service workers. However, the number of extra hours did not correlate with higher psychological impacts. This result shows that it is not the objective number of extra hours worked but the subjective feeling of overworking that influences mental health. For example, some media professionals could be used to stay permanently updated, but during the coverage of the pandemic, the flow of information was constant, varying, and with such potential amount of misinformation and fake news that it was considered an infodemic [56
]. Additionally, healthcare workers may not only have surpassed their regular work shifts but also have faced an unprecedent sustained overload of higher risk of becoming infected and higher moral injury or distress than usual (e.g., [57
]). The situation seems to have an increased impact when healthcare workers assist to dying patients. Moreover, those who reported not feeling emotionally prepared to cope with the new working scenario and were concerned about how the situation would affect them psychologically scored higher on the IES-R. In general terms, participants considered that their work was moderately recognized by the society, with no differences between groups. Perceiving higher social recognition was associated with lower psychological impacts, a result also present in other studies (e.g., [59
]). Consequently, the symbolic gestures of public recognition towards frontline workers (such as scheduled applauses or dedicated advertisements) could potentially contribute to alleviate psychological distress if they are proven to improve the perception of social recognition of professionals’ work.
The fear of infection is a concern commonly found in the literature about frontline workers during the COVID-19 crisis (e.g., [16
]), and this fear was associated with higher psychological impact in our study. The threat of infection is real. For example, around 24% of all the Spanish COVID-19 cases were healthcare workers [54
], and these professionals showed the highest seroprevalence rate among all occupations in Spain [34
]. Not having the adequate protective material was a global problem, and the concern about this defenselessness contributed to higher psychological impacts; therefore, strategies to assure the provisioning of protective material seems a must for frontline workers.
We are aware that the present study was not without limitations. First, the four groups selected do not represent all the possible frontline professionals working during the COVID-19 pandemic. By selecting only healthcare, grocery, mass media, and protective professionals, we missed other relevant frontline workers such as those related to transportation services or finances. Second, the sample sizes were not equal in all the groups. Less than 100 workers participated in the groups of grocery workers and protective service professionals. Finally, the online recruitment may have influenced data collection, since it may have discouraged older workers to participate in the study. Due to the above-mentioned reasons, the findings of this study should only be generalized with caution.
The results of this study can help make recommendations aimed at protecting mental health in frontline workers. First, special attention should be paid to healthcare workers, grocery workers, and media professionals, regardless of their previous experience in similar crises. Specifically, dedicated attention should be paid to females working in the healthcare and grocery sectors and to young media and protective service workers. Within healthcare workers, the most vulnerable professionals are those working in the most affected regions, tending to COVID-19 patients, and/or taking care of dying patients with COVID-19, so more intensive monitoring and measures might be applied to them. Second, acknowledging the potential differences between professional groups regarding how the progression of the crisis impacts their working conditions might also help to provide timely support. In line with other authors [61
] and in the light of our results, a relevant message for human resource departments is the necessity of periodically monitoring the psychological health of frontline workers and acting accordingly.
Third, human resource departments should also schedule frequent breaks for their employees and check and improve their workflows, as well as make sure that their employees regularly enjoy days off in order to reduce objective and subjective overload. Additionally, personal protection equipment should be provided to all frontline workers, as previously stated, to reduce their concerns about becoming infected or infecting others and thus lowering the psychological impact of the crisis. Fourth, frontline workers should also be provided with emotional training on emergency coping techniques by their employers, and easy access to psychological care should be provided to them or at least facilitated [61
]. In this sense, educating healthcare professionals on palliative care and grief management would help to alleviate the psychological impact of working with dying patients in such a difficult situation. Finally, measures should be taken whenever possible to increase the perceived social recognition of their work at both the formal governmental level and the informal level.
Strategically, a national network of psychological support with crisis intervention expertise should be integrated in the human resource departments of frontline workers’ institutions or, more generally, in the National Health Provision—at least during crisis periods—to provide specialized support and prevent the appearance of mental health issues. Importantly, psychologists providing crisis intervention should be proactive instead of waiting to be asked for help. This is essential to reach professionals that may hide their emotional state (such as protective workers in our sample) or those who traditionally delay their request for assistance (such as health workers) [61