Background
In the early days of December 2022, the Chinese government ended its restrictive quarantine measures (e.g. nationwide lockdown) against COVID-19, which started in December 2019. Three years of prolonged exposure to COVID-19 pandemic and the restrictive quarantine policy led to a notable impact on frontline nurses’ mental health. According to positive psychology, traumatic events can have negative effects on individuals as well as positive ones, such as post-traumatic growth (PTG) [1]. The results of cross-sectional surveys conducted in early 2020 in China revealed a moderate and higher level of PTG among nurses fighting against COVID-19 [2]. However, the situation and mechanism of PTG among frontline nurses with prolonged exposure to the COVID-19 pandemic remains unknown. The Chinese model of fighting the pandemic provided an opportunity for studying PTG of individuals with prolonged exposure to public health events. This study aimed to investigate PTG and its relationship with social support and resilience among frontline nurses who had prolonged exposure to the restrictive quarantine measures against the COVID-19 pandemic.
PTG is defined as the positive psychological changes that occur after an individual experiences a traumatic event [3]. The affective-cognitive processing model of PTG explained the production process of PTG: Individuals experiencing a traumatic event conduct cognitive processing, evaluate traumatic events and adopt emotional responses and coping measures. Emotional responses and coping measures will in turn affect cognitive processing and ultimately produce positive psychological changes through the process of adaptation or assimilation [4, 5]. Vicarious PTG (VPTG), also known as secondary PTG, is the positive change experienced by people after observing or dealing with the trauma experienced by others and is commonly identified among health care providers [6]. VPTG and PTG are similar in terms of symptoms and measurement tools. Currently, PTG is commonly used to describe the positive psychological impact of direct or indirect traumatic events experienced by health care providers [7]. Research on PTG mainly focuses on people who have experienced natural disasters, accidental trauma, malignant tumours and chronic diseases; relevant research on health care providers is limited [8]. Nurses who provide professional services for patients with COVID-19 in China reported consistent changes in PTG, such as new perception, positive changes in self-consciousness, interpersonal experience and increased value for life [9, 10].
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Prolonged exposure to the COVID-19 pandemic may affect frontline nurses’ evaluation, emotional responses and coping measures to the event and PTG levels. Studies reported that frontline nurses had a moderate or higher PTG level during the early stages of the COVID-19 pandemic [2]. China enforced restrictive quarantine policies (e.g. limited outings or gatherings) for three years from December 2019 to December 2022. Exposure to the constant threat of COVID-19 led to more anxious and stress for individuals [11]. In particular, for health care providers treating COVID-19 patients, the stressful work environment, threat of the virus and long separation from families could bring negative psychological impact to them.
During COVID-19 pandemic, the increasing number of infected cases imposed considerable workload and heavy psychological pressure on frontline nurses, which can be a catalyst for positive psychological change. A cross-sectional survey conducted in early 2020 in China found a moderate and higher PTG level among frontline nurses fighting against the pandemic [2]. Furthermore, studies demonstrated the significant positive impact factors that contributed to the PTG of frontline nurses [2, 10, 12], including education, time spent on frontline clinical departments against COVID-19, similar work experience in some acute incidence or caring for critically ill patients, supports from families and friends, psychological support, self-efficacy and positive coping styles. Similarly, a systematic review identified a range of individual (e.g. age, gender, education, working years, self-efficacy, personal accomplishment, etc.), interpersonal (e.g. relational support) and work environment (e.g. workload and patient population) factors on health care providers’ experiences of PTG [7].
Social support refers to the material or spiritual resources obtained or felt by individuals to help solve their own difficulties in work and life [13]. The affective-cognitive processing model holds that speed and depth of people’s processing of the affective-cognitive cycle, which ultimately produce PTG, depend on the social support system [5]. Some previous research supported this point. A qualitative study conducted in two months after the pandemic breakout, found that emotional and material support from social groups and the public can empower frontline nurses fighting against COVID-19 and promote positive psychological changes [14]. Literature reviews also demonstrated that social support was the main factor that influenced nurses’ PTG after direct or indirect trauma [7, 15]. Therefore, Hypothesis 1 is proposed: Social support positively predicts PTG in frontline nurses.
