Introduction

Medical rescuers are now facing new occupational hazards due to the novel severe acute respiratory syndrome or COVID-19 (Coronavirus Disease of 2019), which rapidly spread worldwide (^{World Health Organization [WHO], 2020}). They are on the frontline of this pandemic and are the workforce of the national emergency medical system, attending to victims’ needs in pre-hospital settings, transporting them to hospitals and collecting biological material for SARS-CoV-2 analysis. Recent research demonstrated that, during this pandemic, frontline workers presented poorer mental health than other workers (^{Cai et al., 2020}; ^{Sirois & Owen, 2021}). Thus, the COVID-19 pandemic puts an added pressure on medical rescuers and can severely impact their occupational health (^{European Agency for Safety and Health at Work [EU-OSHA], 2020}, ²⁰²¹), as a result of inadequate strategies and resources to deal with work-related stressors and demands (^{Ross & Altmaier, 1994}). However, it can also represent an opportunity to better understand how emergency organizations can efficiently prioritize occupational health, namely by promoting more adaptive strategies (^{Sinclair et al., 2020}).

Medical rescuers have long been considered a population at risk for psychological and occupational problems, especially for burnout and trauma. Burnout was considered by the WHO an occupational phenomenon (^{WHO, 2019}) and is conceptualized as a prolonged and inadequate response to chronic job stressors, characterized by high levels of emotional exhaustion and depersonalization/cynicism, and low levels of personal realization and efficacy (^{Maslach et al., 2001}). Trauma is developed after exposure to acute potentially traumatic stressors, which result in psychological impairments characterized by intrusive thoughts and memories of the trauma stimuli, avoidance, negative changes in mood or cognitions, and reactivity or arousal (^{American Psychiatric Association [APA], 2014}). Another indicator of occupational health is post-traumatic growth, which is conceptualized as a significant and a positive change, after exposure to the same acute traumatic stressors (^{Tedeschi & Calhoun, 1996}). This implies a cognitive reappraisal of the situation, as well as behavioural changes (^{Hobfoll et al., 2007}). Overall, literature prior to COVID-19 has shown the presence of moderate to high levels of burnout (e.g., ^{Portero de la Cruz et al., 2020}) and post-traumatic growth (e.g., ^{Sun et al., 2020}), and a low to moderate prevalence (11 to 20%) of trauma (^{Fonseca et al., 2019}; ^{Petrie et al., 2018}; ^{Soravia et al., 2021}). Despite the still scarce literature, particularly with rescuers, this pandemic has also shown to increase the likelihood of developing and/or exacerbating these symptoms and disorders, namely for burnout and trauma (e.g., ^{Busch et al., 2021}; ^{Sanghera et al., 2020}; ^{Serrão et al., 2021}). For post-traumatic growth, ^{Cui and colleagues (2020}) found moderate to high levels in nurses, but ^{Kalaitzaki and Rovithis (2021}) found relatively low post-traumatic growth in healthcare workers, while facing the COVID-19.

To better understand these work-related psychological outcomes (even when their relation to COVID-19 is not always clear), as well as to better understand the psychological adjustment during the pandemic and how it can be promoted, it is important to analyse which strategies medical rescuers mostly resorted to, namely among coping and emotion regulation strategies. Coping implies cognitive and behavioural efforts and changes, as a process of managing various stressors (^{Folkman, 2013}). These strategies are grouped into problem-focused strategies, mostly used to solve a problem or find a solution, emotion-focused strategies, mostly used when the situation cannot be solved and emotions need to be managed, and dysfunctional or avoidance strategies. Emotion regulation strategies are conceptualized as attempts to influence and modulate which emotion emerges, and how this emotion is experienced and expressed (^{Gross & John, 2003}). Therefore, these strategies can be categorized into antecedent-focused strategies, as cognitive reappraisal, and response-focused strategies, as expressive suppression (^{Gross & Thompson, 2007}). Prior to the COVID-19 pandemic, studies showed healthcare workers and rescuers employed more problem and emotion-focused coping, as well as more cognitive reappraisal (^{Fonseca et al., 2019}; ^{Huang et al., 2019}; ^{Martín-Brufau et al., 2020}; ^{Portero de la Cruz et al., 2020}). During the COVID-19, studies have shown healthcare workers resorted more to problem-focused strategies (^{Jarego et al., 2021}; ^{Roslan et al., 2021}) and cognitive reappraisal (^{García-Batista et al., 2021}).

