Natural disasters affect millions of people around the world.Reference Zhen, Huang and Jin1 Among these, earthquakes are significant traumatic events. Earthquakes in Turkey have caused thousands of people to die, be injured, become homeless, lose their relatives, and become unemployed.Reference Kardaş and Tanhan2 On February 6, 2023, 2 earthquakes, which were called the “Disaster of the Century,” occurred in Pazarcık, Kahramanmaraş province with a magnitude of 7.7 and in Elbistan with a magnitude of 7.6 on the Richter scale. According to official records in Turkey, these earthquakes killed at least 50 873 people, injured more than 122 000, and adversely affected approximately 14 million people.3 It is reported that more than 40 000 aftershocks occurred after the earthquakes that caused major damage in 11 provinces.3, Reference Sehlikoğlu, Yilmaz Karaman and Yastıbaş Kaçar4
Psychological resilience (PR) is defined as the ability to cope positively with trauma, negative experiences and stress, which is crucial for ensuring the sustainability of a healthy workforce.Reference Epstein and Krasner5 Health care workers (HW) participating in earthquake response activities who provide emergency medical assistance in the first stages of disasters encounter sad scenes such as deceased people, seriously injured people, and suffering people.Reference Zhang, Liu and Li6 HW working in various social disasters experience problems such as tension, burnout, fear, helplessness, and sleep disorders.Reference de Snyder VN, Villatoro and McDaniel7, Reference Emirza, Uzun and Şenses8 Compared to the general population of disaster survivors, HW have been reported to experience psychological disorders such as post-traumatic stress disorder, depression, and anxiety more frequently.Reference Ren, Gao and Yang9 Therefore, PR has been considered an important part of the training of disaster workers.Reference Rosen, Miller and Hughes10 There are studies in the literature examining the relationship between PR in HW and other disasters such as hurricanes and the COVID-19 pandemic.Reference Lambert and Lawson11, Reference Pink, Gray and O’Connor12 However, no comprehensive research has been conducted on the PR of HW who experienced the earthquake.
Stress is a condition that occurs when the physical and mental limits of an organism are challenged and threatened.Reference Baltaş and Baltaş13 Post-traumatic stress disorder (PTSD) is a psychiatric disorder that can develop after exposure to traumatic events and is characterized by symptoms such as reliving the traumatic event; avoiding events, places, and activities that evoke the trauma; limited emotional responses; and hypervigilance.14 PTSD manifests itself with symptoms of reliving the traumatic event; avoiding or avoiding events, places, people and activities that are reminders of the trauma; experiencing dullness in emotional reactions and excessive involuntary arousal.Reference Kurt and Gülbahçe15 PTSD is one of the most common types of psychopathology following a mass traumatic event such as an earthquake.Reference Neria, DiGrande and Adams16 The main risk factors for earthquake-related psychopathology depend on the level of earthquake exposure (whether individuals who experienced the earthquake had their homes damaged, lost loved ones, or suffered serious physical injuries).Reference Carr, Lewin and Webster17 HW generally have experience responding to traumatic events in their working lives. However, this disaster, which caused significant loss of life and widespread destruction, was unique for HW because their families and themselves were both victims of this trauma and provided uninterrupted service.
Early recognition of PTSD after an earthquake is very important for the protection of personal and public health.Reference Chen, Chen and Au18 The reactions of individuals to traumatic situations differ from each other both in terms of their ability to use coping mechanisms and in terms of age and experience. In this regard, one of the factors that affects the stress experienced by individuals is PR.Reference Ağırkaya and Erdem19 It is believed that PR plays an important role in shortening the duration of mental symptoms that occur after sudden and highly traumatic events such as earthquakes and facilitating a faster return to normalcy.Reference Canlı and Yılmaz20 Although there are studies examining the relationship between PR and stress symptoms in the literature, there are a limited number of studies investigating this relationship in HW specific to earthquakes.Reference Gezgin Yazıcı and Ökten21, Reference Ke, Chen and Lin22
In our study, we planned to examine the relationship between PR and stress symptoms in HW who experienced the February 6, 2023 Kahramanmaraş earthquake.
Methods
Study Design
The study was conducted to assess the PR and stress symptoms of HW after the 2023 Kahramanmaraş earthquake. The study employs a descriptive and correlational research design.
