# Meso-organisational determinants of healthcare workers' resilience: results of a scoping review

Natalia Oprea, Giorgio Giacomelli, Marco Sartirana, Elisabetta Trinchero, Irène Georgescu

► To cite this version:

Natalia Oprea, Giorgio Giacomelli, Marco Sartirana, Elisabetta Trinchero, Irène Georgescu. Meso-organisational determinants of healthcare workers' resilience: results of a scoping review. Health Policy, 2025, 161, 10.1016/j.healthpol.2025.105412. hal-05491813

HAL Id: hal-05491813

https://hal.science/hal-05491813v1

Submitted on 3 Feb 2026

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_1.png" /></figure>

Distributed under a Creative Commons CC BY 4.0 - Attribution - International License
# Meso-organisational determinants of healthcare workers’ resilience: results of a scoping review

Natalia Oprea<sup>a, *, †</sup>, Giorgio Giacomelli<sup>a</sup>, Marco Sartirana<sup>a</sup>, Elisabetta Trinchero<sup>a</sup>, Irène Georgescu<sup>b</sup>

<figure><img src="image_2.png" /></figure>

## ARTICLE INFO

### Keywords:

Resilience

Healthcare workforce, Meso-level factors

## ABSTRACT

**Background:** Recent financial, environmental, and health crises have underscored the critical—but often overlooked—role of healthcare workers (HCWs) for health system resilience. Given the ongoing physical and psychological demands placed on this workforce, understanding the factors that influence their resilience is essential.

**Objective:** This scoping review aimed to map and synthesise multidisciplinary evidence on meso-level organisational factors that influence individual resilience among HCWs. Specifically, we focused on identifying workplace-related risk and protective factors within the immediate organisational environment.

**Methods:** A scoping review was conducted across multidisciplinary literature, targeting studies that examined individual resilience outcomes in relation to meso-level workplace factors. This approach allowed for the inclusion of diverse study designs and disciplinary perspectives relevant to the research question.

**Results:** A total of 66 studies met the inclusion criteria. The analysis highlighted the importance of intermediate organisational factors—such as job characteristics and empowerment, interpersonal dynamics (e.g., team cohesion, supervisory support), and psychosocial workplace conditions—in shaping HCW resilience.

**Conclusion:** Although resilience is often viewed as an individual trait, this review demonstrates the critical role of meso-level organisational environments in fostering and sustaining HCW resilience. The findings support the need for policies and interventions that strengthen team functioning and workplace climate. Future research should focus on operationalising these insights into actionable strategies that bridge individual and systemic approaches to workforce resilience.

## Research in context

What is already known about this topic?

Healthcare workers (HCWs) are recognised as a bedrock of public health, yet recent crises exposed the rising social and economic costs of their mental health and well-being. Resilience, understood as the individuals and groups' ability to adapt to adversity, offers a crucial lens to address these challenges. Most research on HCWs' resilience spans different disciplines and is often separately examined at system-level, organisational or individual level.

What does this study add to the literature?

This study adopts a meso-level perspective, focusing on how factors such as supervisor-worker interactions, team dynamics, and workplace environments shape HCWs' resilience. By acknowledging the interplay between individual, professional, and environmental determinants, the study suggests a shift from instrumental to context-sensitive interventions, emphasising the importance of both content and implementation process for optimal effectiveness.

What are the policy implications?

This study highlights the role of intermediate level factors affecting individual resilience. To that purpose, policymakers can support health organisations in (1) designing interventions that mitigate threats impacting organisational climate, develop

<footnote><sup>a</sup> Centre for Research on Health and Social Care Management (CeRGAS), SDA Bocconi School of Management, Milan, Italy</footnote>

<footnote><sup>b</sup> MRM, University of Montpellier, Montpellier, France</footnote>

<footnote>* Corresponding author. Via Sarfatti 10, Milan, Italy.</footnote>

<footnote>E-mail addresses: natalia.oprea@sdabocconi.it (N. Oprea), giorgio.giacomelli@sdabocconi.it (G. Giacomelli), marco.sartirana@unibocconi.it (M. Sartirana), elisabetta.trinchero@unibocconi.it (E. Trinchero), irene.georgescu@umontpellier.fr (I. Georgescu).</footnote>
autonomy and role clarity, (2) developing context-specific prop- ositions of quality of life at work at the intermediate level, and (3) increasing middle managers training to support team and HCWs' resilience.

