The role of nurses, who make up the majority of the healthcare team, is becoming increasingly important due to changing disease patterns, such as novel infectious diseases (e.g., COVID-19), as well as structural changes, including an increase in the aging population. Nurses have played a critical role in patient care and management during this difficult time, making their intention to stay (ITS) within their organizations essential for maintaining a stable and competent nursing workforce. This study investigates a unique aspect of nursing by examining how grit and resilience influence nurses' commitment to remain in their roles, specifically in the context of Taiwan's healthcare system. Although the nurses' ITS is a widely researched topic, the distinct emphasis on the role of grit and resilience in this context provides new and unique information. The particularities of the Taiwanese healthcare environment, characterized by a rapidly aging population and evolving disease patterns, further enhance the novelty of this study.

The rapid escalation of the pandemic necessitated quick adaptations in medical services. Nurses faced increased responsibilities, such as implementing protective measures, managing a higher patient load and providing support in various settings like isolation hotels, community screening stations and vaccination sites. The COVID-19 pandemic has had a profound impact on nurses' psychological well-being, job satisfaction, and retention rates. Studies by Tanaka et al. [1] and Mary et al. [2] highlight that the heightened stress and emotional exhaustion experienced by nurses during the pandemic contributed to increased burnout and a higher intention to leave the profession. The overwhelming workload and constant exposure to the virus have taken a toll on nurses’ mental health, underscoring the need for organizational support, including psychological counseling, better work conditions, and stress management programs to help retain healthcare workers during such crises [1-3].

Due to changes in disease patterns, such as novel infectious diseases such as COVID-19, has exacerbated the issue of shortages and turnover in nursing, placing significant strain on healthcare systems. It is crucial to foster the intention of nurses to stay within their organizations to maintain workforce stability and deliver high-quality patient care. Organizations that foster commitment and provide supportive work environments can promote this intention. Friborg et al. [4] developed a resilience scale for adults, identifying personal competence, family support and social support as primary protective factors enabling healthy adjustment under stress and adversity. Duckworth et al. [5] further underscored the role of grit, defined as persistence and passion for long-term goals. The cultivation of grit can enhance individuals' ability to navigate challenges, contributing to positive psychological attributes like self-efficacy, resilience, hope and optimism. Luthans et al. [6] found that self-efficacy; resilience, hope and optimism are the makeup of psychological capital and have a greater impact on Grit than the other way.

Numerous studies have investigated the importance of nurses' ITS during the pandemic [7]. Retaining experienced nursing staffs enable organizations to maintain resilience during crises and adapt to challenging situations. Nurses and midwives, who are resilient and benefit from protective factors such as personal competence, family support and social support, are less likely to leave their organizations [7]. Social support has been identified as a critical factor affecting job satisfaction (JS) and retention intention among nurses [3]. Social support and coping strategies act as mediators between COVID-19 pandemic and turnover intention. Additionally, providing customized training and support to frontline nurses can help them manage stress and challenges.

Given these issues, the primary focus of our study is tackling the urgent problem of nurse’s retention. The necessity of keeping nurses employed, especially during extraordinary health emergencies such as the ongoing pandemic, is vital for preserving the quality and consistency of healthcare services. It has thus emerged as a pivotal concern within Taiwan's healthcare system.

Nurses with higher psychological resilience have lower turnover intentions, and the implementation of training and support measures can enhance the resilience of newly graduated nurses and reduce turnover rates. Yang and Chen [8] observed a negative correlation between job satisfaction and turnover intention among pediatric nurses. In conclusion, promoting resilience, providing social support and ensuring job satisfaction are essential factors that motivate nurses to stay, resulting in workforce stability and the maintenance of high-quality patient care.

Duckworth defines grit as passion and perseverance towards very long-term goals. With grit, one can accomplish difficult tasks without giving up. It is a strength of character that keeps a person going [9]. Grit has a positive association with job performance and retention rates in the workplace [10,11]. Nurses with more grit, demonstrating higher levels of perseverance and passion for their profession [12] contribute to organizational adaptability and responsiveness in challenging circumstances. When grit improves, efforts are made to achieve job satisfaction and maintain organizational commitment through focusing on work with steady effort and interest in the goal. Based on this study, enhancing the grit that predicts individual nurses’ achievement can enhance nursing job performance. [12]. Employees with more grit contribute to lower turnover rates and increased organizational stability [11]. Therefore, organizations that cultivate commitment, belonging and grit can ensure continuity of care and foster a supportive work environment.

