Discussion

Unlike other workplaces, hospitals are institutions with different and intense sources of stress. ^{Reference Ülker15} The burden of disease and the risk of infection caused by COVID-19 puts a strain on the health system. The negativities caused by the global pandemic also have a significant impact on health workers. ^{Reference Adams and Walls5} The pandemic negatively affects the mental health of doctors, nurses, and health personnel because they work long hours, have long shifts, and are under intensely stressful conditions. ^{Reference Dhingra and Dhingra16} In a study by Trumello et al. in 2020, it was determined that stress, burnout, secondary trauma, and anxiety, as well as depression were higher among staff working with COVID-19 patients. In addition, in the same study, it was determined that the levels of stress and burnout were higher in the professionals in units with higher contamination rates. ^{Reference Trumello, Bramanti and Ballarotto17}

Disasters, including outbreaks of serious illnesses, often require a high level of urgent medical interventions initiated without focusing on the psychological well-being of caregivers. In addition to witnessing physical suffering and death, sudden threats to the caregiver’s safety, anxiety, and over-arousal, as well as hypervigilance, sleep disturbance, compelling memories, and thoughts can cause depression and grief. ^{Reference Albott, Wozniak and McGlinch18} In this study conducted with nurses during the Covid-19 pandemic process, the nurses experienced feelings of fatigue (53.6%), anxiety (52.3%), and psychological weakness (52.3%), as well as burnout (45.1%), and despair (28.8%). When the factors affecting these feelings were examined, it was found that they were: concern about transmission to the relatives of the disease (26.1%), intensive working conditions (20.3%), continued increase in the number of cases (17.6%), and isolation conditions (12.4%), as well as the public’s failure to follow the rules for preventing transmission (12.4%). In addition to these, uncertainties when outbreaks first occurred, rapid progress of the disease, and casualties, as well as other unknowns regarding their treatment, reveal many uncertain issues for health systems and health professionals.

Situations that are unspecified, life-threatening, or perceived as threats cause anxiety in individuals. Anxiety is an emotion that occurs when a person feels unsafe. Nurses and other health professionals actively take on a role of treatment and care in this process, where their health is also at risk. The increasing number of cases and subsequent rise in mortality rates are thought to reveal feelings such as anxiety, despair, fatigue, and burnout/ psychological weakness in nurses. Burnout is a multifaceted response to job stress that includes elements of exhaustion, cynicism, and inefficiency. It has recently emerged as a significant risk factor for all clinicians, particularly those who suffer high rates of death and trauma, and who have perceived inappropriate, or inadequate care. The accompanying features of burnout are loss of physical, cognitive, and emotional energy; this may result in decreased ability to use effective coping strategies, negative attitudes and layoffs. ^{Reference Albott, Wozniak and McGlinch18} A study conducted in China revealed that 50.4% had depression, 44.6% had anxiety, 34.0% had insomnia, and 71.5% had psychological stress symptoms among healthcare professionals (doctors and nurses) treating COVID-19 patients. ^{Reference Lai, Ma and Wang6}

Due to the contact-related nature of the pandemic, the most emphasized measures since the emergence of the pandemic are masking, distance, and increased hygiene. It was observed that the failure of society to pay due attention to the specified security measures caused the nurses to experience feelings such as anxiety and despair. Nurses are also concerned about transmitting the virus to their relatives with whom they are in contact. Maraqa et al. determined that in a study with healthcare professionals, the largest stress source for majority of the participants was the possibility of them infecting their relatives. ^{Reference Maraqa, Nazzal and Zink19} The types of support that the group participating in the research currently needs most are financial support (47.1%), financial and moral support (23.5%), and psychological support (21.6%), respectively. 50.1% of the nurses do not consider the support given to healthcare professionals during the pandemic sufficient. Epidemic periods bring along more challenges and longer working hours than the usual working conditions of nurses. In this process, many nurses also got the virus because of their direct involvement in the care of patients. Through this, it is thought that nurses want to see the reward for their devoted work, while also improving their working conditions and social security conditions.

Nurses are healthcare professionals who witness patients’ experiences of suffering and moments of death while providing care. During the Covid-19 pandemic, most of the nurses witnessed these situations and they continue to do so. It is seen that this situation negatively affects the nurses both spiritually and psychologically. As a result, it is thought that the need for spiritual and psychological support of nurses has increased. 71.2% of the nurses who participated in the study reported that family relations were negatively affected during the pandemic. The intense working conditions brought about by the pandemic, in tandem with their concerns about infecting relatives, have led to a decrease in the time allocated to family and relatives for many nurses. As a result of this situation, many nurses and health professionals stayed elsewhere instead of going home in order to isolate themselves from family members. In this process, some hotels in Turkey have offered free accommodation to support health professionals who cannot go home for fear of infecting their relatives.