# 1. Background

Health systems across Europe, and elsewhere, were already strug- gling with multiple crises when COVID-19 hit, unveiling systemic vul- nerabilities related to inadequate resource allocation, weak foresight in planning, and insufficient crisis preparedness [1]. These shortcomings highlighted the urgent need for transformative policy reforms to enhance healthcare systems' resilience. Central to this discourse is the role of healthcare workers (HCWs), recognised as the bedrock of public health, yet persistently under-prioritised on the policy agenda [2,3]. The physical and mental demands placed on HCWs extend beyond the pandemic, reinforcing the need to prioritise their well-being [4] and resilience [5]. The social and economic costs of HCWs' mental health have increased since COVID-19 [6]. Across OECD countries, more HCWs are expressing intent to quit, threatening the “capacity of health systems to respond to current and future health and care needs and to be more resilient” [7, p. 68]. While their contributions during the pandemic have been acknowledged, further organisational support is needed in the post-pandemic era [8]. Despite growing attentions, the ‘human face’ of the HCWs’ crisis remains poorly understood, leaving policymakers with limited actionable insights [5].

Resilience offers a crucial lens to address these challenges by developing new solutions across nations. Literature on resilience in the workplace is extensive, and its conceptual boundaries are blurred [9, 10]. At its core, resilience refers to how individuals and groups adapt to adversity. It involves effective coping, recovery, and dynamic adjust- ment to uncertain conditions [9]. Evidence shows that individual resil- ience can buffer the effects of workplace stress and improve psychosocial outcomes for nurses [11] and physicians [12], while also enhancing practitioners' performance and care quality. Conversely, prolonged exposure to workplace stressors depletes resources, leading to psychological distress, burnout, reduced well-being, and compromised patient safety [13,14].

Most research on HCWs' resilience focuses on system-level [15], organisational or individual factors [11]. However, in the new normal of permacrisis, Burau et al. [16] call for greater understanding of how the combination and dynamics of health systems, policy actors and policy responses occur at different levels. By doing so, it invites researchers to apprehend the dynamic aspects and interactions within organisations at multiple levels, which could elucidate why anticipated health policy objectives are not consistently met. Limited attention has been given to the dynamics between actors within health care organisations. However, recent studies conducted during the COVID-19 pandemic highlight the critical role of managing team dynamics [17]. Building upon this, we propose that the intermediate level of organisations warrants particular attention when developing whole-system approaches for HCWs' resi- lience. This study adopts a meso-level perspective, i.e. the intermediate level of organisations, focusing on how factors such as supervisor-worker interactions, team dynamics, and workplace envi- ronments shape resilience. We conceptualise this as a 'close workplace environment' for HCWs that lies between individual-directed in- terventions and organisation-wise ones. To explore this dimension, we conducted a scoping review guided by the research question: *How are meso-level factors associated with the resilience of HCWs?* The goal was to understand the influence of these factors on individual HCWs' resilience and inform future systematic reviews.

The paper proceeds as follows: Section 2 outlines the methodology; Section 3 presents and discusses the findings; Section 4 concludes with implications for research and policy.

# 2. Methods

We conducted a scoping review to identify and analyse published multidisciplinary literature on individual (mental) health outcomes and workplace-related risk or protective factors. A scoping review was chosen over a systematic review due to the broad nature of our research question and the anticipated diversity in study designs and perspectives [18]. Our aim was to map and systematise concepts and factors to gain a holistic understanding of the phenomenon (see Supplementary Mate- rial). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [19] to ensure transparency and rigour.

A systematic search strategy was developed [20]. First, we explored existing reviews and conducted a preliminary search in Scopus database to refine key terms. The final search string for the title, abstract and keywords covered two areas of research: *resilience* and healthcare *teams/units* (see Supplementary File 1). We searched three data- bases—Web of Science, Scopus, and PubMed—for English-language articles published between 2014 and 2024. A 10-years span was selected to capture both structural and recent, pandemic-related de- velopments. Limiting the timeframe to the past five years would risk bias COVID-19 effects. The literature search was finalised in March 2024.

