Psychological resilience, coping behaviours, and social support among healthcare workers during the COVID-19 pandemic: A systematic review of quantitative studies
College of Nursing, Sultan Qaboos University, Oman
* Corresponding author; email: leo7_ci@yahoo.comAbstract
Aim
To appraise and synthesize studies examining resilience, coping behaviours, and social support among healthcare workers during the coronavirus pandemic.
Background
A wide range of evidence has shown that healthcare workers, currently on the frontlines in the fight against COVID-19, are not spared from the psychological and mental health-related consequences of the pandemic. Studies synthesizing the role of coping behaviours, resilience, and social support in safeguarding the mental health of healthcare workers during the pandemic is largely unknown.
Evaluation
This is a systematic review with a narrative synthesis. A total of 31 articles were included in the review.
Key Issues
Healthcare workers utilized both problem-centred and emotion-centred coping to manage the stress-associated with the coronavirus pandemic. Coping behaviours, resilience, and social support were associated with positive mental and psychological health outcomes.
Conclusion
Substantial evidence supports the effectiveness of coping behaviours, resilience, and social support to preserve psychological and mental health among healthcare workers during the COVID-19 pandemic.
Implications for Nursing Management
In order to safeguard the mental health of healthcare workers during the pandemic, hospital and nursing administrators should implement proactive measures to sustain resilience in HCWs, build coping skills, and implement creative ways to foster social support in healthcare workers through theory-based interventions, supportive leadership, and fostering a resilient work environment.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
This study was not funded.
Introduction
The COVID-19 pandemic is an urgent health concern worldwide that greatly affects the mental health, well-being, and possibly work effectiveness of healthcare workers. Mounting evidence indicates that healthcare workers have suffered a deterioration in their mental and psychological health during the coronavirus pandemic, with reports from individual and review studies showing higher prevalence rates of anxiety, burnout, depression, PTSD, and psychological distress among healthcare workers compared to the general public (Chew et al., 2020; Shechter et al., 2020). In a systematic meta-analysis by shain-Ripoll et al., (2020) the pooled prevalence rate of stress among healthcare workers during the pandemic was 40%; furthermore, 30% of healthcare workers in the pooled analysis had anxiety, 28% experienced burnout, 24% had depression, and 13% had post-traumatic stress disorder. Hence, hospital administrators should pay attention to the mental well-being of healthcare workers as poorer mental health may put them at greater risk for PTSD and even suicide (Reger et al., 2020).
Evidence suggests that during stressful events (including disasters, calamities, and disease outbreak), individuals are more likely to suffer adverse mental and psychological consequences when they are not equipped with sufficient levels of resilience and coping abilities (Labrague et al., 2018; Duncan, 2020). Support from peers, colleagues, family, and friends has also been shown to help individuals sustain emotional balance in the face of threats and stress-inducing events (Nowicki et al., 2020). Earlier studies conducted during other infectious disease outbreaks such as SARS, Ebola, and MERS-CoV identified a protective role for psychological resilience, coping behaviours, and social support in healthcare workers against the psychological and mental health burden of caring for infected patients (De Brier et al., 2020; Baduge et al., 2018). Studies conducted during the COVID-19 pandemic have shown a similar pattern: psychological resilience, coping behaviours, and social support safeguard mental health and well-being among healthcare workers who are on the frontlines of the fights against this deadly virus (Labrague & De los Santos, 2020; Blanco-Donoso et al., 2020; Chew et al., 2020).
Despite the abundance of empirical studies on the topic, no studies have systematically synthesized and integrated the results. A broader perspective on the topic of protective factors for psychological and mental health among healthcare workers is vital for the formulation of effective organizational strategies to better support the mental health of healthcare workers on the frontlines of the COVID-19 pandemic. Hence, this systematic review was conducted to synthesize and integrate evidence pertaining to healthcare workers’ psychological resilience, coping behaviours, and social support during the coronavirus pandemic.
