Factors Influencing Resilience of Medical Workers from Other Provinces to Wuhan Fighting Against 2019 Novel Coronavirus Pneumonia

Objective: To investigate the resilience of medical workers from other provinces to Wuhan to support fighting against 2019 novel coronavirus pneumonia (COVID-19). Methods : In February 2020, medical works supporting Wuhan in the fighting against COVID-19 were eligible to complete an online survey made up of Connor Davidson Resilience Scale (CD-RISC), Hospital Anxiety Depression Scale (HADS) and Simplified Coping Style Questionnaire (SCSQ). Results : A total of 114 medical workers were investigated. The CD-RISC scores of medical workers were at a high level (67.03±13.22). The resilience level was highest for physicians (73.48±11.49), followed by supporting staff, including health care assistants, technicians (67.78±12.43) and nurses (64.86±13.46). There were also significant differences in education, training and support from hospital, adequate preparation and confidence to complete support tasks (P<0. 05). Resilience was negatively correlated with anxiety (r=-.498, P<0.01) and depression (r=-.471, P<0.01), but positively correlated with active coping styles (r=.733, P<0.01). Multiple regression analysis showed that active coping (β=1.314, p<0.05), depression (β= -.806, p<0.05), anxiety (β= -1.091, p<0.05) and training and support from hospital (β= -3.510, p<0.05) were significant influence factors of resilience. Conclusion : that

In December, 2019, the first novel coronavirus pneumonia case was reported in Wuhan, Hubei province, China, which was attracted worldwide attention and caused a global panic due to the high proportion of severe cases and the high mortality rate [1 2]. The World Health Organization (WHO) raised the risk assessment of COVID-19 from "high" to "very high" at global level [3]. The rapid transmission of the 2019 Novel Coronavirus Pneumonia  has resulted in more than 77 150 patients being diagnosed within 8 weeks [4].
Everyday a dramatic increase in the number of infected individuals is causing a huge work burden on medical workers. There is a shortage of doctors and nurses, who are compelled to work longer without taking enough rest. In order to better control the epidemic and relieve the pressure of local medical workers in Wuhan, the country's top health authority organized excellent medical workers from various provinces to support Wuhan. At the time of writing (February 17th 2020), a total of 32,395 medical workers in 278 teams from the country have been sent to Hubei province, to care for patients who are infected and those with suspected infection, strengthen logistics support, help reduce the pressure on local health-care personnel, and combat the ongoing novel coronavirus outbreak [5]. During an outbreak of infectious disease, medical workers are under great pressure due to heavy workload, hazardous working environment [6]. The severe situation is causing mental health problems such as anxiety, depression symptoms [7 8]. These mental health problems not only affect the medical workers' attention, understanding, and decision making ability, which might hinder the fight against infectious disease, but could also have a lasting effect on their overall wellbeing [9 10]. In particular, the non-local medical works, facing the unfamiliar working environment, away from their families, are bound to bear more mental health problems than the local medical works in Wuhan. Protecting the mental health of these medical workers is thus important for control of the epidemic and their own long-term health [11]. Unfortunately, no study has focused on the psychological problems of medical workers from other areas to support the affected areas during infectious disease outbreaks.
Resilience refers to the means and ability for effective adjustment, or to cope successfully with adverse circumstances [12]. As a psychosocial resource, resilience is commonly regarded as positive adaptations when faced with threats or challenges, and resilience is also found to be significantly associated with anxiety and depression symptoms of medical works [13]. An expected influenza pandemic indicated a need to build resilience to maintain the health of individuals within the organization [14]. Consequently, the concept of resilience among medical works facing natural disasters has gained increasing attention since the outbreak of SARS in 2002 [11 14]. Studies have found that nursing staff from China to Liberia to support fighting against Ebola had higher levels of resilience when compared with the wider population [15]. However, there was a lack of information on whether or not these findings are applicable to non-local medical workers from other provinces to Wuhan to support fighting against COVID-2019. Our study may fill this gap.
This study aims to investigate resilience, anxiety, depression and coping of medical works from other provinces to Wuhan to support fighting against COVID-19. Moreover, we aim to determine the impact of demographic variables, such as sex, age and occupation on these factors. Finally, we hope to assess the factors most strongly related to resilience of these medical workers.

Design and sample
In February 2020, a cross-sectional on-line survey on the first-line medical workers from other provinces to Wuhan to support fighting against COVID-2019 was conduceted.
Voluntary respondents were included if they held a professional certificate. Respondents were excluded if they experienced major negative events (such as serious illness, death of a family member, personal health problems) during the study.

Data collection
A QR code was generated by the e-questionnaire website and sent to participants through the WeChat platform so that they could access the questionnaire. The contact information for a member of the research team was included in the survey in case subjects had any questions or required further explanation. The questionnaires took an average of 10 ± 4.48 min to complete.

