Emotional well‐being, spiritual well‐being and resilience of advanced clinical practitioners in the United Kingdom during COVID‐19: an exploratory mixed method study

Abstract Aim To investigate the emotional and spiritual well‐being and resilience of advanced clinical practitioners during COVID. Background Resilience is a protective factor for emotional and spiritual well‐being. The pandemic has taken a toll on health professionals due to significant physical and psychological pressures. The impact of COVID‐19 on well‐being and resilience of advanced clinical practitioners is not known. Method Three validated scales assessed resilience, emotional and spiritual well‐being. Seven hundred and thirty‐four responses were analysed. Results Participants have low levels of emotional and spiritual well‐being. Participants with higher levels of spirituality reported greater resilience and those with higher levels of resilience reported greater well‐being. Conclusion Advanced clinical practitioners' emotional and spiritual well‐being and resilience has been impacted significantly during the pandemic. Interventions are needed at team, service and systems levels to enhance well‐being and resilience. Implications for Nursing Management Worryingly low levels of well‐being and resilience in advanced clinical practitioners have been found; support to increase well‐being and resilience is needed. Our findings can inform policies, resources and interventions aimed at enabling positive adaptation and enhanced resilience. Understanding and responding to the scale and impact of COVID‐19 on health care workers has become a key government recommendation following the pandemic.


| BACKGROUND
The COVID-19 pandemic has had a devastating impact globally including unprecedented deaths of health care workers globally (Jackson et al., 2020). The limited pandemic planning in the United Kingdom led to insufficient supplies of personal protective equipment (PPE), workforce and resource shortages, adding to the stress and pressure health care workers have faced (Jackson et al., 2020). It is, therefore, unsurprising that there has been significant toll on health care workers in terms of absenteeism, sickness and mental health problems (Wood et al., 2021). A systematic review focused on the mental health and well-being of nurses and midwives in the United Kingdom published before the COVID-19 pandemic identified these professionals were already at considerable risk of stress, burnout and mental health problems (Kinman et al., 2020). COVID-19 has exacerbated these stressors with reports of the highest levels of sickness amongst health service staff since 2009 (Twinch, 2020). Health care workers have faced situations that have led to extreme stress, impossible decisions and working with scant resources. As part of the workforce, the coping strategies of advanced clinical practitioners (ACPs) have also been tested, and it is likely that their mental health has been adversely affected (Duncan et al., 2021). In an online workshop exploring participant's (n = 1000) perceptions about the extent to which the full scope of ACP services had been used during the pandemic, 85% of participants reported that ACPs had made a useful contribution to the pandemic response, while 52% felt that these roles were not fully utilized (Health Education England, 2020). This under-utilization may be because the ACP role is not fully understood by policy makers and employers (Health Education England, 2020).
The pandemic response required many ACPs to be redeployed into critical care areas to support direct patient care delivery. Others provided clinical assessment and management in community services for patients being cared for at home or in residential settings. Kang et al. (2020) identified significant stressors for health care workers during pandemics including redeployment, witnessing death and suffering on a large scale, risk of virus transmission at the workplace and at home to loved ones (Kang et al., 2020). Coping with the impact of these stressors during a pandemic requires resilience to protect the professional's mental well-being (Pollock et al., 2020).
There is a close link between mental health and resilience (Hu et al., 2015). When exploring the well-being of health staff during COVID-19, Huffman et al. (2021) found resilience safeguarded against the negative psychological impact of stressors.
In a review of 56 papers focused on the mental health impact of health care workers during pandemics, Ricci Cabello et al. (2020) found that severe stress, burn-out, reduced emotional well-being and long-term psychological damage are commonly reported.
They also report that these factors led to an inability to meet the urgent needs posed by pandemics. Similarly, Rees et al. (2015) identified that reduced emotional well-being of health care workers greatly increases absenteeism and can lead to burnout and compassion fatigue. This impacts on patient care and patient safety (Cheng et al., 2020). Resilience Scale (Connor & Davidson, 2003). Later theories emphasized that resilience can be learnt and is modifiable. Turner (2014) defined resilience as the capacity to recover from adverse circumstances and as a protective factor against stress. One of the characteristics of innate resilience identified is the individual's spirit-the inner being of the individual. Spirituality has been described as innately human and embraces issues of meaning, purpose and hope (Rogers et al., 2020;Wattis et al., 2017). Health care workers who are aware of their own spiritualty and have higher levels of spiritual well-being are more likely to be more resilient (Meybodi & Mohammadi, 2020).
Spirituality has been shown to have a protective impact on resilience (Sharma et al., 2017;Walsh, 2019).
The Cyclic Resilience Development Model (Grafton et al., 2010) identified resilience as a resource that individuals can draw to cope more effectively during stressful situations (positive adaptation) and to use the situation as a learning experience to restore and strengthen the biopsychosocial-spiritual well-being of the self and reduce vulnerability to future stress through greater resilience (cognitive transformation) (Jackson et al., 2007). In contrast, a reduction in resilience leads to burnout which in turn impacts workforce capacity and patient care (Eley et al., 2013).
These definitions and conceptualizations, which indicate the relationship which exists between resilience and biopsychosocialspiritual well-being, informed this study focused on ACPs. While there has been rapid growth in research examining the impact of COVID-19 on emotional well-being and the psychological impact of COVID-19 on health professionals (Mojtahedi et al., 2021), no studies have examined the emotional and spiritual well-being and resilience of ACPs. Identifying these is critically important as the findings can inform policies, resources and interventions aimed at building greater ACP workforce resilience.
The aim of this study was to identify the impact of the COVID-19 pandemic on the emotional and spiritual well-being and resilience of ACPs across the United Kingdom.

