Discussion

The workplace environmental factors that dominated in publications on nursing resilience in the context of a pandemic are related to constructs presented in the HSWERM model. These results suggest universality of the HSWERM due to the consistency of workplace environmental factors that emerged from the literature. This consistency presents reliable data, thus contributing to the understanding of resilience. The applicability of applying the HSWERM framework could be considered in further studies. The main workplace environmental factors that were identified include communication, inter-professional collaboration, access to equipment, targeted training, and supporting well-being.

Channels and styles of communication became altered during the outbreak response. ^{Reference Catania, Zanini and Hayter11} Transparent, true, conscientious, and relevant communication is recommended for nurse leaders in the support of their staff, especially during a pandemic. ^{Reference Prestia12,Reference Carmassi, Foghi and Dell’Oste13} Explicit lines of communication at both team unit and organizational levels are important to ensure that information provided is based on accurate sources. ^{Reference Barbosa, Pereira Gomes and Barbosa Assumpção14,Reference Duncan15} This includes collecting factual information and providing timely notification to all HCWs and personnel departments. ^{Reference Huang, Wang and Liu16} A lack of communicative skills ^{Reference Buselli, Baldanzi and Corsi17} demands strategies to support nurses’ resilience as to encourage them to actively engage in providing feedback to supervisors/team leaders. ^{Reference Akgün, Collett, Feder, Shamas and Schulman-Green18} Recommendations included supporting nurses and nursing students by equipping them with communication skills to develop positive and nurturing inter-professional collaborative relationships prior to an extreme event. ^{Reference Buselli, Baldanzi and Corsi17,Reference Baker-Armstrong19}

There was a great emphasis on the importance of respectful inter-professional collaboration as an essential factor in supporting nurses’ resilience to feel that they are part of a team, to practice safely in a pandemic, while understanding tasks that they may not be fully prepared for. ^{Reference Prestia12,Reference Badahdah, Khamis and Al Mahyijari20–Reference Nguyen, Baillard and Samama26} In disaster situations, multidisciplinary teams may work in different locations, learn, and master new technical procedures in a short time and therefore must quickly find ways to work efficiently together. ^{Reference Fan, Hu and Li22} In this context, nurses had a leading role in facilitating communication and collaboration with a new multidisciplinary team. ^{Reference Fan, Hu and Li22,Reference Nguyen, Baillard and Samama26,Reference Nurses27}

Nurses reported being unfamiliar with the protocols of infectious disease wards. ^{Reference Huang, Wang and Liu16} The response to any disaster may require nurses to step outside of their usual labor regulations, because the decisions that need to be made and skills required may be different from their daily work, which also requires a rapid adaptation process by health practitioners and health care managers. ^{Reference Fan, Hu and Li22} Because roles vary across hospitals, ^{Reference Catania, Zanini and Hayter11} the formation of adequately staffed inter-professional teams ^{Reference Barbosa, Pereira Gomes and Barbosa Assumpção14,Reference Duncan15,Reference Rodríguez and Sánchez28} and more detailed job classification and expected levels of accountability should be available to alleviate role ambiguity and improve work efficiency. ^{Reference Liu, Luo and Haase23,Reference Rosa, Gray and Chow29,Reference Dimino, Horan and Stephenson30}

A great concern was expressed with supply shortage, such as personnel protective equipment for nurses, other HCWs, and nursing students, ^{Reference Jeff, Merkley and Canzian25,Reference Rodríguez and Sánchez28,Reference Almaghrabi, Alfaradi and Hebshi31–Reference Savitsky, Findling and Ereli34} as well as access to hydrogen, ^{Reference Prestia12,Reference Barbosa, Pereira Gomes and Barbosa Assumpção14,Reference Barreto, Oliveira and Freitas35} especially in the first weeks. ^{Reference Liu, Luo and Haase23} Irregular working conditions, without the minimum safety requirements, were reported contributing to the mental burden of these HCWs. ^{Reference Nurses27,Reference Canady36,Reference Huang, Lin and Sun37}

