Resilience, Coping Strategies and Posttraumatic Growth in the Workplace Following COVID-19: A Narrative Review on the Positive Aspects of Trauma

1A new type of coronavirus (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) was identified in December 2019, and on 11 March 2020, the World Health Organization [WHO] declared COVID-19 a global pandemic. Science has made great strides in controlling COVID-19 infection, particularly because of vaccine development. However, predictions on future scenarios point to a possible coexistence with COVID-19 for many years, underlining the need to address the psychological aftermath of the pandemic. Pandemics and bio-disasters have been associated with detrimental consequences for the physical and mental health of individuals, especially in the case of healthcare professionals who generally carry the greatest burden. Data from previous experiences, as in the case of Severe Acute Respiratory Syndrome (SARS) of 2003, Middle East Respiratory Syndrome (MERS) of 2013–2016 and Ebola of 2014–2016, display an alarming picture with symptoms such as anxiety, depression, burnout and post-traumatic stress disorder (PTSD) that persist even after 1–3 years. Likewise, there is growing evidence that COVID-19 is associated with post-traumatic symptoms and psychological disorders, especially for frontline health workers. For example, a recent meta-analysis analyzed 65 studies for a total sample of 79,437 participants and highlighted a prevalence of 34.4%, 31.8%, 40.3%, 11.4%, 27.8%, 46.1% and 37.4% for anxiety, depression, stress, post-traumatic stress syndrome, insomnia, psychological distress and burnout, respectively. Furthermore, the COVID-19 pandemic is characterized by peculiarities not found in previous disasters such as prolonged insecurity and global economic and social consequences, representing a mass traumatic event.

2The post-disaster mental health literature and trauma research have actually shown that adverse effects on psychological health do not always occur and that traumatic experiences can even lead to positive emotional states and growth. Even after experiencing terrible events, the evidence suggests that people may experience some positive aspects, such as in the case of bereavement, rape, cancer, terrorism, natural disasters and even epidemics, as in the case of the MERS outbreak. The ability to adapt to unpleasant situations and to recover quickly from trauma has been studied through the constructs of resilience, posttraumatic growth (PTG) and coping strategies. Research has not yet reached unanimous agreement on the definition and conceptualization of resilience. Generally, the construct can be defined as positive adaptation despite adverse conditions or as the ability to maintain adequate functioning despite destructive events. Posttraumatic growth defines the positive psychological change that occurs following highly stressful and demanding life situations. The positive transformation originally involved three domains, which were then extended to five thanks to the development of the Post-traumatic Growth Inventory (PTGI): “personal strength”, “relating to others”, “appreciation of life”, “openness to new possibilities” and “spiritual change”. The concept underlying the PTG experience concerns the disruption of the individual’s belief system, which is called the “assumptive world”. The following process of emotional regulation and sense making will then lead to growth as a result of the rebuilding attempt. As for the relationship between the constructs, the research results are still inconclusive. For example, according to Tedeschi and Calhoun the adversity experienced is greater in the case of PTG, which involves a qualitative transformation in functioning that exceeds the ability to resist traumatic circumstances. Nevertheless, some studies show a significant relationship between resilience and PTG. Eventually, another factor that strongly affects the psychological outcomes of disaster-exposed employees refers to coping, which can be defined as the set of adaptive or maladaptive cognitive/behavioral strategies used to deal with adverse and stressful events. Coping strategies can be generally classified as problem-focused (e.g., trying to solve the situation, address the cause) and emotion-focused (e.g., reinterpretation, distancing) or as approach-focused (i.e., strategies aimed at dealing with stressor) and avoidance-focused (i.e., maladaptive avoidance of the situation). Furthermore, approach-focused coping styles such as proactive behaviors, seeking social support and facing the situation are associated with greater resilience. Similarly, active strategies such as problem-focused coping and active-relational coping are significantly associated with increased PTG.

