Rev. Enferm. UFSM, v.12, e60, p.1-20, 2022

https://doi.org/10.5902/2179769270622

ISSN 2179-7692

Submissão: 07/06/2022 • Aprovação: 18/10/2022 • Publicação: 15/02/2023

Introduction. 1

Method. 1

Results 1

Discussion. 1

Conclusion. 1

References. 1

Review Article                                                                                                                                                                               

Nurses’ resilience in the COVID-19 pandemic: an integrative review

A resiliência dos enfermeiros na pandemia da COVID-19: revisão integrativa

Resiliencia de las enfermeras en la pandemia de COVID-19: revisión integradora

Thiago Portela Caroccini^I

Alexandre Pazetto Balsanelli^I

Vanessa Neves^I

^I Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil

Abstract

Objective: to verify which factors are associated with resilience among nurses who provide hospital care in the face of the COVID-19 pandemic. Method: an integrative review, carried out in the Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Literature in Health Sciences and Medical Literature Analysis and Retrieval System Online databases. The search took place in May 2022, and 32 studies were selected. Information analysis took place in a descriptive way, confronting the relevant findings. Results: variables that impacted were: age; work experience; education; exposure to stress; personal skills to deal with critical and stressful situations. Conclusion: the literature presents associated factors that impact resilience, allowing the variables to be elucidated. In addition, it supports nurses to improve, creating coping strategies and facilitating their adaptation to challenges of life and work, especially in providing safe care.

Descriptors: Resilience, Psychological; Nursing Care; Pandemics; COVID-19; Hospitals

Resumo

Objetivo: verificar quais são os fatores associados à resiliência entre os enfermeiros que prestam assistência hospitalar frente à pandemia de COVID-19. Método: revisão integrativa, realizada nas bases de dados Cumulative Index to Nursing and Allied Health Literature, Literatura Latino-Americana e do Caribe em Ciências da Saúde e Medical Literature Analysis and Retrieval System Online. A busca ocorreu em maio de 2022, e foram selecionados 32 estudos. A análise das informações sucedeu de forma descritiva, confrontando os achados pertinentes. Resultados: variáveis que impactaram foram: idade; experiência no trabalho; escolaridade; exposição ao estresse; habilidades pessoais para lidar com situações críticas e estressantes. Conclusão: a literatura apresenta fatores associados que impactam na resiliência, permitindo elucidar as variáveis. Além do mais, subsidia o enfermeiro a se aprimorar, criando estratégias de enfrentamento e facilitando sua adaptação aos desafios da vida e do trabalho, principalmente na prestação da assistência segura.

Descritores: Resiliência Psicológica; Cuidados de Enfermagem; Pandemias; COVID-19; Hospitais

Resumen

Objetivo: verificar qué factores están asociados a la resiliencia entre los enfermeros que brindan atención hospitalaria frente a la pandemia de la COVID-19. Método: revisión integradora, realizada en las bases de datos Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Literature in Health Sciences y Medical Literature Analysis and Retrieval System Online. La búsqueda se realizó en mayo de 2022 y se seleccionaron 32 estudios. El análisis de la información se realizó de forma descriptiva, confrontando los hallazgos relevantes. Resultados: las variables que impactaron fueron: edad; Experiencia laboral; enseñanza; exposición al estrés; habilidades personales para hacer frente a situaciones críticas y estresantes. Conclusión: la literatura presenta factores asociados que impactan la resiliencia, lo que permite dilucidar las variables. Además, ayuda a las enfermeras a mejorar, creando estrategias de afrontamiento y facilitando su adaptación a los desafíos de la vida y del trabajo, especialmente en la prestación de cuidados seguros.

Descriptores: Resiliencia Psicológica; Atención de Enfermería; Pandemias; COVID-19; Hospitales

Introduction

The COVID-19 pandemic represents one of the most acute and serious health problems in recent decades, as it has put all countries under extreme medical and ecological conditions, causing health professionals a high level of stress and the need to develop their resilience, being, to a greater extent, affected those involved in direct care of patients with the disease.^1-2

In Brazil, the pandemic situation impaired nursing working conditions, workload, among others. Another important factor to be considered is that it influenced the way nurses provide care, resulting in an increased incidence of adverse events, insufficient nursing staff and poor quality care. ²

In this regard, policies and measures that contribute to the safe and effective practice of care need to be ensured, considering that, until June 2, 2022, approximately 63,555 nursing professionals acquired COVID-19 and about 872 victims died from the disease.^1,3