Regarding the contribution of coping to medical rescuers’ occupational health, studies have shown dysfunctional coping can contribute to burnout and trauma (^{Bamonti et al., 2019}; ^{Fonseca et al., 2019}), and problem and emotion-focused strategies can predict post-traumatic growth (^{Ogińska-Bulik & Kobylarczyk, 2015}; ^{Sattler et al., 2014}). During the COVID-19, a study with 430 Portuguese adults found substance abuse (dysfunctional coping) predicted poorer mental health, and humour and positive reframing (emotion-focused coping) predicted better mental health (^{Jarego et al., 2021}). ^{Kalaitzaki and Rovithis (2021}) in the era of the COVID-19, with 673 healthcare workers, found that both adaptive and maladaptive coping strategies predicted post-traumatic growth. These authors found that positive reframing, use of instrumental support, self-distraction, denial and religion were positive predictors, and that substance abuse was a negative predictor. For emotion regulation, higher expressive suppression and lower cognitive reappraisal contributed to higher burnout and trauma, as well as lower post-traumatic growth (^{Huang et al., 2019}; ^{Sun et al., 2017}).

Thus, it is important to increase our understanding of how the pandemic is affecting medical rescuers’ occupational health, as well as the strategies employed to manage the COVID-19 experience. Moreover, is crucial to analyse how these strategies can contribute to exacerbate or reduce previous symptoms, namely the ones that arise from the most traumatic incidents in their careers or from the exposure to chronic stressors, even if not related to the pandemic. However, it is important to consider the complexity of these relationships and how the pandemic might represent a turning point towards the worsening of symptoms that may signal the early stages of psychopathology. It is also important to contribute to the scarce literature focused on medical rescuers during the COVID-19.

As such, this study aims to first analyse the impact of the COVID-19 pandemic on medical rescuers’ coping and emotion regulation strategies, as well as to analyse their levels of work-related psychological outcomes, such as burnout, trauma and post-traumatic growth. Secondly, this study aims to analyse the contribution of coping and emotion regulation strategies, employed to manage this pandemic, on burnout, trauma and post-traumatic growth. Literature allowed to hypothesize that both coping and emotion regulation strategies will contribute to burnout, trauma and post-traumatic growth. Dysfunctional coping will contribute to burnout and trauma, and problem and emotion-focused coping will contribute to post-traumatic growth. Low cognitive reappraisal and high expressive suppression will contribute to high burnout and trauma, and the contrary will happen for post-traumatic growth.

Method

Results

Regarding the levels of strategies employed to manage the COVID-19 pandemic and medical rescuers’ work-related psychological outcomes (Table 1), findings showed medical rescuers reported moderate levels of emotion regulation strategies and low to moderate levels of coping strategies. They also reported moderate levels of burnout and posttraumatic growth and low levels of trauma. For trauma, 71 (64%) medical rescuers did not meet criteria, 14 (13%) presented levels of clinical concern, 5 (4%) presented the best cut-off value for a probable diagnosis of post-traumatic stress disorder, and 21 (19%) presented extreme levels of trauma (^{McCabe, 2019}). It is important to note that, on average, the most stressful and traumatic incident occurred 5.94 years (SD=4.62, range 0.10-22) prior to data collection.

Table 1. Descriptive statistics of the variables in study 

Overall, correlations showed all dimensions of each variable correlated significantly and positively with each other (Table 2). Emotion regulation and coping strategies correlated significantly: cognitive reappraisal correlated positively with problem, emotion, and dysfunctional coping; and expressive suppression correlated positively with dysfunctional coping (with a higher coefficient than reappraisal). Moreover, emotion regulation and coping strategies correlated with burnout, trauma, and post-traumatic growth. For emotion regulation, only expressive suppression correlated positively with burnout and trauma. For coping, problem and emotion-focused correlated positively with post-traumatic growth, and only emotion-focused correlated negatively with disengagement. Dysfunctional coping correlated positively with burnout, trauma and post-traumatic growth. Moreover, when controlling for years of experience, medical rescuers’ age, being/not being a parent and how long ago the most traumatic incident took place, some correlations changed their significance (Table 2).