3Hence, the literature shows that the aftermath of tragic events can have a positive impact in terms of personal growth and meaning, suggesting that resilient attitudes may be more prevalent than expected. In this regard, Bonanno challenged the grief work assumption, arguing that the most common reaction to highly traumatic events are not symptoms of distress such as PTSD and depression as much as resilience. For example, analyzing the reactions of New York residents after 11 September 2001, Bonanno and colleagues found resilience, defined as the absence of PTSD, in 65.1% of the sample (N = 2752). Nevertheless, this perspective does not imply that resilient people do not experience symptoms of discomfort but rather that these do not compromise the general trajectory of functioning. Evidence shows that traumatic events can bring positive aspects with prevalence rates for growth ranging 30–70% and 40–75% for more traumatizing professions. In addition, growth also occurs in cases of vicarious or secondary trauma as for professionals who work closely with victims of adverse events (e.g., health personnel, social workers). Regarding the specific context of bio-disasters, a recent study analyzed PTG in a sample of healthcare workers (HCWs) involved in the 2015 MERS epidemic in South Korea. The results showed that resilience was the only significant predictor of PTG while the interviews showed that resilience was experienced in terms of the hardiness, persistence, optimism and support sub factors.

4As scholars have pointed out, evidence-based approaches are needed to protect workers’ health and promote successful adaptation in the aftermath of COVID-19. However, most of the available studies have investigated the negative outcomes of the COVID-19 pandemic, highlighting a gap in research examining whether the positive aspects are achievable and how this can be done. In light of this, the purpose of this narrative review is to collect the available evidence on the positive and adaptive aspects in the context of the COVID-19 pandemic. In particular, our main objective is to analyze the protective factors for the mental health of workers with reference to the constructs of resilience, coping and PTG.

5A literature search was performed on the PubMed, EMBASE, Scopus, Web of Science, Google Scholar and Psycinfo databases from 15 April 2021 up to 31 May 2021. The search strategy used a combination of free text and controlled vocabulary, including the keywords “resilience”, “coping strategies”, “posttraumatic growth”, “personal growth”, “workers”, “employees”, “covid-19”, “pandemic”. A manual research was also performed screening the bibliographic references of the most relevant selected papers. The research was based on the following PICO scheme:Population: Workers from any sector.Intervention: The consequences of the COVID-19 pandemic in the workplace.Comparison: Not considered.Outcome: Resilience, coping strategies, posttraumatic growth, personal growth.

6Population: Workers from any sector.

7Intervention: The consequences of the COVID-19 pandemic in the workplace.

8Comparison: Not considered.

9Outcome: Resilience, coping strategies, posttraumatic growth, personal growth.

10Two independent reviewers (G.L.F. and L.G.L.) read titles and abstracts of the papers identified by the search strategy and carried out a first screening; a further selection was subsequently made by analyzing the full text of the articles. Investigators provided their judgment on the inclusion of each document separately, and disagreements were resolved by discussion with a third reviewer (C.P.). Data were manually extracted in a chart developed jointly by the authors, including title, authors, year of publication, type of study, type of job, sample, country where the investigation took place, aims and variables analyzed and a short summary of the findings. In this article, we merged title, authors and year of publication into the category “reference” (see Table 1). After the collection of the relevant data, a synthesis of the evidence was performed following a qualitative and narrative approach. In particular, the findings for each topic (posttraumatic growth, resilience, coping strategies) were collected together, identifying similarities and differences between the selected studies, as well as relationships, risk factors and outcomes.

11The inclusion criteria followed the PICO scheme mentioned above; in particular, we included articles focusing on positive mental aspects related to the COVID-19 pandemic in the workplace, including articles analyzing resilience and coping strategies applied by workers to deal with the psychological strain of managing the pandemic at work. Articles analyzing posttraumatic growth and personal growth consequent to pandemic were also included.

12Articles written in languages other of English were excluded. Reports of less academic significance, letters to the editors, non-peer reviewed articles, individual contributions and purely descriptive studies published in scientific conferences without any quantitative and qualitative inferences were excluded from this review. Furthermore, review articles were not included in the literature synthesis but discussed in other paragraphs. Studies regarding the general population and not specifically focused on workers were also excluded.

