The main source of stress among Chinese frontline healthcare workers caring for COVID-19 patients is from the fear of being infected, the fear of family members being infected, and the discomfort caused by protective equipment. The study nurses, were married, and had worked more than 20 days, suffered higher stress, compared to rescue staff showing lower stress [1].

In Singapore- 906 healthcare workers who participated in a national survey, 48 (5.3%) screened positive for moderate to very-severe depression, 79 (8.7%) for moderate to extreme anxiety, 20 (2.2%) for moderate to extreme stress, and 34 (3.8%) for moderate to severe levels of psychological distress. The commonest reported symptom was headache (32.3%), with a large number of participants (33.4%) reporting more than four symptoms [2].

In a New York study, HCW expressing psychological symptoms were common; 57% for acute stress, 48% for depressive, and 33% for anxiety symptoms (Shecher et al 2020). HCWs have experienced substantial negative mental health effects during COVID-19. Though nurses and women may be more susceptible to acute psychological stress, they have the most growth potential.

Recent literature demonstrates that individuals can grow and change in a positive fashion after trauma or stressful events, which means individuals, might achieve post-traumatic growth (PTG) [3, 4]. There is limited evidence about frontline nurses’ post-traumatic growth and related factors because of caring for COVID19 patients [5]. PTG is a concept that was proposed by [19] which refers to positive psychological changes after an individual experience’s traumatic events. There is possibility for positive change and emotional growth after trauma. After caring for COVID 19

patients, nurses may experience some positive changes. Exploring these changes may assist nurses to find positive perspective and significance regarding their professional experience, which may alleviate the negative effect of traumatic work-related COVID 19 experiences and improve their general well-being [6].

Aim of this study

• Compare the level of anxiety, manifestation of physical and mental stress and anxiety among nurses working two medical centers with different levels of Corona virus exposure
• Examine the relationship between level of stress, anxiety, physical symptoms and posttraumatic growth.

Ethical Approvals

The Hospital's ethics Committee HMO approved the study (0892-20-HMO).

This study is a prospective quantitative cohort study using digital questionnaire distribution using convenience sampling.

Setting: This study took place at two medical centers in a capital city heavily populated with 3 principle religious sectors and public behavior is modest and conservative. Medical center A is a level one, 900 bed university hospital and medical center B is a level 3 hospital containing 350 beds. The city population of one million in a country of over 9 million inhabitants. The city was heavily infected with COVID 19. At the height of the third wave of the pandemic one-day Jan 14, 2021, 14,295 positive cases in the country and 1900 in this one city. On this day, medical center A hospitalized 125 COVID 19 patients (the highest number hospitalized in one medical center in the entire country), Medical center B did not hospitalize any COVID 19 patients.

Questionnaire Description Validity and Reliability: A descriptive cross-sectional survey, using anonymous validated questionnaires. To assess Post traumatic growth, the short form of the Posttraumatic growth inventory was used [7]. This questionnaire has been validated and widely used [5, 7]. The Hebrew translations of this questionnaire have been previously used in studies [7, 8].

Cronbach alpha psychometrics English version 0.90 and Hebrew version 0.90. To evaluate anxiety, mental and physical symptoms, the COVID 19 stress questionnaire was used. In a American and Canadian sample found internal consistency of 0.93 [9].

Materials and Instruments

COVID 19 Stress Questionnaire Includes Questions Related To:

Anxiety – the questionnaire contains 22 Likert scale items (e.g., “I am afraid that I will infect my family”), ranging from 0 (Completely not agree) to 7 (Completely agree). The inter reliability is (α= .91).

Mental Symptoms – the questionnaire contains 9 Likert scale items (e.g., “I feel moody”), ranging from 0 (Completely not agree) to 7 (Completely agree). The inter reliability is (α = .88).

Physical Symptoms – the questionnaire contains 2 Likert scale items (e.g., “I feel various pains”), ranging from 0 (Completely not agree) to 7 (Completely agree). The inter reliability is (α = .57).

Post Traumatic Growth – the questionnaire contains 10 Likert scale items (e.g., “I discovered that I am stronger than I thought”), ranging from 0 (Completely not agree) to 5 (Completely agree). The inter reliability is (α = .87).

Socio-demographic variables included age, gender, marital status, level of education, religious affiliation, place of work and if the nurse worked with COVID 19 patients yes or no.

The electronic survey was delivered to the nursing staff using the medical center e-mails and phone text messages to nurses' cell phones during the first quarter of 2021.