| METHODS
This exploratory mixed method web-based study focused on a cross section of UK ACPs over a 2 month period in 2020. It was designed to determine participants' emotional and spiritual well-being and resilience in relation to their experiences during the COVID-19 pandemic.
This paper reports the quantitative findings. Demographic data and exposure to COVID are also reported. The STROBE criteria were applied and followed for this study.

| DESIGN AND DATA COLLECTION
Three validated scales were used to assess ACPs emotional and spiritual well-being and resilience. These scales were the Warwick-Edinburgh Mental Well-being Scale, FACIT-12 Spiritual Well-Being Scale and Connor-Davidson Resilience 10 Scale.
Emotional well-being was measured using the Warwick-Edinburgh Wellbeing Scale (WEMWBS) (NHS Scotland, 2006). The WEMWBS was developed to measure mental well-being in the general population, as well as being used to demonstrate outcomes for research projects. The scale is validated for use with adults over 16 years and consists of 14 five-point Likert-scale questions related to participants' thoughts and feelings during the previous 2 weeks.
The total scores range from 14 to 70, with higher scores indicating a more positive sense of emotional well-being. Scores below 42 are considered to correspond to low well-being, whereas scores above 60 correspond to high well-being. The scale has been extensively used and validated across a range of populations (Stewart-Brown et al., 2011), and demonstrates good reliability, with a high level of internal consistency in our sample (Cronbach's α = .91).

The Functional Assessment of Chronic Illness Therapy Spiritual
Well-Being (FACIT-12-version 4) is from a collection of scales developed to measure quality of life domains such as social well-being, physical well-being and spiritual well-being in people over 18 years old (Peterman et al., 2014). Version 4 was utilized as this is relevant for health care workers rather than patients. The FACIT-12 was used for this study and scoring remained consistent with commonly observed scoring practices of this scale (Bredle et al., 2011). The  (Connor & Davidson, 2003). After factor analysis, the shorter 10 question scale (CD-RISC10) was developed and has been used in multiple settings, including with health professionals (Connor & Davidson, 2003). The 10 questions on a 5-point Likert-scale relate to trait resilience and psychological resilience, and higher scores indicate higher levels of resilience. The CD-RISC 10 has been extensively used and validated in a range of populations (Davidson, 2018), and it demonstrated a good level of internal consistency in our sample (Cronbach's α = .89).
Permission to use all three scales was given by the authors prior to the study.
An online Qualtrics survey incorporating these scales and demographic questions asked participants to indicate their gender, age, level of education and number of years of experience working as an ACP. Participants were also asked to indicate their professional title,

| DATA ANALYSIS
Analysis was conducted following the instruction guidance developed by the scale authors. Quantitative analysis was completed by the statistician supported by the principal and co-investigators. Six hundred and three surveys were completed in full. One hundred and thirty-one participants (21.7%) had one or more items of missing data.
However, the only variables where more than 5% of participants had missing data were those asking about experiences with COVID-19 (Table 2). Missing values were not imputed, and participants with any missing data for a given variable were excluded from any analyses involving that variable.
Descriptive statistics were calculated for all study variables and presented in Tables 1 and 2. To assess the overall level of emotional well-being, that is, the total WEMWBS scores in the current sample, a one-sample t test comparing this with a previous general population sample taken from the Health Survey for England 2011) was T A B L E 1 Descriptive statistics for all study measures by demographic group  conducted, and the size of this difference was assessed using Hedges' g (Hedges, 1981). Several one-way ANOVAs were conducted to examine whether levels of emotional well-being, resilience (CDRISC-10), overall spirituality (FACIT-SP-12), faith and meaning differed between participants working in different clinical roles and settings, with different levels of highest qualification, and who worked different numbers of hours per week.
A stepwise linear multiple regression analysis was conducted to examine potential predictors of emotional well-being in the current sample. Whether resilience and spirituality predicted emotional wellbeing after controlling for other relevant variables. In the first step, the continuous variables age and the number of years participants had worked, and categorical variables were entered. The categorical variables used were as follows: (dummy coded) sex, whether participants were providing direct care or testing for COVID-19, whether they had previous experience providing care in epidemics and whether they or any of their family or co-workers had been diagnosed with COVID-19. In the second step, resilience, faith and meaning were entered as additional predictors. A similar analysis was conducted to examine potential predictors of resilience, following the same procedure, with the exception that in the second step, faith and meaning were entered as predictors. In order to examine potential predictors of spirituality, the predictor variables described for the first step above were simultaneously entered into a single multiple regression model.
The alpha level for all analyses was set at .05, and any results with p values lower than this were considered to be statistically significant.  The only significant individual predictors of spirituality were sex and having had a family member or co-worker diagnosed with COVID-19, but these accounted for less than 2% of the variance in spirituality (adjusted r-squared = .015), and the overall regression model was only marginally significant, F (7, 446) = 1.96, p = .06. In the current sample, men reported higher levels of spirituality than women (β = .10, B = .72, 95% CI [À.14, .1.58], p < .05) and