All records were imported into a reference manager for de- duplication and then transferred to ASReview, an AI-aided, open- source tool that supports title and abstract screening [21]. ASReview uses an active researcher-in-the-loop machine learning algorithm to rank articles from high to low probability of eligibility for inclusion by text mining. Initial rankings of records are generated by informing the tool with at least one relevant and one irrelevant record. The tool then presents the most relevant titles and abstracts for reviewer's appraisal, updating its rankings iteratively based on eligibility decisions.

Four reviewers (NO, ET, MS, GG) independently screened 2271 records (31 % of the total identified records) in ASReview, with each record reviewed by at least two researchers. Discrepancies were resolved by a third reviewer. Because ASReview lacks a built-in stopping mechanism, either a sampling or heuristic criterion can be applied to determine when to stop screening [22]. In this study, we used the *sampling* criterion, which involves stopping after reviewing a set proportion of high-ranked records (e.g., 10 %). Some studies indicate that screening between 8 % and 33 % of records is sufficient to identify 95 % of relevant articles [23], while more recent evidence in the health policy domain supports 25 % as a reliable threshold [24]. For this study, screening continued after 25 % of total re- cords had been reviewed, ending when 100 consecutive irrelevant articles were found, yielding 2271 screened articles out of 7462 total or 31 %.

Eligibility was guided by the Population, Intervention, Context and Outcomes (PICO) framework (see Table 1). The target population included all healthcare professionals, such as nurses and physicians, including residents, nurses, and physicians in training. We focused on meso-level factors—team dynamics, supervisory relationship, autonomy, scheduling, and stressors from the unit environments. The semantic scope of the review, initially centred on resilience, was broadened via an iter- ative keyword refinement process [25] – is particularly advantageous when the conceptual breadth or semantic variability of a topic necessi- tates a flexible search strategy. In this instance, it facilitated navigating the linguistic heterogeneity and homonymy prevalent in research

<table><caption>**Table 1**

Description of PICO elements.</caption><thead><tr><td>Component</td><td>Description</td></tr></thead><tbody><tr><td>P (population/patient/ problem)</td><td>Clinicians and nurses (physicians, doctors, medical residents)</td></tr><tr><td>I (intervention, exposure)</td><td>Meso-organisational factors (leadership, teams, teamwork, workload, job demand, supervisors, shift organisation)</td></tr><tr><td>C (comparator/context)</td><td>OECD+ countries</td></tr><tr><td>O (outcome)</td><td>Resilience, mental health, well-being</td></tr></tbody></table>
exploring HCWs' resilience, where conceptual overlap with other positive psychology constructs is frequently observed [10]. It also served to include older, yet informative, contributions: such studies might otherwise be overlooked due to the increased scholarly use of the term *resilience* post-COVID-19 pandemic, which could artificially inflate its recent representation despite substantial conceptual overlap. Therefore, despite a primary interest in meso-level factors correlating with individual resilience, including other HCWs' outcomes frequently addressed in positive psychology, namely *well-being* and *mental health*.

Included articles were primary studies (experimental/quasi-experimental, observational, qualitative), published in Q1-Q3 journals indexed by SciMago, set in clinical healthcare settings (e.g., hospital) of OECD+ countries. The review excluded papers that did not address outcomes at the individual level but focused on resilience of organisations. Our specific focus was on physicians and nurses, therefore contributions that did not include one of these healthcare professions were excluded. Furthermore, articles that studied medical students or were conducted in settings other than hospitals were excluded due to the difference in how resilience might be experienced. Finally, articles that investigated only the experience of workplace protective or risk factors without making a connection to our dependent variables were excluded. Reviews, editorials, protocols, and conference abstracts were also excluded.

Data were extracted using a structured charting form based on the Joanna Briggs Institute manual [26]. The form included: (a) articles

details (authors, publication year, journal, country, research design, methods); (b) study characteristics (aims, setting, population and sample, theoretical framework); (c) outcome variables and measurement at the individual, meso and organisational level, and key findings.

To integrate evidence, our analysis followed a two-step process. First, a descriptive summary examined geographical and temporal trends, study design and outcomes. Second, a qualitative thematic analysis focused on meso-level factors. We grouped these factors thematically, ensuring that we retained granularity while simultaneously building a comprehensive understanding of the themes and associated sub-themes. This configurative approach, characteristic of scoping reviews, facilitated the categorisation and summarisation of evidence [27]. The initial phase involved inductively mapping all patterns and outcome relationships, including their directionality [28], to visually illustrate the scope and trends of the research [27]. A visual synthesis revealed thematic clusters, which were refined through comparison with original article description. Multiple team discussions validated and adjusted the emerging themes. The final sub-themes represent interconnected meso-level factors shaping HCWs' resilience and well-being.