Methods
Design
This is a systematic review with a narrative synthesis with results reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.
Data Sources and Search Strategies
Relevant studies were identified through electronic database searches using PubMed, CINAHL, SCOPUS, MEDLINE, and PsychINFO from August 2020 to October 2020. The following MeSH and search terms (‘psychological resilience’, ‘psychological adaptation’ OR ‘coping’, ‘mental health’, ‘health personnel’ OR ‘healthcare workers’, ‘social support’, and ‘2019-nCoV’ OR ‘COVID-19’ OR ‘SARS-CoV-2’ OR ‘severe acute respiratory syndrome coronavirus 2’) were used individually and in combination using Boolean operators (AND, OR and NOT). In addition, cited literature in the articles reviewed were also checked for potentially relevant studies (Figure 1).
Inclusion Criteria
This review included primary studies assessing psychological resilience, coping, and social support among healthcare professionals during the COVID-19 pandemic. The inclusion criteria were as follows: study participants were healthcare workers, study was peer-reviewed, published since the onset of the pandemic, and published in the English language. In this review, healthcare workers are defined as people who work in healthcare settings to provide healthcare services to patients – including doctors, nurses, midwives, nursing assistants, radiologists, physiotherapists, pharmacists, healthcare assistants, and psychologists. Only studies with quantitative designs were included in this review to facilitate homogeneity of the included papers.
Search Outcomes
The initial search yielded 478 articles, from which 121 duplicates were removed. After the removal of duplicates, 357 residual references were reviewed for relevance based on the title and abstract. After screening titles and abstracts based on the inclusion criteria, 239 articles were excluded, resulting in 118 articles. After full text reading of the articles, 87 articles were excluded due to various reasons (e.g., used different study participants, irrelevant to the objective, did not meet the eligibility criteria, and poor quality score (<5). Finally, a total of 31 articles were deemed relevant to the review. The data abstraction process is shown in Figure 1.
Appraisal of Methodological Quality
Two independent researchers appraised the quality of the articles using the Joanna Briggs Institute (JBI) Critical Appraisal for Analytical Cross-Sectional Studies in order to avoid selection bias. The JBI appraisal checklist consisted of eight items examining inclusion criteria, subjects and settings, measurement exposure, use of objective and standard criteria for measurement conditions, confounding variables, management of confounding variables, outcomes measurement, and data analysis. Studies that fulfilled at least five assessment criteria were included in the review.
Data Extraction and Synthesis
Extraction and appraisal of data was completed by two independent researchers. Using a data matrix template, the following data were extracted from the studies: authors, year of publication, country, research approach, samples, measures, key findings, and quality score (Table 1). Due to heterogeneity in the scales used and in the findings of the included studies, statistical pooling was not possible. As such, we used a narrative synthesis to describe the findings. In particular, constant comparison analysis (Miles & Huberman, 1994) was performed to compare findings across studies and to identify patterns and commonalities between studies.
Study Characteristics
Thirty-one articles were included in the review. A majority of studies were conducted in China (14), with the remaining studies conducted in Italy (5), Philippines (2), the United States (2), Turkey (2), Spain (2), Israel (1), Palestine (1), Pakistan (1), and Egypt (1). Sample sizes ranged from 10 to 4,618 participants. Most of the healthcare workers included in the studies were nurses, doctors, nursing assistants, midwives, radiologists, physiotherapists, pharmacists, healthcare assistants, or psychologists.
Most studies had a cross-sectional research design (n = 30), mostly using online surveys, and one study had longitudinal research design. Most studies utilized standardized scales to measure psychological resilience, coping skills, and social support in healthcare workers. Six studies utilized research-designed questionnaires/items to identify coping skills in healthcare workers. The Cronbach’s alphas ranged from 0.81 to 0.96 in studies that reported internal consistency.
