Coronavirus disease 2019 has caused a global health crisis that has required emergency responses in all countries, including Indonesia. As of May 22, 2020, a total of 20,796 people have tested positive for COVID-19 in Indonesia, and the mortality rate has reached 6.4% (Indonesian Task Force for the Acceleration of Handling COVID-19, 2020) . The increasing number of confirmed positive patients and deaths due to COVID-19 has caused an unprecedented health crisis among Indonesian communities, patients, health workers, and the healthcare system. Based on the data from the COVID-19 Handling Team of the Indonesian National Nurses Association (2020), 69 nurses had tested positive for COVID-19, and 21 had died from the disease. Health workers who are at the forefront of handling COVID-19 need to adapt to the new situation in their work environment and try to overcome these stressful circumstances (Liu et al., 2020) . This study aimed to examine the factors that cause and reduce health workers' stress as well as the coping mechanisms used by health workers and to determine what motivates health workers to continue working in the face of the COVID-19 pandemic.
Online cross-sectional surveys via Google Forms were used in this study, which was conducted using snowball sampling through the WhatsApp platform from March 18 to April 30, 2020. This study was approved by the Health Research Ethics Commission of the Faculty of Nursing at Airlangga University (ethical clearance letter No. 2005-KEPK) . The participation of the respondents was voluntary, and they were not coerced in any way. The survey questionnaire was an adaptation that was used in the research undertaken by Khalid, Khalid, Qabajah, Barnard, and Qushmaq (2016) for health workers during the MERS-CoV epidemic. The modified questionnaire used in the present study was called the COVID-19 Health Personnel Questionnaire. The questionnaire consisted of 5 sections with 53 question items written in Indonesian. The sections of the questionnaire explored health workers' feelings (9 items), the factors that caused their stress (17 items), and those that reduced their stress (10 items), the coping mechanisms used by health workers (8 items), and the factors that motivated health workers during the COVID-19 outbreak (9 items).
The descriptive analysis of the 236 health workers who were working in community health centers, hospitals, and volunteers during the COVID-19 pandemic showed that the average age was 33 years, with average work experience of 10 years. The majority of the health workers were women (74.6%), nurses (65.3%), married (59.7%), and living with family (85.2%).
Most of the health workers had received sufficient information related to COVID-19 (94.1%).
Where further information was required, it was obtained from social media/the internet (78.4%).
Furthermore, 73.7% of the respondents indicated that their activities or work had been disrupted due to the outbreak of COVID-19.
The most prominent results related to the feelings of the health workers felt that they had to do this work because it was their duty, and they were fulfilling their ethical obligations (97.9%). Additionally, 97.9% of the health workers appreciated that the hospitals gave special rewards for the work they were doing. The most significant stressor was the requirement to wear personal protective equipment (PPE) every day (96.2%). In contrast, the main factor that reduced their stress was that all health professionals worked together on the frontlines to overcome COVID-19 (93.7%). The three coping strategies most commonly used by health workers to deal with the COVID-19 outbreak were adopting a positive attitude to motivate themselves (98.3%), reading about COVID-19 and its prevention and transmission (98.3%), and following appropriate self-protection measures (mask, gown) (98.3%). Family support was a significant factor motivating health workers to deal with the COVID-19 outbreak (98.7%). The results of the study are more fully described in table 1.
Health workers are at the forefront of dealing with health problems due to the COVID-19 outbreak. Health workers have an obligation to provide health services during the COVID-19 pandemic. It is important to recognize that health workers have been doing difficult and invaluable work during this time of the pandemic (Cox, 2020) . Health workers in clinical settings have an important role in the early detection and treatment of patients, so they are required to use PPE every day as the best protection of healthcare workers (Ha, 2020; Sharma et al., 2020) .
However, using PPE everyday causes discomfort, so it becomes a stressor for health workers.
Discomfort from using PPE includes adverse skin reactions, respiratory difficulty, heat stress, dizziness, and nausea (Yuan et al., 2020) . One of the strategies that can be done to overcome this problem is by providing adequate PPE training to increase safety and comfort (Herron et al., 2020) .
In these challenging times, health workers need adequate support to increase their productivity and keep them motivated (Pathania, Singh, Sohal, & Sawhney, 2020) . This study indicated that for healthcare workers in Indonesia, family support is the main factor that motivates healthcare workers to provide health care services during the COVID-19 outbreak. So it is important to provide opportunities for healthcare workers to make contact and gather with J o u r n a l P r e -p r o o f families to provide mutual support. If it is impossible to meet family members, then each family member needs to communicate regularly by sending positive messages and motivating health workers to deal with the COVID-19 outbreak in a good psychological condition.
Notwithstanding, good collaboration between professionals, effective preventive measures, and a positive attitude when dealing with the pandemic also play an important role in reducing stress.
The availability of adequate information and support from hospitals also helped motivate the health workers in this study to deal with the outbreak.
This work was supported by Professor and Doctor Grant 2020, funded by the Faculty of Medicine, Universitas Brawijaya (Number: 3394.1 / UN10.F08 / PN / 2020)
Declaration of interest: none Table 1 Health workers' feelings (score: 1-5), factors that caused stress among health workers (score: 1-5), factors that reduced stress among health workers (score: 1-4), health workers' personal coping mechanisms (score: 1-5), and factors that motivated health workers (score: 1-4) during the COVID-19 outbreak 