Population and sample
The study was conducted with HW working in a training and research hospital in Turkey between December 2023 and April 2024. The study population consisted of 1580 doctors and nurses working in this hospital. According to the sampling formula [ n = N. t2 p.q / (d2.(N-1) + t2 p.q)] with α = 0.05, p = q = 0.5, and d = ± 0.05, the sample number was calculated as 310, and the study was completed with 313 HW (202 nurse and 111 doctor) who agreed to participate in the study. The criteria for inclusion in the study were working as a nurse or doctor in the hospital, which was determined within the scope of the study, having experienced the earthquake, and voluntarily participating in the research. The determined hospital is in 1 of the 11 provinces where the earthquake occurred.
Data collection tools
Sociodemographic Data Form. The sociodemographic data form was created by the researchers in line with the purpose of the study based on the literature.Reference Kardaş and Tanhan2, Reference Ağırkaya and Erdem19 The form consists of a total of 8 questions related to sociodemographic characteristics (gender, age, marital status etc.) and the situation of being affected by the earthquake (Receiving Post-Earthquake Psychiatric Support, decrease in job Motivation/Performance, or thinking about quitting job after the earthquake).
Brief Psychological Resilience Scale (BPRS). The scale was developed by Smith et al. in 2008 to measure the PR of individuals.Reference Smith, Dalen and Wiggins23 The validity and reliability study of the BPRS was conducted by Doğan in 2015.Reference Dogan24 BPRS is a 5-point Likert type, 6-items and 1-dimension, self-report measurement tool. The lowest score of the scale is 6 and the highest score is 30. An increase in the total score obtained on the scale indicates an increase in PR. In the Turkish adaptation, Cronbach’s alpha coefficient of BPRS was found to be 0.83.Reference Dogan24 In this study, Cronbach’s alpha coefficient was found to be 0.80.
Traumatic Stress Symptom Scale–5 (TSSS-5). The first version of the scale was developed in Turkish to measure 17 symptoms of posttraumatic stress disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV. Participants rated each item assessing posttraumatic stress symptoms on a 4-point Likert-type scale (0 = not at all distressing, 3 = very distressing) and the cut-off point of the scale is 25. The scale was updated by Şalcıoğlu in 2016 in line with the changes made in the PTSD diagnostic criteria in DSM-5 and consists of 20 items.Reference Basoglu, Salcıoglu and Livanou25, Reference Cankardaş and Şalcıoğlu26 In this study, the Cronbach alpha coefficient was found to be 0.91.
Data collection procedure
The research data were collected using the online data collection system. The forms were sent to HW using online methods (WhatsApp or e-mail) and after the forms were filled out, HW were asked to send them back through the online system. The link was shared with the clinic managers and they were asked to share it in their units and reshare the survey forms again at 1-month intervals. In addition, the clinic manager was asked to remind those who had filled out the form before that they should not fill it out.
Data Analysis
Statistical analyses were performed using SPSS 25 (Statistical Package for Social Science). Compliance with normal distribution was examined by assessing skewness and kurtosis. The normal distribution of the data used depends on the skewness and kurtosis values being between ± 2.Reference George and Mallery27 Percentages, means, and standard deviations were used to evaluate scale scores. The t test was used to compare quantitative data in 2 groups, and 1-way ANOVA was used to compare parameters between groups when more than 2 groups were engaged. Cronbach alpha internal consistency coefficients and correlation analyses were used. The P value of less than 0.05 was considered statistically significant.
Ethical Considerations
Approval was received for the research from the Non-Interventional Clinical Research Ethics Committee of Malatya Turgut Özal University (Number:36; Date: 08.12.2023). The participants were informed about the aim and methods of the study and the time they would be asked to allocate for participation in the data collection form. The participant’s confirmation to participate in the study (informed approval principle) was written in the data collection form. The individuals participating in the study were informed that their information would not be disclosed to others and the “principle of confidentiality” was observed. The research was conducted in accordance with the principles of the Declaration of Helsinki. Participants were informed that the collected data would only be used for scientific purposes, so personal information would not be shared with anyone, and that participation in the study was voluntary.
Results
The participants consisted of 226 (72.2%) females, 227 (72.5%) married individuals, and 202 (64.5%) nurses; the mean age was 39.60 ± 8.96 years. 251 (80.2%) of the participants stated that they lived in their own houses, 31 (9.9%) received earthquake-related psychiatric support post-earthquake, 188 (60.1%) stated that their performance had a minor decline, 62 (19.8%) decreased a lot, and 129 (41.2%) thought about quitting their jobs after the earthquake. Also, 39.6% of the participants were diagnosed with PTSD according to the cut-off score of 25 (Table 1).
