Language learning | Spanish » Learning from the past Spanish influenza and the lessons for Covid-19

This article is open access and can be freely distributed Clinical Practice Discussion Nursing history Keywords Resilience/Spanish flu/ Covid-19/Pandemics This article has been double-blind peer reviewed In this article. Details of the evidence available about nurses’ experiences during the Spanish flu pandemic Similarities between nursing work in the pandemics of 1918-19 and 2020 The toll placed on nurses by being depicted as emblems of resilience Learning from the past? Spanish influenza and the lessons for Covid-19 Key points Nurses performed intensive, physically and emotionally demanding work during the 1918-19 Spanish flu pandemics, as do nurses caring for patients with Covid-19 today In both pandemics, nurses have acted as ‘emblems of resilience’ Both groups of nurses have suffered from the stress and strain of service, often resulting in physical and emotional ill health As frontline responders, nurses don personal protective equipment that resembles battledress

Nurses are often used as symbols of propaganda in times of crisis Authors Olivia Gordon is an MA student, Amanda Gwinnup is a PhD student, Christine E Hallett is professor of nursing history; all at the University of Huddersfield. Abstract This study focuses on the resonances between the experiences of British nurses during the Spanish flu pandemic of 1918-19 and those of today’s frontline nurses caring for patients with Covid-19. 100 years ago, nurses performed two highly significant roles. Alongside their complex, clinical work caring for individual influenza patients, they also acted as ‘emblems of resilience’ for a society in crisis and had a calming influence on the population. This calm and courageous image presented by nurses in the early 20th century belied the pressure they were under; many became severely traumatised as a result of their experiences. This study examines not only the mirage of safety and control presented by nurses, but also the toll this collective

mask of resilience took on the individuals behind it. In doing so, it asks whether societies are condemned to repeat the errors of the past and, if so, does it become the role of frontline carers to carry the burden of those mistakes? Citation Gordon O et al (2020) Learning from the past? Spanish influenza and the lessons for Covid-19. Nursing Times [online]; 116: 10, 27-31 T he global coronavirus pandemic reached Britain in February 2020, spreading rapidly among a population whose government seemed unprepared for such an emergency (Nuki and Gardner, 2020; Pegg, 2020; Wenham, 2020; NHS England, 2017). Attempts were made to draw on logistical, medico-scientific and engineering expertise to solve Covid-19-related problems, such as the need for biological testing and contact tracing on a massive scale, thousands of new hospital beds and ventilators, and millions of pieces of personal protective equipment (PPE). The burden of the rapidly emerging crisis fell on existing healthcare staff

and those who returned to practice – the so-called ‘front line’ of the NHS and care services – and it continues to do so. Our study examines the significance of one element of that front line: the nurses caring for patients in hospitals and care Nursing Times [online] October 2020 / Vol 116 Issue 10 27 homes. It uses historical methodology to reflect on the resonances between the experiences of today’s nurses and the experiences of those who cared for patients during the Spanish flu pandemic of 1918-19. The focus of our research is on the dual roles of nurses – as individuals who perform intensive work to preserve life and as ‘emblems of resilience’ for a weakened society. Background This historical study focuses, in part, on the premise that the coronavirus pandemic has significant resonances with the Spanish flu pandemic. Infection rates and death tolls from influenza (H1N1) rose in three distinct waves from June 1918 through to the early summer of 1919; the

exact science of the virus and its prevention came to light only slowly and, although there is dispute over mortality rates, it is estimated to have killed 2-5% of the world’s population (Cipriano, 2018; www.nursingtimesnet This article is open access and can be freely distributed Clinical Practice Discussion Barry, 2009; Johnson and Mueller, 2002). The pandemic was unexpected and came as a shock to societies that had begun to believe they were gaining mastery over epidemic diseases (Condrau and Worboys, 2007; Crosby, 1989; Crosby, 1976), and who had to acknowledge that they did not possess the mastery over nature in which they had confidently believed. Little is known about the work of nurses during the Spanish flu pandemic, or about the impact of that work on those nurses’ own physical and mental health. Existing historical research focuses on the public health response in the US (Jones and Saines, 2019; Stetler, 2017; Keeling, 2010), while insights into the British response