The studies show that resilience play a mediating role in the relationship between grit and the ITS [10,13]. Integrating grit into the nursing profession and nurturing resilience via individual capabilities can reinforce the intention of nurses to remain in their roles, and improve workforce stability and organizational resilience, especially also aids in the provision of high-quality patient care. This study intends to investigate the relationships between grit, resilience, job satisfaction and the intention of nurses to stay. Through hypothesis testing, the research aims to enhance our understanding of how grit and resilience contribute to job satisfaction and the ITS, ultimately supporting healthcare organizations in retaining and maintaining a stable, skilled nursing workforce. The main research question guiding our study is: "What is the impact of grit and resilience on the intention of nurses to stay in their profession during challenging times?"

The purpose of this study is to investigate the impact of grit on the ITS, when this impact is mediated sequentially by resilience and job satisfaction. It also aims to examine the mediating role of grit in the relationship between resilience and the ITS. A cross-sectional design was employed for this research.

Study Setting and Sampling

The study included nurses who had worked at the medical center for at least three months, were not in administrative positions, and willingly agreed to participate after receiving a comprehensive explanation from the research team. Excluded from the study were nurses from non-clinical departments such as the physical examination center and the aesthetic medical center, and those who opted out of participation after the researchers' explanation.

In this study, data were collected through a structured questionnaire distributed to nurses at a public medical center in southern Taiwan between January and March 2021. Using convenience sampling with the research nurse, after explaining the purpose of the research and the method of filling out the questionnaire at the ward meeting in each unit, a number of questionnaires equal to the current number of people in the unit will be provided. Those who are willing to fill in the questionnaire, after completion, the head nurse of the unit will notify the research nurse to collect it. We disseminated 1033 questionnaires. The valid questionnaires are 901.

We based our sample size consideration on the SEM guideline, which suggests a sample size typically more than 10 times the total number of questionnaire items [14]. We used 47 items (29 associated with resilience, 11 with grit, 5 with ITS, and 1 each with job satisfaction and work stress), thus aiming to collect a minimum of 470 fully completed and valid questionnaires. The collection of 901 valid responses bolstered the credibility and validity of our findings.

Grit Measurement

The Traditional Chinese version of the Grit Scale (GS-TC), from the Duckworth Grit Scale [5] translated by Tsai et al. [15], was used in this study. The GS-TC consisted of 11 items with two subscales: consistency of interest (5 items) and perseverance of effort (6 items). The Cronbach's alpha coefficient in this study was 0.70, with the coefficients for the two subscales being 0.74 and 0.82, respectively.

Resilience Assessment

In this study, we used the Chinese version of the RSA (C-RSA), from Friborg et al. [4] which was translated by Wang et al [16]. The C-RSA included 29 items with five dimensions: personal competence which had 6 items, family cohesion that had 7 items, social resources with 8 items, social competence containing 4 items and structured style also with 4 items. The internal consistency of the total scale was 0.89, and the internal consistency of the dimensions ranged from 0.83 to 0.92, with higher scores indicating greater resilience. In this investigation, the Cronbach's alpha coefficient was 0.93, with the coefficients for each subscale ranging from 0.75 to 0.78.

Intention to Stay, Job Satisfaction and Work Stress Evaluation

The ITS measurement tool has been used for the medical professionals and administration staff [17]. This tool consists of five items that are each scored on a five-point Likert scale. Higher scores indicate higher levels of ITS. The Cronbach’s alpha for the previous study [17] was 0.88 and 0.85 in this study.

The assessment of job satisfaction is evaluated their answers on a 5-point Likert scale, spanning from 1 (Extremely dissatisfied) to 5 (Highly satisfied); higher scores signified increased job satisfaction. The evaluation of work stress rated their responses on a 5-point Likert scale, with options ranging from 1 (Never) to 5 (Constantly); higher scores indicated greater stress.

Ethical Considerations

This study received approval from the Institutional Review Board for Medical Research Ethics at Kaohsiung Veterans Hospital (KSVGH110-D03-1). All participants' involvement was voluntary; anonymity and confidentiality of the collected data were maintained to safeguard their privacy.