13The online search retrieved a total of 1504 papers: Pubmed (232), Scopus (68), Embase (55), Web of Science (231), PsycInfo (64) and Google Scholar (854). Among these studies, 1444 records were excluded because they did not match the inclusion criteria, while 57 full texts were assessed for eligibility. After removing duplicates, 46 articles were included in the literature synthesis. The process of the literature search and the selection of papers is shown in Figure 1. The included studies and the main findings are included in Table 1.

14The articles selected were published in several countries, representing a comprehensive sample from various parts of the world, except for Africa and South America, where no published article met the inclusion criteria. The most representative area was Europe (15 articles, 32.7% of the total) and among these, Italy was the country where most of the research was conducted (seven articles, 15% of the total). Among the individual countries, China was the most represented with 10 articles (21.3%). Six articles were published in North America (five in USA and one in Canada, 12.8%). Israel (2), India (2), Pakistan (1), Iran (1), Korea (2), Japan (1) and South-East Asia (2) were also present.

15Three major topics were identified and analyzed: resilience, coping strategies and posttraumatic growth. The findings for each topic are described in the following paragraphs and further summarized in Table 2.

16Despite the numerous negative psychosocial effects of the COVID-19 pandemic, positive consequences in the workplace are also possible. Among the selected studies, 25 articles analyzed resilience during the COVID-19 pandemic, alone or together with other constructs. Studies concerning this aspect mainly included healthcare professionals as a sample (nurses, surgeons, medical assistants, etc.) and, to a lesser extent, non-healthcare workers. All the studies analyzed followed a cross-sectional design except for two longitudinal studies, one prospective controlled trial and one predictive study.

17Resilience was associated in different ways with positive and negative (growth/stress) lockdown outcomes. Resilience correlated with Secondary Traumatic Stress (STS), age correlated with PTG, while education and nearly all coping strategies correlated with both STS and PTG. In Chinese nurses working during the COVID-19 emergency, resilience had the strongest direct effect on intention to stay and significantly influenced PTG and perceived professional benefits. In a study concerning moral injury among healthcare workers in the US, moral injury remained stable over three months, while distress decreased but was not affected by any baseline occupational or resiliency factors. Moreover, resilience played a mediating role between depression and burnout. Individuals at high risk of burnout showed significantly lower levels of resilience. Furthermore, an Inquiry-Based Stress Reduction (IBSR) intervention improved resilience for a sample of teachers in Israel. Through resilience, emotion-focused strategies were negatively related to psychological distress directly and indirectly in a sample of Spanish nurses. Resilience was negatively correlated with depression, stress and anxiety. Age, work experience and level of education had a significant positive correlation with nurses’ resilience score. Resilience had a positive and significant correlation with life satisfaction, positive affect, perceived social support, participants’ age, adoption of personal precautions against coronavirus, nutrition and sleep quality. A Chinese study found that resilience positively predicted PTG and vice versa, creating a cycle of reinforcement between resilience and PTG over time. In addition, burnout was negatively associated with both resilience and PTG. A study conducted on a sample of Malaysian employees showed that resilience was significantly associated with work engagement. Furthermore, self-efficacy influenced work engagement directly and indirectly through resilience. A research carried out on a sample of Vietnamese tourism employees highlighted that core beliefs challenge was positively related to workers’ resilience while cognitive reappraisal played a mediating role in this relationship. Resilience also plays a crucial moderating role in the relationship between PTSD and PTG: High levels of resilience enhanced PTG beyond the mean level. In another study carried out on a sample of Chinese front-line nurses, resilience was negatively associated with PTSD. An Indian study conceptualized a resilience “framework” pointing out three concepts: Forming a “resilient identity”, the resilience “management” and working through socio-occupational distress. Canadian research underlined the importance of resilience factors (i.e., trait resilience, family functioning, social support, social participation and trust in healthcare institutions) in association with mental health and well-being. Lower stress correlated with higher trait resilience, which, among the five factors, seemed to be the most important. Resilience is also a mediator between the effects of social support and mental health among HCWs.

