key: cord-0924879-ws9n8fza authors: Alhawatmeh, Hossam; Alsholol, Rahaf; Aldelky, Heyam; Al-Ali, Nahla; Albataineh, Raya title: Mediating role of resilience on the relationship between stress and quality of life among Jordanian registered nurses during COVID-19 pandemic date: 2021-11-16 journal: Heliyon DOI: 10.1016/j.heliyon.2021.e08378 sha: 7ac6661a8c801d453bed87dbdeb6d5f6c9fab8bf doc_id: 924879 cord_uid: ws9n8fza RATIONALE: Registered nurses are struggling on the front line to manage patients with COVID-19 and other illnesses, placing them at increased risks for severe perceived stress. Although perceived stress has often been considered a significant risk factor for impaired quality of life among registered nurses, having resilience has been generally shown to be associated with better quality of life. PURPOSE: This study aimed to investigate the mediating effects of resilience on the relationship between perceived stress and quality of life in Jordanian clinical registered nurses during the COVID-19 pandemic. METHODS: The study used a cross-sectional correlational design with an online survey and adhered to the STROBE guideline for cross‐sectional studies. A total of 550 registered nurses working in 6 hospitals were conveniently selected. Data were collected via a demographic questionnaire, the Perceived Stress Scale (PSS), the Connor-Davidson Resilience Scale (CD-RISC), and the WHOQOL scale. Descriptive, Pearson correlation, t-test, one-way ANOVA, and hierarchical linear regression analyses were used to analyze the data. RESULTS: The results indicated that resilience was negatively correlated with perceived stress and quality of life. Further, resilience was found to play a partial mediating role in the relationship between perceived stress and quality of life. Therefore, the results partially supported our study hypotheses. CONCLUSION: Health policy makers and administrators in Jordan should be aware of the importance of assessing and improving nurses’ resilience to decrease devastating effects of stress on quality of life. life and the quality of their provided care [14, 15, 16] . The literatures shows that level of education, work experience, age, and gender are significantly associated with nurses' resilience [17, 18] . Hence, enhancing nurses' resilience levels, with taking in consideration the nurses' demographic and professional characteristics, is crucial for allowing them to provide high-quality care and deal effectively with adverse events in healthcare settings during the COVID-19 pandemic [19] . According to the transactional theory of stress (TTS) [20] , coping strategies play a mediating role in the relationship between perceived stress and health outcomes. Resilience is commonly defined as a coping ability to tolerate adversity and bounce back from adverse circumstances [21] . Accordingly, resilience is expected to mediate the relationship between perceived stress and quality of life. However, little is known about the mediating role of resilience in the relationship between perceived stress and quality of life among clinical registered nurses during critical situations, such as the COVID-19 pandemic, in Jordan. Thus, this study aimed to investigate the influence of perceived stress on quality of life, and the mediating effects of resilience on the relationship between perceived stress and quality of life in clinical registered nurses in Jordan during the COVID-19 pandemic. In applying the transactional theory of stress (TTS) [20] to understand stress experienced by nurses during the COVID-19 pandemic, the role of appraisal of a stressful situation and individuals' variations in response to the same stressors are emphasized. According to the TTS, stress refers to the individual's relationship with environments which the individual views as taxing or exceeding their resources and threatening their health [20] . On a daily basis, nurses encounter different types of stressors in the workplace [22] , and these stressors are appraised as either being benign or a threat [24] . Based on the TTS [20] , stress responses are caused by individuals' subjective evaluation or interpretation (i.e., J o u r n a l P r e -p r o o f cognitive appraisal) of stressors, which explains the variations in the ways people respond to the same stressors and the coping resources they use. Cognitive appraisal, which refers to how individuals, such as nurses, evaluate an experienced event and perceive it to influence their goals and well-being, is a core component of the TTS and includes primary and secondary appraisal of stressors [20] . Primary appraisal involves appraising the relevance of an event to one's well-being as being either irrelevant, benign positive, or stressful (i.e., challenging, threatening, or harmful). Meanwhile, secondary appraisal refers to the nurse's evaluation of the coping resources available to manage events appraised as stressful [20] . The lack of effective coping resources can trigger emotional, physical, and social reactions, eventually impairing health outcomes, work performance, and quality of life [7, 8] . Coping is defined as cognitive and behavioral efforts used to manage stressful situations [20] . Resilience is a coping ability associated with positive emotions that may have adaptive benefits during stressful experiences [23] . Thus, high resilience is proposed to better enable nurses to easily overcome stressful situations [24] , develop other efficient coping strategies, and adapt cognitively to changing situations [25, 26] . Recently, more research focus has been