### 3. Results

Our initial search yielded 7462 records after removing duplicates. After screening, 234 relevant articles were reviewed in full, and 66

<figure><img src="image_3.png" /><figcaption>Fig. 1. PRISMA-ScR flow diagram.</figcaption></figure>
studies met inclusion criteria for data extraction and analysis. The PRISMA-ScR flowchart summarising this process is presented in Fig. 1 [19].

### 3.1. Overview of studies

The 66 included studies covered a range of countries: 12 from the USA, 10 from Australia, five each from Canada and the UK, and four each from Germany and Spain. Most studies (40 studies, 64 %) were published after 2021. Despite the timeframe, only 18 studies (29 %) focused specifically on COVID-19-related aspects.

Survey-based design (cross-sectional or longitudinal) dominated the methodological landscape (43 studies, 71 %), followed by 10 qualitative studies, mostly using semi-structured interviews. Observational and mixed-method designs each appeared in seven studies.

The topic of HCWs' resilience and well-being appeared across multiple disciplinary domains. Half of the studies (33) were published in healthcare management journals, which addressed a broad spectrum of healthcare management themes published by the Journal of Nursing Management (6), the International Journal of Environmental Research and Public Health (4), the International Journal of Nursing Studies (4), PLOS One (4) and Health Care Management Review (2). An additional 16 studies (25 %) stemmed from the field of medicine and clinical nursing, with BMJ Open contributing 8 articles. The remainder came from applied psychology, occupational health, and public and HR management journals.

In terms of population, nurses were the most frequently studied group (32 studies), followed by interprofessional samples (nurses and physicians, sometimes including technicians or nurse assistants, 21 studies), and physicians or junior physicians (12 studies). Studies were conducted in diverse acute care settings, including general, teaching/ academic, specialised hospitals (forensic, psychiatric hospitals, children's hospitals), in both public and private systems. Sample sizes ranged from 10 to 23,087, with a median of 356 participants.

Burnout, including three dimensions of exhaustion, depression, and anxiety, and stress were the most studied outcomes, addressed in nearly 60 % of studies. Resilience and well-being were the primary focus in 38 % of papers. Burnout and well-being were more commonly studied in nurses, while stress was more often addressed in physician-focused studies.

The predominance of nursing-focused research may reflect greater survey accessibility and numerical representation of nurses in the workplace. However, the relative underrepresentation of physicians may contribute to less visibility of physicians' mental health concerns. Only few studies directly compared outcomes across professional groups, and fewer still explored differences in contributing factors affecting physicians versus nurses. A full overview of study characteristics is provided in Table 2.

### 3.2. The concept of resilience

The literature on HCWs' resilience spans psychology, sociology, organisational behaviour, health services management, and health policy. However, these perspectives are rarely integrated, leading to disciplinary siloing that impedes the development of comprehensive, transdisciplinary understanding of HCWs' resilience and the implementation of solutions in practice. This fragmentation is also reflected in the often-ambiguous conceptualisation of constructs proximal to resilience in the literature [10,29]. Increasingly, resilience is employed to understand the multifaceted responses of individuals and groups to demanding circumstances [9]. Burn and colleagues [9] offer a valuable framework of five key resilience components, serving as a heuristic for this review: surmounting adversity, adaptation, effective recovery ('bouncing back'), ordinariness, and mental health as a significant correlate. The initial three components are characteristic behavioural expressions of resilience, while the fourth underscores its

non-exceptional nature, and the fifth highlights one of its most frequent correlates. Iasiello and colleagues [10] further show that resilience and well-being are frequently analysed within the umbrella concept of positive mental health, revealing areas of convergence and divergence. These initial conceptualisations offer a dual benefit: first, they bring attention to core defining attributes; second, they underscore the common conceptual link in the literature between resilience, mental health, and well-being within the broader discourse of HCWs' positive psychology.

### 3.3. Meso-level factors

The factors identified in this review were categorised considering, on one hand, the thematic categories within which the main factors (antecedents of resilience) are grouped, and on the other hand, the nature of the relationship these factors have with the outcomes considered (i.e., whether they are a source of support or demand). Antecedents of resilience were grouped in three overarching categories, namely *relational factors*, *job-related factors*, and *environment-related factors*.