18Sixteen of the studies (34%) included in the review analyzed coping strategies applied in the workplace to deal with the pandemic emergency. Most studies used a cross-sectional design and surveys to explore the type of coping strategies and their association with psychological outcomes. Only two studies used a qualitative approach and one study employed a longitudinal design. Fourteen studies explored coping strategies among healthcare workers, while the other two investigated this topic in teachers and mechanical Turk workers, respectively. In healthcare workers, coping strategies seem to play a fundamental role in the management of the emergency and the related occupational stress. Positive and negative coping strategies were identified. The former were associated with a reduction in poor mental health outcomes. Active coping strategies were also positively associated with resilience. The key positive coping strategies were a positive attitude towards the problem, social network, peer support, teamwork, self-reliance, problem negotiation and self-care. Seeking social support was a common coping strategy. In addition, in some studies, this strategy was adopted to a greater extent by workers with lower mental well-being. A problem-focused attitude was found to be a protective factor for reducing anxiety and depression while another study highlighted an association between this coping strategy and higher levels of nurses’ psychological distress. Emotion-focused strategies were negatively related to nurses’ psychological distress directly and indirectly through resilience and were mostly employed by men. Comparing problem and emotion-focused coping strategies, only problem-focused coping was effective in reducing PTSD symptoms, mediating the positive effect of organizational support. PTG was also linked to coping strategies, being predicted by a mixture of adaptive and maladaptive strategies. Escape-avoidance coping strategy was common and was associated in some studies with a higher level of stress along with overcommitment. At the same time, as pointed out by Maiorano et al., avoidance strategies allowed workers in the first phase of emergency to limit their sense of helplessness and inability, favoring resilience and the activation of proactive attitudes. Religious practices were also investigated as coping strategies, being highlighted as common but not significant in reducing stress levels, although workers with higher levels in the hope/optimism dimension in the field of spirituality showed less coronavirus-related anxiety. Finally, lower age and female gender, along with lower resilience and less adaptive defensive functioning, were predictors of stress. Even in non-healthcare workers, coping strategies were common methods for dealing with the new conditions dictated by the pandemic. In teachers, similarly to healthcare workers, avoidance coping strategies were associated with higher stress and reduced positive psychological outcomes.

19Among the selected studies, nine articles (19%) analyzed PTG during the COVID-19 pandemic, alone or in combination with the other constructs. All of the selected articles were studies analyzing prevalence, level and possible association of PTG in healthcare workers who dealt with the health emergency at some level. Six articles out of nine (66%) explored the PTG of nurses, while the other three had generic healthcare workers as a sample. Most of the studies used the Post Traumatic Growth Inventory Scale (PTGI by) to assess the impact of this variable on HCWs, one study used the Changes in Outlook Questionnaire (CIOQ by) and one study used a qualitative approach through interviews with the subjects involved. Pandemic-related distress and growth are connected in a complex relationship that depends on intra- and inter-personal factors. In nurses working in the COVID-19 emergency, an intensification of traumatic stress symptoms has emerged, for example regarding symptoms of avoidance. At the same time, they also reported positive changes in the existing situation, which may be an expression of adaptation in the form of PTG. In particular, healthcare workers working on the frontline seem to have higher levels of PTG compared to non-frontline healthcare workers. Some factors have been recognized as being associated with PTG: In one study, PTG was influenced by the length of service, self-confidence in frontline work and psychological intervention or training during the epidemic. Workers have often experienced PTG through “deliberate rumination”, a process of seeking value and meaning to their own experience or through the tendency to positively reappraise events. Fear of contagion and awareness of the risk were found to be associated with PTG while lack of personal accomplishment was a key negative influence factor. In another study, a combination of adaptive coping strategies predicted the level of PTG, as described also by study; passion for work was also a determinant for the development of PTG. Other personal factors associated with PTG were sex, fertility and marital status. Moreover, resilience seems to play an important role in the development of PTG, as reported in study, which showed that the higher the nurse’s resilience, the easier it is to perceive professional benefits, which results in stronger intent to continue working on the frontline. High levels of resilience enhanced growth beyond mean and clinically relevant levels of PTSD.

