resilience, depression and self-efficacy among Brazilian nursing professionals during the cOViD-19 pandemic

This aim of this study was to analyze levels of resilience, depression and self-efficacy among Brazilian nursing professionals during the COVID-19 pandemic. We conducted an analytical cross-sectional study between October and December 2020. Student’s t test, analysis of variance and multiple linear regression were used to investigate the impact of two main factors (Re-silience and Self-efficacy) on depression. A total of 8,792 nursing professionals participated in the study; 5,124 (58.8%) had low levels of resilience. The mean overall score for Depression was 0.74, ranging from 0.59 to 0.80, while the mean overall score for Self-efficacy was 0.68, ranging from 0.56 to 0.80. The variable that had the strongest impact on depression levels was Resilience, explaining 6.6% of the outcome (p < 0.001, AdjustedR2 = 0.066). In general, respondents had low levels of resilience and self-efficacy and showed high mean depression scores. Level of resilience had an impact on depression. The findings reveal an urgent need for actions to promote the psychological health of nursing professionals working in crisis situations such as pandemics.

and self-efficacy are related to coping with economic, social and job changes involving context, culture and collective responsibility 13,14 .
Nursing professionals with high levels of self-efficacy and resilience are less likely to develop mental disorders such as depression and burnout.In addition, more resilient nursing professionals have higher levels of well-being in the workplace and everyday life.The aim of this study was to analyze levels of resilience, depression and self-efficacy among nursing professionals in Brazil during the COVID-19 pandemic.

Method Study design
We conducted a cross-sectional analytical study with nursing professionals working in all regions of Brazil.The data were collected between October and December 2020 using an online questionnaire.

Population
The following individuals were considered eligible: nursing professionals (nurses, nursing technicians and auxiliary nurses) working directly in care delivery during the six months prior to data collection in different public and private care settings across all states and regions in Brazil.

Data collection
The data were collected using an online questionnaire created on SurveyMonkey.The link was made available on social media platforms, including Facebook, Twitter, Instagram, WhatsApp, and via email.The form containing the questionnaire was made up of two parts: an informed consent form and survey form.

Data collection instruments
Three instruments were used for data collection: a sociodemographic questionnaire; the Brief Resilient Coping Scale; and the General Health Questionnaire (GHQ-12).The sociodemographic variables were as follows: profession (nurse/ nursing technician/auxiliary nurse); sex (male/ female); age group (18-30 years, 31-50 years and 51 and over); region (Northeast, North, Midwest, Southeast and South); skin color (white, black, brown, yellow); marital status (married/ stable union, single/divorced and widowed); COVID-19 diagnosis (yes/no); and worked in a campaign hospital during the pandemic (yes/ no).
The Portuguese version of the Brief Resilient Coping Scale consists of four items with a 5-point Likert response scale: 5) Almost always, 4) Very often, 3) Often, 2) Occasionally, 1) Almost never.A score of less than 13 indicates low resilience and a score of more than 17 indicates strong resilience 15 .
The General Health Questionnaire (GHQ-12) is used to assess health-related factors.Applied to different populations and contexts, the questionnaire originated from a 60-item instrument 16 .The 12-item version of the instrument is widely used today 17 .For the purposes of the present study, we explored the factorial structure of the GHQ-12, extracting two oblique factors: depression and self-efficacy.The items are answered using the following 4-point Likert scale: 0) Not at all; 1) No more than usual; 2) More than usual; and 3) Much more than usual.Factor 1 (depression) comprised items 2, 5, 6, 9, 10 and 11, while Factor 2 (self-efficacy) consisted of items 1, 3, 4, 7, 8 and 12.The factorial structure identified for the present study is similar to that extracted from a sample of school teachers 17 .

