The nursing profession is considered one of the most stressful [Arslan et al., 2019]. Caring for patients with COVID-19 has considerably impacted the psychological and physical status of nurses in terms of distress, anxiety, depression, and post-traumatic stress disorder (PTSD), as well as heavy workload, which threatens the physical and mental safety and reduces their quality of life of nurses (Hazavehei et al., 2019; Xiong et al., 2020) (34,35). However, resilience has a pivotal role in improving and enhancing the nurses’ response to crisis (Carmassi et al., 2020) (36). Indeed, resilience indicators have been shown to be protective factors for mental health outcomes in nurses during the COVID-19 pandemic (Baskin &Bartlett, 2021; Labrague, 2021) (37, 38).
Concerning the demographic characteristics of the studied nurses, the present study revealed that the majority of nurses were female; their age was less than 24 years, with a mean age of 23.48 ± 0.73 years and they were married. This is due to the fact that at the time of the Corona pandemic, younger nurses who did not suffer from chronic diseases were more volunteer to serve corona patients than older nurses. Also, the highest percentage of nursing staff were females, and most nurses in Egypt get married at an early age. This was consistent with the results of previous studies; Keener et al., (2020); Inocian E, et al. (2021) (39, 40) found that the majority of participants were females, under 25 years of age (Taylor A., 2020) (41); and married (Woon et al., 2021) (42) On the contrary, Elnehrawy S. & Zewiel M., (2021), Asnakew et al., 2021) ((43, 44), mentioned that the majority of nurses were males, single (Jose et al., ( 2020), Elnehrawy S. & Zewiel M., (2021) (45, 43), and the mean age of the respondents was 36.16 (8.17) years or more (Zhang & Ma, 2020) (46).
Additionally, the present study illustrated that about two-thirds of the studied nurses were working as nurse practitioners with less than five years of experience. Slightly more than half of the studied sample had not participated in COVID-19 prevention programs. This may have been attributed to the fact that, during the current pandemic and as a result of the great spread of the Corona virus with the lack of healthcare members trained to deal with such infectious diseases, hospitals were forced to work any nurse even if they did not have enough experience to deal with isolation cases or had not participated in any COVID-19 prevention programs before that. These findings confirmed the results reported by Wang et al. (2020), who concluded that 51.5% of participants work as nurse practitioners, the majority is satisfied with their career, and 76.7% have not participated in SARS prevention and control programs. Also, this study was in agreement with the findings that showed that the participating nurses had a mean of 5.6 ± 4 years of experience. (Jose et al., 2020). Moreover, the majority of the studied nurses receive support from their families. This is due to the fact that the family in our Egyptian culture and rural society is the main source of support and safety for family members. This was consistent with the results of previous studies that stated that the majority of participants reported increased support from family members Wang et al., (2020), Woon et al., (2021), and Zhang Y., & Ma, (2020), are examples of such studies.
Concerning the nurses’ quality of life in the current study throughout the Program Phases, there were statistically significant improvements in the physical quality of life and total SF12 scores post program implementation. This can be explained by COVID-19, which is very frightening. A heavy workload can disrupt the work-life balance, and the nurses may not be able to do the life-related activities, and the quality of life may be affected. There was also a physiological and psychological burden among the nurses due to their direct contact with patients, work load, and lack of experience and knowledge in dealing with COVID-19 patients, but after increasing the nurses’ awareness of dealing with COVID-19 patients, it led to an improvement in their quality of life. This point of view was in agreement with Matos et al., 2021), who carried out a study about quality of life prior and during the COVID-19 Pandemic; it was concluded that the SARS-CoV-2 pandemic has had a detrimental influence on the quality of life of care providers because health professionals experience changes in their lives as a result of their work pressure. Also, this finding was consistent with the results from previous studies about the quality of life of healthcare providers (Çelmeçe and Menekay 2020; Suryavanshi et al., 2020; Woon et al., 2021). It indicated that increased severity of anxiety and a higher degree of work environment stressors disrupted the quality of life of healthcare workers during the COVID-19 pandemic.
