**4. Discussion**

This study unveiled several work-related risk factors for stress among healthcare professionals managing COVID-19 in the Fever Clinics in Saudi Arabia. While role conflict and ambiguity were positively associated with stress levels, social support was inversely associated with stress levels.

Our results concurred with a recent study conducted on healthcare professionals in primary healthcare centers in Saudi Arabia during the COVID-19 time that showed high role conflict and ambiguity levels, especially among those working at the Fever Clinics. This research also showed a tight correlation between work-related stressors and stress levels [29]. Additionally, one study in the pre-COVID-19 time conducted on healthcare professionals from Italy showed that role ambiguity was a significant risk factor for emotional exhaustion and negatively affected participants' wellbeing and psychosocial competence [36].

The Minister of Health in Saudi Arabia initiated the Fever Clinics in the wake of the COVID-19 pandemic to offer preventive and curative services for people showing COVID-19 symptoms. Given the rapidly changing guidelines and protocols of COVID-19 management and the fact that the scientific knowledge on the virus is still limited, the Fever Clinics' healthcare professionals might have incomplete details on their job requirements. Together, these factors can explain role conflict and ambiguity and the resulting stress among health care professionals working at the Fever Clinics [29]

The inverse association between social support and stress levels was expected. Two recent studies conducted on healthcare professional in Saudi Arabia showed that, during the COVID-19 pandemic, participants who did not perceive enough emotional support from society and the workplace had higher stress levels than those who perceived enough emotional support [29,37]. This finding elucidates the need to provide social support to healthcare professionals on the frontlines to improve their psychological health.

Of note, this study also showed that younger and non-Saudi healthcare professionals were more likely to report stress than their older and Saudi counterparts. The vulnerability of younger people to stress during the COVID-19 pandemic has been reported, highlighting the importance of tailoring mental health interventions for this age group [38]. The disparity in stress levels between Saudi and non-Saudi healthcare professionals can be attributed to the fact that non-Saudi healthcare professionals could not travel to their home countries because of the travel restrictions associated with the COVID-19 pandemic. It could also reflect a worse occupational environment or fewer financial motivations. However, this association should be further studied in future research.

#### **5. Strengths and Limitations**

This study had many strengths, including the multistage random sampling approach, using validated and reliable scales data to collect data on the work-related stressors and stress levels, and focusing on healthcare professionals in the frontlines managing COVID-19. Still, some limitations should be addressed. First, since the cross-sectional design cannot guarantee causality, studies with prospective designs are needed to confirm our results. Second, the data collecting tool had no information on the lack of personal protective equipment, one of the significant stressors among healthcare professionals during the COVID-19 time. Third, we accessed participants using emails. Online surveys have many advantages such as cutting time, saving funds, decreasing missing data, yet they include some limitations such as the high possibility of non-response bias. Since we have no data on the nonrespondents, we cannot guarantee that the respondents had similar sociodemographic data and work-related stressors [39].

#### **6. Conclusions**

The current study showed that among healthcare professionals working at the Fever Clinics and managing COVID-19 in Saudi Arabia, role conflict and ambiguity were positively associated with stress levels. In contrast, social support was inversely associated with social support. We believe that the reasons behind role conflict and ambiguity among healthcare professionals in the Fever Clinics in Saudi Arabia should be studied, and tailored interventions should be put into practice.

**Author Contributions:** Conceptualization, S.A. and F.A.; data curation, S.A. and F.A.; formal analysis, S.A.; methodology, S.A. and F.A.; project administration, S.A.; supervision, S.A. and F.A.; validation, F.A.; investigation, S.A.; writing—original draft preparation, S.A., and F.A.; writing—review and editing, S.A., and F.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Ministry of Health (protocol code: 31-30M and date of approval: 16 March 2021).

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** Data is available upon reasonable request by contacting the corresponding author.

**Acknowledgments:** The authors thank Khalid Al-Mansour for his permittance in using the data. Also, the authors also thank leaders of primary health centers and healthcare workers who participated and assigned a part of their time to this study.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


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