Resilience refers to the dynamic process in which an individual adapts well to life difficulties [16]. The framework of resilience in action believes that mental resilience is an individual’s innate potential, and when external supportive resources meet an individual’s psychological needs in terms of safety, belonging, talent and value, some individual characteristics, such as mental resilience, can be generated [16]. The results of a national survey of 71,477 nurses in China indicated that nurses’ resilience is positively related to their career development [17]. Individuals with a high level of resilience are better able to cope with stress, are less likely to experience job burnout and have stronger motivation for their career development. A systematic review also confirmed that resilience is one of the promoting factors for PTG of nurses [7]. At present, several studies have detected the correlation among psychological resilience, social support and PTG of health care providers [2, 7, 18, 19], and research on their interaction mechanism is lacking. Thus, Hypothesis 2 is proposed in this study: Social support affects PTG of frontline nurses through resilience.
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Research has emphasised the great significance of studying pandemic-driven PTG and its intervention strategies [20]. PTG plays important effects on maintaining nurses’ mental health and promoting positive transformation of negative emotions. During COVID-19 pandemic, frontline clinical nurses have indirectly or directly experienced its related events. Transforming the negative impacts of pandemic into positive ones and improving nurses’ PTG are therefore important. This study explored the mediating effect of resilience in social support and PTG among frontline nurses with prolonged exposure to the COVID-19 pandemic to afford a theoretical basis for intervention measures formulation.
Methods
Study design
This study employed a descriptive, quantitative and cross-sectional survey design at two tertiary hospitals in Shenzhen City in southern China. Strengthening the Reporting of Observational Studies in Epidemiology checklist for cross-sectional studies was adopted to ensure research quality.
Participants
Nurses from the two tertiary hospitals were selected by convenience sampling method in January 2023. The following are the inclusion criteria: (a) licenced-registered nurses with 12 months and more work experience in current hospital; (b) participated in fighting against COVID-19 for more than six months, including COVID-19 sampling in communities, worked in patients’ isolation hotels or cared for COVID-19 patients in hospital in the past three years. The following are the exclusion criteria: (a) nursing student interns or (b) experienced other traumatic events in the past three years in addition to the pandemic, such as natural disasters, serious traffic accidents, cancer and other serious diseases, and change in civil status.
Sample size was calculated using G*Power software. A sample size of 220 nurses could achieve an effect size of 0.05, alpha value of 0.05 and statistical power of 80%.
Instruments
Demographic questionnaire
A self-made demographic questionnaire was used to collect sociodemographic data of nurses, including gender, age, marriage, education, years of work, professional title, department, types of anti-pandemic work, number of COVID-19 patients cared for daily in the past week, whether they were infected with COVID-19 and severity of symptoms.
Post-traumatic growth inventory
The PTG of participants in this study was assessed using the Chinese version of Post-traumatic Growth Inventory (PTGI) [21], containing 20 items and 5 dimensions: life perception, personal power, new possibilities, relationship with others, and self-transformation, and responding on a six-point Likert scale, with 0 representing ‘no change at all’ and 5 representing ‘very big change’. Higher total score indicates higher PTG level. A total score of < 60, 60 to 66 and ≥ 66 is classified as low, medium and high level of growth, respectively. PTGI is mainly used for patients with accidental trauma and chronic diseases and for medical workers. The Chinese version of PTGI has acceptable reliability with a Cronbach’s α of 0.87 [21].
Social support rate scale
Social support was examined using Social Support Rate Scale (SSRS) [22]. SSRS has three dimensions (e.g. subjective support, objective support, and support utilisation) with 10 items. Items 1 to 4 and 8 to 10 were rated on a four-point Likert scale from 1 (cannot get support) to 4 (can get sufficient support). Item 5 calculated the total score of five questions using a four-point Likert scale from 1 (no support) and to 4 (full support). In items 6 and 7, responding to ‘no source” scored 0; or rated the number of listed sources ‘from the following sources’. Total score ranged from 12 to 66, with higher scores showing better social support. The Cronbach’s α of SSRS ranged from 0.89 to 0.94 [22].