Table 2 Correlations matrix 

Note. ^aControlling for how long ago the most traumatic incident took place; ^bControlling for years of experience; ^cControlling for medical rescuers’ age; ^dControlling for being or not being a parent; ^* p<.05; ^** p<.01; ^*** p<.001.

The predictive value of coping and emotion regulation strategies on burnout, trauma and post-traumatic growth was analysed (Table 3). Findings showed a higher weight of coping strategies on all variables, when compared to emotion regulation. For burnout and trauma, only expressive suppression and dysfunctional coping were positive predictors. For post-traumatic growth, emotion regulation strategies were not significant predictors and only problem and emotion-focused coping were positive predictors, especially problem-focused.

Table 3 Predictors of burnout, trauma and post-traumatic growth: Coping and emotion regulation strategies 

Note. ^* p<.05; ^*** p<.001.

However, suppression significantly predicted burnout in the Model 1, but lost its predictive value when adding coping strategies in the Model 2, namely dysfunctional coping. For trauma, expressive suppression also reduced its predictive value when coping strategies were added. Thus, possible indirect effects and simple mediation analysis were explored. Only partial mediations were found, and they are presented in Table 4 (for standardized values) and Figures 1 and 2 (for unstandardized values). Overall, findings showed dysfunctional coping mediated the effect of expressive suppression on burnout and on trauma. Therefore, dysfunctional coping had an indirect effect on how the use of expressive suppression strategies can promote burnout and trauma (Table 4). High levels of burnout and trauma were predicted by a higher use of expressive suppression strategies, which were further aggravated by a higher use of dysfunctional coping strategies.

Table 4. Simple mediation models for burnout and trauma: Standardized coefficients and effects 

Note. DV=Dependent Variable; IV=Independent Variable; M=Mediator; LLCI=Lower Limit Confidence Interval 95%; ULCI=Upper Limit Confidence Interval 95%; ^*** p<.001. Only standardized coefficients and effects are presented.

Figure 1. Simple mediation model for burnout: Unstandardized coefficients and effects 

Figure 2. Simple mediation model for trauma: Unstandardized coefficients and effects 

For burnout (Table 4 and Figure 1) and for trauma (Table 4 and Figure 2), the effect of expressive suppression on dysfunctional coping, as well as the effect of dysfunctional coping on burnout and trauma, were positively significant. When dysfunctional coping, the mediator, is not considered in the model (total effect), expressive suppression positively predicted burnout and trauma. The same happened when dysfunctional coping was included (direct effect), but with a weaker coefficient. The indirect effects were also significant.

Discussion

Overall, regarding the impact of the COVID-19 pandemic on the strategies medical rescuers resorted to, and regarding their levels of work-related psychological outcomes, findings showed moderate and adequate levels for both, although there is some degree of concern for burnout and trauma. Findings revealed medical rescuers moderately employed coping and emotion regulation strategies to manage the COVID-19 pandemic. They resorted more to adaptative strategies, such as problem and emotion-focused coping and cognitive reappraisal, and resorted less to non-adaptative strategies, such as dysfunctional coping and expressive suppression. These results are in line with studies conducted prior to this pandemic (^{Fonseca et al., 2019}; ^{Huang et al., 2019}; ^{Jarego et al., 2021}; ^{Martín-Brufau et al., 2020}; ^{Portero de la Cruz et al., 2020}) and fill in the gap of knowledge related to medical rescuers’ COVID-19 experience. Moreover, it is important to note that medical rescuers who resorted more to problem and emotion-focused coping also resorted more to cognitive reappraisal strategies. Medical rescuers who resorted more to dysfunctional coping, also resorted more to expressive suppression (with a higher Pearson’s coefficient than for cognitive reappraisal).