| RESULTS
participants who had had a family member or co-worker who had been diagnosed with COVID-19 (β = .11, B = .68, 95% CI [.13, 1.22], p < .05), reported higher levels of spirituality than those who had not. impact on emotional well-being and meaning as ACPs are required to practice outside their zone of confidence or expertise (Twinch, 2020).

| DISCUSSION
Sixty seven percent (67%) of our participants report not having had experience of providing care during previous pandemics.
The importance of a 'mentoring culture' and organisational support has been identified as contributing to 'meaning making' and facilitating a supportive work environment (Malloy et al., 2015). Our findings suggest that meaning making and a sense of purpose as care providers may have facilitated positive adaptation and cognitive transformation to cope effectively during these stressful situations (Grafton et al., 2010). Indeed, HEE (2020) reported that the impact of COVID-19 on the working lives of ACPs is stark with over 90% stating that the COVID-19 response has changed the way they work to some extent. Although the impact on their working lives has been significant, over 70% felt that the response had created opportunities for them to develop their skills and knowledge.
Modelling of our participants' responses revealed a gender difference in resilience and well-being with male ACPs reporting higher levels of meaning and emotional well-being. With only 12% (n = 71) male respondents, these results should be viewed with caution and should be investigated further. The other significant factor was age.
Older ACPs reported higher levels of emotional well-being than younger ACPs. This finding may be a consequence of the mandated limited social contact experienced by younger people during COVID-19 (Bu et al., 2020). Our findings may also be informed by Cai et al. (2020)  recommend that to prevent long term mental health problems and moral injury all health care workers should be prepared for the moral dilemmas they will face during a pandemic with ongoing support and meaningful narratives which may help individuals to process and reflect on the trauma experienced. The government has highlighted that the potential longer-term effects of COVID-19 on the workforce now requires an operational approach to support staff recovery, as their health and well-being is a major factor in retention of an experienced workforce to deliver a sustainable service (HM Government, 2022).
Although our study design has enabled us to understand some of the factors that have impacted ACPs emotional and spiritual wellbeing and resilience, there are limitations to this study. This study was conducted during the first national lockdown and, as such, is a snapshot in time. The respondents self-selected and self-reported.
This means they may have only shared what they felt comfortable reporting and sharing. In addition, due to the study design it is a challenge to establish any causal relationships from the findings.
Finally, as the COVID-19 crisis has had such a significant impact on practitioners, and we asked for their response's mid pandemic, recall bias may be present. A repeat of this study was conducted in late 2021 to collect longitudinal data which will help to better understand the true extent of how COVID-19 has impacted ACPs in the United Kingdom. Heterogeneity of the sample could also be improved as most of the participants were female and from a nursing background.

| CONCLUSION
The challenges facing health care workers globally has been unprecedented. Research highlighting the frontline experiences of health care staff during COVID-19 reports the anxiety and stress they experience.
ACPs in the United Kingdom have played an integral role in providing care to patients in challenging situations. These challenges have been complex and variable impacting their emotional and spiritual well-being and resilience. Our study builds on the evidence to establish a baseline of the initial impact on well-being, spirituality and resilience on ACPs.
It is concerning to see levels of resilience and well-being are lower than pre-COVID-19 results. The impact of these challenges on wellbeing and resilience has significant implications for staff retention.
There is now a need to consider how to improve ACPs emotional and spiritual well-being and resilience to prevent long-term implications and an adverse impact on patient care.

| IMPLICATIONS FOR NURSING MANAGEMENT
Nurse managers need to monitor the wellbeing of their employees to prevent a further crisis in the healthcare system. This study has significant implications for nursing management who can respond with changes in policy, practice, research and education to support their staff. Recovery of the workforce will need embedded change and a preventative approach for staff well-being and health, to attract and retain those members of the workforce that are highly skilled and experienced such as ACPs.