key: cord-0709273-gho0lysd
authors: Baskin, Rachel G.; Bartlett, Robin
title: Healthcare worker resilience during the COVID‐19 pandemic: An integrative review
date: 2021-07-09
journal: J Nurs Manag
DOI: 10.1111/jonm.13395
sha: 9b37eb6b0d950e2b0fc3dd340cce33a637b4dcb7
doc_id: 709273
cord_uid: gho0lysd

AIM: The purpose of this review was to examine resilience among healthcare workers during the coronavirus‐disease‐2019 (COVID‐19) pandemic. BACKGROUND: The COVID‐19 pandemic has caused an unprecedented strain on healthcare workers internationally. Rising infection rates, inadequate personal protective equipment, and the lack of availability of hospital beds has resulted in further deterioration of the already‐fragile mental health of healthcare workers. Resilient workers have lower rates of burnout and improved patient outcomes. EVALUATION: PubMed and the Cumulative Index to Nursing and Allied Health Literature databases were searched using the terms resilience, nurse and COVID‐19 to identify studies on resilience during the COVID‐19 pandemic. Results were organized by outcome measures for comparison. KEY ISSUES: Resilience scores among frontline healthcare workers worldwide during the COVID‐19 pandemic in the studies reviewed were overall found to be in the moderate range. Data from the United States showed a decrease in nurse resilience, whereas participants from China had increased resilience compared with pre‐pandemic levels. CONCLUSIONS: Building resilience in nurses and other healthcare workers can serve as a protective factor against negative outcomes related to the job, including burnout, anxiety and depression, and can improve patient outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies for building resilience in healthcare workers are discussed.

The coronavirus-disease-2019 (COVID-19) pandemic has caused an unprecedented strain on healthcare systems and healthcare workers around the world. Rising infection rates, inadequate personal protective equipment, and the lack of availability of hospital beds has resulted in further deterioration of the already-fragile mental health of healthcare workers (Firew et al., 2020) . The negative state of healthcare worker mental health was documented prior to the COVID-19 pandemic (National Academies of Sciences, Engineering, and Medicine, 2019). Being a healthcare worker during a pandemic comes with a myriad of stressors beyond those typically experienced.

According to the National Academies of Sciences, Engineering, and Medicine (2021) Future of Nursing 2020-2030 report, nurses' wellbeing is affected by the demands of the job, which in turn affects their work.

Resilience is defined as the ability to positively adapt to traumatic or adverse experiences (Luthar & Cicchetti, 2000) . Resilience can be measured using various tools, including the Connor-Davidson Resil- ience Scale (CD-RISC) 25-item version and 10-item version (CD-RISC10). Davidson (2018) recommended that scores be interpreted based on the quartiles of scores obtained from the general population.

Scores within the first quartile are considered low resilience scores, the second and third quartiles are considered intermediate resilience scores, and scores in the fourth quartile are considered high resilience scores (Davidson, 2018) . Based on the United States (U.S.) general population, a score of 73 or below indicates low resilience, and a score of 91 or higher indicates high resilience (Connor & Davidson, 2003; Davidson, 2018) . The CD-RISC 25-item scale had a Cronbach's alpha value of 0.89 in the general population, indicating good internal reliability (Connor & Davidson, 2003) .

"When stress overpowers resilience, performance … can degrade" (National Academies of Sciences, Engineering, and Medicine, 2019, p. 42) . With the challenges of the pandemic and their effect on healthcare workers, it is imperative that leaders and healthcare institutions understand the current state of healthcare worker resilience and burnout. Understanding the broad range of effects associated with the pandemic will inform leaders as they plan for helping healthcare personnel manage current and future challenges associated with their work.

Prior to the COVID-19 pandemic, burnout was occurring at alarming rates of 35%-54% among nurses and physicians (National Academies of Sciences, Engineering, and Medicine, 2019). The inverse relationship between resilience and burnout has been established in previous studies (Colville et al., 2015; Guo et al., 2018; Rushton et al., 2015) . Interventions aimed at building resilience in healthcare workers can help to decrease rates of burnout, therefore improving patient safety (Garcia et al., 2019) and decreasing hospital-acquired infections (Cimiotti et al., 2012; Van Bogaert et al., 2014) and medication errors (Van Bogaert et al., 2014) . Not only does resilience correlate negatively with burnout, but there is also evidence of its inverse relationship with post-traumatic stress disorder (PTSD), further elevating the importance of resilience among health care workers (Rodríguez-Rey et al., 2019; Schäfer et al., 2018) .

Previous systematic reviews related to the COVID-19 pandemic have looked at the effects of the pandemic on mental health outcomes including depression, anxiety and fear in nurses and other healthcare workers (da Silva & Neto, 2021; de Pablo et al., 2020; Sheraton et al., 2020) . None of these reviews have measured resilience, an important factor associated with burnout prevention (National Academies of Sciences, Engineering, and Medicine, 2019).

The purpose of this integrative review was to examine resilience in healthcare workers during the COVID-19 pandemic. Based on the results of this review, methods of increasing nurse resilience will be discussed.