Resilience can be interpreted as the ability to challenge, conquer, emerge strengthened or adapted by the experience of adverse situations. This scenario makes the leadership progressively develop the ability to adapt to changes, playing a fundamental role in maintaining mental health, as well as mitigating the negative effects of employee stress and progressively developing them, making them part key to achieving organizational and personal success.^4-8

The concept of resilience gradually receives more attention, especially in the health area in question, from nurses.⁴ This is due to the fact that nurses provide direct care to patients, and the experiences of this care are stressful. Additionally, the hospital environment is undergoing successive transformation, leaving little time for emotional recovery of the staff. In a survey by the American Nurses Association, 79% of nurses rated the workplace as the number one in danger of stress and that the COVID-19 pandemic contributed to the worsening of that stress.⁵

At the peak of the crisis caused by the coronavirus, indicators showed that nurses who had adequate levels of resilience coped better with the impact of the pandemic, resulting in reduced anxiety, post-traumatic stress, emotional exhaustion and depression, consequently providing safer care. Thus, many hospital institutions have invested in programs and interventions to develop nurses’ resilience in health care. ^2,4,6

Resilience was identified as an essential protective factor against the effects on mental health caused by traumatic events and other adversities, including the COVID-19 pandemic, resulting in greater job satisfaction, with superior retention, greater perception of quality of nursing care and better clinical performance. ^2,3

The resilience-moderating factors identified in the studies were age, marital status, education, sex, salary and general health status. Work-related reasons included length of experience in the role, professional position and organizational climate. External aspects included family support and pandemic coping skills.^4,6

Studies have shown that implementing psychological training, stress management, crisis intervention training, and mindfulness meditation can strengthen resilience as well as improve quality of nursing work and service.^7-8

The mediating elements that are related to resilience show the need to establish links between external and internal factors to the work environment. Therefore, studies characterize the main elements and their characteristics that interfere in hospital nurses’ resilience. However, there are still few studies in the literature that point to effective actions that develop and increase hospital nurses’ resilience in pandemic situations. ^7-8

Considering the above, it can be considered that this research aims to verify which factors are associated with resilience among nurses who provide hospital care in the face of the COVID-19 pandemic.

Method

This is an integrative literature review, developed in six stages: research question elaboration; literature search of primary studies; data extraction; assessment of primary studies; analysis and synthesis of results; and presentation of review. As a starting point, the question was elaborated: what are the factors associated with resilience among nurses who provide care in the hospital environment in the face of the COVID-19 pandemic? When preparing the question, the PICo methodology was used (P - Population, I - Interest, Co - Context), in which it was defined as: Population: nurses; Interest: the state of resilience; Context: the hospital environment in the COVID-19 pandemic. ⁹

The search for primary studies was performed in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Latin American and Caribbean Literature in Health Sciences (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE) databases, through the National Library of Medicine National Institutes of Health (PubMed).

To perform the search, the following controlled and uncontrolled descriptors from the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS) terminology were selected: Resilience, Psychological; Nursing care; COVID-19; Pandemics; and Hospitals.

Due to the theme being recent and exclusive to the pandemic, a filter was applied for the period of publication of the articles, to ensure an adequate number of primary studies, being selected articles from December 2019, published until 2022. Furthermore, to ensure a broad search, the controlled descriptors were used in different ways, separately and in combination with the Boolean operators AND and OR. The search in the electronic databases included articles with a research focus on nurses’ resilience during the COVID-19 pandemic, published in Portuguese, English or Spanish (Figure 1).

Articles present in more than one database were counted once. The search for primary studies in the selected databases took place in May 2022, being prepared by one of the authors of this study. The selection of articles was carried out by two review authors, independently, in which they obtained an agreement rate above 80%, and, in cases of disagreement, the third reviewer selected the article. All selections were made through Rayyan software.

We excluded studies that did not report resilience, as they had a mixed audience, unable to separate a sample of nurses and nursing professionals in general. We also excluded articles identified as reflection/theoretical, editorial or response letter, comments, theses and dissertations.

Data extraction was performed independently, and a data collection form was developed to organize the main information regarding the studies as: publication identification (article title, language, authors, publication date); publication journal; and methodological characteristics (publication type, research type, sample/participant and results).

For material analysis, it was decided to group and categorize resilience information according to the type of research, number of participants, results obtained in relation to resilience, presenting moderators that interfered with resilience (Chart 1). The analysis of results was performed descriptively. Subsequently, comparisons were made, emphasizing the differences and similarities of the studies.

The flowchart presents the selected articles and the sequence adopted until the inclusion of those considered relevant for analysis, according to the criteria proposed for the study (Figure 1).