Data Analysis

We implemented Harman's single-factor test, to examine the potential of this inherent possibility of common method variance (CMV) bias. We performed an exploratory factor analysis on 47 items (29 related to resilience, 11 to grit, 5 to ITS, and one each to job satisfaction and work stress) using principal component analysis with varimax rotation and enforced the extraction of a single factor. The first factor accounted for 24.99% of the variance, which is below the threshold of 50%. Thus, based on these findings, we did not identify the presence of CMV bias in our study.

Descriptive statistics were used to examine participants' demographic characteristics. One-way ANOVA was employed to compare research variables among age, department and years of work groups, while t-tests were used to assess differences between groups by gender, marital status and employment status. Pearson's correlation analyses were conducted to investigate the bivariate associations among grit, resilience and ITS.

In the structural equation model (SEM) analysis, we employed the maximum likelihood estimation method by using the IBM SPSS software and AMOS 23.0. The assumptions of linearity, normality, homoscedasticity, independence and adequate sample size for SEM analysis were validated in our data. We examined scatterplots to verify linearity, evaluated skewness and kurtosis values to determine multivariate normality, and scrutinized the variance inflation factor (VIF) to detect any multicollinearity. We ensured the goodness of fit of our model by using multiple indices, including the chi-square/degrees of freedom ratio (χ2/df), the standardized root-mean-square residual (SRMR), the root mean square error of approximation (RMSEA), the goodness of fit index (GFI), the comparative fit index (CFI) and the Tucker-Lewis index (TLI) [18]. The χ2/df ratio, which is a measure of absolute fit, was utilized to examine the discrepancy between the data and the fitted model. A χ2/df ratio of less than 5.0 indicates a good model fit. The SRMR is another absolute fit measure that quantifies the average discrepancy between the observed and predicted correlations. A value of SRMR less than or equal to 0.08 is considered a good fit. RMSEA, an absolute fit index, assesses the error of approximation in the population. A value of less than 0.08 indicates a good fit. GFI is an absolute fit index that indicates the proportion of variances and covariances in the sample data that is accounted for by the model. A value greater than 0.90 suggests a good fit. CFI and TLI are incremental fit indices, which compare the specified model with a null model. A value greater than 0.90 is considered a good fit for both indices.

Results

Characteristics of the Sample

The demographic specifics and characteristics of the sample, which consists of 901 participating nurses show in Table 1. The majority of the samples were female (96.8%), with ages ranging from 21 to 57 years, with a mean age of 34.35 and a standard deviation of 9.86. No notable differences were found in the mean scores of job satisfaction and ITS across gender and education level groups. Approximately 30.7% of the participants were married, and 87.9% had earned a university degree or higher.

Significant differences in the ITS mean score (p < .05) were observed among age, marital status, employment status, years of work experience and unit groups. Likewise, significant differences were noted in the mean score of job satisfaction for age and marital status groups (p < .05).

Associations among Study Variables

Variable descriptive statistics and correlations among variables can be found in Table 2 below. The results of Pearson's correlation analyses (two-tailed) among the C-RSA subscales, the GS-TC subscales and ITS. The correlation coefficients, which range from -0.013 to 0.689, were determined to be statistically significant with a p-value less than 0.01. The insignificant correlation between perseverance of effort and consistency of interests may result from their representation of distinct facets of grit. Perseverance of effort helps individuals by remaining committed to their goal pursuit; consistency of interests provides individuals with the focus necessary to achieve their goals. Hagen et al. [19] mentioned htat grit is a predictor of academic success over and above established constructs like interests or conscientiousness. Similarly, social competence and consistency of interests belong to different domains, which might explain their insignificant correlation.

Test of the Study Model

The goodness of fit results for this model were as follows: χ2/df = 4.59 (less than 5.0), SRMR = 0.039 (less than or equal to 0.08), RMSEA = 0.063 (less than 0.08), GFI = 0.97 (greater than 0.90), CFI = 0.97 (greater than 0.90) and TLI = 0.95 (greater than 0.90). Thus, all these indices met their respective reference criteria, indicating that the model provided a good fit for the data. Figure 1 presents the final model, including the significant correlation effect paths of the research variables (all p < 0.05) and provides support for our goals.