Inclusion Criteria: all nurses employed in both medical centers, who agreed to participate in the study.

Exclusion criteria: Nurses not able to read the language of the questionnaire, not having cell phone ability to receive text messages, and not an employee of either medical center.

Data Analysis

The data were analyzed using SPSS software version 25. Descriptive statistics were analyzed using means, standard deviations, and ranges for the continuous variables, and frequencies and percentages for the categorical variables. Correlations were assessed using Pearson tests. Differences were assessed using independent sample t-tests, One-way ANOVA and MANOVA. Post hoc pairwise tests were corrected using Hochberg correction. Multivariate analyses were conducted using Linear models. Linear models using the PROCESS software plugin by Hayes, with 5000 iterations, assessed moderations. Significance was considered for p-value lower than 0.05.

The sample was consisted of 536 nurses (86.7% females), with an average age of 45.15 y/o (SD= 12.23). The nurses in this city are reflective of the city population regarding religiosity, 36% ultra-religious, 31% define themselves as conservatively traditional religious and only 31% consider themselves secular [18]. Most of the sample were married or in relationship (79.3%), and the majority (78%) had an academic education. Most of the sample worked at Medical Center A -treating COVID 19 patients, (72.4%), and the rest at Medical Center B- not treating COVID 19 patients. (27.6%). About a half of the nurses treated COVID-19 patients (47.3%). Among them, a little more than a third worked less than one shift a week at the COVID-19 department (36.0%), a third worked between 1 to 2 shifts (29.6%), a tenth worked 3 to 4 shifts and a fifth worked the COVID-19 department only. Finally, most of the sample worked both during the first (73.1%) and the second (85.4%) waves of COVID-19.

Regarding the descriptive data of the study variables, total average of anxiety level was 3.84 (sd 1.72). The items scoring the highest anxiety were " I fear when someone coughs or sneezes near me, I will get sick" mean 4.10 (sd 2.06) and when I meet someone returning from abroad, I fear they are infected with COVID 19- mean 4.34 (sd 2.18). The total average of physical symptoms average 1.15 (sd 1.75) and average mental symptoms average score1.63 (sd 1.97) The average Post traumatic growth score was 2.83 (sd1.65) (Table 1).

Table 1: Means, standard deviations, ranges, frequencies, and percentages for the sample demographic characteristics.

Correlation Between Study Variables

The correlations between the study variables were assessed using Pearson correlations (see Table 2).

Table 2: Means, standard deviations, and Pearson correlations between the study variables.

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

1= Anxiety compared to mental symptoms

2 =physical symptoms compared to mental symptoms to anxiety.

3= post growth compared to physical symptoms mental symptoms and growth

The results show that Anxiety (M = 2.04, SD = 1.04) had positive correlations with Mental Symptoms (r = .52, p < .01), Physical Symptoms (r = .41, p < .01) and Post Traumatic Growth (r = .14, p < .01). Meaning, the higher the anxiety from the COVID-19 virus, the worse the mental and physical symptoms, but the higher the post traumatic growth.

The Mental Symptoms (M = 1.63, SD = 1.47) had a positive correlation with the Physical symptoms (r = .63, p < .01). Meaning, the worse the mental symptoms, the worse the physical symptoms.

The Physical Symptoms (M = 1.15, SD = 1.52) had a positive correlation with Post Traumatic Growth (M = 2.38, SD = 1.13; r = .17, p < .01). Meaning, the worse the physical symptoms the higher the posttraumatic growth.

H1: Anxiety from Exposure to the COVID-19 Is Positively Correlated with Mental and Physical Symptoms.

As table 2 shows, there are positive correlations between the anxiety levels and the mental (r = .52, p < .01), and physical symptoms’ levels (r = .41, p < .01). Meaning, greater the anxiety from exposure to the COVID-19 vires the worse the mental and physical symptoms. H1 was supported.

H2: Anxiety from Exposure to the COVID-19 Is Positively Correlated with Post Traumatic Growth.

As table 2 shows, there is a positive correlation between anxiety levels and post-traumatic growth (r = .14, p < .01). Meaning higher anxiety levels are correlated with higher post-traumatic growth. H2 was supported.

H3: Post Traumatic Growth Is Positively Correlated with The Symptoms’ Levels.

As table 2 shows, post-traumatic growth had a positive correlation with the physical symptoms (r = .17, p < .01), but it was not found to be correlated with the mental symptoms (r = .04, p = .36). Meaning, higher post-traumatic growth is correlated with poor physical state. H3 was partially supported.

