key: cord-0878849-ox96hhpd authors: Righi, Lorenzo; Ramacciani Isemann, Christian; Rosati, Moris; Pallassini, Maurilio; Pozza, Andrea title: Coping strategies at the frontline of care: Comparisons between Covid‐19 and non‐Covid‐19 units' nurses and the role of moderator variables date: 2022-03-09 journal: Nurs Forum DOI: 10.1111/nuf.12715 sha: 9c79fea03ab0a6fc9be5a9edb78f87489881abbc doc_id: 878849 cord_uid: ox96hhpd INTRODUCTION: Relatively few studies focused on the coping strategies adopted by the healthcare workers during the second phase of the pandemic. The present study compared the coping strategies between Italian nurses working in Covid‐19 and in other units and it explored whether socio‐demographic and work‐related variables moderate the relation between the type of unit and coping strategies. METHODS: A web‐based questionnaire that included sociodemographic and work‐related questions and the Coping Orientation to Problem Experienced—New Italian Version‐25 item was administered. Moderation effects between variables and coping strategies were analyzed using generalized linear models. RESULTS: 253 nurses participated. Nurses who worked in a Covid‐19 unit had significantly lower scores on Avoidance Strategies subscale and higher scores on Positive Attitude and Social Support subscales than nurses working in other units. DISCUSSION: Gender differences emerged only on the social support coping dimension, with women being more likely to adopt social support than men. No association between the type of unit and the other coping strategies was found. CONCLUSION: Nurses working in Covid‐19 units showed better coping strategies than their colleagues: this suggests that support interventions aimed to promote coping strategies should be offered also to Covid‐19‐free units' nurses. the frontline of care reported severe depressive and anxious symptoms, insomnia, posttraumatic stress symptoms, and work-related stress. An additional emotional burden experienced by healthcare workers was the fear of introducing the virus into their own homes and exposing family members to Covid-19. [12] [13] [14] Covid-19 units represent the front-line of care against the virus, a very distressing and exhausting healthcare environment, where working with Covid-19 patients involves long hours and prolonged, continuous contact with critically ill and dying patients; a strong sense of responsibility is required. 15, 16 1.2 | Coping: A buffer against stressful situations According to Lazarus, 17 mental health is not only direct function of the level of stress, but also it depends on how people appraise and face critical situations. Coping may be defined as a process implying the use of a series of skills and strategies to face stressful situations. [18] [19] [20] [21] [22] In the literature on coping, several theoretical models have been proposed. One of the most empirically supported is the model introduced by Carver et al. 23 who identified 15 coping strategies and made several distinctions within the overall categories of problem-focused and emotional-focused coping (e.g., active coping, planning, restraint coping, seeking social support for emotional reasons, focus on and venting emotions, positive reinterpretation, and acceptance), each one measured by a scale of the Coping Orientations to Problems Experienced (COPE). 23 Subsequently, in an Italian sample, Sica et al. 24 revised the COPE and identified five independent coping strategies including Social Support (e.g., the tendency to get advice from other people about what to do to cope with a stressor), Avoidance Strategies (e.g., the tendency to avoid thinking of and/or to refuse to believe that something negative has happened), Positive Attitude (e.g., the tendency to look for something good in what is happening), Problem Solving (e.g., the tendency to focus on dealing with a problem) and Turning to Religion (e.g., the tendency to use prayer as a resource to deal with the negative emotions related to an event). This structure has been further confirmed by Foà and colleagues. 25 Literature studies that examined the correlations between the COPE-NVI dimensions and psychological well-being or distress measures in samples of the general population or healthcare workers consistently showed that avoidance strategies and positive attitudes represent respectively dysfunctional and functional strategies, while turning to religion seems to be neither functional nor dysfunctional. [25] [26] [27] [28] [29] [30] Problem solving has been generally found to be a functional strategy 24, [27] [28] [29] [30] even if not all the studies did support this outcome 25 ; social support seeking has been generally found to be a dysfunctional strategy, since it correlated positively with psychological distress outcomes in most of the available studies (i.e., four out of six studies). 24, 26, [28] [29] [30] A classification of the coping strategies according to the direction of the correlations with psychological well-being or distress outcomes in the studies 24, [26] [27] [28] [29] [30] which used the COPE-NVI is presented in Table 1 . T A B L E 1 COPE-NVI functional and dysfunctional coping strategies according to the correlations with psychological well-being or distress outcomes 41 found that coping based on positive attitudes was adopted by half of their sample, together with the search for social support and turning to religious practices. Relatively few studies focused on the coping strategies adopted by the nurses during the second phase of the pandemic when their responses to the virus spread may have changed over time due to the vaccination plan. [42] [43] [44] In addition, no study explored potential differences between the coping strategies of nurses working in Figure 1 . Since no study focused on the relation between the type of unit and coping strategies during the pandemic, we had not a specific hypothesis regarding these relationships. The assessment of potential differences in the coping strategies of nurses working in different types of units might suggest the introduction of tailored psychological support interventions aimed at promoting specific coping strategies. 