Figure 1: The final model and standardized path model both had standardized path coefficients (all p < 0.05).  GS-TC: The Traditional Chinese version of the Grit Scale, C-RSA: The Chinese version of the Resilience Scale, JS: job satisfaction, WS: work stress, ITS: intention to stay.

Table 1:  Distribution of demographic data, JS and ITS across categorical elements.

Note: * p <.05, ** p <.01, *** p <.001

Table 2: Correlations among Continuous Variables.

Note: The correlation coefficients were determined to be statistically significant with a significance level of p < 0.01 (**). PC: personal competence, FC: family cohesion, SR: social resources, SC: social competence, SS: structured style, PE: perseverance of effort, CI: consistency of interests, ITS: Intention to stay.

Path Coefficient Results of SEM

The path coefficients result of the SEM presents in Table 3. We found that the GS-TC had a positive correlation with the ITS (β= 0.400, p < .001) as well as positively correlated with the C-RSA of resilience (β = 0.524, p < .001). The C-RSA was positively related to JS (β = 0.160, p < .001) and JS was positively correlated to ITS (β = 0.158, p < .001). Furthermore, we found that the C-RSA was positively related to the GS-TC of grit (β= 0.366, p < .001). Among all the dimensions of GS-TC and C-RSA, the highest absolute values were found for personal

competence (0.908) and perseverance of effort (0.749). C-RSA does not significantly predict ITS, with an unstandardized estimate of -0.070 (p > 0.05) and a standardized estimate of -0.080. Previous research indicated that resilience did not directly affect turnover intention but had exerted indirect effects through comprehensive job involvement [20]. GS-TC does not significantly predict WS, with an unstandardized estimate of 0.019 (p > 0.05) and a standardized estimate of 0.064. However, earlier research had identified a significant negative relationship between grit and perceived stress among college students and community adults [21]. GS-TC does not significantly predict JS, with an unstandardized estimate of -0.006 (p > 0.05) and a standardized estimate of -0.021. Nevertheless, prior research revealed a positive association between job satisfaction and salesperson grit, as grittier individuals tended to be more satisfied in their jobs [22]. The final structural equation graph excluded non-significant correlation paths.

Table 3: Path Coefficients Results.

Note: ^a Unstandardized regression coefficients (Default model) and ^b standardized regression coefficients. PC: personal competence, FC: family cohesion, SR: social resources, SC: social competence, SS: structured style, PE: perseverance of effort, CI: consistency of interests, ITS: intention to stay, WS: work stress and JS: job satisfaction.

Direct and Indirect Associations GS-TC on ITS and C-RSA on ITS

Understanding the effects of resilience (C-RSA) and grit (GS-TC) on nurses' ITS in their profession is crucial for healthcare organizations looking to improve retention rates and overall job satisfaction. Table 4(a) and 4(b) show that the two pathways are identified as having a significant impact on ITS: one mediated by job satisfaction and the other mediated by grit.

(a) Direct and Indirect Effects of Grit On ITS

Grit exerted a significant direct impact on nurses' ITS, contributing to 96.39% of the total effect. Additionally, grit indirectly impacted ITS through a pathway involving resilience and job satisfaction, accounting for 3.61% of the total effect. This highlights the importance of grit as a key factor influencing nurses' intention to remain in their profession.

(b) Effects of Resilience On ITS

Resilience exhibited two significant mediated effects on nurses' ITS. First, resilience indirectly influenced ITS through job satisfaction, accounting for 15.12% of the total effect. Second, resilience influences ITS through grit, accounting for a substantial 84.88% of the total effect. This finding suggests that enhancing nurses' resilience may significantly improve their ITS by increasing their grit.

Table 4: Direct and Indirect Effects of GS-TC on ITS.

Note: GS-TC: grit; C-RSA: resilience; ITS: intention to stay; JS: job satisfaction.

Table 5: Effects of C-RSA on ITS.

Note: GS-TC: grit; C-RSA: resilience; ITS: intention to stay; JS: job satisfaction.

This research demonstrates several significant strengths and brings to light three main findings: firstly, grit and resilience play a decisive role in the ITS among Taiwan's nursing professionals, with resilience exerting a more substantial impact on the ITS through its influence on grit rather than job satisfaction. Secondly, older, married, permanent employees, particularly those with a decade or more of professional experience, demonstrate a heightened ITS, attributed to factors such as perceived job security, organizational commitment, personal support systems and professional familiarity. Lastly, the interconnectedness of grit, resilience and job satisfaction significantly influence the intention of nurses to remain in their profession.