20Since the beginning of the COVID-19 pandemic, scholars have collected substantial evidence regarding the tremendous impact of this situation on the workforce, especially in the case of healthcare workers dealing directly with the disease. The sudden and massive outbreak of COVID-19 has overwhelmed even the most advanced healthcare systems and has significantly affected almost all business sectors, leading to the need for organizational changes. After an initial pandemic phase characterized by a significant lack of resources, the situation continues to exert extreme pressures on healthcare professionals. Furthermore, in non-health settings, the economic crisis, the implementation of safety and contagion measures, the adoption of remote work, increased and decreased workloads and the overall uncertainty about the future have negatively affected the mental health of workers in several economic sectors. To the best of our knowledge, this review represents the first attempt to comprehensively analyze the positive aspects of COVID-19 seen as a traumatic experience in the workplace. Indeed, a better understanding of the mental processes underlying traumatic experiences and their determinants seems crucial in planning occupational safety and health practices.

21Most of the retrieved articles considered healthcare professionals as a sample, as the literature has extensively analyzed the impact of the sanitary emergency on these workers. Despite the negative mental effects, dealing with the COVID-19 pandemic has forced workers to develop resilience strategies, as during other outbreaks. As already mentioned, resilience is generally defined as the ability to adapt and maintain adequate functioning despite adverse events and can be conceptualized as a trait, outcome or process. For healthcare workers, coping with mental health problems such as anxiety, depression and burnout during the emergency can be challenging. Overwhelmed by the workload, the lack of material and human resources, workers also face an increased risk of ‘moral injury’ when addressing the ethical challenges of the pandemic and the discrimination experienced due to the fear of contagion by the general population. As evidenced by previous research, psychological resilience is a fundamental variable in reducing and preventing the negative psychological effects of the pandemic. In our review, we found that resilience is associated with lower levels of depression, anxiety and burnout. Resilience improves personal growth and perceived professional benefits and has a positive impact on work engagement even in non-healthcare workers. Overall, we found that age and work experience positively correlate with aspects of resilience in workers. A relevant point is that resilience is considered not only at the individual level, as a key role is played by the organizational resilience mechanisms that shape the way healthcare professionals experience the crisis. Resilience seems to be a pivotal variable in dealing with work-related stress, even in the toughest situations, such as the COVID-19 pandemic. The close relationship between the organizational and personal levels underscores the need for practical measures to support and strengthen resilience, including education, resilience training and interventions to create the feeling of being prepared Furthermore, interventions should focus on young and less experienced workers, as they are the most vulnerable in terms of developing resilience. Closely related to resilience, we found that coping strategies play a fundamental role in the management of the emergency and the related occupational stress. Negative coping mechanisms like escape and avoidance strategies or overcommitment seem to be associated with worse mental outcomes, while positive attitude towards the problem, social network, peer support, teamwork, self-reliance, problem negotiation and self-care play a positive role in reducing stress and boosting resilience. Consistent with research on previous epidemics/pandemics, dysfunctional attachment and maladaptive coping have been highlighted as risk factors for reduced mental well-being. At the same time, resilience indicators (hardiness, vigor) and self-efficacy were found to be protective factors for good mental health outcomes. As pointed out from previous research we found some differences between different categories of healthcare professionals, with nurses experiencing less resilience and more occupational stress. In our view, this may be partly related to the tremendous workload of nursing professionals in caring for COVID-19 patients, who have demanding needs (e.g., pronation in ICU). Interestingly, being a female worker and having less work experience appear to be negative factors for developing adequate forms of coping and resilience, and this may be associated with previous findings on the need for specific training and education to build resilience mechanisms. Arguably, professional experience and higher education levels can be seen as protective factors, as ‘experienced’ workers have more psychological and even professional resources to learn from the disaster rather than being overwhelmed. The negative association between the female gender and the development of effective coping strategies is consistent with previous research on this aspect. Indeed, women tend to adopt emotion-focused strategies to change their feelings, and these types of strategies can be less effective in coping with stressful situations than problem-focused methods, which are more common among men. However, other studies suggest that male workers also adopt emotion-focused coping strategies and more research is needed to explain the mechanisms underlying gender differences. Fighting daily with the virus, as in the context of pandemics, can be considered a form of bio-disaster and traumatic experience. For those involved in the recovery and relief efforts during and after a disaster, the experience has frequently been reported as fulfilling, worthwhile, rewarding and meaningful and can make workers feel they have benefited both personally and professionally. In the context of the COVID-19 pandemic, posttraumatic growth forms have been detected in healthcare workers after the early stages, especially in those on the front line. Several positive factors influencing resilience have also been highlighted in the development of PTG, such as the length of service, self-confidence in frontline work and psychological intervention or training during the epidemic. It seems that more experienced workers express a higher level of PTG, probably due to a higher initial level of awareness, as previously highlighted. At the same time, high levels of resilience and positive coping strategies enhance personal growth so that intervention fostering resilience are likely to help develop PTG.