Distribution of sociodemographic characteristics of participants
* According to TSSS-5, 25 is accepted as the cut-off point for diagnosis. SD: Standard Deviation
When the mean scores of the participants on the BPRS and TSSS-5 were analyzed, it was found that the mean total score of the BPRS was 18.57 ± 4.10 and the mean total score of the TSSS-5 was 22.25 ± 10.46.
After the examination of the relationship between the total score averages of the BPRS and TSSS-5 scales of the participants (Table 2), it was found that there was a negative correlation between the participants’ BPRS scores and TSSS-5 scores (r:-0.523, P = 0.00).
Relationship between participants’ BPRS and TSSS-5 average scores
** P < 0.01 significant r: Pearson correlation coefficient
The results of the t test showed that there is a significant difference between the total scores of both BPRS (t = -6.66, P = 0.00) and TSSS-5 (t = 6.86, P = 0.00) according to the participants’ thoughts about quitting their jobs (Table 3).
Comparison of BPRS and TSSS-5 scores of the participants according to their thinking about leaving the job and decrease in their work motivation/performance
t: independent sample t-test *p ≤ 0.01 significant F: ANOVA
Bonferroni: Post-hoc test
$ \overline{X}: $
Mean SD: Standard Deviation
According to the results of the analysis, it is observed that there is a statistically significant difference between the mean scores obtained from both BPRS and TSSS-5 according to the decline in job motivation/performance (respectively: F = 18.535, P = 0.00; F = 33.019, P = 0.00). According to the Bonferroni result, it was determined that the total BPRS scores of the participants with no change in their job motivation/performance were higher than those with a minor decrease and those with a significant decrease, and similarly, the total BPRS scores of those with a minor decrease were higher than those with significant decrease. According to the Bonferroni result, it was determined that the participants who had no change in their job motivation/performance had lower total TSSS-5 scores than those with a minor decrease and those with a significant decrease, and similarly, the total TSSS-5 scores of those with a minor decrease were lower than those with a significant decrease (Table 3).
Discussion
The Kahramanmaraş Earthquake was the most devastating in Turkey’s history in terms of the damage it caused and the number of casualties.Reference Ozkula, Dowell and Baser28 This study examined the relationship between PR and stress symptoms in HW who experienced the earthquake. The most important finding of our study was that traumatic stress symptoms decreased as the level of PR increased in HW who experienced the earthquake. In other words, in our study, it was determined that there was a negative relationship between PTSS-5 and BPRS. PR is the capacity of individuals to overcome difficulties.Reference Ağırkaya and Erdem19 Recent research, including new insights from neurobiology, genetics/epigenetics, neuroimaging, and endocrine and inflammatory systems, suggests further links between trauma, PR, and mental disorders.Reference Horn and Feder29–Reference Iacoviello and Charney31 In studies conducted with different groups, a negative relationship between PTSD developing after earthquakes or other traumas and PR has been reported.Reference Dhungana, Koirala and Ojha32, Reference Sakarya and Güneş33 In a recent study conducted with nursing students after the Kahramanmaraş earthquake on 6 February 2023, it was found that PR affected traumatic stress symptoms and physical symptoms.Reference Gezgin Yazıcı and Ökten21 Again, in line with our research results, it is stated in the literature that resilience protects against mental disorder, specially PTSD.Reference Hoge, Austin and Pollack34, Reference Friborg, Barlaug and Martinussen35 It can be suggested that the PR of HW who continue to provide services after disasters should be increased to reduce their PTSD and maintain the continuity of care.
In our study, the rate of HW diagnosed with post-traumatic stress disorder according to the TSSS-5 scale was determined to be 39.6%. In a study conducted in Turkey after the Elazığ earthquake in 2020, severe post-traumatic stress symptoms were found in 25.8% of HW.Reference Cansel and Ucuz36 In a study conducted after the Nepal earthquake in 2015, it was found that 21.9% of HW met the criteria for PTSD.Reference Shrestha37 The rate found in our study appears to be higher than the literature. This difference may be due to the difference in the measurement methods used or the difference in the destructive dimensions of the earthquake. HW who reside in the region before the disaster occurs are also considered victims of the disaster, unlike those who come to assist afterward. The fact that the participants in our study were also victims of the disaster may have caused a higher level of stress compared to the HW who were not earthquake victims in some of the other studies but only came to intervene in the disaster. In gender studies on PTSD that developed after the earthquake, it was determined that women experienced more PTSD,Reference Sehlikoğlu, Yilmaz Karaman and Yastıbaş Kaçar4 and the fact that the participants in our study were predominantly female (72.2%) may have led to this situation.