Figure 1 - Study selection process flowchart. Sao Paulo, SP, Brazil, 2022

Results

The 32 articles analyzed portray the level of resilience in nurses, with 75% referring to cross-sectional descriptive studies; 9% did not report the type of research in their method; 6% were qualitative; and the others, with 3% each, were observational, mixed and correlational. There was a predominance of studies carried out in China (n = 8), followed by Spain, Iran and Turkey (n = 4, each), the Philippines and the United States (n = 2, each), and the other countries appear with 1 job, such as Indonesia, Kenya, Switzerland, Saudi Arabia, Korea, Italy, France and India. The year with the highest number of publications, taking into account the chosen criterion, was 2021, with 22 articles published. Chart 1 contains information extracted from publications.

Chart 1 – Characteristics of studies included in the integrative review. Sao Paulo, SP, Brazil, 2022

546 nurses

134 nurses

Correlate resilience and burnout.

*Item identification (A), followed by the order number.

Discussion

Studies on resilience in the pandemic show that perceived stress decreased as resilience increased. Factors such as age, experience, area of expertise, knowledge in administration and in hospital preparation for COVID-19 showed a statistically significant and positive relationship, bringing a growing body of evidence, suggesting that health professionals’ resilience impacts the provision of safe care and represents an important source of research to understand it as an essential protective factor against the mental health effects of traumatic events and other adversities, including the pandemic.^2,4,14,27

Sociodemographic variables may or may not affect resilience. Female participants had lower scores and there was a difference between age groups. The results found were linear in various age groups so that the lowest resilience was 25 years old, and the highest, above 45 years of age. With professional experience and level of education, it was no different, the higher the level of education and the time of experience, the greater the degree of resilience. On the other hand, there was no statistically significant relationship in resilience between nurses with different marital status and those who exercise. However, the reported resilience score in nurses who did not exercise was lower than in those who did.^28,30

During the COVID-19 pandemic, it became evident that more experienced nurses showed a greater ability to adjust and adapt to changes in the work environment. The pandemic period, in which nurses dedicated themselves to the care of patients with COVID-19, contributed to the development of their resilience. ^2,14,27

In fact, increasing age, greater work experience and schooling, their exposure to stress, as well as their technical and behavioral skills to deal with critical and stressful situations facilitate adaptation, giving nurses the possibility to act effectively and more resilient, whatever the situation.^26,30

Resilience is an essential element for nurses in the development of their work, especially in facing the pandemic. Without resilience or with low levels, professionals can become exhausted and even leave the profession. Other researchers demonstrated an interesting result: nurses were tested for COVID-19 and positives reported lower resilience than those who tested negative.¹⁸

Professional experience in a pandemic is inherent and relative, and may vary within countries and between institutions. Newly admitted nurses were less resilient when compared to more experienced ones, and, for these, factors that could harm mental health were not demonstrated. Another important point was the difference in resilience between variables; in this case, it was evidenced that women showed a lower resilience than men. The difference in resilience scores was not significant between marital status and parental status groups. However, childless nurses had a higher level of resilience.^27,29-30

Nurses use their nursing knowledge and skills to prevent psychological burden and increase resilience. This awareness is evident in the findings on the difference in resilience scores between different levels of work experience, age, education and training for COVID-19 care, with an increase in each of the factors leading to a higher level of resilience. Moreover, the hiring regime, such as permanent and permanent nurses, and private hospitals had higher levels of resilience.^14,29-30

Positive affect, such as psychological support in the work environment, contributes to a high level of resilience, and this set protects frontline nurses, reducing the risk of burnout or burnout and fatigue. Other scholars in Turkey report that there is a positive and significant relationship between resilience and work performance, as the greater the enthusiasm for care, the higher the resilience score.^16,31 In fact, lack of psychological and social support from family members, especially children, plays a negative role on nurses, reducing their levels of resilience during the COVID-19 pandemic.^30-31

Resilience helps reduce and overcome the negative emotions nurses went through during the COVID-19 pandemic.¹⁵ However, other work shows that the higher the level of anxiety, the lower the resilience score during the pandemic. In a result found in a study with nurses in Kenya who reported more moderate to severe symptoms of depression, distress and exhaustion and a poor sleep pattern and, consequently, a lower resilience, 56.3% of nurses had a moderate to high level of anxiety.^10-11,15,26 It is noted that, even if burnout is high, it was not related to resilience, but in the “Emotional fatigue or emotional exhaustion” dimension, it was negatively related to the mean resilience score. Other studies also report that nurses from COVID-19 hospital units triggered an increase in stress and psychological exhaustion, but that was mitigated by the professional experience that translates into a higher level of resilience, both acting with a protective role during the pandemic period.^1,12-14

