Distress and pleasure indicators in health care workers on the COVID-19 front line

Abstract Objective to evaluate distress and pleasure indicators in health care workers on the front line of care for suspected or confirmed COVID-19 cases. Method an exploratory, analytical and cross-sectional study with a quantitative approach. The studied sample consisted of 437 health professionals invited by electronic means, who answered the questionnaire on sociodemographic information, occupational aspects and clinical conditions. Distress and pleasure at work were considered as outcomes, which were analyzed with multinomial logistic regression regarding the associated independent variables. Results Most of the participants were female (71.0%), nurses (55.6%), with a weekly working shift of 40 hours or more (75.8%); 61.6% of the participants suffered from mental distress. The psychosocial characteristics of high-strain work and low social support were reported by 23.8% and 52.9% of the participants, respectively. In the multiple analysis, distress and lack of pleasure at work were associated with high job strain, low support from co-workers and mental distress. The profession is also associated with distress at work. Conclusion distress and lack of pleasure at work are associated with occupational characteristics and mental strain among health care workers in the COVID-19 scenario.


Introduction
The study of the relationship between man and work and its consequences for mental health highlights the role of a French thought current called Psychopathology of Work, which was built based on the conceptions and research developed by Christophe Dejours (1) , called "Psychodynamics of Work". In this approach, studies involving health care workers stand out, due to their exposure to workloads and all the consequences arising from a professional routine that requires knowledge, technical skills and constant attention. In addition to that, it is characterized by daily contact with pain, suffering such as fear of dying, concern about contaminating family members and anxiety for not knowing what the following day would be like, tend to intensify the emotional pressure they experience (2) .
A recent study involving Nursing professionals showed that, in this pandemic context, stress, burnout, and moral distress can be accentuated, with negative repercussions on the workers' physical and psychological health (3)(4) . On the other hand, interpersonal relationships in health teams make it possible to transform the perception of the realities experienced and the professional identity itself, which can promote pleasure in these professionals (5) .
Work is a strengthening element of people's health and develops the perception of pleasure, with important evidence that positive aspects should be valued in the management of human resources in health (6) . Among the health professionals, the complexity involved in caring for suspected or confirmed COVID-19 patients is responsible for an excessive demand of personal resources from the teams, turning this context into a risk to the workers' health.
It is in this worrying and challenging scenario, but also propitious to the development of knowledge about positive aspects of professional strengthening, that this research is inserted, with the objective of evaluating distress and pleasure indicators in health care workers on the front line of the care provided for suspected or confirmed COVID-19 cases.

Type of study
This is an exploratory, analytical and cross-sectional study with a quantitative approach. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) script for observational studies was followed, as recommended by the EQUATOR network.

Participants
Due to the limitations of face-to-face access to the potential participants and institutions, in the first half of 2020, due to the pandemic, the sample was assembled by convenience, considering any health professional in the Brazilian territory who was active in the front line of the care provided to suspected or confirmed COVID-19 patients, at any care level and in any part of the Brazilian territory. A total 437 workers answered the invitation.

Data collection
The invitation took place by the snowball method, starting from the researchers' contact database, with virtual dissemination via email and social networks between April and June 2020. In the invitation, the sole research selection criterion was included, which was professional practice in assisting suspected or confirmed COVID-19 cases. The website address contained a form with the following information: a) sociodemographic data (gender, age at the time of the research, federal unit of residence/work); b) occupational aspects (current profession, health care level in which the person works, number and nature of the institution(s) with which the person has an employment contract, type(s) of labor contract, weekly working hours, psychosocial characteristics of work, perception of distress and pleasure at work) and c) clinical issues (history of morbidities, mental distress).