Data collection and ethical consideration
Ethics Committee of hospital has approved this study (ID number: 2022-075). All procedures were conducted in accordance with the Declaration of Helsinki. Date were collected through an online questionnaire platform (https://www.wjx.cn/). During the data collection and data analysis, we conducted several measures to data protection. Participant recruitment was followed the voluntary principle. The confidentiality of sensible personal information, e.g. marriage, department, gender, age, and professional title, was strictly maintained to guarantee the anonymity of participation. All data collected were anonymous, kept confidential, and used for research purposes only. The participants were not in any way identifiable in the reports and papers. Only the corresponding author (Zeng) have access (account number and password) to online data. The research data were stored safely in a encrypted computer folder, and nobody (except the researcher responsible for data analysis, i.e. Yi and He) could access the data without permission from the corresponding author (Zeng). The personal data were kept for six years after the study, after which the researcher would destroy it.
The anonymous online questionnaires comprised three parts, inclusion and exclusion criteria, information sheet and informed consent, and the specific questionnaire. The web link for accessing the online questionnaire were distributed to nurses through a WeChat group that includes all the 425 nurses in the hospital. Firstly, the online questionnaire presented the inclusion and exclusion criteria. The potential participant read the information and self evaluate whether they meet the criteria (clicking the ‘YES’ or ‘NO’ button). The next page is the information sheet and informed consent form. Each potential participant received a detailed introduction about the study, including study purpose, contents and duration, data collection procedures, and potential risks and benefits. Participants were required to carefully review the relevant introduction and then make decision about whether to participate (‘YES’ or ‘NO). Only participants clicked “YES” were guided to signify their informed consent, and then able to proceed to the next part of the survey. Participants had the right to refuse to participate or withdraw from the study. The researcher’s contact information was provided to participants, including the researcher’s name, phone number, and WeChat number. The participants could ask questions about the study at any time. Data were collected from 15 to 22 January 2023.
Data analysis
Data cleaning was adopted to ensure data quality and study validity. We used IBM SPSS version 25.0 (IBM) and PROCESS Macro to analyse data. Descriptive statistics were employed to summarise the participants’ demographic characteristics, PTG, resilience, and social support scores. Frequencies and percentages were calculated for categorical variables, whereas mean and standard deviations were obtained for continuous variables. We used Pearson’s correlation analysis to investigate the relationship among PTG, resilience and social support. Lastly, we used the PROCESS Procedure Model 4 [24] to examine the mediating effect of resilience between social support and PTG. Furthermore, we selected the bootstrapping method with 5,000 bootstrap samples in PROCESS. The effect is considered significant if the 95% confidence interval of the effect does not cover the value of zero with a two-tailed P-value below 0.05.
Results
Online survey was sent to 425 nurses, 388 completed the survey, with a response rate of 91.3%, and 378 valid surveys were actually obtained. Ten questionnaires with incomplete answers were excluded. Among the participants, 84.66% of them had experience caring for hospitalised COVID-19 patients, 68.78% participated in COVID-19 sampling in communities and 35.09% supported other medical institutions or patients’ isolation hotels. About 55% of frontline nurses cared for more than six COVID-19 patients per day in the past week; 91.80% had been infected with COVID-19, and more than half of nurses (51.85%) had moderate or severe symptoms of COVID-19 infection. Table 1 shows the frontline nurses’ characteristics.