Furthermore, working long hours without sufficient breaks and ventilation may contribute to a diminishing psychological quality of life (Roslan et al., 2021). Lower health-related quality of life has been documented in healthcare professionals who are directly involved in caring for COVID-19 patients (Stojanov et al., 2020; Dosil et al., 2020), particularly in terms of the mental health component (An et al., 2020; Stojanov et al., 2020). Moreover, Xie et al. (2021) and Zhang et al. (2021) illustrated that the overall quality of life of the study participants was lower during the pandemic period.
It was clear that there was statistically significant improvement in the nurses' IES-R domains' mean scores after the program implementation in intrusion, hyper arousal, and avoidance domains, and the total mean score of IES-R, but the improvement in the avoidance domain was not statistically insignificant. This may have been attributed to the continuous daily exposure of the nurses to the death of patients every moment, the high rates of infection in the country, fear for themselves, their families and their children; their young age and lack of experience with insufficient awareness of dealing with the pandemic, all these factors may have led to an increase in the post-traumatic stress symptoms among nurses. But after program implementation, the nurses increased their awareness of the pandemic and how to deal with it. The nurses assumed this reduced post-traumatic stress symptoms.
The results of the current study were in agreement with the conclusion that the participants who received training reported lower intrusive syndrome, avoidance syndrome, and hyper-arousal syndrome scores than those who did not receive such training. (Tang et al., 2017). In the same line, previous studies consistently reported high levels of PTSS among healthcare workers who had been quarantined (Lee et al., 2018; Asnakew et al., 2021) Moreover, Vagni. et al. (2020) found that the mediation analysis revealed that 18% of the effect of "total stress" on arousal and 25% of the effect of "total stress" on avoidance were found to be significantly mediated, while the effect of total stress on intrusion was not mediated. OOn the contrary, (Zhang Y., & Ma, 2020) found that among participants who experienced a mild stressful impact, the mean IES-R subdomain scores were 14 for intrusion, 16.8 for avoidance, and 10.8 for hyper arousal. The ratio of probable PTSD (IES-R ≥ 30) was found to be 32% (Sahin, et al., (2021).
The current study highlighted that enhancement in the nurses' dispositional resilience (DRS-15) domains mean scores in post program than pre implementation, with statistically significant differences between pre and post program in commitment, control, and challenges domains and a total mean score of DRS-15. The improvements in resilience skills may be related to the studies where nurses did not clearly define the meaning of resilience prior to this study. But after implementing the program, the nurses improved some skills in themselves, such as autonomy, self-confidence, self-efficacy, humor, and hope. This also indicated that the nurses had responded effectively to the intervention program. This point of view was in agreement with some previous studies (Elnehrawy & Zewiel, 2021; Taylor 2020; Harfush, et al., 2020, Elsayes & Abdelraof 2020), which reported that the mean score of resilience increased post intervention with a highly statistically significant difference between pretest and posttest scores. In the same line, (Chesak et al., 2015; Craigie et al., 2016) illustrated that the awareness resilience scores increased in the experimental group as well as nurses' self-confidence, self-mindfulness, communication, and problem-solving skills improved after a training program related to resilience.
In contrast to this result, a study by Pines al. (2014) concluded that no significant differences were found between pre and post-test, after teaching topics including resiliency and behaviours of resilient nurses, professional empowerment, conflict management, and teamwork to the nurses. Also, Chesak (2015), found that implementing the SMART resilience training program in a sample of 19 new nurses and 20 controls found that the scores for the education intervention group were nearly identical on the pre-and posttests. This discrepancy may be due to using different tools and different content.