Demographic characteristics
Demographic information was collected through a self-designed questionnaire consisting of questions regarding personal variables, such as sex, age, occupation, marital status and education.

Hospital Anxiety and Depression Scale
Hospital Anxiety and Depression Scale (HADS) was used to determine the presence of depression and anxiety among medical workers [16]. It consists of 14 total items, 7 items each for depression and anxiety scale. A score between 0 and 21 is given for either anxiety or depression. For each scale, scores of 8-10 indicate mild symptoms and greater than or equal to 11 indicate moderate/severe symptoms. Higher scores on each individual scale reflect severe forms of depression and/or anxiety. In this study, Cronbach's alpha was 0.428 for anxiety, 0.702 for depression.

Resilience
Resilience was measured using the Connor Davidson Resilience Scale (CD-RISC). This is a 25-item test that yields a score between 0 and 100. Higher scores indicate higher resilience. The 25 items are subdivided into three factors, including hardiness (13 items), strength (8 items), and optimism (4 items). Previous studies have demonstrated that this scale has good reliability and validity for use with Chinese adults [17]. In the present study, Cronbach's alpha 0.931.

Coping style
Coping style was measured by a Simplified Coping Style Questionnaire (SCSQ). This questionnaire was developed in Chinese by Xie YN [18] based on the Ways of Coping questionnaire by Folkman and Lazarus. It is a 20-item self-report questionnaire that includes two dimensions, active coping (12 items) and passive coping (8 items), with higher scores representing greater active/passive coping manners. Participants were asked to agree or disagree on a 4-point Likert scale according to how frequently they adopt on each item from 0 "never" to 3 "very often". The instrument has been commonly used in Chinese and the Cronbach's alpha coefficients for the two dimensions were 0.890 and 0.802, respectively. Coping strategies are classified as active or passive. Higher scores reflecting more frequent use of the strategy.
Statistical analyses SPSS 20.0 were used for data analyses. Data showing a normal distribution were reported as mean ± SD. Differences in resilience scores between medical staff with different demographic characteristics were assessed for significance using the independentsamples t test and one-way ANOVA. Pearson correlation was used to explore the correlation among anxiety, depression, coping style and resilience. Potentially influence factors for resilience were analysed using a multiple linear regression analysis. For all tests, the level of significance was set at P < 0.05.

Associated factors analysis
The results revealed significant differences in the resilience for occupation, education, mental health training, adequate preparation, confidence to complete task (Table 1).

Correlational analysis
The Pearson correlation coefficients of all variables are shown in Table 2. Resilience, active coping, anxiety and depression were significantly correlated with one another (p < 0.05). The passive coping were not significantly correlated with resilience in Pearson's correlation analysis.

Multiple linear regression analysis
To identify the critical factors that predict resilience, a multiple linear regression was conducted for independent variables, occupation, education, mental health training, adequate preparation, confidence to complete task, anxiety, depression, active coping, passive coping. In this study, occupation and education were multiple classification variables. After setting dummy variables for multiple classification variables, resilience was taken as the dependent variable and each dummy variable, mental health training, adequate preparation, confidence to complete task were set as independent variables. Stepwise was selected as the method to establish the multiple linear regression model. Multi-collinearity between the predictors (e.g., numbers of hospital admissions, numbers of diseases diagnosed, asthma, disc, atopic dermatitis) was suspected but collinearity among these predictors was not found; for example, the range of tolerance, variation inflation factor, and condition index were 0.747-0.963 (evaluation criteria: >0.  Table 3. Table 3 Multiple linear regression analyses to assess the influence factors of resilience.