Data analysis
The data were analyzed using descriptive statistics.The scores of the depression and self-efficacy scales were assessed using exploratory factor analysis of the GHQ-12 to calculate weighted means.The score of the resilience scale was calculated using the simple means of the scale items.
Student's t-test and analysis of variance (ANOVA) were used to compare resilience, depression and anxiety scores with sociodemographic variables, COVID-19 diagnosis and working in a campaign hospital during the pandemic.The data were analyzed using SPSS version 20.0.
A multiple linear regression analysis (forward method) was performed to determine the impact of the two main factors (resilience and self-efficacy) on depression.Resilience and self-efficacy were the independent variables and depression was the dependent variable.We also calculated R 2 , adjusted R 2 and change in R 2 .A 95% confidence interval was adopted for all analyses.

ethical aspects
The project was approved by the ethics committee of the Ribeirão Preto Nursing School, University of São Paulo (code number 4.258.366).The study was conducted in accordance with the ethical norms and standards for research involving human subjects set out in resolutions 466/2012 and 510/2016.All participants signed an online informed consent form.

results
A total of 8,792 nursing professionals participated in the study, including 5,767 nurses (65.6%).Most of the respondents (7,437 or 84.6%) were female and from the Northeast (2,643 or 30.1%), as shown in Table 1.
Over half of the respondents (5,124 or 58.8%) obtained low overall scores for resilience.The mean overall score for "depression" was 0.74, with scores ranging from 0.59 to 0.80.The mean overall score for "self-efficacy" was 0.68, with scores ranging from 0.56 to 0.80.
Statistically significant differences in self-efficacy scores were observed for the following variables: profession (p < 0.001); marital status (p < 0.001); and worked in a campaign hospital (p = 0.01).
The findings show that the two main factors (resilience and self-efficacy) had a statistically significant impact on depression (F(2.8789)= 317.031,p < 0.001; adjusted R 2 = 0.067).Table 3 shows the coefficients of the significant predictors, revealing that the variable with the strongest impact on depression was Resilience, explaining 6.6% of the outcome.