Various demographic factors such as age, marital status, job permanency and years of experience can influence the willingness of nurses to continue in their positions. Older and more experienced nurses typically enjoy increased job security and a stronger commitment to their organizations due to their accomplishments, professional stability and established workplace relationships [23]. Married nurses often have robust support systems that aid in managing job-related challenges. These support systems, in turn, foster job satisfaction and contribute to higher retention intentions [23]. Secure and enhanced benefits for permanent employees likely elevate their ITS. This scenario underscores the importance of stable employment and comprehensive benefits as indicated by De Cuyper et al. [24]. Senior nurses who are satisfied with their role and organizational culture are often able to achieve financial stability and develop connections within the organization. These factors can lead to enhanced job satisfaction and decrease in the desire to leave the job.

    Job satisfaction which links directly to employee retention can see improvements by cultivating resilience in nurses. A myriad of studies suggests that resilience indirectly impacts turnover intention through various factors such as work engagement, job satisfaction and social support [25]. Employees with greater resilience generally exhibit improved psychological well-being and work engagement, leading to lower turnover intentions. [26]. Alongside resilience, social support is a key component in managing stress and maintaining well-being, with higher perceived organizational support being linked to increased job retention [27]. As such, creating a supportive work environment that provides necessary resources and mentorship, consequently strengthening resilience among nursing professionals and promoting retention.

Grit, resilience and job satisfaction are crucial interconnected factors influencing the intention of nurses to stay in their profession. Resilience and grit mutually reinforce each other, with resilient nurses more likely to display grit when faced with challenges and gritty nurses demonstrating high resilience by maintaining commitment to their long-term goals despite obstacles. Both grit and resilience significantly contribute to job satisfaction, a critical determinant of the intention of nurses to stay.

Grit, characterized by perseverance and passion for long-term objectives [5], can notably predict resilience, further impacting the ITS among nursing professionals. Nurses exhibiting high grit levels tend to demonstrate better clinical competence and commitment to their jobs and organizations [11]. Given that grit affects resilience, which in turn impacts job satisfaction, the indirect influence of grit on the intention of nurses to stay in their profession becomes evident.

Resilience, reinforced by the presence of grit, plays a vital role in shaping the ITS among nursing professionals. Resilience can facilitate the cultivation of grit, a high level of resilience nurses are likely better prepared to develop grit when faced with challenges, persistently maintaining their motivation and focus despite obstacles [5]. Consequently, this adaptability and resilience can significantly influence the intention of nurses to continue in their profession.

Grit and resilience are pivotal factors in influential the ITS among nursing professionals. Southwick et al. [11] demonstrated that grit has a more direct impact on employee retention, suggesting that grit is a central factor in determining whether employees remain in high-pressure jobs. Resilience, in this context, plays a more moderating role, helping employees maintain a positive mindset in difficult times, thus mitigating the negative effects of stress and promoting retention. Lee et al. [23] showed that grit serves as a significant predictor of retention in high-stress occupations, with resilience acting as a mediating variable. Resilient employees are better equipped to handle workplace stress, which in turn helps them stay in their roles longer. This finding further supports the idea that while resilience enhances an employee's ability to cope with challenges, grit plays a more direct and dominant role in long-term job stability. In summary, the literature suggests that grit more direct and significant impact on employee retention compared to resilience which tends to influence retention indirectly. Specifically, fostering grit among employees and supporting their resilience through targeted interventions may be key strategies for enhancing long-term workforce stability. Other elements such as self-efficacy, social support and organizational culture also interact with grit and resilience, potentially boosting job satisfaction and the ITS [23]. Master the traits and uniqueness of perseverance and resilience and take steps to develop these traits in nursing staff to increase staff retention and ensure high-quality care.

Implications for Policy and Practice

Interventions to enhance grit and resilience among nursing professionals can focus on fostering perseverance, maintaining passion for long-term goals, and developing effective coping strategies and adaptability. In terms of policy, these findings suggest that it would be beneficial for organizations to provide resources such as stress management techniques, problem-solving strategies, skill development opportunities and mentoring programs. Implementing such policies could help to bolster the resilience and grit of nurses, leading to improved job satisfaction and a stronger ITS in the profession. Moreover, an impactful practice would be to pair experienced nurses with novices for the exchange of experiences, knowledge and coping methods. Understanding the distinct roles of grit and resilience has crucial implications for the way healthcare organizations tailor interventions to meet the unique needs of their nursing professionals. By creating policies and practices that foster these qualities, organizations can make a substantial impact on long-term employee retention and the overall quality of patient care.