Table 3 summarises this classification, while the following sections outline the main findings across studies.

#### 3.3.1. Relational factors

##### Co-worker interaction

Supportive, respectful, and trusting relationships among colleagues were found to influence HCWs' well-being, work experience and delivery of quality patient care. A positive teamwork climate—marked by coordination, open communication and mutual support—was linked to increased resilience scores (+7 %) [30]. Informal social contact and peer mentoring (e.g. one-on-one conversations) further enhance team cohesion.

During the COVID-19 pandemic, Kranenburg and fellows [31] found that supportive team spirit, based on safety, trust and a sense of belonging within teams contributed to HCWs' resilience. Collaborating in teams where appreciation and respect are shown, with clear division of tasks, was highly valued by professionals. Similarly, Brown et al. [32] found that tightly-knit teams, altruism, and camaraderie between nursing staff provided sources of resilience to frontline workers. Surgeons cited social connectedness (i.e. physical proximity) and ease of communication as protective factors against burnout, especially under distancing restrictions [33].

Social support is a protective resource for employees in high-strain environments. Increased social support from teammates is associated with higher resilience scores and workplace well-being [34], or lower psychological distress [35]–[37]. Colleague emotional support—reassuring and caring for others, encouraging and attentively listening—was linked to reduced nurse's burnout, with a stronger effect on depersonalisation and emotional exhaustion [38]. Similarly, nurses struggling with emotional control who received a co-worker support during the workday felt less emotionally exhausted after work [39]. Effective co-worker support can moderate the effects of traumatic events (patient assault, patient death by suicide) [40], being associated with fewer health symptoms and lower safety concerns. Daily social support mitigated the effects of workplace incivility [41], and reduced depressive symptoms and disengagement when combined with supervisory support [42,43]. Interventions designed to strengthen teams' cohesive-ness, such as explicit, structured peer mentoring, could favour one-on-one contact at potential times of stress and benefit teamwork climate in the unit [30].

Conversely, conflicts, disrespect, incivility, favouritism, and unfair treatment in units or departments negatively affect team dynamics and ultimately individuals' health outcomes.

Workplace incivility experienced daily instils a climate of disrespectful interactions and rudeness among HCW, leading to increased emotional exhaustion after work, reduced daily vitality and affected bedtime [41], as well as reduced well-being [44,45]. Interestingly, some
<table><caption>**Table 2**