have been presented as part of wider studies of nursing work during the First World War, focusing primarily on combatrelated injury and disease (Hallett, 2020; Hallett, 2014; Hallett, 2011). What is known is that the doctors of the time expressed a sense of helplessness in the face of this incurable disease, regarding “careful nursing” as patients’ only chance of recovery, while nurses themselves went beyond the normal call of duty, working long hours and taking pride in saving lives (Hile, 2018; Wood, 2017). During the Spanish flu pandemic, nurses in all developed countries were engaged in campaigns for professional recognition. British nurses attained their professional register with the passing of the Nurses Registration Act on 23 December 1919, and it is likely they gained such recognition, in part, as a result of their widely praised work with both patients wounded in the war and those affected by the pandemic (Hallett and Cooke, 2011). l compensation to nurses who perform

arduous and essential work. In particular, the study aimed to explore ways in which the nursing profession itself might work to make its contribution more visible to counter the production of images that are too comfortable and simplistic, depicting nurses as frontline heroes. T  o explore ways in which the nursing profession might reflect on the 1918-19 Spanish flu pandemic and its impact on nurses, to recognise both the value of resilience and its darker side. QUICK FACT 2-5% Percentage of the world’s population killed by the Spanish flu pandemic Literature review Writers have often found it difficult to write about how Britain combatted the 1918-19 Spanish flu pandemic, paradoxically because there is “both too much and too little information” (Quinn, 2008): much was written, but the disease was not well understood, and many primary sources merely repeat expressions of horror and anxiety without giving clear information about responses to the pandemic. Many of the

surviving written sources on the topic are either American or Canadian; very little has been written from a British perspective. It has also been argued that there is a lack of secondary literature on the pandemic because it was simply not as memorable as the concurrent First World War. Tom Quinn (2008) argued that “the lives of the pandemic victims were cut short by an unseen, unknown enemy; there was nothing heroic about it at all – in most cases death was messy and painful, but essentially private”. As a result, those who were killed by the pandemic were not remembered like the soldiers who died in action, despite the fact that the number of people killed by H1N1 was drastically higher (Quinn, 2008). Jane Elizabeth Fisher (2012) has also argued that the Spanish flu pandemic has been neglected by historians due to its “awe-inspiring destructive power and the inability of human language to adequately represent mortality on such a large scale”. This argument has also been

supported by Alfred W Crosby, one of the first historians to write about the Spanish flu pandemic in depth, as he believed that “major writers of that generation were busy memorialising the experience of the Great War” and, therefore, found little reason to write about influenza (Crosby, 1989). As a result, there is also a large gap in nursing history during this challenging time. Many authors mention and recognise the ongoing work of nurses and other frontline medical staff, but very few go into detail about the role of the nurse, especially when faced with a new strain of disease that did not have a miracle cure. Historian Nancy Bristow (2012) emphasised the importance of nurses in her book American Pandemic; she highlighted that “there wasn’t much a doctor could do” and quoted a physician who said the main reasons for doctors to visit patients was “to find out ALAMY Aims This study was designed to meet three urgent current needs: l T  o better understand what permits

nurses to: Perform exhausting physical and emotional work to save the lives of people with an acute, untreatable infection; Remain calm, thereby exerting a calming influence on the population as a whole; Present themselves as emblems of resilience, enabling a population to exhibit more general resilience at a time of crisis. l T  o address the failure of governments and societies to offer adequate protection, recognition and During the Spanish flu pandemic, nurses at a hospital in Washington DC donned face masks to care for patients; sheets were used to isolate patients from each other Nursing Times [online] October 2020 / Vol 116 Issue 10 28 www.nursingtimesnet This article is open access and can be freely distributed Clinical Practice Discussion who was dead and then bury them”, leaving nurses as the main source of care. Although little attention has been given to the nurses who cared for H1N1 patients in 1918-19, what does exist indicates that, as argued by Pamela