placed on stress and coping among nurses. However, the concept of resilience as a coping strategy among nurses has only recently emerged. Additionally, previous studies which have explored stress and coping among nurses have lacked theoretical backgrounds. Therefore, the current study will use Lazarus and Folkman's transactional model to explain the mediating role of resilience as a coping strategy in the relationship between perceived stress and quality of life among registered nurses. We hypothesize that: 1) there is a negative association between perceived stress and resilience, 2) there is a positive association between resilience and quality of life, 3) there is a negative association between perceived stress and quality of life, and 4) resilience mediates the relationship between perceived stress and quality of life. J o u r n a l P r e -p r o o f The study used a cross-sectional correlational design with an online survey and adhered to the STROBE guideline for cross-sectional studies. Convenience sampling was used to recruit registered nurses who were authorized to take care of COVID-19 patients and who were working in any of 8 selected hospitals in Jordan (2 private hospitals, 2 public hospitals, 2 military hospitals, and 2 university hospitals) located in the three biggest cities in Jordan (Amman, Irbid, and Al-zarqa). Nurses were considered eligible if they had completed bachelor's degree in nursing, were working full-time with inpatients, and had at least 6 months of clinical experience. Nurses who were doing internships or any other training or volunteer work and nurses working in the outpatient clinics were excluded. A priori of power analysis by G*Power was used to calculate the required sample size. Assuming α of 0.05, power of 0.95 (generally required largest sample size), effect size of 0.075 (medium effect size [27] , and a maximum of 9 tested predictors (the main study independent variables and demographic variables), the resulting required sample size was 324. Considering low response rate due to using an online survey method and the busy schedule of nurses during the pandemic, we expected that the response rate would be low. Considering an expected response rate of 50%, 324 participants should be added, yielding the final total sample size of 648. The study data were collected using an Arabic online self-administered questionnaire. The questionnaire consisted of four parts: sociodemographic data, the Connor-Davidson "not true at all" (0), "rarely true" (1), "sometimes true" (2), "often true" (3), and "true nearly all of the time" (4). The total possible score ranges from 0 to 100, with higher scores indicating higher resilience. The CD-RISC has demonstrated good reliability (α = .88 and .89), test-retest reliability (.87), and convergent and divergent validity [28, 29] . A Cronbach's alpha of 0.91 was reported for this scale among a sample of Arab adults [30] . ranging from 0 (never) to 4 (very often). The total possible score ranges from 0 to 40, with higher scores indicating higher levels of perceived stress [31] . The PSS has been validated for use among college students. In the original study, the scale had internal consistency coefficients ranging from .84 to 36 and test-retest reliability of .85 [31] . The Arabic version of the PSS showed adequate psychometric qualities among the Jordanian general population. The exploratory factor analysis revealed two factors with eigenvalues greater than 1.0 (45.0% J o u r n a l P r e -p r o o f of the variance); the Cronbach's alpha coefficients were 0.74 for Factor 1, 0.77 for Factor 2, and 0.80 for the whole scale [32] . been used in a study among nurses [33] . The psychometric properties of the Arabic version of the WHOQOL-BREF were tested among a general Arab population, and the results indicated acceptable validity and reliability, with Cronbach's α of ≥ .70 [34] . The study data were collected through an online survey using Google Forms (Free Online Surveys). After obtaining approval from the institutional review board (IRB) at Jordan University of Science and Technology, the principle investigator contacted nursing managers working in different public, private, military, and university hospitals inviting them to ask their registered nurses to participate in the study. Nurses who agreed to participate were sent the survey link through email or WhatsApp, based on their preference. The electronic consent form was included on the front page of the online survey and an "I accept" button provided participants access into the survey. A reminder was sent to nurses who had still not completed the survey after one week of receiving the link. The study data were collected from May 17 th , 2020 to August 15 th , 2020. Approval was obtained from the IRB at Jordan University of Science and Technology. The questionnaires were coded, and the participants were assured that all data would be kept anonymous and confidential and used for research purposes only. Permission to use the selected scales was obtained from the original authors. Data analysis was conducted using the IBM SPSS statistics software (version 25.20). Descriptive analysis, including means, standard deviations, frequencies, and percentages, was used to describe the study variables. The statistical assumption of normality for the continuous variables was assessed using the Kolmogorov-Smirnov test and visual histograms. Levene's test of equal variance was used for testing the homogeneity of variance statistical assumptions for the measured concepts and continuous variables. The