22This narrative review represents one of the first attempts to identify the possible positive aspects associated with the COVID-19 pandemic in the workplace. To the best of our knowledge, this is the first comprehensive review addressing personal and psychological growth during and after the COVID-19 pandemic. This review provides in-depth insight into the positive mechanisms underlying workers’ resilience, especially HCWs. Identifying such positive associations seems fundamental to guide policy makers and stakeholders towards the future organization of work. Despite its narrative approach, this review used PRISMA compliant method to search the literature, adding value to the evidence retrieved. Nevertheless, despite having followed the guidelines of the literature, some limitations should be addressed. The included studies were conducted in several countries with differences in terms of culture and healthcare systems. The pressure on the workforce may vary according to the type of pandemic management, the level of material and immaterial resources and the time of the pandemic in which the study was conducted while social norms could shape the psychological response, resulting in different experiences of the traumatic event. Hence, the level of resilience, PTG and the type and role of coping strategies could have been influenced by the different external circumstances (e.g., prolonged versus brief COVID-19 experience could influence the level of PTG as it takes longer to develop). Another limitation could lie in the heterogeneity of the measurements and in the fact that most of the studies relied on self-report measures. Even if this review includes longitudinal studies that investigate PTG resilience and coping strategies (e.g.,), the majority of the studies employed a cross-sectional design, limiting the strength of the conclusions and the possibility of making causal inferences on the relationships between the variables. A further limitation concerns the lack of heterogeneity of occupations, with most of the research conducted in the healthcare domain with healthcare workers samples (e.g., nurses). Nevertheless, this population was the most affected by the COVID-19 pandemic, making it a suitable target for studying the consequences of traumatic experiences. Future reviews could investigate the role of other positive psychology constructs in determining post-disaster mental health outcomes.

23This narrative review offers interesting insights into the possible positive outcomes of the COVID-19 pandemic seen as a mass traumatic event and stimulates reflection on what kind of interventions could be implemented. Indeed, health promotion and prevention strategies are essential to foster successful adaptation to challenging environmental conditions. Previous research has highlighted that the constructs of resilience, PTG and coping strategies are intertwined in a complex relationship (e.g.,). For example, fostering PTG can lead to enhanced self-efficacy, cognitive flexibility, resilience and better coping skills. Similarly, greater resilience can lead to higher levels of PTG creating a virtuous cycle, as suggested by longitudinal findings. Hence, organizations should implement interventions to foster resilience, PTG and adaptive coping through counselling services, social connection strategies and targeted training with the aim of creating positive cycles. For example, trauma risk management has proven to be an effective strategy for enhancing the ability of workers to provide support to other colleagues, thus creating a growth environment, while practices such as self-care, small group discussions, mindfulness programs, computer-based trainings and competency training are effective in promoting resilience. Some practical implications are listed in Table 2.

24The COVID-19 pandemic can be analyzed as a traumatic event that can lead to detrimental consequences for the health of the workers, in particular for the healthcare population and for those directly involved in the management of the emergency. However, positive outcomes are also possible, as underlined by the trauma literature on resilience, coping strategies and posttraumatic growth. Considering the possible coexistence with COVID-19 and the long-term consequences, organizational interventions should be aimed at improving adaptive coping skills, resilience and the PTG of employees, thus leading to fulfilling experiences in a virtuous circle.