Methodological Quality Score
Using the Joanna Briggs Institute critical appraisal checklist, the majority of the studies were rated as moderate in quality (26/31) and five were rated high. Issues related to identification of potential confounding variables and how these confounders were managed and controlled were common in the included articles.
Major Findings
Study results were classified into the following categories: (1) levels of resilience and coping, (2) specific coping skills, (3) coping in relation to mental health, (4) resilience in relation to mental health, (5) social support in relation to mental health, and (6) strategies to enhance resilience, coping behaviours, and social support.
Levels of Psychological Resilience and Coping
Six studies reported data on level of psychological resilience (Bozdag & Ergun, 2020; Huang et al., 2020a; Huang et al., 2020b; Khalaf et al., 2020; Lin et al., 2020; Labrague & De los Santos, 2020a) and three studies described level of coping behaviours in healthcare workers (Lin et al., 2020; Nie et al., 2020; Mi et al., 2020). High levels of psychological resilience were reported in three studies (Bozdag & Ergun, 2020; Huang et al., 2020a; Lin et al., 2020) and moderate levels of psychological resilience were reported in four studies (Luceno-Moreno et al., 2020; Huang et al., 2020b; Khalaf et al., 2020; Labrague & De los Santos, 2020a). In one cross-sectional study of healthcare workers assigned to radiology units in China, online survey data indicated that 83.8% of participants reported higher psychological resilience (Huang et al., 2020a). Similarly, a study by Lin et al. (2020) reported high levels of resilience in Chinese healthcare workers; however, among them, nurses were found to have lower resilience when compared to doctors and other medical staff. In a study from Turkey, healthcare workers scored 18.43 points out of a possible 30 points on the brief resilience scale (BRS), indicating a greater capability to rebound from the adversity associated with the coronavirus pandemic. On the other hand, four cross-sectional studies reported moderate levels of psychological resilience among physicians (Khalaf et al., 2020), medical staff (Huang et al., 2020b), and hospital nurses (Labrague & De los Santos, 2020a) who were on the frontlines during the pandemic. In another study, healthcare workers in Spain obtained a mean score of 3.02 on the Brief Resilience Scale (BRS), indicating a moderate capacity to bounce back to a healthy state in the face of adversity (Luceno-Moreno et al., 2020).
With regards to coping mechanisms, three studies measured ways of coping among healthcare workers using the Simplified Coping Style Questionnaire (Lin et al., 2020; Nie et al., 2020) and a researcher-designed coping behaviour scale (Mi et al., 2020). The three studies reported higher scores for positive vs. negative coping mechanisms, suggesting that when confronted with stress-inducing events such as the COVID-19 pandemic, healthcare workers are able to utilize positive coping mechanisms.
Specific Coping Skills
Fourteen studies identified specific coping mechanisms employed by healthcare workers during the pandemic (Blanco-Donoso et al., 2020; Cai, 2020; Chen et al., 2020; Chew et al., 2020; Dong et al., 2020; Giusti et al., 2020; Labrague & De los Santos, 2020; Maraqa et al., 2020; Mi et al., 2020; Nie et al., 2020; Salman et al., 2020; Shechter et al., 2020; Vagni et al., 2020; Xiao et al., 2020). Among these fourteen studies reporting specific coping styles among healthcare workers during the pandemic, eleven quantitative studies (Cai, 2020; Blanco-Donoso et al., 2020; Chew et al., 2020; Dong et al., 2020; Giusti et al., 2020; Labrague & De los Santos, 2020; Nie et al., 2020; Xiao et al., 2020; Chen et al., 2020; Maraqa et al., 2020; Vagni et al., 2020) indicated that healthcare workers use support from and communication with family, friends, and colleagues as their primary coping mechanisms to manage the adverse mental health consequences of the COVID-19 pandemic. Religious coping mechanisms such as praying were reported as an important coping mechanism in three cross-sectional studies. For instance, in two separate studies involving healthcare workers in Pakistan (Salman et al., 2020) and Palestine (Maraqa et al., 2020), praying and other religious activities were the highest-ranked coping mechanisms. In the United States, where prevalence of COVID-19 is highest, frontline emergency healthcare workers identified religious coping mechanisms such as praying as one of the most important ways to combat the mental and psychological burden of the pandemic (Shechter et al., 2020).