2 | METHODS The questionnaire included sociodemographic questions (gender, age, marital status, living with family members in the same home, i.e., children or old relatives) and work-related information (years of working as a nurse, work setting, region, healthcare profession, nursing workload as measured by the frequency and intensity of contacts with Covid-19 patients and with other patients, respectively). Frequency of contacts with Covid-19 patients was measured through the following question: "How many contacts did you have with Covid-19 cases?" The responses to the question related to frequency were coded according to the following categories: "None" = 1; "Occasional contacts (-2 contacts) = 2"; "Few contacts (3-5 contacts) = 3"; Several contact (6-8 contacts) = 4"; "Many contacts (9-10 contacts) = 5"; "A very large number of contacts (over 10 contacts) = 6." The intensity of contacts with Covid-19 patients was measured through the following question: "How close were your contacts with Covid-19 cases?". The responses to the question related to intensity were coded according to the following categories: "Very low intensity contact (physical proximity without touch, attending the same environment)" = 1; "Low intensity contact (physical proximity with touch, conversation) = 2"; "Moderate-intensity contact (maneuvers on other body parts than breathing tract, duration less than 5)" = 3; "Medium intensity contact (assistance maneuvers not on the airways, lasting more than 5 ')" = 4; "High-intensity contact (swab execution)" = 5; "Very high-intensity contact (advanced airways management)" = 6. The COPE-NVI-25 was developed by Foà et al. 25 with the aim to assess the coping styles adopted by subjects in difficult or stressful situations; this is a short version of the COPE. 23 The COPE-NVI-25 showed as good psychometric skills as those shown by the original version. It is capable to evaluate coping strategies in a hospital con- proved to be an instrument as valid as the original COPE, but easier to administer. The COPE-NVI-25 is a multi-dimensional inventory that assesses individual differences in coping styles. It is comprised of 25 items, which are rated on a 4-point scale ranging from 1 (I usually don't do this at all) to 4 (I usually do this a lot). 30 The instrument includes five subscales corresponding to five different coping styles: Social Support (example item: "I seek moral support from friends and relatives"), Avoidance Strategies (example item: "I admit to myself that I can't deal with it, and quit trying"), Positive Attitude (example item: "I try to learn something good from experience"), Problem Solving (example item: "I focus on dealing with this problem and, if necessary, I put from other things aside"), and Turning to Religion (example item: "I try to find comfort in my religion"). A higher score on a particular subscale indicates a greater use of that specific coping strategy. In the present study, the scores for each one of the COPE-NVI-25 scales were calculated by summing the scores obtained by the participants on the items that were related to the target scale in the validation study. 30 Table 2 . The results of the independent-sample Student's t-tests showed that women had significantly higher scores on the COPE-NVI-25 Social Table 3 ; the correlations between age and work-related variables and COPE-NVI-25 scores are shown in Table 4 Table 7, showed that the predictors did not have any effects on the scores of the COPE-NVI-25 Social Support scores. Little is known about the coping strategies adopted by the nurses during the second phase of the pandemic, and no study compared the coping strategies between the nurses working in Covid-19 units and those in other units. The present study examined potential T A B L E 2 Descriptive characteristics and COPE-NVI-25 scores (n = 253) mechanisms 57 according to which people who directly confront themselves with stressful situations are more likely to adopt strategies focused on the task, while people far from the problem may be more likely to use worry and avoidance behaviors as a strategy to get control of the anticipatory distress related to such events and prevent a negative emotional contrast. 58 Overall, this result suggests that during the second phase of the pandemic, support interventions should be offered also to the nurses of non-Covid-19 units who might have dysfunctional coping strategies based upon avoidance. Avoidance is generally considered a coping strategy adopted by the person when facing a stressor when she/he perceives herself/himself incapable to manage the emotions that result from such stressor. 53 Therefore, it might be useful whether interventions aimed to foster self-efficacy in managing emotions are implemented in non-Covid-19 units, as suggested in previous studies. 58, 59 As mentioned before, a higher level of avoidance strategies amongst the nurses working in non-Covid-19 units might suggest the use of a tailored support intervention for this group of nurses, such as Acceptance and Commitment Therapy modules aimed to promote psychological flexibility, that is, the capacity to get in contact with negative feelings when facing stressful events. 