Discussion
Resilience is an ability of reduce the effect of a distressing event by anticipation and preparation or to "bounce back" once it has occurred [19]. In this study, we measured the situation of resilience, anxiety, depression, and coping among medical workers from other provinces to Wuhan to support fighting against COVID-19 and explored influence factors of resilience. The most important and significant finding of this study was that resilience of medical workers from other provinces to Wuhan to support fighting against COVID-19 were related to active coping, depression, anxiety and mental health training. Firstly, the resilience of medical workers in this study was negatively associated with depression and anxiety. In other words, participants who scored higher on resilience showed a lower score on anxiety and depression. Data collected from 1,012 Greek nurses suggested that resilient nurses had lower anxiety [20]. In a study among health care workers in Toronto, incidence of new episodes of psychiatric disorders after the SARS outbreak were similar to or lower than community incidence rates, which may indicate the resilience of medical workers who continued to work in hospitals one to two years after the SARS outbreak [21]. The results indicated that resilience could work as protective factor for anxiety, depression. In addition, there is a positive association between positive coping and resilience, that is, medical workers who tend to adopt positive coping have higher resilience. A survey on the psychological status of Chinese medical workers during the SARS outbreak in 2003 showed that they tended to adopt healthier forms of coping [22]. The study among American nurses suggests that, during times of change in the workplace, if nurses are encouraged to use positive coping strategies, they may have higher levels of resilience [23]. A study in China suggested that new nurses with high levels of resilience could buffer the negative influence of workplace incivility by using a positive coping style [24]. Based on the knowledge of the relationship, we could develop a training intervention providing information about effective coping to improve individual resilience. Moreover, medical workers trained from hospitals have higher resilience. Resilience is supported at an organizational level by effective training and support, during an epidemic [25]. The variables that were associated with psychological distress were also associated with an inverse (protective) association with the perception of being adequately trained and supported by the hospital or clinic (β=-.20, p = .03) among Toronto hospital workers one to two years after the SARS outbreak [21].
Our data suggest that medical workers in the present study had a good resilience, active coping and a relatively low level of anxiety and depression. The respondents in this study had a mean CD-RISC score of 67.04 ± 13.22) scoring higher for resilience than medical workers of other published Chinese study (59.50 ± 12.77) [26]. Since the outbreak of SARS in 2003 and the Wenchuan earthquake in 2008, Chinese government pays unprecedented attention to health sector [27]. Substantial resources have been devoted to improving disaster resilience in China, with a particular emphasis on mitigating the impact of wide-spread infectious diseases and mass casualty incident. Adequate material and psychological support has been provided to front-line medical personnel from the state to the provinces. In addition, scores of anxiety and depression after the COVID-19 outbreak were similar to or lower than community incidence rates, which may indicate the resilience of medical  [28]. The trend was for nurses to report higher psychiatric morbidity than administrative staff controls or doctors, which may lead to higher resilience among nurses [7 29]. This finding indicates that the resilience of nurses faced public health emergencies was improved, but also needs to be concerned.
We further found that there were significant differences in the resilience in terms of education, training and support from hospital, adequate preparation, and confidence to complete task. Our data show that a bachelor's degree has a higher resilience score than a master's degree or above, and a diploma degree (p < 0.05). This is probably due to the sampling error that nearly 75% of our sample has a bachelor's degree. Future studies should expand the sample size to explore the impact of different education on the resilience of medical workers during the pandemic. In our data, training and support may bolster the resilience of medical workers who are at higher risk by virtue of their psychiatric history and fewer years of health care experience. Based on the knowledge that resilience following SARS was higher in health care workers who felt effectively trained and supported [25], the health system could develop a training intervention that provides information about the status of the epidemic and knowledge about infectious disease prevention, easing the fear and anxiety of supporting medical workers. Our study suggests that in addition to more training, it seems that more time should be left for support staff to be adequate prepared, which provides implications for future pandemics.
Last but not least, it is important to remember that many of the interventions adopted were not isolated, but were part of a package includes educating, informing and boosting the morale of the medical workers to enhance the confidence to complete the task during the outbreak.

Limitations
First of all, all variables were evaluated using electronic questionnaires, which carries the risk of bias. Respondents may not want to report truthfully about negative aspects at their job for electronic rather than paper-and-pencil. Moreover, due to time and place limitations, the study included only the first-line of medical works from other provinces to Wuhan to support fighting against COVID-19, not the follow-up medical works. Therefore, this study failed to clarify the resilience level of this medical workers in different time periods and track its changes. Future research should employ a longitudinal design to test the level of resilience.

Conclusions
In conclusion, this study may be the first report to describe resilience levels of medical workers from other provinces to Wuhan to support fighting against COVID-19 and to investigate the association between their resilience and mental-related variables. It is necessary to examine the resilience of medical workers for establishing a safe healthcare system to respond effectively when national disasters occur. The present findings suggest that efforts to enhance resilience should focus on different occupations and educational levels, provide training in knowledge and skills related to infectious diseases, and strengthen psychological assistance, so as to help medical workers fully prepare and enhance their confidence in the face of illness.

Acknowledgments
We would like to express my sincere thanks to the medical workers who are on the front line to combat the outbreak of COVID-19.

Authors' contributions
YX-M contributed to experimental design. LJ and GH-J were the first-line nurses from Guangxi province to support Wuhan fighting against COVID-19, and assisted in the questionnaire survey with RY-H. CY and HY-F were responsible for data collection, input, and analyses. RY-H drafted and revised the manuscript, to which YX-M contributed with significant knowledge and critical expertise.
All the authors read and approved the final manuscript.

Funding
None.

Availability of data and materials
All data generated during this study are included in this published article.

Ethics approval and consent to participate
Data collection commenced after obtaining ethical clearance from Guangxi Medical University Affiliated Tumor Hospital Ethics Committee (No:LW2020013). Participants were asked to read the purpose of the study and had to tick the box "I agree to participate" in order to enter the main survey. Respondents were allowed to withdraw consent at any time during the study.

Consent for publication
Not Applicable.