J Wood (2017), nurses “proved their worth” during the pandemic. Wood suggested this was a “significant point in the profession’s history”, when nurses were able to demonstrate the importance of care when there is no cure. It was known that people’s “best chance of survival was to be utterly selfish” and focus on protecting themselves, which was the opposite of how the nurses behaved: they endangered themselves to care for others and to provide an emblem of hope and resilience for people in need (Spinney, 2018). Method In reflecting on the echoes between the pandemics of 1918-19 and 2020, our study explored a range of archival, published and oral-history sources to establish the nature of nurses’ work with H1N1 patients in 1918-19 and the significance of the trauma they experienced as a result. Due to the current coronavirus pandemic, our research took place during a period of total, and then partial, lockdown in Britain, when it was not possible to travel to

physical archives. The study team, therefore, focused on primary-source materials available online or, in some cases, material from the Royal College of Nursing (RCN) archive and the National Archives that had previously been retrieved. Material included nurses’ personal writings, textbooks and articles in professional nursing journals (namely, Nursing Times, the British Journal of Nursing and Nursing Mirror). We also examined newspapers (via digital archives) and images that illustrate how the picture of the resilient nurse was constructed in 1918-19. Among the most important sources for the study were: l W  ar Office files (WO399 series, recently made available online by the National Archives); l M  inistry of Pensions files (PIN series, which had already been made available to us as photographed material). We examined 320 pension files held at the National Archives for details about the experiences of nurses whose health broke down as a result of their war service, and then

deliberately selected a small number of case studies from those whose health was said to have been damaged by the stress and strain of their work (Box 1). Box 1. Spanish flu pandemic: the nurses experience The following accounts and documents dating from the time of the Spanish flu pandemic detailed the nurse experience: l Nurses’ pension files held by the National Archives (series PIN26) (Bit.ly/ TNAPensionFilesWW1) – case studies: l Lilian Atkins – PIN26/19994, WO399/217 l Isma Brown – PIN26/20016, WO399/1008 l Edith Burdge – PIN26/20020, WO399/1121 l Florence Cattell – PIN26/20027, WO399/10318 l Mary Cleverly – PIN26/20035 l Margaret Hollow – PIN26/20110 l Nurses’ war office files: series WO399 (Bit.ly/WONursRecordsWW1) l Royal College of Nursing archive – oral history T/10A, Elizabeth Cockayne; interviewer: Dr Christopher Maggs (Bit.ly/RCNACockayne)  ursing Times. l Nursing journals – British Journal of Nursing, Nursing Mirror and N l Articles in

local newspapers: l Dearth of nurses. The Globe; 19 February 1919 l Brave nurses who “carried on”. Gloucestershire Chronicle; 15 June 1918 l Urgent appeal for VAD nurses. The Scotsman; 15 November 1918 l Nursing influenza sufferers. Sunderland Daily Echo and Shipping Gazette; 25 November 1918. l Influenza epidemic: voluntary nursing scheme at Northwich. Runcorn Guardian; 17 December 1918. Results In Britain, combating the Spanish flu pandemic – a fight that came hard on the heels of a global conflict – involved the strenuous and demanding work of providing care, treatment, and physical and emotional support for hundreds of thousands of patients. Each patient required: l O  xygen therapy (if available); l C  areful positioning to enhance lung capacity; l F  requent hydration; l C  areful and effective nutrition (at certain points in the natural history of the disease). Patients with a severely compromised lung capacity were also taught how to breathe more effectively.

Such care was considered ‘total care’; it also included the heavy work of washing patients and turning them frequently to prevent pressure ulcers. This fundamental nursing care has been referred to as comprising the “thousand things” that nurses did to keep patients alive long enough for their own immune systems to overcome disease when a cure was not available (Tesseyman et al, 2017). Beyond this resource-intensive one-toone patient care, nurses were also performing a significant social role. The image of the nurse as “invincible healer” (Hallett, 2011) acted as a calming device for whole populations. The British nurses of 1918-19, in common with those of many other developed countries, donned Nursing Times [online] October 2020 / Vol 116 Issue 10 29 uniforms and veils and presented themselves as both military heroines and selfsacrificing angels. Newspapers, journals, novels and films from the time indicated that people were genuinely moved by these powerful exemplars

of hope and civic duty, and were, therefore, enabled to practise a form of collective resilience. As with today’s coronavirus pandemic, the Spanish flu pandemic found people unprepared. Newspapers did not, initially, report the severity of it; this was part of an attempt to maintain wartime morale. However, as stated by a journalist from The Globe in early 1919, this caused a “great misunderstanding by the general public” in how to treat and respond to the pandemic (The Globe, 1919). Our study identified five distinct resonances between the experience of nurses during the Spanish flu and the current coronavirus pandemics: l N  urses in all settings (both civilian and military) during the Spanish flu pandemic had to undertake physically and emotionally intensive work, involving constant attention to patients’ breathing, positioning, nutritional and hydrational status, and mental and emotional morale. During the current pandemic, attention must be paid to, essentially, the same