independent samples t-test and one-way ANOVA were used to assess the statistical significance of the mean differences in the nurses' perceptions of quality of life and perceived stress across the levels of measured binary and multi-level categorical demographic and professional characteristics. Pearson's correlation coefficient (r) test was used to assess the associations between the metric variables. The scale's reliability was assessed using the Cronbach's alpha test of internal consistency. The study hypotheses representing the correlations between the study variables (i.e. resilience, perceived stress, and quality of life) and the mediating effect of resilience were tested using hierarchical multiple regression analysis. A variable is defined as a mediator when it meets the following conditions: (a) the independent variables are strongly correlated with the dependent variables; (b) the independent variables are associated with the mediator; J o u r n a l P r e -p r o o f and (c) the independent variables and the mediator are correlated with the dependent variables [35] . Within the correlation framework, a 3-step regression analysis was performed to test the mediating effects, as per many previous studies. In the present study, perceived stress was first regressed on resilience, and then quality of life was regressed on resilience. Finally, quality of life was regressed on resilience and perceived stress. The separate coefficients for each regression equation were examined. There are three possible ways of interpreting the results of regression coefficient examination. First, when the coefficient of the first step is insignificant, mediating effects analysis is ended. Second, when the coefficients of the first and second step are significant and the coefficient for the independent variable (resilience) in the third step is insignificant, this indicates a significant full mediating effect. Third, when the coefficient of the first step and the second step are significant, and the coefficient for the independent variable (perceived stress) in the third step is less than the result of the second step, this represents a significant partial mediating effect [35] . Table 1 presents the characteristics of the study sample. Of 650 surveys sent to registered nurses, 550 surveys were completed and submitted, with a response rate of 85% (see figure 1 ). Most of the participants were female, married, and working two shifts (day and night shift). The mean age of the participants was 29.61 years. Additionally, most of the participants held a bachelor's degree in nursing. The mean number of years of nursing experience among the participants was 6.85 years. The basic descriptive statistics of perceived stress, resilience, and quality of life are shown in Table 2 . The mean score for perceived stress was 19.50, the mean score for resilience J o u r n a l P r e -p r o o f was 61.57, and the mean score for quality of life was 52.46. The domain of satisfaction with environment had the lowest mean score in comparison to the other domains, whilst the domain of psychological satisfaction had the highest mean score. Table 3 shows the bivariate analysis results for the association between quality of life and the selected sociodemographic and professional categorical characteristics. The Pearson's correlation coefficient (r), the independent samples t-test, and one-way ANOVA were used. The findings showed that quality of life level differed significantly according to educational level (p<.001) and hospital type (p<.001). Further, quality of life correlated significantly with nursing experience (p<.01). Table 3 also shows the bivariate analysis results for the association between psychological resilience and the selected demographic and professional characteristics. The findings showed that psychological resilience differed significantly according to educational level (p<.05) and hospital type (p< .05). Meanwhile, the variables gender, age, marital status, number of children, work experience, and work shift pattern were not found to be significantly associated with psychological resilience. Our finding regarding the direct relationship between perceived stress and QOL is similar to the findings of previous studies, which have indicated a negative relationship between perceived stress and QOL among registered nurses from different countries [7, 8, 36, 37] . It has been reported that during the COVID-19 pandemic, registered nurses have encountered various stressors which they have appraised as exceeding or taxing their coping resources and ultimately jeopardizing their quality of life (4,5, 6, 7, 8) . According to Lazarus and Folkman (1984) , perceived stress results in the triggering of emotional, physical, and social reactions. If these reactions last for a long time and are not coped with effectively, they can lead to poor health outcomes and threaten health and quality of life [20] . [38] . Also, Shi et al. (2015) reported that resilience functioned as a partial mediator in the relationship between stress and life satisfaction among Chinese medical students [39] . Further, our findings showed that registered nurses' psychological resilience is a buffering mediator between perceived stress and quality of life. According to the TTS [20] , a coping mechanism, as a mediator between perceived stress and quality of life and health, is described as a personal effort to manage these challenges and demands appraised as taxing or exceeding the resources of the person. Psychological resilience is often described as a coping