One of the moderators who demonstrated a significant increase in resilience and prevention of psychological exhaustion highlighted the importance that the organization provides to the professional through its institutional policies. The pandemic management, as well as training, intensifies the team’s trust in the institution, and, consequently, this becomes a more resilient environment.¹⁸ On the other hand, the level of resilience was negatively correlated with the degree of trust in public health authorities and the fact that hospital protocols change daily, in addition to the physical exhaustion of wearing Personal Protective Equipment all day.^8,17-19

Thus, workplaces with constantly changing demands and organizational policies that are not adequate to nurses’ principles increase psychological exhaustion, decreasing resilience and can lead to unsafe care.¹⁹

Another moderator that impacts nurses’ resilience, such as sleep disorder, was reported as one of the most punctuated symptoms among nurses with a higher degree of anxiety and a lower resilience score.^19-20

Fear of infection, followed by death and less adaptation to overcome the situation due to lack of preparation, was the moderator that negatively impacted nurses’ resilience. When compared to previous pandemics, COVID-19 frontline nurses who participated in the Ebola or severe acute respiratory syndrome (SARS) outbreak had lower levels of anxiety and depression, and were more resilient. On the other hand, the spirit of adaptation and, consequently, greater resilience to the rapid changes and challenges they faced were the strengths that increased frontline nurses’ resilience. Institutions that provide social and organizational support contribute to the development of their nurses’ resilience, especially in the face of pandemics.^19-23

Universally, nurses are a major force in the fight against COVID-19, and their resilience not only affects their mental health, but also the quality and safety of care they provide to patients with COVID-19; therefore, education and work experience were determined as factors that contribute to resilience. Resilience training programs and increased knowledge on how to work in a situation arising from unknown diseases increase the level of resilience, improving care practice.²⁹ A similar study reports that knowledge of infectious disease protocols, continuing education provided by the hospital, skills and self-regulation during the pandemic were facilitators for increasing resilience and care security among the sample studied.²³

Regardless of what was happening, the pride of being nurses stood out in the face of difficulties and psychological overload caused by the pandemic. Nurses were especially strengthened by teamwork and the involvement of everyone in the care. Therefore, when referring to being a nurse or the pride of being a nurse, all showed high resilience related to the theme.⁸

Resilience was positively associated with quality of care and job satisfaction, being negatively associated with the intention to leave the institution, reducing the effects of fatigue on nurses’ job satisfaction, organizational turnover, and quality of care.⁴ Similar findings in China found that resilience was significantly correlated with nurses’ overall work engagement and its various dimensions. Moreover, strengthening the sense of organization, emotional identity and improving resilience are key factors in increasing engagement at work and improving care provided.⁹

An important factor observed was decreased hypochondria during the pandemic, given the increase in resilience in front-line nurses.²³ As the situation continues, managers should help nurses understand the challenges of burnout through an environment where they have positive affect, providing discussions about resilience. Negative affect in the work environment can lead to hidden exhaustion in nurses. Ideal resilience interventions should be tailored to multiple health care providers, utilizing mental health resources and multidimensional perspectives, ensuring a higher level of resilience.^30-31

Highly challenging situations can have a positive impact on individuals’ resilience, working as a protective factor against psychological distress; however, psychological exhaustion occurs in the Intensive Care Unit regular staff, and the non-effective staff of the sector did not have difficulties to face the pandemic scenario and there was no change in resilience.^31-32

It cannot be disregarded that, as a result of the novelty of COVID-19 care, the positive results in younger nurses were strengthened, as the learning process influenced the psychological state. It is worth mentioning that, in the same work, continuous efforts to adapt and assist in care practices to face the first wave of the COVID-19 pandemic were essential and necessary for the result.³¹ Obviously, this crisis put unexpected pressure on nurses, who had to go through the pandemic and train the staff, which reinforced care, with the responsibility to improve the quality of care provided.^32-33

Internal actions for the nursing staff increase resilience, a fact observed in a study that correlated resilience, anxiety, depression, support strategies, training and motivation among nurses in Wuhan. Resilience was positively correlated with motivating actions, as well as with staff training and support, and negatively correlated with depression and anxiety. Other feelings, such as being prepared and confident for daily work activities, were not significantly associated with resilience.³²

Resilience is the ability to reduce the effects of a distressing event by anticipation and preparation, helping health care professionals better recover from trauma, in this case the COVID-19 pandemic. Providing training can increase resilience scores and help protect nurses’ mental health. Furthermore, managers need to dedicate more time to nurses’ preparation actions, benefiting the worker’s confidence to perform their tasks.³²