Limitations of the Work

This study has several limitations. Participants were recruited from only one public medical center in Taiwan, and the results cannot be generalized. Additionally, the Traditional Chinese version of the Grit Scale and the Chinese version of the Resilience Scale for Adults were used, which may not fully capture the cultural nuances of these constructs within the Taiwanese context. Despite these limitations, our findings contribute to the understanding of how nurturing grit and resilience can enhance retention and maintain high-quality care among nursing professionals in challenging times.

Recommendations for Further Research

The results of this study provide several recommendations: First, evaluate the causal relationships between grit, resilience, job satisfaction, and ITS among caregivers in a longitudinal study. Secondly, future research should increase sample diversity, such as different medical institutions, to ensure the generalizability of the research results. Third, add other variables such as workload and work-life balance. Finally, qualitative and quantitative research was combined to gain a deeper understanding of caregivers' lived experiences and their reasons for staying or leaving.

We provide evidence that grit mediates the effect of resilience on ITS, and that a sequential chain of resilience and job satisfaction also mediates the effect of grit. By illustrating the significant roles of grit, resilience and job satisfaction, we suggest that interventions aimed at cultivating these attributes could prove effective. Measures such as fostering a supportive organizational environment, providing resources and mentorship, implementing training programs, and introducing initiatives to improve job satisfaction could boost grit and resilience, enhancing the intention of nurses to stay. This in turn, supports workforce stability and the provision of high-quality patient care.

Acknowledgments: The author extends appreciation to the researchers, hospital administrators, and nurses for their help in gathering data.

Funding Statement: This study received Kaohsiung Veterans Hospital’s funding.

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A-26-years old unmarried female came with complaints of raised lesions and pigmentation over the face for 6 months. On evaluation patient was diagnosed as acne vulgaris grade-2 with Post inflammatory hyperpigmentation (PIH) (Figure – 1a, b). She was treated outside with oral and topical medications for the above complaints with minimal response. Patient was concerned about pigmentation over face and was counselled for chemical peel regarding both acne and PIH. Two sittings of 4% Retinol peel were done two weeks apart along with photoprotection. The retinol peel was applied evenly over face and allowed to stay for 8 hours, then cleansed off gently. We witnessed a drastic improvement not just with acne part but also with PIH over face, thus highlighting the role of retinol peel in PIH.  (Figure – 1c, d).

PIH being a challenge to dermatologists have multiple modalities of treatment such as topicals (hydroquinone, retinoids, kojic acid, azelic acid), chemical peels like (glycolic acid (35%), salicylic acid (30%), mandalic acid, jessner solution) and lasers (Co2 laser, Q-switched Nd:YAG laser, Pico laser).3

Chemical peeling a cost-effective, quick and safer method for treating PIH is becoming popular now.1,2 Chemical peels for acne has already been established as a well-known treatment modality with proven results and is a routine procedure. From our case it’s noticeable that retinol peel has a dramatic effect with near normal resolution of PIH along with acne and gives even tone and improves texture, even in individuals with Fitzpatrick – type 4 skin which was not well discussed in literature. Another advantage of chemical peels are relatively less adverse effects compared to other modalities of treatment. On conclusion, retinol peel can be opted as routine option to treat PIH over face with better outcome compared to other modalities even with individuals of skin type (Fitzpatrick 3-5).Acne induced post inflammatory hyperpigmentation is routinely treated with lasers and other superficial and deep peels which is costly and requires multiple sessions and has considerable side effects with acne being treated separately, comparatively retinol peel is cost-efficient, requires only two sessions with minimal side effects. We suggest to consider using retinol peel as a routine option for treating acne along with post inflammatory hyperpigmentation over face with excellent results.

Figure 1 (a, b): multiple, discrete, hyperpigmented and skin coloured papules and hyperpigmentation’s (black circle) present over b/l cheeks, temporal, mandibular regions - baseline. (c, d): Lesions showing near normal resolution of papules and pigmentation with improved texture after 4 weeks.