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Table 1
Demographic characteristics of participants (n = 378)
Variables | Category | Mean ± SD/n (%) |
|---|---|---|
Gender | Male | 61 (16.14) |
Female | 317 (83.86) | |
Age (years) | 31.57 ± 6.56 | |
Marital status | Single/divorced/widowed | 173 (45.77) |
Married | 205 (54.23) | |
Education | College degree | 54 (14.29) |
BSN | 319 (84.39) | |
MSN | 5 (1.32) | |
Years of experience in nursing (years) | 9.99 ± 7.24 | |
Job title | Nurse | 79 (20.90) |
Nurse practitioner | 150 (39.68) | |
Nurse-in-charge | 131 (34.66) | |
Associate professor of nursing | 18 (4.76) | |
Work of fighting against COVID-19 | Caring for COVID-19 patients in hospital | 320 (84.66) |
Working in patients’ isolation hotels | 133 (35.19) | |
COVID-19 sampling in communities | 260 (68.78) | |
Number of COVID-19 patients taken care of last week (cases) | None | 56 (14.81) |
1–5 | 117 (30.95) | |
6–10 | 57 (15.08) | |
≧ 11 | 148 (39.15) | |
I was infected with COVID-19. | Yes | 347 (91.80) |
No | 31 (8.20) | |
Severity of symptoms when I was infected with COVID-19. | None | 5 (1.32) |
Mild | 146 (38.62) | |
Moderate | 163 (43.12) | |
Severe | 33 (8.73) |
The results of outcome variables for frontline nurses are presented in Table 2. All variables were normally distributed. The score of PTGI was 56.84 ± 17.48, indicating low PTG. Pearson’s correlation analysis results indicated a statistically significant and positive correlation between social support and PTG, resilience (r = 0.439, 0.281, all p < 0.001), and a statistically significant and positive correlation between resilience and PTG (r = 0.288, p < 0.001) (Table 2).
Table 2
Correlations between study variables
Mean | SD | SSRS | RS-14 | PTGI | |
|---|---|---|---|---|---|
SSRS | 37.47 | 9.17 | 0.439** | 0.281** | |
RS-14 | 67.07 | 15.70 | 0.288** | ||
PTGI | 56.84 | 17.48 |
Multiple linear regression analysis was performed with PTGI scores of frontline nurses as dependent variables and SSRS and RS-14 scores as independent variables. The results showed that both social support (β = 0.192, P < 0.001) and psychological toughness (β = 0.203, P < 0.001) entered the regression equation (Table 3). Higher scores of SSRS and RS-14 were associated with higher PTGI scores. A total of 10.80% of the total variation in PTG was explained (adjusted R2 = 0.108, F = 2.758, P < 0.001, Durbin-Watson value = 1.943).
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Table 3
Results of multiple linear regression analysis on the influencing factors of PTG of frontline nurses (n = 378)
B | SE | β | t | p | |
|---|---|---|---|---|---|
Constant | 27.941 | 4.278 | — | 6.531 | < 0.001 |
SSRS | 0.366 | 0.103 | 0.192 | 3.548 | < 0.001 |
RS-14 | 0.226 | 0.060 | 0.203 | 3.752 | < 0.001 |
Common method bias was tested with Harman’s single-factor test. The results showed 7 factors with feature roots greater than 1, cumulative variable explained by the first factor was 33.23%, less than 40%, indicating this study had no serious common method bias.
The results of mediating effect analysis showed that social support could significantly predict resilience (a = 0.752, SE = 0.079, P < 0.001). Social support could significantly predict PTG (c’ = 0.366, SE = 0.103, P < 0.001), and resilience could also significantly predict PTG (b = 0.226, SE = 0.060, P < 0.001). Bootstrap test results showed that resilience had a significant mediating effect between social support and PTG (ab = 0.170, BootSE = 0.077, 95% CI [0.031, 0.330]), as shown in Table 4. The mediating effect accounted for 31.72% of the total effect ([a×b]/c=[0.752 × 0.226]/0.536 = 0.3172), indicating that a partial mediating role of resilience between social support and PTG, as shown in Fig. 1.
