Resilience, Occupational Burnout, and Parenting Stress in Nurses Caring for COVID-2019 Patients

Background: Caring of patients with Corona Virus Infection Disease (COVID 2019) may have had an impact on the occupational burnout, resilience, and parenting of the nurses. Purpose: Evaluation occupational burnout, resilience, and parenting stress in nurses caring for COVID 2019patients. Methods: The present study is a cross-sectional study Base on Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE). 420 nurses cared for COVID 2019 patients in 5 hospitals selected via convenience sampling. Each participant completed the scales online. Data were analyzed in SPSS v. 22. Results: Occupational burnout has a negative correlation with resilience and a positive correlation with parenting stress and can predict 61.32% of changes in the occupational burnout variance of nurses. Conclusion: the resilience, parenting stress, marital status, number of children, employment status, and gender predicated High percentage of the nurses’ occupational burnout variance. The nurse managers should use these ndings to provide appropriate environments for nurses, that to develop more comprehensive plans for support of nurses for the current and future crises.

The high fatality rate of COVID-19 worldwide has caused many people to experience considerable tension with adverse effects on their social activities and psychological security [7]. Due to the special nature of their occupation, nurses are at higher risk of suffering serious physical and psychological harms, including stress and depression. It is obvious that these psychological crises can in uence nurses' personal and family responsibilities as well, subject them to occupational burnout, and adversely affect their performance of their parental duties [8,9]. In January 2020, WHO declared the COVID-19 pandemic to be a public health emergency of international concern (PHEIC) [10]. According to the same organization, nurses play a signi cant role in healthcare and treatment systems in caring for and improving the health of patients infected with the coronavirus [1,8]. However, caring for COVID -19 patients has subjected nurses to great psychological tension and work stress, thus the need for taking measures to protect nurses' psychological and physical well-being [1]. Accordingly, Stuijfzand et al.
(2020) state that healthcare professionals during epidemic and pandemic (Severe Acute Respiratory Syndrome(SARS), Middle East respiratory syndrome coronavirus(MERS), Ebola Virus Disease), experience a lot of mental health problems including psychological distress, insomnia, alcohol/drug misuse, and symptoms of posttraumatic stress disorder (PTSD), depression, anxiety, anger and burnout [11]. Also, Lehmann et al. (2020) represent that health care professionals reported Depression, stress, social isolation, and job fatigue during Ebola outbreak. Social isolation has been largely due to parenting stress and concerns about the transmission of the disease to their children and other family members, On the other hand, although job stress and fatigue can affect their tolerance, but they have overcome these tensions and work pressures with team working and observing the principles of infection control [12]. A study conducted by Liu et al. (2020) con rms that, compared to other members of medical staff, nurses experience higher levels of anxiety and depression in caring for COVID-19 patients and face more di culties in the performance of not only their professional duties, but family responsibilities and daily activities [7]. Similarly, he study of Roy (2020) shows that nurses are experiencing high degrees of stress, anxiety, depression, and post-traumatic stress disorder (PTSD) in the COVID-19 crisis. Thus, it is essential that the executive administrators of healthcare systems and the crisis committees of hospitals consider the status of nurses' psychological well-being, anxiety, depression, and occupational burnout [13]. The present study is an attempt at measuring occupational burnout, resilience, and parenting stress in nurses who care for COVID-19 patients in Iran.

Study design and setting
This study was a cross-sectional research investigation conducted Base on Strengthening the Reporting of Observational Studies in Epidemiology Statement (STROBE) from February to June 2020. The two following aims were examined in study "evaluation of occupational burnout, resilience, and parenting stress in nurses who care for COVID-19 patients" and "investigating the relationship between occupational burnout with resilience, parenting stress and demographic characteristics in nurses who care for COVID-19 patients".

Participants and sampling
In this study sample size has been estimated 630 samples according to the study of Roy et al. With β = 80% and α = 0.05 and taking into account the 10% drop in each group. The participants were selected via convenience sampling. So nurses, who provided care to COVID-2019 patients in 5 hospitals a liated with University of Medical Sciences in the west of Iran, were invited and selected via convenience sampling to participate in the study. The inclusion criteria were: being willing to participate, being in practice in one of the hospitals assigned for Covid-19 patients, and having at least one month of work experience in caregiving wards for patients with COVID2019. The subjects who failed to answer more than half of the items on their questionnaires or did not turn in their questionnaires were excluded. The subjects were asked to complete and submit the questionnaires-a personal (demographic) characteristics questionnaire, an occupational burnout scale, resilience scale, and, if they were parents, the parenting stress scale-online. The researchers sent emails and reminder messages to the participants, so that, the majority of the questionnaires (90%) were gathered in June. 420 of the subjects completed and returned the questionnaires via e-mail or a social network. Thus, the response rate was 66.7%. The nurses' reasons for not participating in this study were High prevalence of COVID2019 in Iran, heavy workload and intensive shifts, also infected with COVID2019.