This integrative review was conducted to identify levels of resilience among healthcare workers during the COVID-19 pandemic, because resilience is associated with burnout and patient outcomes.

Methodology by Whittemore and Knafl (2005) was the guiding framework for this integrative review. The review process is made up of five stages: problem identification, literature search, data evaluation, data analysis and presentation (Whittemore & Knafl, 2005) . The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was utilized to guide the search methodology (Moher et al., 2009) . Two searches were performed in December 2020 and February 2021 for relevant published articles from 2019 forward. The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases were searched using the terms: nurse, resilience, and COVID-19 (or coronavirus, 2019-ncov, sars-cov-2, or cov-19 in CINAHL) . Articles were limited to those published in English, available in full-text, and from peer-reviewed journals.

Per PRISMA guidelines, eligible articles were screened for relevance to the review, and duplicates were removed (Moher et al., 2009) . Studies were considered eligible for inclusion if they explored resilience either quantitatively or qualitatively in frontline healthcare workers specifically during the COVID-19 pandemic. Articles were excluded if they were not empirical research, if the data reported were not collected during the COVID-19 pandemic, and if resilience was not measured. Some of the studies also reported on burnout among healthcare workers, psychological outcomes including PTSD, anxiety and depression, and some reported on work engagement. Figure 1 shows the PRISMA flow diagram and demonstrates how many articles were reviewed at each stage of the search process (Moher et al., 2009) . Eligible articles were exported to a computer-based software (Zotero) for screening of abstracts, then for full-text article review (Zotero.org, n.d.) . Data within the full-text articles were searched for measurement of resilience using a formal tool (if a quantitative design). Means and/or correlation values were examined. Due to different resilience tools being utilized by the studies included in this review, scores had to be converted to low resilience, moderate resilience and high resilience for comparison.

Results of Pearson correlations and regression analyses were also reviewed to identify relationships of resilience to other variables studied during the pandemic including anxiety, depression, work engagement and others.

A total of 191 articles were screened for inclusion criteria between the two searches; 32 were selected for this review (Figure 1 ). The studies were conducted from countries worldwide, including China (n = 11) (Cai et al., 2020; Hu et al., 2020; Huang et al., 2020; Leng et al., 2020; Li et al., 2020; Liang et al., 2020; Lin et al., 2020; Liu et al., 2020; Lyu et al., 2020; Ou et al., 2020; Pang et al., 2021) , Italy (n = 1) (Catania et al., 2020) , Iran (n = 2) (Afshari et al., 2021; Meybodi & Mohammadi, 2020) , France (n = 1) (Altmayer et al., 2020) , Japan (n = 1) (Awano et al., 2020), Saudi Arabia (n = 1) (Balay-odao et al., 2021) , the United States, (n = 3) (Barzilay et al., 2020; LoGuidice & Bartos, 2021; Resnick, 2020) , Singapore (n = 1) (Goh et al., 2020) , India (n = 2) (Jose et al., 2020; Nathiya et al., 2021) , Turkey (n = 3) (Kılınç & Çelik, 2020; Yıldırım et al., 2020; Yörük & Güler, 2020) , the Philippines (n = 1) (Labrague & de los Santos, 2020), Canada (n = 1) (Lapum et al., 2020) , Spain (n = 2) (Lorente et al., 2020; Luceño-Moreno et al., 2020) , the United Kingdom (n = 1) (Roberts et al., 2021) and Ethiopia (n = 1) (Tsehay et al., 2020) . A summary of the articles included in this integrative review and their results can be found in Table 1 .

Overall, resilience scores among frontline healthcare workers during the COVID-19 pandemic in the studies reviewed were in the moderate range (CD-RISC range = 35.54-92.77) (Afshari et al., 2021; Cai et al., 2020; Jose et al., 2020; Kilinc & Celik, 2020; Leng et al., 2020; Li et al., 2020; Lin et al., 2020; Lyu et al., 2020; Nathiya et al., 2021; Ou et al., 2020; Pang et al., 2021) . In two studies conducted in Asia, physicians had higher resilience scores than nurses (Awano et al., 2020; Lin et al., 2020) , and support staff had the highest resilience scores (mean = 73.48) compared with doctors (mean = 67.78) and nurses (mean = 64.86) (Lin et al., 2020) .

Frontline workers, (e.g., doctors, nurses and ancillary staff) had lower CD-RISC10 scores than non-frontline workers (median = 18 and median = 23, respectively; = 0.061) (Awano et al., 2020) . Nurses on the frontline reported emotions across a spectrum from negative to positive: from sadness, hopelessness and exhaustion to hopeful, grateful, and supported (Resnick, 2020) .