Table 4
Effect analysis of resilience as a mediator between social support and PTG of frontline nurses (n = 378)
Model | B | SE | t | P | 95% CI | |
|---|---|---|---|---|---|---|
Direct effects | social support→PTG | 0.366 (c’) | 0.103 | 3.548 | < 0.001 | 0.163, 0.570 |
Indirect effects | social support→resilience | 0.752 (a) | 0.079 | 9.478 | < 0.001 | 0.596, 0.908 |
resilience→PTG | 0.226 (b) | 0.060 | 3.752 | < 0.001 | 0.108, 0.345 | |
Total effects | social support→PTG | 0.536 (c) | 0.094 | 5.685 | < 0.001 | 0.351, 0.722 |
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Fig. 1
Final model
×
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Discussion
PTG is a positive result of fighting against traumatic events. The participants in this study reported a lower level of PTG than the frontline nurses during the COVID-19 pandemic in April 2021 in Wuhan, China (56.84 ± 17.48 vs. 65.65 ± 11.50) [18] and in June to June 2020 in Jiangsu, China (56.84 ± 17.48 vs. 67.17 ± 14.79) [12]. The data collection timepoints and whether the participants were infected with COVID-19 may explain the difference in PTG levels. In 2020 and 2021, as a result of restrictive quarantine measures, China reported a low number of new confirmed COVID-19 cases (28 confirmed cases by 1 April 2021). In December 2022, since the Chinese government ended the restrictive quarantine measures, the number of COVID-19 cases increased rapidly. At the time of data collection for this study (15 to 21 January 2023), more than 50% of the participants had cared for an average of six or more COVID-19-infected patients per day in the previous week. Meanwhile, 92% participants were infected with COVID-19 in the past month. The heavy nursing workload and their COVID-19 infection experience, as well as the fatigue of fighting against the pandemic in the past three years, may have affected the emotional-cognitive cycle of individuals to traumatic events, thereby resulting in increased negative emotions and inhibiting the process of producing positive psychological changes [4].
The results of our study indicated a positive relevance between social support and PTG of frontline nurses with prolonged exposure to the COVID-19 pandemic. Thus, Hypothesis 1 was valid. Previous studies [2, 12, 18] demonstrate social support was a predictive factor for PTG of clinical nurses with traumatic experience. Frontline nurses, participated in fighting against the COVID-19 in Wuhan city in early days of the pandemic outbreak, reported significantly higher PTGI score for those having more support from familymembers and friends [2]. Zhang et al.’ study investigated the status of PTG of 1,790 the COVID-19 pandemic frontline nurses and its influencing factors, the results revealed that participants’ PTG was positively correlated with social support [12]. Furthermore, research demonstrated that 1 year after peak of the COVID-19 outbreak in China, Chinese individuals developed both positive (i.e. PTG) and negative (i.e. depression and anxiety) changes after experiencing the COVID-19 related stress, and social support served as important protective factor of mental health, safeguarded people from psychological distress, and promote PTG [18]. A longitudinal study that explores factors protecting Swiss nurses’ self-perceived quality of life during the COVID-19 pandemic showed that frontline nurses’ health status had not changed significantly when the pandemic’s effects lessened, but their perceived stress and social support all diminished between the four data collection timepoints from February 2021 to September 2022. This longitudinal study also found the frontline nurses’ resilience and perceived social support were protective factors of nurses’ health [25]. Social support can transform trauma into growth by activating and promoting an individual’s emotional-cognitive cycle during traumatic events [3]. Clinical frontline anti-pandemic work is characterised by high intensity and high risk, which brings pressure to nurses’ family life and daily work. The results of an explanatory study conducted in China demonstrated that social support promoted health care workers’ PTG by alleviating psychological stress during the pandemic [26]. A sound support network, which consists of support from superiors, colleagues, family and friends, are the promoting factors for PTG of frontline nurses [9]. Good social support creates a safe and comfortable working and living atmosphere for individuals, enabling them to think about traumatic events from a positive side and gain PTG.
Our study also found the positive relation between resilience and PTG of nurses with prolonged exposure to the COVID-19 pandemic. Resilience, an essential sources to facilitate psychological health and improve individual’s understandings of meaning in life when facing adversity [17], has proven to be a critical buffer against the psychological stress caused by COVID-19 pandemic [27]. A cross-sectional survey of 1,094 healthcare professionals exposed to/worked with COVID-19 patients in eight countries in 2021 found that higher resilience was significantly associated with less psychological distress [28]. A study conducted by Emirza and Kozcu on 160 frontline healthcare workers in the pandemic indicated that psychological resilience was related to better mental well-being through challenge appraisals (i.e. view the stressful situation as a challenge rather than a threat) [29], suggesting that protecting and promoting frontline health care professionals’ mental health in public health events is possible by empowering them with positive appraisals about the adversity [19]. According to the framework of resilience in action [16], nurses with stronger resilience have better sense of control, openness to experience and emotion adjustment during anti-pandemic work, which reduces the negative impact of external risk factors on individual beliefs. Moreover, such nurses are more likely to treat adversity as a challenge and show cognitive flexibility. A descriptive cross-sectional survey, conducted on January 2022 (during the third wave in Qatar) among staff nurses during the COVID-19 pandemic in Qatar, identified positively and significantly correlation between self-compassion and resilience scores [30]. Research has shown that self-compassion significantly affects behavior and psychosocial skills, including well-being, positive self-evaluation, and stronger social connections in population during COVID-19pandemic and lockdown situations [31].
