During the COVID-19 pandemic, the usual dynamics of work in primary care (personalized and individualized attention in the clinic, follow-up by the same family doctor) were broken. Usual care was also discontinued, except in consultations and unproven emergencies or for IDVC-related pathologies.19 The availability of PEP was reduced to reduce the risk of infection, especially in the early stages. A quarter of the participants reported acute stress, which was more intense when there was a perceived increased risk of SARS-CoV-2 infection.
Regarding specific training in the use of PPE, we found a clear lack of training by the health professionals surveyed. Less than half received specific training on the use and correct placement of PPE. This contrasts with World Health Organization (WHO) recommendations, which specify the need for prior training for workers who will use PPE , as well as studies that report the consequences of lack of training. Thus, the FREMAP study conducted in 2011 concluded that only 13.6% of professionals had used PPE correctly, largely due to the absence of training programs and their insufficient content .
At the time of writing, scientific societies throughout Europe, such as the Royal College of Surgeons in England and the European Society of Intensive Care Medicine, are conducting different surveys to find out about the protection measures of the health care workers, as well as their level of prior training. At the moment, we do not have the perspective of the current situation of training in the use of PPEs in European health care workers. However, it is worth noting that during the Ebola health crisis, several studies revealed a lack of training of health workers in the use of PPEs [11–15].
The protocols developed by the Spanish Ministry of Health for the management of COVID-19 specify that PPEs must be composed of standard precautions, contact precautions and precautions for transmission by drops . This contrasts with the data obtained in this survey, in which more than half of those surveyed stated that they had supplemented their personal protective equipment through donations. About 40% of the participants reported that they did not have complete personal protective equipment, thus exposing their safety and highlighting the lack of resources to which they have been subjected during healthcare provided to patients of COVID-19. It should also be noted that on the date of the survey, i.e. 42 days after the state of alarm was declared, some health professionals still reported that they did not have adequate protective equipment.
These data are consistent with the fact that the Ministry of Health has included in the document of "Procedure for action for occupational risk prevention services against exposure to SARS-CoV-2" an annex specifying " alternative strategies in crisis situations ”  in order to give alternatives in situations where resources are limited, supporting in this way, the results obtained in the survey. The lack of availability of adequate protection material, as well as the possibility that some of the donations received could not have passed through the adequate quality certification; have been able to contribute decisively to the high number of healthcare providers infected by COVID-19 in Spain, emphasizing the fact that health professionals did not perceive increased stress because this material was donated.
In the matter of the questions on the distress scale, it is highlighted that despite being a group capable of dealing with stressful situations, and that this is part of their normal work routine, 23.7% (n = 123) of the participants obtained a score higher than 15 in the acute stress scale validated in patient care COVID-19, with an average score of 10.31 points. This indicates that the majority of the participants would find themselves in a situation of emotional distress with a high percentage of participants in a situation of emotional overload. The main sources of stress were being able to infect the family when they returned home, as well as not being able to disconnect from the workplace. On the other hand, despite the stress levels, most of the survey participants consider that they continue to maintain their decision-making capacity, as well as their abilities to empathize with patients.
Among the factors associated with a higher level of distress, female sex, work in rural settings and younger professionals stand out. With regard to younger professionals, this could be justified by the lack of work experience and of dealing with critical situations, as well as the fact of not having faced previous situations with similar characteristics, such as the Ebola health crisis, the crisis health of SARS or the health crisis of Influenza A. Although youth itself, does not seem to have had higher levels of job stress in general lines in other studies. On the other hand, different studies have related the female sex with a greater emotional involvement in different analyzes of labor involvement, as well as it has been established that women are twice as likely to experience negative emotions in stressful situations than men .
It also highlights that the participants who have not received specific training in the use of PPE associated with a higher level of distress, something that shows the emotional impact that lack of training on available resources can produce in the perception of work stress, something that has been confirmed in previous studies on the emotional impact on the health work environment [19–21]. Regarding rural health workers, there are no previous studies that indicate higher levels of stress with respect to urban health workers. Although some determining factors that generally increase their stress levels have been identified in other studies, such as role overload and role ambiguity, determining factors that have undoubtedly happened during the acute phase of the pandemic .
On the other hand, in this study, several factors have been identified that have contributed to mitigating the level of perceived distress among the participants, to highlight: the availability of PPE, reinforcement in the cleaning and hygiene tasks of the health care center as well as the absence of health workers on sick leave due to COVID-19 at their workplace. Likewise, performing COVID-19 RT-PCR significantly reduced fear and anxiety responses. These data emphasize the need to provide material resources as well as tests to health care professionals involved in the management of COVID-19 patients in order to improve their distress levels.
Regarding the representativeness of the physicians who have responded, it can be seen that the age ranges of the participants are mostly between 30–64 years, something that represents quite well the professionals involved in healthcare, especially in Primary Care in Spain. There is a clear predominance of the female sex, a fact that may be due to the increasing feminization of the health professions. Thus, in 2018 a study estimated that the average age of PCPs in Spain was 49.2 years with 61.6% of women .
Regarding the impact that COVID-19 has had on the structuring of work, our study highlights the change made in the healthcare model by PCPs in health care centers during the acute phase of the pandemic. Telephone attention has acquired a main function, reducing the follow-up of chronic patients. Something that shows the need to provide Primary Care with telemedicine tools, that allows better management of chronic healthcare demand.
There are several limitations of this study. The objective of the study was not to achieve a representativeness of all the regions of the country, but to reach a minimum number of surveys that were diverse and in a short time to be able to know the situation first hand and be able to provide relevant information in a short time, so that it could contribute points of reflection for an improvement plan in the situation related to COVID-19. In the same way, the survey was sent to PCPs linked to various scientific societies, therefore especially motivated on the subject.
Among the strengths of the study it is worth highlighting the large sample size, the representation of various PCPs with different conditions and workplaces involved in health care, as well as a distribution throughout the Spanish geography. In the same way, the questionnaire raised by the research team has been previously tested to see its suitability, being endowed with the necessary validation and having been prepared and reviewed by professionals with extensive knowledge and experience on the subject.
To our knowledge, this is the first study carried out to determine the emotional impact and perception of distress of PCPs during the management of the COVID-19 pandemic in Spain, as well as its relationship with the lack of adequate PPE and specific protection measures for this situation. This is a key aspect since they represent one of the groups with the highest number of people infected internationally by the COVID-19 pandemic.