Discussion
In general, the respondents had low levels of resilience and self-efficacy and high mean depression scores.Men obtained significantly higher mean resilience scores than women, while nurses showed higher levels of resilience than nursing technicians.Finally, nursing professionals who worked in a campaign hospital during the COVID-19 pandemic obtained significantly higher Resilience scores than those who did not.
To speak of the positive impacts of the COVID-19 pandemic would be to disregard the deaths that occurred 18 .However, despite the chaotic situations experienced during the pandemic, such as the shortage of ICU beds, personal protective equipment and qualified professionals, nursing professionals in Brazil were committed to tackling the crisis, especially those working on the frontline.
The international literature presents evidence of the general relationship between level of resilience and gender.A study with Spanish university students using the Connor-Davidson Resilience Scale showed that male students obtained higher scores for the factors optimism and adaptation to stressful situations 19 .Other studies have also reported significant differences between genders [20][21][22] .With regard to profession, the present study revealed that nurses obtained high-er resilience scores than nursing technicians.A study investigating psychosocial stress and resilience among nursing professionals in the South of Brazil did not find any statistically significant differences in resilience scores between professions 23 .Further research should be conducted to elucidate this question, because both professionals with secondary education level and higher education qualifications may have low levels of resilience.
Nursing professionals in Brazil are divided into categories and poorer working conditions in lower-skilled categories may influence the mental health of workers.A study with nursing technicians in three of Brazil's regions showed that poor working conditions, such as low pay, overwork and psychic burdens, are frequent among this category 24 .Another study found that approximately half of nursing technicians had mental disorders associated with financial and work issues 25 .These issues were aggravated by the pandemic, which led to changes in the dynamics of everyday work.
Our findings regarding professionals working in campaign hospitals are inconsistent with the literature, with a study investigating resilience showing that health professionals working with the diagnosis and treatment of people with COVID-19 were more vulnerable to mental illness 26 .Adverse situations involving exposure to health risks can trigger high levels of stress and symptoms of mental illness.However, it is important to consider that campaign hospitals were better equipped than other health facilities during the first months of the pandemic, which may have influenced nursing professionals' perceptions of the safety of working on the frontline.
Our findings reveal statistically significant differences in self-efficacy for the variables profession and working in a campaign hospital during the COVID-19 pandemic, with nurses obtaining higher scores than nursing technicians and auxiliary nurses and nursing professionals who worked in campaign hospitals obtaining higher scores than those who did not.Nursing professionals obtained generally low overall scores for self-efficacy.Similar results were found in a study in Italy, which showed that nurses had low self-efficacy and that female nurses were more likely to have low self-efficacy than male nurses 27 .A study with nurses in Wuhan showed that self-efficacy was one of the main factors affecting anxiety among nurses 28 .
Studies investigating self-efficacy among nursing teams during the COVID-19 pandemic are scarce in both the national and international literature.However, based on Bandura's 29 definition of self-efficacy -a person's belief in their ability to perform a task -it is possible that the differences between nurses, nursing technicians and auxiliary nurses may be partially related to the activities performed by nurses, such as leading nursing staff and the management of nursing and health services.In addition, authors have suggested that a belief in one's own ability can influence other indicators such as resilience 30 .
It is important to implement interventions designed to develop and maintain high levels of self-efficacy among nursing professionals, especially during times of pandemic.A study with Jordanian nurses showed that coping self-efficacy was a protective factor against psychological distress during the COVID-19 pandemic 31 .The authors suggested the implementation of stress-reduction strategies and referral to psychological services aimed at reducing mental distress among nursing professionals experiencing stress due to the pressure of a heavy workload or exposure to risk.
The data presented show that nurses had a significantly higher mean depression score than nursing technicians and auxiliary nurses and that resilience and self-efficacy had a significant influence on depression, with the former explaining 6.6% of the outcome.
Clinical nurses face situations that negatively affect their physical and mental health on a daily basis.They face high levels of workplace stress, which negatively affect care delivery 9,10 .The low levels of resilience observed in the present study influence the mental health of nursing professionals.The pandemic aggravated obstacles to care, negatively impacting nursing professionals.Actions are therefore needed to promote the physical and psychological well-being of professionals working in exceptional situations.Studies have shown that resilience plays an important role in promoting the mental health of people in times of pandemic 32 .
Resilience plays a fundamental role in coping with unexpected situations among nursing professionals.However, these factors should not be analyzed in an isolated manner.It is important to understand the circumstances under which these professionals work and think critically beyond the pandemic as an isolated conditioning factor.From this perspective, an international review covering four countries highlighted that organizational support and participation in policy and procedure development resulted in higher resilience scores among nurses 33 .Further research with nursing professionals in Brazil is therefore needed to investigate factors related to the involvement of nursing teams in management decision-making and the formulation of nursing care policies.
Our findings regarding symptoms of mental disorders are similar to those of a study conducted in the Northeast of Brazil, which found that symptoms of depression and anxiety were more frequent among professionals working in services with inadequate working conditions 34 .The international literature has documented high levels of depression among health professionals who worked in care services during the COVID-19 pandemic 35,36 .
A systematic literature review found that the pooled prevalence of depression among nurses working during the COVID-19 pandemic was 35%, which is consistent with the results of the present study 37 .The findings in the literature and the results of the present study suggest an urgent need for actions to address the difficulties experienced by nursing professionals during crisis situations like pandemics.Urgent measures are needed to promote self-care focusing on protective factors for the mental and physical health of nursing professionals.
Good occupational protection practices and the provision of personal protective equipment were found to be protective factors against depression among pediatric nurses in China 38 .The COVID-19 pandemic has brought the academic and public discussion of the psychological problems faced by nursing professionals when subjected to unexpected care situations center stage.
The promotion of the psychological and physical health of nursing professionals is increasingly urgent in the face of crisis situations such as pandemics.The government and professional bodies should develop actions to better equip workers to cope with similar situations in the future.Under adequate working conditions, nurses should be prepared to lead a multiprofessional team without adversely affecting their own general health.
The main contributions of this study can be summarized as follows: 1) Low levels of resilience contribute to higher levels of depression, which is important for discussions about the elaboration of public policies designed to improve levels of resilience among nursing professionals, especially those working during unexpected events such as pandemics; and 2) the results encompass the three categories of nursing professionals (nurses, nursing technicians and auxiliary nurses) working during the pandemic in all of Brazil's regions, contributing to a better understanding of issues related to the mental health of nurses in Brazil.

conclusion
Our findings show that the COVID-19 pandemic had psychological impacts on nursing professionals working in health services during the crisis.The respondents obtained generally low scores for resilience and self-efficacy, aspects that are considered protective factors against depression, and level of resilience had an impact on depression.In general, respondents showed low levels of resilience and self-efficacy and high scores for depression.These findings reveal an urgent need for actions to promote the psychological health of nursing professionals working in crisis situations such as pandemics.

table 2 .
Mean resilience, depression and self-efficacy scores according to demographic variables, profession, COVID-19 diagnosis and working in a campaign hospital.Brazil, 2021 (n = 8,792).