This improvement, whether in quality of life or dispositional resilience and in post-traumatic stress level, could be attributed to the variety of educational methods that the researchers used, such as lectures, discussions, demonstrations, and re-demonstration, online handouts, videos, audios, and pictures on the Zoom Cloud Meeting platform, as well as a simple colored booklet letting each nurse get started. In many educational programs, too much reliance is placed on the distribution of written materials in the form of booklets. They can remind nurses of the topics they have learned in other ways. They can provide additional information for those who have a particular interest in any health practice. Booklets are better used when they are short, written in plain language, full of good pictures, and used to back up certain educational types. This is in accordance with Sheha et al., (2020) and Masters, (2013) who indicated the Pyramid of Learning, which showed that people can retain 10% of what they read, 20% of what they see and understand (audiovisual), and 50% of what they learn through discussion.
As regards to comparisons between the various demographic characteristics and total scores of quality of life SF-12, IES-R, and DRS-15 scores, the present study demonstrated few significant differences between pre and post-test. Total quality of life scores are higher in nurses under the age of 24, who are single and female, and who have social support from their family. One possible explanation for this may be the higher level of perceived safety of the surrounding environment among those who were single or young nurses due to their fear of the risk of spreading infection to their family members, and therefore the impact on the person's quality of life will be less. Also, family support as one of the emotional coping methods can protect nurses by positively supporting them. This enables them to view stressful events as less threatening. These findings corroborated the findings of Woon et al. (2021), who discovered that demographic data were significantly associated with respondents' physical health and psychological quality of life.
In the same line, this result agrees with Stojanov et al. (2020), who reported a significantly higher quality of life for those who were single, divorced, or widowed compared with those who were married. This finding was consistent with Asante et al. (2019), who stated that better social relations and social support have been documented to predict higher psychological status and quality of life among healthcare workers. Also, Hadning & Ainii (2020) concluded that all health professionals who participated in the study indicated good physical and psychological health with moderate social relationship quality and environmental health. This finding was in contrast with Sahin et al. (2021), who stated that there was no difference between men and women in terms of WHOQOL-BREF scores except for the mental subscale score, which was found to be lower in women than in men.
It was observed that total IES-R scores were higher in nurses less than 24 years of age, married and males than females. This may be due to the lack of experience of nurses working in similar stressful situations at a younger age. Married nurses are more concerned about spreading the infection to their family members and their children. Also, increased post-traumatic stress in men is due to the fact that the male is the head of the family and bears all their responsibilities. This was supported by a previous study (Chong et al., 2004) involving 1257 HCWs in a tertiary hospital affected by SARS that found an increased risk of PTSS among males, reported that the general practitioners working during the SARS outbreak who met psychiatric vulnerability for PTSD were more likely to be younger.
Also, this was consistent with the results of previous studies that concluded that during COVID-19, HCWs who were younger were more likely to experience higher levels of post-traumatic stress symptoms, depression, anxiety, and acute stress (Rossi et al., 2020; Chatterjee et al., 2020; Elbay et al., 2020; Romero et al., 2020, Song et al., 2020). On the contrary, previous literature suggests that women are positively and significantly associated with posttraumatic stress symptoms (Luceo-Moreno et al., 2020; González-Sanguino et al., 2020). Furthermore, Orrù et al. (2021; Asnakew et al., 2021) found that the age of participants was found to be significantly associated with PTSD. While Sahin (2021) reported that there was no statistical difference between men and women according to IES-R score,
It was noted that nurses who had no family support were more likely to develop post-traumatic stress symptoms as compared with those who had strong and moderate family support. This may be due to a lower degree of perceived support from the family, which will increase stress because the family is the primary support for its members. This was supported by Wu et al. (2009), who concluded that social isolation and separation from family were found to be associated with higher rates of PTSS in the SARS outbreak. As well as having friends or close relatives with the infection, those healthcare providers who had poor social support were more likely to develop post-traumatic stress disorder as compared with those who had strong and moderate social support (Asnakew et al., 2021, Cabello et al., 2020). The result of this study was contrasted with Si et al. (2020), who found that they did not find any significant association between post-traumatic stress and perceived social support.