60 The fact that the type of unit was not associated with problem solving suggests that perhaps interventions aimed at promoting this type of coping strategies might not be directed at a specific type of unit, but they would be useful for all the types of units. Initial analyses showed that gender differences emerged in the social support coping dimension: in particular, women were more likely to adopt social support as a coping strategy than men, in line with data from previous studies. 23 As discussed in the Introduction, social support seeking has been generally found to be a dysfunctional coping strategy in most of the studies which used the COPE-NVI. [22] [23] [24] 26 However, such gender-based difference was not detected in subsequent analyses based on generalized linear models. In addition, women were less likely to use a coping style based on positive attitudes than men, in contrast with previous data. 8 Specifically, older nurses might perceive themselves as more at risk for the development of the Covid-19 symptoms than younger ones. Alternatively, this result might be attributed to the so-called effect of "unrealistic optimism" (i.e., the tendency to unrealistically evaluate as positive a challenging event compared to its objective negative consequences) which is typical of younger people. 61 Otherwise, a lower level of avoidance strategies amongst younger nurses than amongst older ones might be related to a higher work motivation present in the younger group of nurses, as suggested by previous studies. However, all these interpretations remain speculative as we did not use measures of these constructs to control for such effects. A key limitation concerns the cross-sectional design of the study that did Nurses working in Covid-19 areas show more functional coping strategies than their colleagues working in Covid-19-free settings; nurse managers should verify these strategies steadily among nurses working in Covid-19-free units. The systematic use of the COPE-NVI-25 scale could lead managers to an early identification of those nurses with dysfunctional coping models and to eventually plan and prioritize tailored support interventions to promote psychological flexibility, such as the creation and spreading of information contents 65, 66 and the implementation of peer support teams. [66] [67] [68] Organizational strategies also should aim to enhance care for patients affected by Covid-19: whereas possible, an appropriate job rotation between Covid-19 and Covid-19-free areas may reduce dysfunctional coping strategies and increase the capacity to get in contact with negative feelings. Not only nurses working on the frontline but also their "second-line" colleagues should be supported to face the magnitude of these unexpected events, also in future. The results of the present study suggest that in the second phase of the pandemic, nurses who work in close and constant interaction with Covid-19 patients show more functional coping attitudes than their colleagues employed in Covid-19-free areas. Overall, men are more likely to use positive attitudes than women and experienced professionals display a higher use of avoidance strategies than the younger ones, irrespective of the unit type they work in. As compared with men, women working with Covid-19 patients show an increased use of positive attitudes and a higher search for social support. These aspects should be considered to strengthen nurses' strategies to face any future major stressful events. The data that support the findings of this study are available from the corresponding author upon reasonable request. Christian Ramacciani Isemann https://orcid.org/0000-0001- Andrea Pozza https://orcid.org/0000-0002-6634-6106 A literature systematic review with meta-analysis of symptoms prevalence in Covid-19: the relevance of olfactory symptoms in infection not requiring hospitalization Impact and consequences of COVID-19 pandemic on complicated grief and persistent complex bereavement disorder Situation Report-10: data as reported by 30 The psychosocial impact of COVID-19 pandemic in Italy: a lesson for mental health prevention in the first severely hit European country At the epicenter of the Covid-19 pandemic and humanitariam crises in Italy: changing perspectives on preparation and mitigation Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: stress and psychological impact among frontline healthcare workers Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients The psychological impact of epidemic and pandemic outbreaks on healthcare workers: rapid review of the evidence The prevalence of common and stress-related mental health disorders in healthcare workers based in pandemic-affected hospitals: a rapid systematic review and metaanalysis Prevalence of stress, depression, anxiety and sleep disturbance among nurses during the COVID-19 pandemic: a systematic review and meta-analysis Prevalence of psychological morbidities among general population, healthcare workers and COVID-19 patients amidst the COVID-19 pandemic: a systematic review and meta-analysis Risk for pathological contamination fears at coronavirus time: proposal of early intervention and prevention strategies Healthcare providers experience of working during the COVID-19 pandemic: a qualitative study Covid-19 outbreak: a challenge calling for early intervention on contamination obsessive fears? The impact of the COVID-19 pandemic in an intensive