live-saving imperatives, but the measures taken are now mediated through new and demanding technologies. First-hand accounts of www.nursingtimesnet This article is open access and can be freely distributed Clinical Practice Discussion “Nurses often presented an outward show of resilience long after their reserves of energy had expired” l l ALAMY l nurses on the front line in 1918-19 show nurses’ determination to help their patients despite the high risks. Elizabeth Cockayne, a fever nurse during the pandemic, was asked if she noticed any difference between general and fever nursing, and responded: “No, I don’t think that I did. I think I was always wanting to give; I was always wanting to nurse and to do what I thought was helpful to them, no matter what it was” (Bit.ly/RCNACockayne) “ Stress and strain of service”, the phrase frequently used in Ministry of Pensions’ files for nurses demobilised in 1919 (Bit.ly/TNAPensionFilesWW1), bears resonance with the

experiences of today’s nurses, in that not all trauma is physically inflicted: fear, worry and exhaustion can cause trauma. One of the findings of our work, to date, is that a range of physical illnesses were caused by (but not necessarily attributed to) ‘active service’ in 1918-19. Many nurses, for example, experienced painful kidney infections that left lifelong damage, as a result of not being able to void their bladders when needed. Not being able to focus on their own physical needs was a hidden cause of trauma, and a similar failure to attend to their own needs appears to be affecting today’s nurses. In 1918-19, the stress of caring for H1N1 patients went well beyond the ‘normal’ stresses of the job; many nurses were openly afraid of contracting influenza in the course of their work (Bit.ly/RCNACockayne) and there was uncertainty about when the pandemic would end. These same fears and uncertainties are experienced by today’s frontline nurses. T  he nurses on

‘active service’ in 1918-19 were obliged to live away from home, often for many months at a time. Many of today’s nurses and carers have chosen to live away from their families and friends as a precaution, and it may feel as though they are ‘deployed in place’, believing themselves to be on active service. T  he act of putting on PPE can be traumatising: it is an act that preludes the day’s hard work and its attendant emotional and physical stresses. PPE highlights risk and is symbolically akin l to the battledress of a solider or medic. This, along with government and media hype about frontline workers and the use of military tropes, may heighten stress. In 1918-19, infectious diseases nurses were already accustomed to donning protective gear over their uniforms, but this is a new experience for many of today’s nurses and heightens their sense of crisis. A  t the beginning of the Spanish flu pandemic, war nurses already had a long history of being used as propaganda

to support public morale. Images of nurses as angels and heroines appeared in numerous newspaper articles – such as those outlined in Box 1. Similarly, in the first months of the coronavirus pandemic, there was a focus on the frontline nature of nursing work, its dangers and the sacrifices that nurses and other healthcare workers were making. This creates additional stress and pressure for frontline carers, even as it offers comfort to the rest of the population. Case studies Among our case studies were six nursing sisters, named in Box 1. All were experienced, professionally trained nurses who joined the nursing services in 1914 or 1915. All six served until 1919 and continued to work as nurses following their demobilisation, with varying degrees of success. Isma Brown and Mary Cleverly both suffered breakdowns at their places of work in 1920, and both were institutionalised at different times during 1920 and 1921. Five of the six women received war disability pensions from the

Ministry of Pensions, but one – Mary Cleverly – was denied this on the grounds that she had allowed too much time to elapse before applying in 1929. Edith Burdge was able to continue in her profession for a significant length of time: she worked as a part-time night nurse after relocating to Canada. The nurses were pensioned for: l N  eurasthenia; l P  sychoneurosis; l D  ebility; l E  xhaustion psychosis. Common symptoms shared by all six women included severe headaches, insomnia and depression; nightmares, “tremors in the limbs” and “hysterical paralysis” affected a few. Their experiences of medical care and treatment varied but stress and strain of service was cited as the cause of psychological trauma in all six. Nursing Times [online] October 2020 / Vol 116 Issue 10 30 Wearing personal protective equipment is vital when caring for patients with Covid-19, but can result in trauma Discussion Our study drew out the resonances between the work of British nurses