Unit and organizational culture for kindness and positive staff behaviors was developed in programs designed to support newly hired employees ^{Reference Buselli, Baldanzi and Corsi17} that increased the use of positive self-talk ^{Reference Baker-Armstrong19} and could be conducted in daily hope huddles during shift changes ^{Reference Dimino, Horan and Stephenson30} or by an organizational debriefing following a traumatic event. ^{Reference Pitman24} Managers were asked to ensure that time and space was given to help staff reflect on and make sense of the morally difficult decisions they took. ^{Reference Huang, Lin and Sun37,Reference Horsch, Lalor and Downe38} Self-care strategies needed to be realistic and readily available; for example, debriefing after critical events could help nurses begin to recognize some of the challenges and pain they have experienced or small initiatives such as free lunches in break rooms. ^{Reference Akgün, Collett, Feder, Shamas and Schulman-Green18}

Although health professionals were willing to work overtime, ^{Reference Almaghrabi, Alfaradi and Hebshi31} stressors were found to be associated with longer working hours, ^{Reference Badahdah, Khamis and Al Mahyijari20} increased workload, ^{Reference Bahar, Koçak and Samancıoğlu Bağlama32} the lack of visibility of their schedule, ^{Reference Nguyen, Baillard and Samama26} and prolonged separation from the family. ^{Reference Carmassi, Foghi and Dell’Oste13,Reference Buselli, Baldanzi and Corsi17} The use of replacement teams in some organizations enabled HCWs to rest and restore their energy. ^{Reference Prestia12}

When health systems are not ready to deal with an infectious disease outbreak, rapid facilitation of training ^{Reference Liu, Luo and Haase23} is required. Lack of training as one of the top five barriers to safe patient care ^{Reference Park, Behrouz-Ghayebi and Sury39} also led to higher infection rates among peers. ^{Reference Fan, Hu and Li22} Little knowledge of COVID-19 protection measures was significantly related to lower resilience and higher levels of anxiety among nurses. ^{Reference Huang, Wang and Liu16,Reference Savitsky, Findling and Ereli34,Reference Canady36} Pre-work training was recommended as an effective way to quickly adapt nurses to practice change as part of an emergency response. ^{Reference Fan, Hu and Li22,Reference Akgün, Collett and Feder40} Suggested training and resources for nurses ^{Reference Akgün, Collett, Feder, Shamas and Schulman-Green18,Reference Baker-Armstrong19,Reference Akgün, Collett and Feder40} included videos and educational materials to staff. ^{Reference Liu, Luo and Haase23}

Several papers mentioned the importance of health systems to plan urgent actions to support their employees’ mental health, ^{Reference Badahdah, Khamis and Al Mahyijari20,Reference Canady36,Reference Alvarez, Almaguer and Santos41} with special interventions to promote mental well-being of those exposed to COVID-19 ^{Reference Canady36,Reference Pollock, Campbell and Cheyne42} and to reduce negative mental health outcomes. ^{Reference He, Chen and Pan43} Key lessons that can equip health care staff with positive coping strategies in a time of unprecedented pressure ^{Reference Thusini44} included the creation of an online psychological counseling group, ^{Reference Liu, Luo and Haase23} the provision of information for staff to easily access mental health services, ^{Reference Alvarez, Almaguer and Santos41} and monitoring for the diagnosis of illnesses, stress, and burnout. ^{Reference Barreto, Oliveira and Freitas35} Increasing the contact of nurses with psychologists and social workers collaborated in reducing tension, anxiety, and depression. ^{Reference Barbosa, Pereira Gomes and Barbosa Assumpção14} Providing virtual support groups for all health care professionals led by an experienced chaplain or social worker in intensive care settings could help support teams in addition to providing individual support. ^{Reference Bussinguer21,Reference Akgün, Collett and Feder40}

Nurses were advised to seek help, contact the employee assistance program at the organization, ^{Reference Horsch, Lalor and Downe38} and use improved emotional and cognitive resources to reinforce a sense of altruism, and to address anxiety and fear of contagion or death. ^{Reference Buselli, Baldanzi and Corsi17} A healthy balance between work and personal life could include practicing deep breathing, positive self-talk, practicing mindfulness, and supporting others when possible, ^{Reference Buselli, Baldanzi and Corsi17,Reference Baker-Armstrong19} as well as access to cognitive-behavioral intervention programs. ^{Reference Badahdah, Khamis and Al Mahyijari20}