mechanism that helps individuals respond effectively to stressors faced in daily life, allowing them to overcome their struggles by focusing on the real problem and how to deal with it effectively instead of being distracted by these stressors [40] , Previous studies have revealed that when faced with demanding situations, nurses with good resilience experience less stress and are able to overcome the stressful situation more easily than nurses with low resilience [41, 42, 43] . Rutter (2002) proposed that resilient people are optimistic about their ability to successfully overcome and control the challenges they encounter in their daily life. Several studies have shown that resilience-based therapy is effective in allowing individuals to overcome stress [44] . Psychological resilience may buffer the detrimental impacts of perceived stress on health and quality of life by enhancing people's ability to overcome challenges and adversities and cope with struggles and stressors [37, 45] . Although our findings showed that perceived stress can affect QOL through the mediation of psychological resilience, the mediation was partial and the mediation effect ratios were only 28.0%, suggesting that other variables may play a mediating role in the relationship between perceived stress and QOL. The results partially supported our hypotheses, since J o u r n a l P r e -p r o o f resilience as a coping mechanism partially mediated the relationship between perceived stress and quality of life. This partial mediation showed that other factors, such as other coping mechanisms, may play a mediating role in the relationship between resilience and quality of life. According to Lazarus and Folkman (2018) , many coping mechanisms mediate the relationship between perceived stress and quality of life, including problem-focused and emotion-focused coping mechanisms [20] . Huang et al. (2020) found that nurses in China had relied on problem-focused coping methods during the outbreak of COVID-19 [46] . Thus, it is Although the results of this study address a gap in the literature, there are limitations to our study that should be taken into consideration in future research. Firstly, the use of a cross-sectional study design did not allow for understanding the causal relationships between the variables. Secondly, there are many confounding factors, such as other coping strategies, which were not included and examined in our study design, therefore limiting the internal validity. Thirdly, convenience sampling was used to recruit participants, which may have resulted in findings that may not necessarily be representative of nurses in Jordan and may therefore threaten the external validity. However, the generalizability was improved by recruiting registered nurses who were working in any of 8 selected hospitals in Jordan (2 private hospitals, 2 public hospitals, 2 military hospitals, and 2 university hospitals) located in the three J o u r n a l P r e -p r o o f biggest cities in Jordan. Fourthly, the study data were collected using self-report questionnaires, which may have led to response bias and therefore negatively impacted the internal validity. It is recommended that longitudinal studies or randomized controlled trials (RCT) are conducted to further confirm our results. Our study is largely based on quantitative methods. Qualitative or mixed-model methods should be considered to explore the interrelationships between psychological resilience, perceived stress, and quality of life. Further, whilst only psychological resilience as a mediating variable was included and examined in our study to explore the relationship between resilience and quality of life, other factors, such as social support, may also mediate this relationship among registered nurses. Thus, future research should consider other factors which may mediate the relationship between resilience and quality of life. Finally, it is recommended that future studies use probability sampling methods in order to increase the representativeness of the sample. In the 21st century, healthcare systems worldwide are seeking to deliver high-quality care, improve patient satisfaction, and decrease nurse turnover. However, this cannot be to the improvement of nurses' work environments and the effective achievement of organizational goals. Further, this will create optimistic work environments and guarantee the personal safety of nurses, thereby enabling them to continue providing the highest quality of patient care during their battle against the pandemic. As with regards to nursing education institutions, the findings of this study shed light on the importance of integrating resilience-based stress reduction programs in the nursing curricula in Jordan. This will help nursing students strengthen their psychological resilience before entering the work environment. Further, nursing faculties and administrators in Jordan should be proactive in addressing nursing students' stress and hence poor quality of life. Nursing students are the future of the nursing profession. If nursing faculties do not take reasonable and realistic steps to help students manage the overwhelming demands of their roles, the nursing profession could fail to thrive [49] . With the nursing profession in Jordan facing continuous pressure to recruit nurses and reduce nurse turnover, nursing faculties and administrators should work to reduce stress among nurses through resilience-based stress reduction programs, as stress is a major cause of nurse turnover. 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