The Parenting Stress Index-Short Form (PSI-SF)
Created by Abidin in 1995, the Parenting Stress Index comprises 3 subscales: parental distress (items 1 through 12), parent-child dysfunctional interactions (items 13 through 24), and child characteristics (items 25 through 36). The scale measures parental stress on a 5-point Likert scale ranging from 1 (=completely disagree) to 5 (=completely agree). [18]. In their studies, Yeh (2001) and Reitman (2002) report the reliability of the scale to be 0.89 and 0.90 respectively [19,20]. Assessing the reliability and validity of the scale in Iran, Shirzadi nds the reliability of the various dimensions of the index to be between 0.59 and 0.86, which are acceptable values [21].

Statistical methods
After data were collected, they were analyzed using descriptive statistics (frequency, percentage, mean, and standard deviation) in SPSS v. 22. To investigate the relationship between occupational burnout on the one hand and resilience and parenting stress on the other, the researchers applied the chi-square test, independent t-test, and ANOVA. Signi cance level was set at 0.05. Subsequently, the variables of demographics, resilience, and parenting stress which were found to correlate with occupational burnout (p<0.25) were entered into multiple linear regression with the backward technique. Before executing the analysis of multiple linear regressions, the researchers examined the assumptions of normality of data, homogeneity of variance, and independence of residuals.

Demographic Information
Of the 420 nurses who participated in the study, 73.8% were female and 26.2% were male. The range of the participants' ages was between 23 and 55 years with the mean of 35.24±3.56 years. The majority of the participants 73.8% were married, 54.8% of whom had two children. Also, most of the participants had a bachelor of science in nursing 63.1%, were contractual employees 50.5%, had 11 years of work experience, and worked 32 rotating shifts per month. The ndings of the study showed that there was a statistically signi cant relationship between occupational burnout on the one hand and marital status, number of children, employment status, and gender on the other.

Resilience, occupational burnout and parenting stress in the participants
The resilience means score of the nurses who participated in the present study was 32.33±2.57, the occupational burnout means score was 32.33±2.57. Also, the parenting stress mean score of the 310 nurses who were married and had children was found to be 17.53±1.58 during the COVID-19 crisis (Table   2). The ndings of the study show that there is a strong and inverse correlation between occupational burnout and resilience in nurses who care for COVID-19 patients (p<0.001, r=-0.70). Also, a more strong and inverse correlation p was found to exist between occupational burnout and resilience in married nurses than single nurses. The results showed a positive correlation between the occupational burnout and parenting stress scores of the nurses with children (p<0.001, r=0.74) ( Table 3).  (Table 4).