It should be noted that resilience is normally defined as a dynamic process in which an individual adapts well to life difficulties [16], but researchers had proposed that negative aspects of resilience were common, such as masking vulnerability or preventing effective action to address risk [32]. Similarly, the frontline nurses among COVID-19 pandemic who evidenced successful adaptation may struggle with covert psychological difficulties, including depression and posttraumatic stress, in specific post-COVID-19 situations [18]. Interventions are needed to address the negative aspects of resilience for the frontline nurses. For those even had adapted well in the pandemic, mental health services could be supplied to screen and identify covert psychological issues, as a result, to provide proper solutions.
This study is the first to report on the mediating role of resilience between social support and PTG among frontline nurses with prolonged exposure to a public health event, thus contributing additional knowledge regarding the importance of harnessing resilience. The mediating effect of resilience explains the mechanism of social support affecting PTG of frontline nurses, thereby validating Hypothesis 2. In other words, resilience improved the positive effects of social support and resulted in improved PTG. To our knowledge, studies that investigate the role of resilience of medical personnel in social support and PTG during the COVID-19 outbreak are lacking. Previous research focused on confirming the mediating role of psychological resilience between social support and PTG among patients with breast cancer [34], colorectal cancer survivors [35] and patients with COVID-19 [18]. The results of a systematic review of quantitative studies (published from the onset of the pandemic to October 2020) demonstrated resilience and social support were related with positive mental and psychological health outcomes among health care workers during the pandemic [33]. A high level of resilience corresponds to people’s greater interest in learning new ideas and experiences, who are then able to accurately perceive and accept external support resources of the individual, thus promoting PTG [15].
It should be noted that the resilience was a partial mediator in the relationship between social support and PTG among frontline nurses, other potential factors might not have been accounted for in this study. Previous studies have identified several significant positive impact factors for PTG of health care providers, including psychological support, self-efficacy, coping styles, personal accomplishment [2, 7, 12]. Given the the partial mediating role of resilience, further research should consider other relevant variables of PTG, and the intervention developed to foster PTG of frontline nurses were recommended to take into account strategies generating resilience and other variables, such as sefl-efficacy.
Conclusion
The mediation analysis in our study found that social support had a direct positive effect on resilience and PTG. Meanwhile, resilience partially mediated the relationship between social support and PTG. Efforts to improve PTG among frontline nurses with prolonged exposure to a public health event should focus simultaneously on theory-driven strategies to enhance social support and resilience.
Limitations
Firstly, this study used a cross-sectional design, which had a weaker power to identify the the causal relationship of study variables. Secondly, the participants in this study were recruited in only one city of China, thus limiting the representativeness of participants and the generalisability of this study to other areas in China. Thirdly, the partial mediating role of resilience indicated that other potential factors might not have been accounted for in this study. Therefore, future studies should recruit other participants with diverse sociodemographic and ethnic backgrounds and take into account more relevant variables of PTG of participants.
Implications of the study
The results of this investigation indicate that social groups, healthcare organizations and nurse leaders should apply strategies to improve pandemic-driven PTG of frontline nurses, especially for those with prolonged exposure to the pandemic event. It would be beneficial for nurse leaders to establish a culture that provides emotional and material support to meet the frontline nurses’ psychological needs and to generate resilience. Additionally, prioritizing resilience by empowering frontline nurses to perceive and manage emotions in pandemic situations and positively reevaluate them can positively impact their PTG.
Acknowledgements
The authors would like to acknowledge and thank all the nurses who participated in the study.
Declarations
Ethics approval and consent to participate
Ethics Committee of Southern University of Science and Technology hospital has approved this study (ID number: 2022-075). All participants were informed about voluntary participation and asked to sign the informed consent.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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