Characteristics of included articles.</caption><thead><tr><th>Reference</th><th>Country</th><th>Population</th><th>Observations</th><th>Setting</th><th>Research design</th><th>Theories</th><th>Outcome(s)</th><th>Covid-19 related</th></tr></thead><tbody><tr><td>Atkins et al. (2023)</td><td>US</td><td>HCPs (mixed)</td><td>1127</td><td>Hospitals</td><td>Mixed methods</td><td>N/A</td><td>Psychological distress</td><td>Yes</td></tr><tr><td>Bae et al. (2021)</td><td>South Korea</td><td>Nurses</td><td>166</td><td>University hospitals (N = 2)</td><td>Quantitative (observational)</td><td>N/A</td><td>Burnout</td><td>No</td></tr><tr><td>Barros et al. (2022)</td><td>Portugal</td><td>HCPs (mixed)</td><td>479</td><td>Public (N = 3) and private (N = 2) hospitals</td><td>Quantitative (observational)</td><td>N/A</td><td>Depression and anxiety</td><td>Yes</td></tr><tr><td>Bernburg et al. (2016)</td><td>Germany</td><td>Doctors</td><td>435</td><td>Hospitals (N = 12)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Stress and depression</td><td>No</td></tr><tr><td>Blanco-Donoso et al. (2017)</td><td>Spain</td><td>Nurses</td><td>370<sup>1</sup></td><td>Hospitals</td><td>Quantitative (observational)</td><td>Conservation of Resources (COR) Theory</td><td>Emotional exhaustion, fatigue, and negative affect; psychological detachment</td><td>No</td></tr><tr><td>Brewer et al. (2023)</td><td>US</td><td>Nurses</td><td>147</td><td>Hospital (N = 1)</td><td>Quantitative (observational)</td><td>Clinician Well-being Framework</td><td>Well-being</td><td>Yes</td></tr><tr><td>Brown et al. (2021)</td><td>Australia</td><td>HCPs (mixed)</td><td>20</td><td>Hospitals (N = 5)</td><td>Mixed methods</td><td>N/A</td><td>Resilience and stress</td><td>Yes</td></tr><tr><td>Burns et al. (2021)</td><td>Canada</td><td>Doctors</td><td>400</td><td>Hospital (N = 1)</td><td>Quantitative (observational)</td><td>N/A</td><td>Burnout</td><td>No</td></tr><tr><td>Carmona-Cobo & Lopez-Zafra (2022)</td><td>Spain</td><td>Nurses</td><td>96</td><td>Hospitals</td><td>Quantitative (observational)</td><td>N/A</td><td>Emotional exhaustion</td><td>No</td></tr><tr><td>Chana et al. (2015)</td><td>UK</td><td>Nurses</td><td>102</td><td>Acute NHS trust<sup>2</sup></td><td>Quantitative (observational)</td><td>N/A</td><td>Burnout, psychological distress</td><td>No</td></tr><tr><td>Chatzioannidis et al. (2018)</td><td>Greece</td><td>Nurses and doctors</td><td>635</td><td>Hospitals (N = 17)</td><td>Quantitative (observational)</td><td>N/A</td><td>Psychological distress</td><td>No</td></tr><tr><td>Corgan et al. (2021)</td><td>US</td><td>Doctors</td><td>14</td><td>Psychiatric hospital (N = 1)</td><td>Qualitative</td><td>N/A</td><td>Well-being</td><td>No</td></tr><tr><td>Daouda et al. (2022)</td><td>France</td><td>HCPs (mixed)</td><td>694</td><td>Hospital (1 = N)</td><td>Quantitative (observational)</td><td>N/A</td><td>Perceived stress, Fatigue</td><td>No</td></tr><tr><td>Debets et al. (2022)</td><td>Netherlands</td><td>Doctors</td><td>385</td><td>Hospitals</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Burnout</td><td>No</td></tr><tr><td>De Wijn et al. (2022)</td><td>Netherlands</td><td>Nurses</td><td>701</td><td>Hospitals (N = 19)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Emotional exhaustion, depersonalisation, post-traumatic stress</td><td>No</td></tr><tr><td>Diehl et al. (2021)</td><td>Germany</td><td>Nurses</td><td>437</td><td>Various<sup>3</sup></td><td>Quantitative (observational)</td><td>Stress-Strain-Resources Model</td><td>Resilience, Burnout</td><td>No</td></tr><tr><td>Finuf et al. (2021)</td><td>US</td><td>HCPs (mixed)</td><td>44</td><td>Hospitals (N = 14)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Burnout, subjective well-being</td><td>Yes</td></tr><tr><td>Fond et al. (2022)</td><td>France</td><td>HCPs (mixed)</td><td>10,325</td><td>Public and private hospitals</td><td>Quantitative (observational)</td><td>N/A</td><td>Depression and emotions regulation</td><td>Yes</td></tr><tr><td>Forbes et al. (2019)</td><td>Australia</td><td>Junior doctors</td><td>15</td><td>University hospitals (N = 3)</td><td>Qualitative</td><td>N/A</td><td>Well-being</td><td>No</td></tr><tr><td>Gilardi et al. (2019)</td><td>Italy</td><td>Nurses</td><td>356</td><td>Hospitals (N = 4)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Burnout</td><td>No</td></tr><tr><td>Gomez-Lopez et al. (2019)</td><td>US</td><td>HCPs (mixed)</td><td>1594</td><td>University hospitals (N = 2)</td><td>Quantitative (observational)</td><td>Job Demand-Control-Support (JDCS) Model</td><td>Psychological distress</td><td>No</td></tr><tr><td>Hesselgreaves & Scholarios (2014)</td><td>UK</td><td>HCPs (mixed)</td><td>247</td><td>Hospitals (N = 5)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Strain</td><td>No</td></tr><tr><td>Hong et al. (2021)</td><td>South Korea</td><td>Nurses</td><td>319</td><td>Hospitals<sup>4</sup></td><td>Quantitative (observational)</td><td>N/A</td><td>Post-traumatic stress</td><td>No</td></tr><tr><td>Jelen et al. (2024)</td><td>Canada</td><td>Nurses and doctors</td><td>58</td><td>Quaternary care network (N = 1)</td><td>Qualitative</td><td>N/A</td><td>Distress</td><td>Yes</td></tr><tr><td>Jubin et al. (2023)</td><td>Switzerland</td><td>Nurses</td><td>1013</td><td>Hospitals (N = 8)</td><td>Quantitative (observational)</td><td>Neuman System Model</td><td>Well-being</td><td>Yes</td></tr><tr><td>Kang & Han (2021)</td><td>South Korea</td><td>Nurses</td><td>435</td><td>Hospital (N = 1)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Resilience</td><td>No</td></tr><tr><td>Kedmi-Shahar et al. (2022)</td><td>Israel</td><td>Nurses</td><td>50</td><td>Hospitals (N = 8)</td><td>Qualitative</td><td>N/A</td><td>Yes</td><td>Yes</td></tr><tr><td>Kelly et al. (2021)</td><td>US</td><td>HCPs (mixed)</td><td>348</td><td>Forensic mental hospital (N = 1)</td><td>Quantitative (observational)</td><td>N/A</td><td>Safety and well-being after patient violence</td><td>No</td></tr><tr><td>Kilroy et al. (2022)</td><td>Canada</td><td>Nurses</td><td>2174</td><td>Hospitals (N = 105)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Burnout, Psychological empowerment</td><td>No</td></tr><tr><td>Kohnen et al. (2023)</td><td>Belgium</td><td>Nurses</td><td>1729</td><td>Hospitals</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Burnout</td><td>No</td></tr><tr><td>Kohnen et al. (2024)</td><td>Belgium</td><td>Nurses</td><td>1117</td><td>Hospitals (N = 13)</td><td>Quantitative (observational)</td><td>Self-Determination Theory (SDT); Job</td><td>Burnout</td><td>No</td></tr></tbody></table>