Resilience scores had statistically significant (p < 0.05 or smaller) inverse relationships with PTSD Luceño-Moreno et al., 2020) , anxiety (Awano et al., 2020; Barzilay et al., 2020; Hu et al., 2020; Labrague & de los Santos, 2020; Lin et al., 2020; Luceño-Moreno et al., 2020; Pang et al., 2020; Roberts et al., 2020; Yıldırım et al., 2020) and depression (Awano et al., 2020; Barzilay et al., 2020; Hu et al., 2020; Lin et al., 2020; Luceño-Moreno et al., 2020; Pang et al., 2021; Roberts et al., 2021; Yıldırım et al., 2020; Yörük & Güler, 2020) . Roughly half of nurses reported moderate to high burnout, and those who had higher burnout scores reported lower resilience scores (Hu et al., 2020) . There were statistically significant (p < 0.05 or smaller) negative correlations between resilience and the burnout subscales emotional exhaustion and depersonalization, and a positive correlation with the burnout subscale personal accomplishment (Hu et al., 2020; Jose et al., was related to infection control processes, risk of infecting loved ones, and the distress of watching colleagues suffer, and even die, from COVID-19 (Catania et al., 2020) . These nurses also emphasized that the presence of teamwork increased resilience and their drive to overcome the challenges that the COVID-19 pandemic presented to them (Catania et al., 2020) .

The findings from this review confirmed what has been reported in previous studies in terms of the existence of an inverse relationship between resilience and burnout (Colville et al., 2015; Guo et al., 2018; Rushton et al., 2015) . The articles included in this review also pro- can inform future studies of interventions aimed at increasing resilience to improve mental health outcomes in healthcare workers, which could also improve patient outcomes.

Six of the 12 studies (50%) that measured resilience in this review using the CD-RISC reported resilience scores below the 25th percentile (score of less than 74) based on U.S. population values (Afshari et al., 2021; Cai et al., 2020; Kilinc & Celik, 2020; Li et al., 2020; Lin et al., 2020; Nathiya et al., 2021) . However, because the majority (n = 27; 84%) of studies were conducted in Europe and Asia, the lower mean resilience score of 59.99 in the Chinese population may be a better comparison value. Connor and Davidson (2003) reported that the mean CD-RISC (resilience) score in the general U.S. population was 80.4, which is considered intermediate or moderate. The mean CD-RISC in a Chinese population in Hong Kong was 59.99 (SD = 13.92) (Ni et al., 2015) ; therefore, moderate and high resilience scores would be a lower number in that population compared to the U.S. population. According to Ni et al. (2015) , low scores of resilience in the Chinese population were 53 or below, whereas high resilience scores were 72 and above. Davidson (2018) noted that because scores on the CD-RISC tool depend on geographic location of the sample, results should be interpreted with caution. This makes comparing results of international studies throughout the COVID-19 pandemic more challenging.

The mean CD-RISC score among Chinese nurses in a study prior to the COVID-19 pandemic was 63.52 (Guo et al., 2018) , and the mean CD-RISC score in Australian operating room nurses was 75.9 (Gillespie et al., 2007) . Mean resilience scores in Chinese nurses during the pandemic ranged from 51 for those with PTSD to 73.5 for those without PTSD . Whereas Chinese nurses showed an increased level of resilience during the pandemic, nurses in the United States had lower resilience scores compared with studies conducted prior to the pandemic. The mean 10-item CD-RISC score in nurses in the U.S. pre-pandemic was 32.08 (Kelly et al., 2021) , compared to a mean CD-RISC10 score of 29.74 during the COVID-19

pandemic (Petzel, 2021 At this time, there is insufficient experimental data reported on strategies that will strengthen nurse and healthcare worker resilience (Cameron & Brownie, 2010; Delgado et al., 2017; National Academies of Sciences, Engineering, and Medicine, 2019) . At the individual level, nurse managers can gauge the current emotional state of staff members on their units, which can be done, for example, by using a mood meter at a monthly staff meeting or at other times ( Figure 2 ). Nurse leaders should remind staff that they are allowed to express feelings and concerns openly (Tomlin et al., 2020) As we remain hopeful to quickly move from the core phase to the end phase at the conclusion of the pandemic, healthcare organizations and leaders need to allow staff time to process their feelings.

The end phase is the time for healthcare organizations to thank and reward staff members, as well as recognize staff members who are demonstrating signs of post-traumatic stress and provide them with appropriate mental health resources (Tomlin et al., 2020 interventions designed to build resilience should be studied by nurse researchers to identify their impact on resilience scores among nurses and other healthcare workers, and the impact of resilience on patient outcomes. In addition, as identified by the National Academies of Sciences, Engineering, and Medicine (2019), organizational interventions must be explored to address the challenges of the effect of nurse burnout on the provision of quality healthcare.

COVID-19 has exacerbated challenges in an already fragile healthcare system. According to the National Academies of Sciences, Engineering, and Medicine (2019), individual worker resilience is one mediating factor between health system factors (e.g., excessive workload, inadequate staffing, work distraction and organizational culture) and worker burnout/professional well-being. Because resilience among healthcare workers has been further challenged by the pandemic, it is critical that strategies to enhance worker resilience, both from the individual and the healthcare systems levels, be designed and tested.

This collaboration was made possible by the Nightingale Challenge offered by Sigma Theta Tau International. The Nightingale

Challenge is a mentoring programme designed to develop the next generation of nurses and midwives.

None.

None.

IRB submission was exempt due to this research being a review of publicly available data.

Author elects to not share data.

Rachel G. Baskin https://orcid.org/0000-0001-5422-8818

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