Hypothesis 4: There Are Differences Between Demographic Groups at The Post Traumatic Growth (Table 3).

Table 3: Differences between demographic groups at the Post Traumatic Growth.

For assessing the differences between demographic groups at the Post Traumatic Growth independent samples t-tests and One-Way ANOVA tests were conducted. Post hoc pairwise comparisons were conducted using Hochberg’s correction. The correlation between the nurses' age and Post Traumatic Growth was assessed using Pearson correlation.

The results showed a difference between the nurses with different marital statuses (F (2, 529) = 4.77, p < .01). Specifically, singles (M = 2.78, SD = 1.01) had higher post traumatic growth in comparison with married or in relationship nurses (M = 232, SD = 1.14), (p < .01) (Figure 1).

No other differences were found.

The hypothesis was partially confirmed.

H5: There Are Differences Between Nurses Who Worked With COVID-19 Patients and Those Who Did Not at Study Variables (Table 4).

Table 4: Comparison between nurses who worked with COVID-19 patients and nurses who did not at the anxiety, symptoms, and post-traumatic growth levels.

For assessing the differences between nurses who worked with COVID-19 patients and those who did not at the anxiety, symptoms, and post-traumatic growth levels MANOVA model was conducted.

The results show that the nurses who worked at the COVID-19 department (M = 1.26, SD = 1.59) had greater physical symptoms in comparison with the nurses who worked at the regular department (M = 1.05, SD = 1.45), (F (1, 531) = 19.80, p < .01, ?2 = .04).

No other differences were found.

The hypothesis was partially supported.

Multivariate Analysis for Predicting Post Traumatic Growth (Table 5).

Table 5: Multivariate analyses for predicting Post Traumatic Growth mediated by department type.

For assessing the most important factors for predicting Post Traumatic Growth, linear regression was conducted. The predictors were the study variables, anxiety from COVID-19 infection levels, mental symptoms, and physical symptoms; as well as the marital status which was found to have a significant correlation with post-traumatic growth. The analysis was conducted for the whole sample, and for each subgroup (nurses who treated/did not treat COVID-19 patients) independently.

After controlling for the nurses’ marital status, the model which was conducted for the whole sample shows that high anxiety (β = .13, p < .01), high physical symptoms levels (β = .22, p < .01), and low mental symptoms (β = -.19, p < .01) predicted high post-traumatic growth.

For the nurses who did not treat COVID-19 patients, the results show positive correlation between physical symptoms and post-traumatic growth (β = .27, p < .01). However, for the nurses who treated COVID-19 patients, the results showed that high anxiety (β = .17, p = .03), and low mental symptoms (β = -.22, p = .01) predicted post-traumatic growth.

Mediation Models for Predicting Post-Traumatic Growth (Figure 2)

For assessing the hypotheses that mental and physical symptoms levels will mediate the correlation between anxiety levels and post-traumatic growth two regression models were conducted, with physical and mental symptoms degree as mediators.

Anxiety levels -> Physical Symptoms -> Post-traumatic Growth

The model was conducted using the PROCESS software plugin by Hayes, with 5000 iterations. The model showed a significant positive indirect effect between anxiety levels and post- traumatic growth (B = 0.06, CI [0.02, 0.10]). Specifically, anxiety levels are positively related to physical symptoms (B = 0.60, p < .01), which in turn leads to higher post traumatic growth (B = 0.10, p < .01). A full mediation path was found.

Anxiety levels -> Mental Symptoms -> Post-traumatic Growth

For assessing the hypothesis that mental symptoms levels will mediate the correlation between anxiety levels and post-traumatic growth a regression model was conducted, with mental symptoms degree as a mediator.

The model was conducted using the PROCESS software plugin by Hayes, with 5000 iterations. The model showed no significant indirect effect between anxiety levels and post-traumatic growth (B = -0.02, CI [-0.08, 0.03]).

The aim of this study was to explore differences in anxiety, mental and physical symptoms and posttraumatic growth in nurses working in two medical centers.

The current study found relatively low levels of posttraumatic growth. A study investigating 174 Chinese nurses found PTG score among frontline nurses was at moderate level, and South Korean nurses found a new Meaning to their work. The South Korean participants discovered new values during the pandemic and expressed being proud to work as a nurse delivering high quality care during an international pandemic [10]. A Spanish study explored 172 healthcare professionals; nurses' aides and physicians found that demands related to the fear of infection, were significantly associated to posttraumatic growth. The authors in the Spanish study summarize that the capability to keep equilibrium between work and recreational activities, despite by being overwhelmed by work, may display mental changes that allow healthcare professionals to be engaged with more recovery experiences after work [11]. These findings support the findings in our study.