Effectively, nursing institutions and managers must adopt practices that aim to reduce stress and amplify the level of resilience among nurses. They must also create a harmonious, healthy work environment, maintaining a good psychological condition, thus improving nurses’ skills and habits of resilience in response to high demand, greater complexity of care and emotional overload, especially during pandemics.^32-34

Controlling the work environment with preventive actions is increasingly listed. The risk of psychological disorders is 6 times higher in non-resilient nurses than in resilient nurses. Furthermore, the risk of psychological disorders was 2.42 times higher in nurses who were at a low point in their careers and dissatisfied with their lives than those who were professionally satisfied and very satisfied with their lives. In view of this, managers and nurses must create means, through actions that strengthen resilience and develop skills to deal with difficulties, adapt to new conditions, have realistic and positive expectations, protecting work and life.³⁴

Feelings of being adequately prepared and confident to complete tasks were associated with resilience. Having a high level of resilience results in greater autonomy, personal growth, optimism and better purpose in life. However, there is a need for a greater number of effective interventions and training with social support to ensure adequate mental health for nurses.^32,34

Study synthesis reveals that more time should be dedicated to nurses’ preparation, both psychologically and in the family and professional support network, benefiting the confidence to complete their care with quality and safety. In other words, the review shows that nurses’ resilience can be strongly influenced and maintained by support strategies and preventive planning.

Nursing managers perform numerous vital functions in health institutions such as: assisting patients; directing a group of collaborators; influencing through effective communication and interpersonal skills; implementing evidence-based practices; directing staff members, among other activities. They possess unique attributes that allow them to perform effectively in their positions, including critical thinking skills, the ability to envision a positive future, and lead hard times, as well as supporting their staff who are often experiencing high levels of anxiety and stress, part of which involves strengthening organizational and workforce resilience. ^16,35

Thus, it is essential to reflect on the role of leaders during the pandemic, and, in the near future, managers must focus on local and constant actions to increase resilience. From this perspective, it is important to rethink their preparation to incorporate the theme into the internal processes of hospital institutions and, thus, positively influence health care improvement.

Although this study provides important evidence for nursing managers to assist nurses regarding resilience during the pandemic, some limitations were identified. In the context in question, studies were not analyzed according to the occurrence of the first, second or third wave, with no chronological separation, requiring further revisions, in order to understand if there were differences in resilience management in each wave. Also, the absence of Brazilian productions on the subject is highlighted, which made it impossible to compare the evidence with the international context.

It is suggested the need to develop new studies that can assess other variables that affect resilience, the different strategies and actions to increase resilience regarding the impacts on direct patient care, on nurses’ quality of life, on satisfaction, on meaning of nurses’ work and the impact on costs with the turnover of less resilient professionals.

Conclusion

It was identified, in this present research, that resilience is a psychological protector, and, as it increases, stress decreases, and factors such as age, experience, area of activity, knowledge in administration and hospital preparation for COVID-19 were significant for increasing nurses’ resilience, impacting the provision of safe care. Due to the pandemic, sociodemographic variables may or may not affect resilience as well as the organizational support provided to nurses acts directly on the state of resilience.

In practice, it is essential that nurses are aware of the variables that affect resilience and, consequently, the quality of care provided, subsidizing themselves with resources to manage work in pandemic contexts. It is also essential that managers demonstrate the importance of assertive actions to improve mental health, in this case, resilience.

The findings provided evidence of which factors were related to resilience, its importance as well as the need for focused coping strategies as psychological protection factors for nurses. The implementation of educational interventions to increase resilience in developing new skills and successfully adapting to challenges of life and work should be considered not only in pandemic situations, but in everyday life, for patient care.

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Author’s Contributions

1 – Thiago Portela Caroccini

Corresponding author

Nurse, Graduate degree - Email: thiagocaroccini@gmail.com

Research conception and/or development and/or article writing.

2 – Alexandre Pazetto Balsanelli

Nurse, PhD - Email:  alexandre.balsanelli@unifesp.br

Review and approval of the final version.

3 – Vanessa Neves

Nurse, PhD - Email:   vanessa.neves@unifesp.br

Review and approval of the final version.

Editor-in-Chief: Cristiane Cardoso de Paula

Associate Publisher: Daiana Foggiato de Siqueira

How to cite this article

Caroccini TP, Balsanelli AP, Neves V. Nurses’ resilience in the COVID-19 pandemic: an integrative review Rev. Enferm. UFSM. 2022 [Access at: Year Month Day]; vol.12, e60: 1-20. DOI: https://doi.org/10.5902/2179769270622