during the 1918-19 Spanish flu pandemic and the practice of today’s nurses during the current coronavirus pandemic. Enabling patients to breathe, giving oxygen and preserving life until immune systems could eradicate the disease were the most important direct elements of nurses’ work during the Spanish flu pandemic. Today’s nurses are performing similar work, but they are aided by technologies such as ventilation and continuous positive airway pressure – technologies that both support their work and add pressure and responsibility to their role. Records indicate that nurses in the early 20th century who cared for patients with Spanish flu, in both civilian and military hospitals, during the 1918-19 pandemic regarded themselves as having provided an essential national service. In many cases, they had felt unable to request demobilisation until the crisis was over. In analysing the significance of stress and strain in nurses serving during a national emergency and exhibiting

characteristics of resilience, our primary sources indicated that nurses often presented an outward show of resilience long after their reserves of energy had expired. Recent literature from psychology and the health sciences relating to the ‘dark side of resilience’ has suggested there is a correlation between resilience and highly unfavourable outcomes, such as burnout, debility and serious illness (Yu et al, 2019; Britt et al, 2016; Fleming and Ledogar, 2008; Lifton, 1999). Many of the nurses in the early 20th century who received war disability pensions for psychological trauma associated www.nursingtimesnet This article is open access and can be freely distributed Clinical Practice Discussion with war service did not receive any specialist treatment and were left unable to earn a living as professional nurses. Neurasthenia was the most common diagnosis given to traumatised nurses, and the stress and strain of active service were the most common reported underlying causes.

The nurses of that time were able to make use of cotton gowns and masks that were washed at high temperatures in hospital laundries, rendering them safe for reuse; at the outset of the coronavirus pandemic, nurses had no such reassurance. According to Dean (2020), reporting for the RCN, 39% of nurses polled during a nationwide survey stated that “they [were] being asked to reuse items of PPE that [had been] marked as single use”. On 16 April this year, the RCN (2020) set out its official guidance on the possibility that nurses without PPE might have to refuse to care for patients – an unprecedented move from a professional association that had never, in its 104-year history, sanctioned the withdrawal of essential life-saving treatment. Nurses remain icons of society, not only eliciting the now-famous movement to clap for the NHS, but also being held up as examples to encourage members of the public to give service to their nation. Their use in this way – as exemplars of civic

duty – has inspired unprecedented levels of volunteering. When the UK government asked for volunteers to work on a community level, helping the most vulnerable people, more than 400,000 people responded to the call within 24 hours. Children painted rainbows and put them in their windows, as a sign of hope and to act as a reminder that one day the storm would pass. We believe it was this example of nurses as emblems of resilience that encouraged the British people to display a more general resilience. The price paid by those nurses, in stark terms of lives lost, has been prominent in the British mass media, but the more complex problem of physical and mental damage requires closer scrutiny. This work was limited by our inability to travel to archives to access a greater number of primary sources; however, work is ongoing and findings will be reported when all our work is complete. Conclusion It has become a truism for the British people, during the coronavirus pandemic, that nurses

are both heroic frontline carers and individuals at risk of trauma. The battlefield metaphor that places nurses in all For more articles on coronavirus and Covid-19, go to nursingtimes.net/coronaclinical “We believe it was the example of nurses as emblems of resilience that encouraged the British people to display a more general resilience” settings (including hospitals, care homes and the community) in the almostmythical role of being both self-sacrificing angels and superheroes is largely unhelpful to a profession that is working to secure the resources it needs to do its job, protect its workforce, and attain the recognition that comes with professional expertise. Nurses hold a dual role at a time of national emergency: as life-saving professionals and, collectively, as a calming influence on society. They promote and enable engagement with public policies, including compliance with lockdown measures, support for vulnerable neighbours, and personal and collective resilience in

the face of hardship and fear. Our project highlights the complexity of the task confronting nurses during a pandemic of a severe, life-threatening respiratory disease. Their work brings them close to patients, while also drawing attention to them as icons of society. They struggle to fulfil their dual roles, while also protecting themselves and gaining recognition for the significance and complexity of their work. Their manifest success during the current pandemic has helped strengthen the social contract between society and its nursing profession while, simultaneously, providing lessons for the current and any future pandemics. Our study provides evidence of the high toll placed on the health and wellbeing of nurses in the early 20th century, due to their work with H1N1 patients. In so doing, it highlights the need to pay close attention to the pressures faced by today’s nurses in their work with patients who have Covid-19. NT References Barry JM (2009) Pandemics: avoiding the