In our study, it was found that 60.1% of HW had a slight decline in work motivation/performance, and 19.8% had a great decrease. In a study, 59% of HW described a decrease in their functionality at home and work after the earthquake.Reference Shrestha37 In another study, HW who had PTSD after the earthquake were found to be less willing to continue their jobs in the future.Reference Nieh, Hsu and Cheng38 In a recent study conducted in Turkey, it was found that 53.9% of the nurses who were not directly present in the region affected by the earthquake felt tired, 54.3% experienced a decrease in the energy level required for work, and 46.6% experienced a decrease in effort and desire to perform well. The rate in our study is higher than in studies in the literature. This may be because the HW in our study were directly exposed to the earthquake and because the destructive dimension of the earthquake was high.
The sustainability of a healthy workforce largely depends on PR.Reference Epstein and Krasner5 It has been determined that stress negatively affects the social and professional functionality of working individuals.Reference Sehlikoğlu, Yilmaz Karaman and Yastıbaş Kaçar4 In our study, 41.2 % of the participants thought of quitting their jobs after the earthquake. In line with the literature, it is seen that the level of PR is lower and stress symptoms are at a higher level in those who think of quitting their jobs compared to those who do not. Also, in our study, it was found that participants who had no change in job motivation/performance had higher levels of PR and lower levels of stress symptoms. People who are psychologically more resilient have more resistance in terms of getting stressed by stressful life events. Therefore, they can see this as an opportunity and demonstrate their personal skills better.
Limitations
An important feature of our study is that it is one of the limited number of studies in which PR and stress symptoms were investigated in HW who experienced the earthquake. The limitations of our study include the fact that it was cross-sectional and our participants were selected only from HW working in a training and research hospital. Conducting the study in a single hospital, which may affect the generalization of the results of the study, as it will affect the cultural expression of the stress response to trauma. Another limitation of our study is that the severity of personal trauma experiences of health care professionals (death of loved ones, intervention to traumatic injuries, working in a rescue team, etc.) were not included in the study. In addition, the fact that the sample was taken from many areas of the hospital and that no distinction was made between those working in surgical and emergency trauma areas, who may be more exposed to traumatic life experiences in the acute phase, and those who are not in the emergency response team is another limitation of the study.
Also, the use of online self-report scales to diagnose PTSD and the absence of a clinical interview led to a more subjective assessment. Another limitation of our study is the limited number of questions in the sociodemographic form to determine whether participants were affected by the earthquake (although this was done to increase participation).
Conclusion and Recommendations
In our study, it was observed that traumatic stress symptoms decreased as the level of PR of HW increased. People with a higher level of PR can cope with post-earthquake stress symptoms more easily and reach their normal functionality. Health professionals have a critical role in dealing with disasters. HW involved in disaster response should undergo psychological screening for mental disorders before and after disasters. HW can be given regular training on stress management techniques, empathy and PR, including decision-making in times of crisis, before a disaster, and psychological support groups and a solidarity network can be created for HW after a disaster. Practices aimed at increasing PR in this group may prevent possible job losses by reducing stress symptoms and increasing job motivation/performance. Psychological screenings can be conducted on HW at regular intervals. These screenings can be made mandatory by the Ministry of Health and all HW can be encouraged to participate in these screenings. Similarly, mandatory resilience training programs can be developed. Governments and policy makers can create legal regulations for these screenings and training programs. Also, with the increase in the number of disasters on a global scale in recent years, there is a need for long-term longitudinal studies in larger sample groups, including HW working in hospitals of different sizes.
Author contribution
Study conception/design; Hatice Polat, Kerim Uğur; Data collection/analysis; Hatice Polat, Kerim Uğur; Drafting of manuscript; Hatice Polat, Kerim Uğur, Tunahan Sun; Critical revisions for important intellectual content; supervision; Hatice Polat, Kerim Uğur, Tunahan Sun; Statistical expertise; Hatice Polat, Kerim Uğur; Administrative/technical/material support; Hatice Polat, Kerim Uğur, Tunahan Sun.
Competing interests
The authors have no conflicts of interest.
Ethical standard
The study approval was obtained from the Malatya Turgut Özal University Non-Interventional Clinical Research Ethics Committee (Number:36; Date: 08.12.2023).