care unit (ICU): psychiatric symptoms in healthcare COVID-19 pandemic and health anxiety among nurses of intensive care units Coping theory and research: past, present, and future Psychological Stress and the Coping Process. McGraw-Hill Stress and ways of coping among nurse managers: an integrative review Psychological and coping responses of health care workers toward emerging infectious disease outbreaks: a rapid review and practical implications for the COVID-19 pandemic What strategies do the nurses apply to cope with job stress?: a qualitative study An examination of stress, coping, and adaptation in nurses in a recovery and monitoring program Assessing coping strategies: a theoretically based approach Uno strumento per la misura degli stili di coping: il Coping Orientation to Problems Experienced -Nuova Versione Italiana (COPE-NVI) COPE-NVI-25: Italian validation of short version of the Coping Orientation to the Problems Experienced (COPE-NVI) Covid-19 outbreak in Italy: are we ready for the psychosocial and the economic crisis? Baseline findings from the PsyCovid study The protective role of life satisfaction, coping strategies and defense mechanisms on perceived stress due to COVID-19 emergency: a chained mediation model Psychological effects of the COVID-2019 pandemic: perceived stress and coping strategies among healthcare professionals First COVID-19 wave in Italy: coping strategies for the prevention and prediction of burnout syndrome (BOS) in voluntary psychologists employed in telesupport Predicting perceived stress related to the Covid-19 outbreak through stable psychological traits and machine learning models Coping responses of emergency physicians and nurses to the 2003 severe acute respiratory syndrome outbreak Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak Strategies used to cope with stress by emergency and critical care nurses Gender differences among cancer nurses' stress perception and coping: an Italian single centre observational study Age differences in stress and coping processes Age differences in coping and emotional responses toward SARS: a longitudinal study of Hong Kong Chinese Nursing and coping with stress Cognitive flexibility and flexibility in coping in nurses -the moderating role of age, seniority and the sense of stress Psychological impact and coping strategies of frontline medical staff in Hunan Between Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic Impact of the COVID-19 pandemic on mental health in the general Chinese population: changes, predictors and psychosocial correlates Associations of COVID-19 risk perception with vaccine hesitancy over time for Italian residents Emotional responses and coping strategies in nurses and nursing students during Covid-19 outbreak: a comparative study Mental health of healthcare workers during the COVID-19 pandemic in Italy The psychological impact of the COVID-19 outbreak on health professionals: a cross-sectional study Mental health and risk perception among Italian healthcare workers during the second month of the Covid-19 pandemic Factors associated with mental health outcomes among health care workers exposed to Coronavirus Disease 2019 Major stressors and coping strategies of frontline nursing staff during the outbreak of Coronavirus Disease 2020 (COVID-19) in Alabama Challenges, experience and coping of health professionals in delivering healthcare in an urban slum in India during the first 40 days of COVID-19 crisis: a mixed method study Perceived stress and professional quality of life in nursing staff: how important is psychological flexibility? Impact of COVID-19 on anxiety, stress, and coping styles in nurses in emergency departments and fever clinics: a cross-sectional survey Experiences of nurses during the COVID-19 pandemic: a mixed-methods study Differences in distress and coping with the COVID-19 stressor in nurses and physicians Statistical Power Analysis for the Behavioral Sciences Worry as a mediator between psychosocial stressors and emotional sequelae: moderation by contrast avoidance A novel theory of experiential avoidance in generalized anxiety disorder: a review and synthesis of research supporting a contrast avoidance model of worry Emotion regulation, coping, and psychological symptoms Emotional intelligence and coping styles: an intervention in geriatric nurses Perceived stress and professional quality of life in nursing staff: how important is psychological flexibility? Unrealistic optimism about susceptibility to health problems: conclusions from a community-wide sample Post-traumatic stress disorder in Italy: a comprehensive evaluation of all the ICD comorbidities and gender-related differences COVID-19-related stress, anxiety and depression during the pandemic in a large population enriched for healthcare providers The impact of the Coronavirus Disease (COVID-19) pandemic on nurses' turnover intention: an integrative review Mitigating the psychological impact of COVID-19 on healthcare workers: a digital learning package COVID-19: peer support and crisis communication strategies to promote institutional resilience Grupos de escucha y apoyo en un hospital universitario como modelo de intervención para profesionales de la salud durante la pandemia de COVID-19 [Listening and support groups in a teaching hospital as a model of intervention Support groups and individual mental health care via video conferencing for frontline clinicians during the COVID-19 pandemic Coping strategies at the frontline of care: comparisons between Covid-19 and non-Covid-19 units' nurses and the role of moderator variables