mistakes of 1918. Nature; 459: 324-325 Bristow NK (2012) American Pandemic: The Lost Worlds of the 1918 Influenza Epidemic. Oxford University Press. Britt TW et al (2016) How much do we really know about employee resilience? Industrial and Organizational Psychology; 9: 2, 378-404. Cipriano PF (2018) 100 years on: the Spanish flu, pandemics and keeping nurses safe. International Nursing Review; 65: 3, 305-306. Condrau F, Worboys M (2007) Second opinions: epidemics and infections in nineteenth-century Britain. Social History of Medicine; 20: 1, 147-158 Nursing Times [online] October 2020 / Vol 116 Issue 10 31 Crosby AW (1989) America’s Forgotten Pandemic: The Influenza of 1918. Cambridge University Press Crosby AW (1976) Epidemic and Peace 1918. Greenwood Press. Dean E (2020) Covid-19: nurses say they are not getting adequate PPE. Nursing Standard [online]; 10 April. Fisher J (2012) Envisioning Disease, Gender, and War: Women’s Narratives of the 1918 Influenza Pandemic. Palgrave

Macmillan Fleming J, Ledogar RJ (2008) Resilience, an evolving concept: a review of the literature relevant to Aboriginal research. Pimatisiwin; 6: 2, 7-23 Hallett CE (2020) Emotional containment: nurses and resilience. In: Van Bergen L, Vermetten E (eds) The First World War and Health: Rethinking Resilience. Brill Hallett CE (2014) Veiled Warriors: Allied Nurses of the First World War. Oxford University Press Hallett CE (2011) Containing Trauma: Nursing Work in the First World War. Manchester University Press. Hallett CE, Cooke H (2011) Historical Investigations into the Professional Self-Regulation of Nursing and Midwifery: 1860-1998, Volume 1 Nursing. London: Nursing and Midwifery Council. Hile E (2018) “Like Brave Soldiers”: Nursing and the Spanish Influenza Epidemic of 1918 in the United States. Unpublished thesis Bowling Green, OH: Bowling Green State University. Johnson NPAS, Mueller J (2002) Updating the accounts: global mortality of the 1918-1920 “Spanish” influenza

pandemic. Bulletin of the History of Medicine; 76: 1, 105-115. Jones MM, Saines M (2019) The eighteen of 1918–1919: black nurses and the great flu pandemic in the United States. American Journal of Public Health; 109: 6, 877-884. Keeling AW (2010) “Alert to the necessities of the emergency”: US nursing during the 1918 influenza pandemic. Public Health Reports; 125: Suppl 3, 105-112. Lifton RJ (1999) The Protean Self: Human Resilience in an Age of Fragmentation. University of Chicago Press. NHS England (2017) Emergency Preparedness, Resilience and Response (EPRR). NHSE Nuki P, Gardner B (2020) Exercise Cygnus Uncovered: The Pandemic Warnings Ignored by the Government. telegraphcouk; 28 March Pegg D (2020) What was Exercise Cygnus and What Did it Find? theguardian.com; 7 May Quinn T (2008) Flu: A Social History of Influenza. New Holland Publishers. Royal College of Nursing (2020) Guidance for Members: Refusal to Treat Due to Lack of Adequate PPE during the Pandemic. RCN Spinney L

(2018) Pale Rider: the Spanish Flu of 1918 and How it Changed the World. Vintage Stetler CM (2017) The 1918 Spanish influenza: three months of horror in Philadelphia. Pennsylvania History: a Journal of Mid-Atlantic Studies; 84: 462-487. Tesseyman S et al (2017) Crisis at Guy’s Hospital (1880) and the nature of nursing work. Nursing Inquiry; 24: 4, e12203. The Globe (1919) Dearth of nurses. The Globe; 19 February. Wenham C (2020) The UK was a Global Leader in Preparing for Pandemics. What Went Wrong with Coronavirus? theguardian.com; 1 May Wood PJ (2017) Managing boundaries between professional and lay nursing following the influenza pandemic, 1918-1919: insights for professional resilience today? Journal of Clinical Nursing; 26: 5-6, 805-812. Yu F et al (2019) Personal and work-related factors associated with nurse resilience: a systematic review. International Journal of Nursing Studies; 93: 129-140. www.nursingtimesnet