Discussion
This study showed nurses have reported high levels of occupational burnout low levels resilience and high levels tension in their relations with their children. Though a few studies have addressed the work stress, knowledge, and awareness of nurses who care for COVID-19 patients, there are not any studies of resilience, occupational burnout, or parenting stress in this group of caregivers. Therefore, the researchers had to use articles which measure resilience, occupational burnout, or parenting stress in nurses who care for patients with other speci c diseases. The occupational burnout means score of the nurses was found to be 32.33±2.57, which indicates high burnout. Occupational burnout in nurses is a hot topic in nursing associations: studies show that the physical and psychological pressures of caring for patients lead to occupational burnout in the long run and, thus, nurses' length of service, work shifts, and salary must be rede ned according to the type of patients they care for and the units where they work [22]. However, most of these studies report the occupational burnout of nurses with 5 years' or more work experience to be average, which is not consistent with the ndings if the present study [22][23][24]. This discrepancy can be attributed to the sudden emergence of COVID-19 which is highly infectious and has signi cantly increased nurses' workload and caused them to have to work longer shifts and stay away from their families in the past few months. The results of the present study show a statistically signi cant difference between the married and single participants in terms of their occupational burnout scores (p<0.033). This difference may be due to the fact that, in addition to stress in the workplace, married nurses, especially those with children, are subject to greater psychological tension (p<0.031) as a result of disruption in their performance of their duties as spouses and parents [22,[25][26][27]. The results of the study also show that contractual nurses (p<0.039) and female nurses (p<0.041) suffer from greater occupational burnout. Job insecurity, lower salaries, and the lower physical-psychological resilience of female nurses can account for the statistically signi cant difference between the occupational burnout scores of contractual and permanent nurses and male and female nurses [22,27]. Similarly, the study of Salahian et al shows that nurses' employment status and gender have an impact on their occupational burnout [22]. In the present study, the resilience means score of the nurses was found to be 32.33±2.57, which is considered low [28,29]. In contrast, other studies report average to high levels of resilience for nurses, even for those who provide care to critically or terminally ill patients. The discrepancy can be attributed to lack of a de nite treatment for COVID-19 and the high speed and rate of the infection which have subjected nurses to severe physical and psychological tension with extremely adverse effects on their resilience [28][29][30]. The parenting stress means score of 298 of the participants was found to be 17.53±1.58. There are studies on parenting stress in working mothers or parents with a chronically ill child [31,32]; however, there has not been much research into parenting stress in nurses. This lack of research may be due to the fact that nurses who work in rotating shifts can spend at least a few hours a day with their children and attend to their upbringing. But in the COVID-19 crisis, many nurses have to work longer hours caring for the infected and, due to the high infectiousness of the disease, would rather reside in hospitals temporarily or have their relatives take away their children to their own homes for the safety of their children. Stress in the workplace, fear of transmitting the infection to their children, having to stay away from their children, and inability to monitor their children's upbringing have subjected nurses with children to extra psychological tension and, consequently, increased occupational burnout in them.
The results of the present study show a strong and inverse correlation between the participants' occupational burnout with resilience, and a strong and direct correlation between the participants' occupational burnout with parental stress. In addition the variable of resilience, parenting stress, number of children, marital status, employment status, and gender descripted about 61.32% of the occupational burnout variance in the nurses who provided care to COVID-2019 patients. Study was not found that had evaluated and predicted the relationship between occupational burnout with resilience, parenting stress and demographic characteristic in nurses at the same time. Therefore, other studies were used that examined the relationship between occupational burnout with resilience or occupational burnout with parenting stress or occupational burnout with demographic factors. In this regard, Amini et al. stated that there is an inverse relationship between occupational burnout with resilience of nurses [28]. Also, Zou et al. expressed occupational burnout was negatively related to resilience [33], these ndings are consistent with the results of present study. In addition Salahian et al. stated nurses who worked in the infectious diseases ward reported more occupational burnout than nurses in other wards and job stress, role clarity, and workload predicted about 36.5% of the nurses' occupational burnout variance [22]. However nurses in present study provided care to COVID-2019 patients considering rapid transmission of the disease and their high workload, they have reported more occupational burnout and less resilience, which is consistent with the results of present study.
Ra ee et al, and Ahmadi et al. expressed individual characteristics of nurses (gender, work experience) and workplace are effective on nurses' occupational burnout, which is consistent with the present study [34,35].
Finally, the results of the study show that nurses who provide care to COVID-19 patients and have had to work more shifts in recent months are affected by higher levels of occupational burnout, have less resilience, and are experiencing more tension in their relationship with their children than before the emergence of the pandemic. In view of the persistence of the COVID-19 crisis in Iran and the world in coming months, it is mandatory that health administrators take effective measures to reduce nurses' occupational burnout and enhance their physical and psychological well-being.
One of the major limitations of the present study was the relatively low return rate of the questionnaires via e-mail which could have been due to the hectic work schedules of nurses in the crisis. Moreover, the variables addressed in the present study were measured over a 6-month period-it is suggested that future studies assess occupational burnout, resilience, and parenting stress in nurses who care for COVID-19 patients in coming months and years in other societies and larger samples in order to acquire a more accurate understanding of nurses' occupational burnout in in this crisis. Health administrators and policy-makers can use these ndings to develop more comprehensive plans for the current and future crises.

Conclusion
In the present study, the nurses who care for COVID-19 patients were found to be suffering from high levels of occupational burnout. Also, the results showed that nurses' occupational burnout correlates with their resilience, parenting stress, marital status, number of children, employment status, and gender: these variables predicated 61.32% of the subjects' occupational burnout variance. The nurse managers and policy makers of health organizations should examine and use the ndings of this study in order to provide appropriate environments for nurses, also to develop more comprehensive plans for support of nurses for the current and future crises.

Declarations
Ethics approval and consent to participate The institutional review board of the medical universities located in the west of Iran provided ethics approval (approval number: 9904242498). Also at the beginning of each interview, the researcher introduced herself and explained the goals of the study and assured that all information would remain con dential and that they could withdraw from the study at any time. The researchers provided the opportunity for participants to inform the researcher about their withdrawal from the study at any stage of the research and assured. Finally, the written consent was obtained from study participants.

Consent for Publication
Not applicable

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request