Research instruments
As for the psychosocial characteristics of work, the version of the Job Stress Scale for Portuguese spoken in Brazil was used, which measures the participants' perception of psychosocial factors at work, considering three dimensions: task demands, control over their fulfillment and support from supervisors and coworkers (7) . The questionnaire contains 17 items, with Baptista PCP, Lourenção DCA, Silva-Junior JS, Cunha AA, Gallasch CH.
four answer options on a Likert scale, to assess the three dimensions (8) . The interaction between demands and control allows classifying the working conditions according to quadrants, as follows: active work (high demand and high control), passive work (low demand and low control), low-strain work (low demand and high control) and high-strain work (high demand and low control). This last quadrant is considered the most harmful for the worker. The cutoff points established to delimit them were the midpoint of each dimension: The pleasure domain score allows classifying the condition as satisfactory (above 4.0), critical (between 3.9 and 2.1) or severe (equal to or less than 2.0). The distress domain score allows classifying the condition as severe (above 4.0), critical (between 3.9 and 2.1) and satisfactory (equal to or less than 2.0) (9) .
To assess mental distress, the Brazilian version of the Self-Reporting Questionnaire (SRQ-20) was used, with 20 questions about depression, anxiety and stress symptoms and dichotomous answers (yes/no). Mental distress is considered when the participant answers positively to seven or more questions (10)(11)(12) .

Data analysis
The continuous variables were presented using descriptive statistics (frequencies, mean values and standard deviations), being categorized for analysis.
Distress and pleasure at work were considered as outcomes. The categorical variables were submitted to the Chi-square or Fisher's exact tests, with each outcome. Variables whose p-value was equal to or less than 0.20 were selected for the multinomial logistic

Results
The studied sample consisted of 437 health professionals. According to Table 1, the majority were female, nurses, with a weekly workday of 40 hours or more and without morbidities. The mean age was 38.4 years old (median of 37; standard deviation + 9.95). As for the psychosocial characteristics of work, high demand and low social support were reported by 23.8% and 52.9% of the participants, respectively. Most suffered from mental distress at the time of the research. Rev Latino-Am. Enfermagem 2022;30:e3519.
As for pleasure at work, Table 2 shows that the mean score indicated a critical level, with the professional fulfillment factor at a satisfactory level and the freedom of expression factor at a critical level. In the distribution analysis according to the categories of this dimension, Table 3 shows the statistically significant variables: demand-control, social support at work and mental distress, which were selected for multiple logistic modeling. As for distress at work, the mean score presented critical levels, with severe professional burnout and lack of critical recognition, as shown in Table 2. Table 3 presents the statistically significant variables in the analysis of the distribution of the independent variables and the distress categories selected for the multiple analysis: profession, demand-control, social support at work and mental distress.   Table 4 presents the final multinomial model of distress at work, which showed that nursing technicians and assistants were more likely to have severe conditions than other categories of health care workers. The perception of a high-strain and low social support job increased the chance of critical and severe distress levels, as well as the state of mental distress.
As for pleasure at work, Table 5 shows that participants with high-strain work were more likely to have critical or severe conditions of scarce pleasure at work than other psychosocial conditions. In addition to that, the perception of low social support at work was associated with a greater chance of critical and severe conditions of reduced pleasure at work. On the other hand, mental distress was only associated with critical conditions.