In the current study 80% of sample are married or in relationship. The marital status was found to have a significant correlation with post-traumatic growth. In this study sample being single is found to be an important element in posttraumatic growth. A similar Chinese study exploring COVID 19 and post traumatic growth among nurses found no significant differences between married or single nurses [7]. Moderate to high PTG occurs more commonly in women, younger subjects, and professionals with training, extroversion and openness to experience [12].

Higher resilience was associated with greater family support, optimism, and positive religious coping, while higher posttraumatic growth was associated with greater optimism and positive religious coping. These findings underscore the protective role of optimism with respect to both resilience and posttraumatic growth. In a 2015 Israeli study comparing stress levels and growth between community working nurses and psychiatric nurses found psychiatric nurses reported higher levels of traumatic stress but lower levels of growth compared to community nurses. While stress symptoms were found to positively relate to growth among community nurses, these variables were negatively associated among psychiatric nurses [13]. These findings do not support results in the current study which found that higher the anxiety from the COVID-19 virus, the worse the mental and physical symptoms, but the higher the post traumatic growth. The difference in patient population, mental disease compared to COVID 19 pneumonia, may explain this. Nurses caring for COVID 19 patients are exposed in the media and have been demonstrated as national heroes [14]. This may have an impact on coping with stress and growth.

The general religiousness of the city population climate might have a protective factor in preventing post trauma. A Turkish qualitative study report that nurses received multi- dimensional support from their environment including work, family related and spiritual based. These sources of support enabled them to cope with the struggle. Social support empowers nurses in their struggle to care for patients during epidemics and may play an intermediary role in psychological rehabilitation [15].

In addition, this city has had much history of terror attacks and nurses have been exposed to many sources of trauma caring for mass casualties. Most nurses have successfully developed coping mechanisms to prevent post trauma stress and have established behaviors promoting growth. A 2020 Israeli study exploring 82 emergency room nurses found that the nurses' growth levels were immune to their stress levels [16]. The findings support the conception that positive post traumatic growth and secondary stress levels of trauma may co- exist and co-vary [17].

Another protective factor for this nurse population might be the hospital system administration. This management offered free psychology and psychiatric first aid and follow up for any and every nurse in need. Another action initiated by this hospital organization was to arrange nurse work schedules so that the same nurses did not have to work with COVID 19 patients consistently. The nurses were offered a split work schedule where they could work partially in their home units partially in COVID 19 units [20, 21].. The human resource department in the organization supported frontline nurses by organizing donations of food (cooked by well-known chefs), gifts to the COVID 19 staff and when nurses fell sick or couldn’t go home established living arrangements.

Although this study was conducted in two hospitals, it is still focused in one city with a very specific character and therefore, there is a need to examine these variables also among nurses working in other hospitals in Israel. This specific character may limit the generalizability of these study findings. Another limitation is the timing of data collection. This study was conducted during 2 months in 2021, although during one of the peak virus waves and we do not know whether the feeling of growth, anxiety, mental and physical symptoms change over time. Therefore, there is room to conduct this study again at another point in time to examine whether and what differences exist over time.

The findings of the study indicate that nurses have the ability to grow both in situations where anxiety is high and in exceptional pandemic situations. At the same time, in order for nurses to be able to grow after traumatic situations in health organizations, it is important to learn and strengthen the sources of strength that allow nurses to grow. Our research shows that a support network such as marriage and friends increase the likelihood of growth after trauma and organizations may need to develop a social support system among peers that will enable shared growth.

Implications for Nursing Management

In spite of this nurse sample demonstrating levels of stress, anxiety, and physical symptoms when caring for COVID 19 patients, professional growth exists. This is essential for frontline nurses to know and nurse leaders. We can use this information when preparing nurses for work in COVID 19 departments and for supporting them throughout their clinical experience. We should attempt to emphasize the positive professional benefits of working in this stressful environment.

Nursing management and administration can use the findings from this study to see the "big picture" during crisis situations. Nurse leaders can support frontline nurses in understanding that after overcoming stressful crisis situations, a period of professional growth can occur.

Developing workshops and seminars illustrating the post traumatic growth phenomenon may assist nurse leaders in providing resources for frontline nurses. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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