Involvement in distraction activities (such as engaging in sports, exercise, music, yoga, or meditation) were also identified as an important coping mechanisms utilized by healthcare workers during the height of the pandemic (Shechter et al., 2020; Maraqa et al., 2020; Mi et al., 2020; Chen et al., 2020; Dong et al., 2020). Other coping mechanisms identified by healthcare workers included learning about COVID-19 and its prevention (Chen et al., 2020; Cai, 2020) and adherence to infection control guidelines (Dong et al., 2020; Cai 2020; Maraqa et al., 2020).
Coping in Relation to Mental Health
Nine studies described the interaction between coping skills and mental health in healthcare workers during the COVID-19 pandemic (Baboe et al., 2020; Chew et al., 2020; Di Monte et al., 2020; Hou et al., 2020; Maiorano et al., 2020; Mi et al., 2020; Nie et al., 2020; Vagni et al., 2020; Zhu et al., 2020;). The use of positive coping mechanisms such as seeking social support, positive thinking, and problem solving were associated with lower levels of traumatic stress, stigma (Chew et al., 2020), psychological distress (Baboe et al., 2020), stress symptoms (Nie et al., 2020), anxiety, and depression (Zhu et al., 2020; Mi et al., 2020). On the other hand, utilization of negative coping skills, such as avoidance, were strongly linked with increased levels of emotional stress (Chew et al., 2020), PTSD symptoms (Hou et al., 2020), psychological distress (Nei et al., 2020; Baboe et al., 2020), and fatigue (Hou et al., 2020). In one study, the use of emotion-centred and avoidant coping styles were associated with increased levels of emotional exhaustion, while problem-centred coping styles were strongly associated with decreased scores on the depersonalization subscale and increased scores on the personal accomplishment subscale of the MBI (Di Monte et al., 2020). Interestingly, unlike previous studies, a two separate studies in Italy found that the use of a negative coping style – specifically, the blocking of unpleasant emotions and thoughts – was found to effectively reduce psychological distress (Vagni et al., 2020) and PTSD (Maiorano et al., 2020). Vagni et al. (2020) and Maiorano et al., (2020) both argued that by blocking negative emotions, healthcare workers are able to continue their work and experience lower perceived levels of stress.
Resilience in Relation to Mental Health
A number of papers examined the effects of psychological resilience on the mental health of healthcare workers (12/31) (Di Monte et al., 2020; Huang et al., 2020a; Khalaf et al., 2020; Labrague & De los Santos, 2020a; Labrague & De los Santos, 2020b; Li et al., 2020; Lin et al., 2020; Lucero-Moreno et al., 2020; Maiorano et al., 2020; Mohave et al., 2020; Tam et al., 2020; Yoruk & Guler, 2020). Of these, eight studies reported a protective role of psychological resilience against coronavirus-related anxiety. Increased psychological resilience in healthcare workers was associated with lower incidence of pandemic-related anxiety among nurses working in hospitals (Labrague & De los Santos, 2020a) and public health centres (Labrague & De los Santos, 2020b). Results obtained from Israel and Egypt showed a similar pattern in which lower levels of coronavirus-related anxiety were associated with higher levels of resilience (Mosheva et al., 2020; Khalaf et al., 2020). In two separate studies from China, healthcare workers with higher scores on psychological resilience measures reported significantly lower levels of anxiety than those who obtained lower scores on psychological resilience measures (Huang et al., 2020a; Lin et al., 2020). In a study involving 720 healthcare workers in the United States, resilient participants were more likely than non-resilient participants to report reduced levels of anxiety, stress, fatigue, and insomnia (Huffman et al., 2020).