Psychological resilience is defined as a person’s adaptation process: the ability to recover himself or the ability to overcome change successfully against important stress sources such as a trauma, a threat or family or relational troubles, serious health problems, as well as workplace and financial problems. ^{Reference Çam and Büyükbayram9} Health care workers represent a group at specific risk, because they provide care for confirmed or suspected cases and/ or generally maintain close contacts while physical distancing is warranted. ^{Reference De Brier, Stroobants and Vandekerckhove20} Considering the psychological resilience levels of the nurses, it was concluded that they got an average of 17 points from the scale, which was between 6 and 30 points, thus showing that their level of resilience was low. Most of the nurses participating in the study got results close to the average from the psychological resilience scale. In a study conducted in Japan, it was also concluded that the psychological resilience levels of nurses are lower than that of other occupational groups and are a risk factor for the development of depression. ^{Reference Avano, Oyama and Akiyama21}

The COVID-19 pandemic affects not only physical health but also mental health and well-being. The viral epidemic puts health workers who provide frontline care during outbreaks at high risk of developing mental health problems. The current pandemic is a new source of stress (or traumatic agent) from psychopathological points of view. ^{Reference Abdullah and Mohammed22} In this study, the average point of the nurses’ ‘Perceived Stress Scale (PSS)’ was 31.74 ± 7.18. In the validity study of the scale, it is stated that a score of 27 and above means the perceived stress is at a moderate level. Also, most of the nurses highly rated their perceived stress. Hence, the conclusion is that the level of stress perceived by the nurses who created the sample was medium. Surrati et al., in a study conducted with healthcare professionals, determined that the perceived stress in healthcare workers was at a moderate level. ^{Reference Surrati, Mansuri and Alihabi23} The coronavirus (COVID-19) outbreak has exposed healthcare professionals to challenges such as unique stress factors and psychological trauma. Allbott et al. describes these challenges as uncertainty about the ultimate size, duration, and effects of the crisis; concerns about the level of preparedness within individual health organizations and the public sector; potential threats to 1's health, lack of adequate personal protective equipment, and other necessary medical supplies; and the risk of transmission of the virus to loved ones and colleagues. ^{Reference Albott, Wozniak and McGlinch18} A study with health professionals found that nurses had 8 times higher stress levels than other occupational groups. The reason for this was that nurses were directly involved in the diagnosis, treatment, and care of COVID-19 patients. ^{Reference Chekole, Yimer, Mekonnen and Mekuriaw24} Factors, such as the nurses’ direct and long-term contact with Covid-19 patients due to their primary caregiver role in the health system and the increase in the care burden caused by the rise in the number of patients due to the pandemic, are thought to increase the perceived stress in nurses.

The reactions of people when they encounter stressful and traumatic situations differ. In these and similar situations, there are individuals who give reactions that result in mental disorders such as anxiety and depression. There are also individuals who recover from this negative situation in a short time and continue their normal lives. For people who recover and survive after stressful and traumatic events, this power is called psychological resilience. Resilience affects the disease process and subsequent health as it helps to adapt flexibly to changes caused by stressful events and to recover from negative emotional experiences. ^{Reference Bozdağ and Ergün25} In our study, it was concluded that as the psychological resilience levels of nurses increased, their perceived stress levels decreased.

All healthcare professionals experience various stressful situations such as working under time, pressure, increased workload, undertaking multiple roles, and having emotional problems during their clinical practice. The increase in stressors experienced in the workplace may negatively affect the physical and mental health of health professionals and may reveal symptoms such as burnout and traumatic stress. This may adversely affect the well-being of employees as well as their ability to practice. ^{Reference McCann, Beddoe and McCormick26} Coping and resilience are strategies that protect the mental and psychological health, restore balance, and facilitate adaptation that are adversely affected in the face of stressful situations, traumatic events, and difficulties. Individuals who do not have these strategies may experience more negative mental and psychological problems in situations such as disasters, diseases, and epidemics. ^{Reference Labrague27} It is therefore vital to support healthcare professionals in maintaining physiological well-being, self-efficacy, and feelings of hope. Individual peer support also helps the person to create a sense of self-efficacy and purpose by allowing them to share their lives. It is crucial to identify and support nurses who have inadequate or inappropriate coping behavior, who are at high risk of exposure to danger/ trauma during a crisis, and who may be prone to stress reactions. ^{Reference Albott, Wozniak and McGlinch18}

During the COVID-19 pandemic process, healthcare professionals working on the front lines, who do not have enough opportunities for sleep and rest, and who have a heavy workload, may experience anxiety, depression, distress, and sleep problems. It is stated that it is important to provide an adequate resting environment for health workers and to plan job rotations during long-lasting disasters such as pandemics. ^{Reference Muller, Hafstad and Himmels28}

It is stated that peer support groups and structured stress management interventions are effective in reducing stress, increasing well-being and resilience, and it is emphasized that these approaches should be applied to cover the pre-pandemic period. ^{Reference Chesak, Perlman, Gill and Bhagra29} McCann et al. suggested the implementation of strategies and mentoring programs aimed at developing positive and nurturing professional relationships, positive thinking, increasing emotional insight, and maintaining life balance; benefits also include improving spirituality in order to strengthen psychological resilience in nurses. ^{Reference McCann, Beddoe and McCormick26}