Furthermore, the current study discovered that total dispositional resilience scores rise in nurses who are younger than 24, single, and female.This may be because of their higher ability to learn and their minds being free of responsibility towards the family and the burdens of life. Also, women are more fearful and anxious about their families than men due to the biological structure of their femle. Therefore, she will feel more fear for her family and an additional source of stress was the realisation of the risk of the virus and transmitting it to loved ones. This was consistent with the results of Zhang et al. (2020), who showed that a higher level of burnout in the subscale of depersonalization was observed among participants of younger age.
In contrast to some literature, male participants' commitment, control, challenge factor, and total resilience scores did not differ significantly from those of female participants (Elnehrawy S. & Zewiel M., 2021). Also, Jose et al. (2020) illustrated that there is no significant association between the resilience of frontline nurses in an emergency and socio-demographic variables, but the nurses who were exposed to COVID-19 patients (40%) reported high resilience, and the personal accomplishment among frontline nurses in an emergency was found to have a significant association with gender.
concerning correlations between total scores of QOL (SF-12), IES-R and DRS among nurses throughout the program phases. There was a statistically significant positive correlation between total scores of QOL (SF-12) and DRS before the program implementation, while there was a highly statistically significant positive correlation after the program implementation. This is due to increased resilience scores in dealing with COVID-19 and training in how to deal with it leading to an increased nurse's quality of life. This was consistent with the results of Giovannetti et al. (2020), who concluded that increased resilience positively affected their lives, 65% reaching a clinically significant improvement in the mental component of health-related quality of life. At the same line, Kunzler et al. (2020) reported that a statistically significant improvement in resiliency and overall quality of life at 8 weeks of intervention was observed. The study findings are consistent with previous research that found strong correlations between overall HRQoL and resilience factors (Tal-Saban & Zaguri-Vittenberg, 2022).
It was clear that there was a statistically significant correlation between total scores of QOL (SF-12) and IES-R before the program implementation, while there was a highly statistically significant positive correlation after the program implementation. This may have been attributed to the fact that when the nurses were trained and their awareness of the Corona pandemic increased, their post-traumatic stress level decreased, and thus their quality of life improved. This point of view was in agreement with Woon et al., (2021), who stated that the stress due to frequent exposure to COVID-19 patients and psychological sequelae contributed to a lower quality of life. In the same line, Sahin et al. (2021) reported that IES-R scores were negatively correlated with quality of life. A previous study suggested that the majority of the respondents reported an average level of secondary traumatic stress (66.9%) in the professional quality of life domains (Inocian et al. (2021).
As a consequence of the improvement in the present study nurses’ QOL and DRS-15 after implementation of the program, there were significant decreases in their IES-R. This is an objective indicator of the success of the intervention since it indicates that their improved QOL led to a lower IES-R among studied nurses. The finding adds to the evidence of the success of the intervention program. This was consistent with previous research that found resilience to be a significant protective factor for most post-traumatic stress symptoms, including arousal, intrusion, and avoidance (Vagni M. et al., 2020; Luceo-Moreno et al., 2020), Li et al., (2020).
However, resilience is an important protective factor for most symptoms of PTSD, and training about it reduces the degree of post-traumatic stress for nurses and enhances their autonomy, self-confidence, and self-efficacy. Moreover, Harfush (2020) found that there was a significant correlation between resilience and psychological well-being and that there was a statistically significant negative correlation was found between resilience and all psychological problems. Also, the result of the present study is supported by research conducted in India (Shalini & Kumar 2019) that proved a high level of resilience helps to manage stress and positively deal with challenges in life and decision-making. This was in contrast with the results of a cross-sectional study on 184 HCWs (50.5% females) including measures of resilience, which did not find any significant association with secondary traumatic stress (Orrù et al., 2021).