Four studies reported a strong link between personal resilience and depression (Luceno-Moreno et al., 2020; Lin et al., 2020; Khalaf et al., 2020; Yoruk & Guler, 2020), suggesting that interventions to enhance resilience among healthcare workers may help prevent or reduce the occurrence of depression in this population during the COVID-19 pandemic. In addition to depression and anxiety, a few more studies confirmed the protective role of psychological resilience against psychological stress (Tam et al., 2020; Luceno-Moreno et al., 2020; Khalaf et al., 2020), emotional exhaustion (Di Monte et al., 2020), and PTSD symptoms (Maiorano et al., 2020; Lucero-Moreno et al., 2020; Li et al., 2020). In one study, resilience partially mediated the association between institutional support and coronavirus-related distress (Tam et al., 2020).
Discussion
This systematic review is the first to examine psychological resilience, social support, and coping behaviours among healthcare workers during the COVID-19 pandemic and their effects on mental and psychological health. Despite the threat caused by the new virus and the pandemic’s mental health consequences, HCWs reported having moderate to high levels of psychological resilience. In explaining this occurrence, it is important to note that the studies included in the review were conducted during the first wave of the pandemic. Therefore, HCWs are still equipped with substantial personal resources (e.g., coping, self-efficacy, resilience) to combat the psychological burden caused by the coronavirus pandemic (Chen & Bonanno, 2020). However, with the increasing cases of infected patients, increasing patients’ death, increased workload due to increasing COVID-19 admissions, and lack of personal protective equipment, HCWs’ resilience, or ability to bounce back from stressful events, may eventually decline or deteriorate in the long run (Ferreira et al., 2020). Additionally, the lack of social connectedness and the seemingly no definite end in sight for social restrictions may contribute to this decline. As the virus continues to spread along with the threat of the new COVID-19 variants, it is imperative that proactive measures to sustain resilience in HCWs are continuously instituted. These measures may include limiting shift hours, providing adequate hospital supplies, providing rest areas in the hospitals, and providing timely updates and accurate information to HCWs regarding the virus.
Coping strategies – that is, mechanisms that an individual can employ to manage the impacts of potential threats– has been long considered an important personal resource to effectively reduce the impact of stress and its accompanying adverse consequences (Lazarus & Folkman 1987). It was evident in this review that healthcare workers utilized both positive (e.g., use of social support and praying) and negative (e.g., use of distraction activities) coping strategies to effectively manage the stress associated with the COVID-19 pandemic. Interestingly, the use of religious coping mechanisms – such as reading the Bible for Christians or reciting the Quran for Muslims – has been identified as an effective strategy to reduce stress, anxiety, and their adverse effects during the height of the pandemic. As a coping strategy, prayer provides context, social connection, and inner strength, making an individual capable of managing stress more effectively. This type of coping is not only practical, but also safe during the pandemic as it doesn’t require contact with someone. A substantial amount of studies have established a positive link between religious coping mechanisms and reduced anxiety, aggression, psychological distress, and depressive symptoms as well as enhanced optimism, hope, quality of life, and psychological health (Solaimanizadeh et al., 2020; O’Brien et al., 2019).