Discussion
When evaluating the distress and pleasure indicators in health care workers on the front line of care, it was identified that most of the professionals under study were in mental distress (61.6%), evidencing that, during evolution of the pandemic in Brazil, distress presents critical levels. This scenario indicates the potential for low pleasure and high distress, in addition to presenting severe professional burnout.
The COVID-19 pandemic has imposed a sudden and impacting change in the work process on health care workers. The increase in the workload in health services, added to the lack of Personal Protective Equipment, the absence of established protocols and the fear of contamination, produced mental distress in health professionals who work on the front line (13) .
In this context, the mental distress perceived by the workers was identified in scientific productions carried out worldwide (13)(14)(15) . In Brazil, a study that compared psychological symptoms among the categories of health care workers observed a high prevalence of depression, anxiety and stress symptoms and a psychological impact in all categories (16) .
Mental illness in health care workers is not unprecedented, as it has been target of scholars from different countries, covering multiple professionals such as nurses and doctors, as well as medical students, among others. The very nature of the action object of these professionals, exemplified by the constant proximity to suffering, pain and death, has been one of the major causes for distress.
However, since the last two decades, the World Health Organization has signaled its concern with human resources in health, prioritizing aspects such as training, retention, remuneration, appreciation and improvement of the working conditions in its agendas, with goals even to combat precariousness of the work in health (17) .
Therefore, the COVID-19 pandemic takes place in a scenario that already revealed significant concern for the health care workers. Added to this, in a context of constant changes and unpredictability, the risk for increased mental distress is reported in several studies (18)(19) .
In the current research, the factors that presented a significant association with low to moderate pleasure, in the pandemic context, were high-strain work and the perception of low social support. Allied to these data, among all categories of health care workers active in the front line against the pandemic, nursing technicians and assistants presented a significant association with distress at work. Thus, the results of this study indicate that nursing technicians and assistants experience greater distress at work, in addition to low pleasure due to highstrain work and low social support.
Corroborating the findings, another recent study, which used the EIPST scale, details that identification with the tasks, freedom to speak at work and solidarity among colleagues are the main revealers for pleasure.
On the other hand, stress and exhaustion, as well as feelings of dissatisfaction, injustice, indignation and emotional exhaustion, proved to be the main indicators for distress (20) .
A study carried out with workers in the hemodialysis service related distress to the lack of freedom of expression and recognition at work, with the need for interventions to avoid harms to the workers' health (21) (22) .
In In professions considered altruistic, such as those of health care workers, whether medical or nursing professionals, heroism assumes the meaning of the apex of the self-fulfilled professional (23) . Thus, understanding the pandemic, encouragement, a sense of involvement, professional self-fulfillment and the courage to stand firm in the face of confrontation have been observed in health care workers (24) . Considering the scientific literature on the theme, despite the irrefutable importance of the  (14) .
It is noteworthy that, in the dimension of pleasure on the front line of the Brazilian pandemic, the results of this study point to high pleasure in professional fulfillment, as well as potential for low pleasure in freedom of expression.
A study carried out before the pandemic with workers from Basic Health Units, using the Scale of of Pleasure and Distress Indicators at Work (EIPST), showed that professional fulfillment was also satisfactory; however, the freedom factor and lack of recognition presented a serious risk of illness, which can be indicative of injustice, indignation and devaluation for the work performed (25) .
Another study that used the EIPST scale, before the pandemic and in the Brazilian South region identified that pleasure at work was linked to professional fulfillment with autonomy, freedom and creativity. In this sense, contrary to distress at work, experiences of pleasure and well-being have a strong relationship with being able to express one's feelings and exercise one's creativity (26) .
In the hospital environment, a study evaluated the association between indicators of distress and pleasure at work using the EIPST scale and it was observed that the pleasure indicator was satisfactory. Another significant association in this study was in relation to absenteeism, in which Nursing professionals who were not absent from the service had higher means of pleasure, while higher means of distress were found in those who were absent (27) .
In addition, it is important to highlight the hardship and excess work inherent to the complexity of caring for patients with COVID-19, which makes the service demand higher. It is difficult to intervene in this issue, as the nature of the pandemic imposes this scenario.
However, the findings of this study reveal that, despite the difficulties faced in working on the COVID-19 front line, health care workers still feel pleasure in their professional performance, especially due to professional fulfillment. On the other hand, there are aspects that generate distress or reduced pleasure at work that can be modified through management, such as lack of freedom, low social support and lack of recognition.
The results advance with diverse evidences of the importance of striking a balance between pleasure and distress at work, highlighting the role of management and social support, as lack of support, added to work overload and poor performance management, generates experiences of distress (28) .
As a limitation of this research, it is highlighted that, despite the national scope of the sample, there is a mismatch between the demographic distribution of the country and the participants' place of residence, as this is a snowball study with participation of workers with greater access to the Internet.

Conclusion
This study aimed at evaluating distress and pleasure indicators in health workers on the front line of care for