For medical rescuers’ work-related psychological outcomes, low levels for trauma and moderate levels for burnout and post-traumatic growth were found. These outcomes resulted from exposure to acute or chronic stressors, related or not to the COVID-19. In future studies, these stressors ought to be directly addressed so to undoubtedly understand if they are related to this pandemic. Furthermore, for medical rescuers who reported trauma symptoms, 19% presented extreme levels of trauma and 13% presented levels that are of clinical concern, even if the most traumatic incident happened, on average, about six years ago. Thus, the most traumatic incident does not seem to be related to the COVID-19, for most of medical rescuers. However, for a few the incident might be related to this pandemic, since the range of time for the occurrence of the critical incident was between 1 month and 22 years, and for 8 rescuers the incident occurred within the 6 months prior to data collection (which coincided with the beginning of the COVID-19 pandemic). However, only 1 medical rescuer mentioned a critical incident related to the COVID-19 on the open-ended questions of the Impact of Event Scale-Revised. These results are in line with previous studies conducted prior to and during the COVID-19 pandemic (^{Cui et al., 2020}; ^{Fonseca et al., 2019}; ^{Petrie et al., 2018}; ^{Sanghera et al., 2020}; ^{Serrão et al., 2021}; ^{Soravia et al., 2021}; ^{Sun et al., 2020}), although higher levels of burnout were found with nurses, who might be more exposed to emotional labour than medical rescuers (^{Portero de la Cruz et al., 2020}). Therefore, a closer attention to burnout and trauma symptoms ought to be a concern for researchers and practitioners, during and after the COVID-19.

The strategies medical rescuers resorted to and the work-related psychological outcomes correlated with each other. The results from the regression analyses are in line with these findings and showed a greater weight of coping strategies on burnout, trauma and post-traumatic growth, when compared to emotion regulation strategies. For post-traumatic growth, emotion regulation strategies were not even significant predictors. The scientific literature is lacking in studies which explore these two strategies during the COVID-19 pandemic, as well as in studies which explore how strategies employed to manage the COVID-19 can have an impact on work-related psychological outcomes, that may or may not be related to this pandemic.

For burnout and trauma, expressive suppression and dysfunctional coping were significant predictors, with higher coefficients for dysfunctional coping. These findings, which are in line with other studies (^{Bamonti et al., 2019}; ^{Fonseca et al., 2019}; ^{Huang et al., 2019}; ^{Sun et al., 2017}), showed that dysfunctionally dealing with and avoiding acute or chronic stressors, as well as suppressing the expression of emotions can lead to burnout and trauma. Furthermore, resorting to dysfunctional coping exacerbated the impact of expressive suppression on burnout and trauma. Thus, actively suppress the expression of emotions, leads to a higher use of dysfunctional or avoidance coping, which in turn leads to and worsens burnout and trauma symptoms. Therefore, to prevent both burnout and trauma it is important for medical rescuers to reduce the use of dysfunctional coping and of expressive suppression, which are closely related and reinforce each other. The analysis of these indirect effects is lacking in the scientific literature and this study shows similar paths for the development and/or exacerbation of burnout and trauma in medical rescuers. For this population, it may be that acute/traumatic and chronic stressors share common origins, namely their daily critical incidents, and therefore have a similar impact on how rescuers employ coping strategies, which in turn lead to burnout and trauma.

For post-traumatic growth, emotion regulation strategies were not significant predictors, and only problem and emotion-focused coping were. Problem-focused presented a higher coefficient and therefore showed to have a greater impact on this work-related psychological outcome. Focusing on solving the problem and the situation at hand, more than dealing with the emotions that arise from this situation, appear to have a greater contribution to personal growth after a traumatic incident. Thus, problem-focused strategies, and emotion-focused at some degree, contribute to the process of cognitive reappraisal of stressors and behavioural changes, which are characteristic of post-traumatic growth (^{Hobfoll et al., 2007}; ^{Tedeschi & Calhoun, 1996}) and are in line with other studies (^{Kalaitzaki & Rovithis, 2021}; ^{Ogińska-Bulik & Kobylarczyk, 2015}; ^{Sattler et al., 2014}). Therefore, the regulation of emotion and of emotional responses may not have an important role on post-traumatic growth, highlighting the importance of cognitive mechanisms on positively changing and transforming after a traumatic incident (^{Hobfoll et al., 2007}; ^{Tedeschi & Calhoun, 1996}).