Seeking social support as a means of coping with adversity has been categorized as a problem-focused coping strategy (Samios et al., 2020) and has been found to effectively reduce stress. Mounting evidence has strongly linked adequate support from managers, co-workers, family, and friends with positive mental health outcomes for both healthcare and non-healthcare professionals during stressful and traumatic events such as calamities, accidents, disasters, and disease outbreaks (Baduge et al., 2018; Labrague et al., 2018). During the pandemic, when stress and anxiety are elevated, adequate social support may help healthcare workers maintain healthy emotional states. However, the different restrictions to combat the virus, including social distancing, lockdown, and quarantine measures, may prevent HCWs from engaging in activities previously learned to effectively cope with stress. For instance, studies conducted before the pandemic identified social support (from friends, peers, family, and even the community) and involvement of outdoor distraction activities (e.g., outdoor exercise) as important coping skills to combat stress among nurses (Lim et al., 2010; Ha & Sung, 2018). However, with the on-going pandemic, utilising these coping strategies can be more challenging. Because promoting social connectedness is of vital importance (as social isolation is what makes this crisis unique compared to other crises), it is essential to find creative ways to foster relationships (e.g., online social connection), to ensure that HCWs are socially and emotionally connected with their families and friends, without the risk of being infected or of infecting them. Other alternative ways to effectively cope with the mental health burden of the pandemic included formulating a new routine that incorporates healthy and optimistic behaviours, such as exercising, journaling, and writing in a gratitude journal (Stuart et al., 2021; Huang et al., 2020).
Psychological resilience, like social support, has long been considered a protective factor against the adverse psychological effects of stressful or traumatic situations (Hart, Brannan, & De Chesnay, 2014). In the context of pandemic, a wide range of evidence has demonstrated that resilient healthcare workers are more likely to rebound effectively and endure the pandemic-associated psychological burden than non-resilient healthcare workers (Foster et al., 2020). The role of psychological resilience in protecting individuals against the mental health consequences of an emergency or disaster situation has also been confirmed in previous studies (Labrague et al., 2018; Duncan, 2020). Our finding also add support to earlier research conducted prior to the pandemic in which higher resilience in healthcare workers was strongly linked to reduced burnout, compassion fatigue, anxiety, depression, and psychological distress (Mealer, Jones, & Meek, 2017).
Limitations of the study
Although this study provided current understanding of resilience, coping behaviours, and social support among HCWs, a few limitations of the review were identified. Potentially relevant research published in other languages were excluded as this review included only articles published in English language. Further, it is worth noting that this review included articles published during the first wave of the pandemic, therefore, on-going investigations are needed to explore how resilience, coping behaviours, and social support among HCWs change through the different waves of the pandemic.
Implications for Nursing Management
This review suggests that building resilience and increasing coping skills and social support among healthcare workers may protect them against the adverse mental and psychological health consequences of the coronavirus pandemic. As such, hospital administrators should foster psychological resilience and reinforce positive coping strategies among healthcare workers by implementing theory-tested interventions or programs. Due to restrictions including social distancing and lockdown measures, these interventions could be delivered in innovative ways, such as webinars, online workshops, and on-demand videos. Interprofessional, web-based nightly debriefing programs (Azizoddin et al., 2020) and online cognitive behavioural therapy (Weiner et al., 2020) have been demonstrated to enhance resilience and morale in healthcare workers and improve clinical processes for quality patient care. Furthermore, increasing social support may provide a sense of greater emotional security among healthcare workers, thereby reducing their apprehensions and anxiety so they can function effectively during the pandemic. If healthcare workers are encouraged to express their feelings and concerns and openly discuss their experiences and challenges in the care and management of COVID-19 patients, their morale will improve and their mental health will be sustained.
As positive coping strategies were seen to improve mental health in healthcare workers, providing training in the development of self-efficacy and effective coping skills may help healthcare workers better manage the increased work pressures that have accompanied the COVID-19 pandemic. Hospital administrators should consider increasing healthcare workers’ access to mental health professionals during the pandemic in to support their mental health needs.
Conclusions
The review findings suggest that healthcare workers manage their stress during the height of the COVID-19 pandemic by utilizing both problem-focused (e.g., use of social support and religious practice) and emotion-focused (e.g., use of diversionary activities) coping strategies. Furthermore, this review found substantial evidence on the value and effectiveness of coping mechanisms, psychological resilience, and social support in preserving the mental health and psychological well-being of healthcare workers during disease outbreaks such as the coronavirus pandemic. Considering the global extent of the pandemic, this review is of interest to international readers – particularly hospital administrators.
Data Availability
Data is available upon request.