(continued on next page)
<table><caption>Table 2 (continued)</caption><thead><tr><th>Reference</th><th>Country</th><th>Population</th><th>Observations</th><th>Setting</th><th>Research design</th><th>Theories</th><th>Outcome(s)</th><th>Covid-19 related</th></tr></thead><tbody><tr><td>Kowalczuk et al. (2020)</td><td>Poland</td><td>Nurses</td><td>558</td><td>Hospitals</td><td>Quantitative (observational)</td><td>Demands-Resources (JDR) Model<br>Job Demand Control (JDC) Theory</td><td>Subjective work experience; subjective general health</td><td>No</td></tr><tr><td>Kranenburg et al. (2022)</td><td>Netherlands</td><td>HCPs (mixed)</td><td>38</td><td>University hospital (N = 1)</td><td>Qualitative</td><td>Job Demands-Resource (JDR) Model</td><td>Resilience and vitality</td><td>Yes</td></tr><tr><td>Kunie et al. (2017)</td><td>Japan</td><td>Nurses</td><td>789</td><td>Hospitals (N = 3)</td><td>Quantitative (observational)</td><td>Motivating Language Theory</td><td>Psychological distress</td><td>No</td></tr><tr><td>Lanzara et al. (2023)</td><td>Various<sup>5</sup></td><td>Nurses and doctors</td><td>612</td><td>Hospitals (N = 7)</td><td>Quantitative (observational)</td><td>N/A</td><td>Depression and anxiety</td><td>Yes</td></tr><tr><td>Laschinger & Nosko (2015)</td><td>Canada</td><td>Nurses</td><td>1205</td><td>Hospitals</td><td>Quantitative (observational)</td><td>Positive Organisational Behaviour (POB)</td><td>Post-traumatic stress disorder</td><td>No</td></tr><tr><td>Lee et al. (2015)</td><td>US</td><td>Nurses and doctors</td><td>1066</td><td>Children hospitals (N = 19)</td><td>Quantitative (observational)</td><td>N/A</td><td>Resilience</td><td>No</td></tr><tr><td>Lee et al. (2023)</td><td>Australia</td><td>Nurses</td><td>167</td><td>Public (92 %) and private (11 %) hospitals</td><td>Mixed methods</td><td>N/A</td><td>Psychological distress and subjective well-being</td><td>Yes</td></tr><tr><td>Leineweber et al. (2014)</td><td>Sweden</td><td>Nurses</td><td>23,087</td><td>Hospitals (all in the country)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Burnout</td><td>No</td></tr><tr><td>Madathil et al. (2014)</td><td>US</td><td>Nurses</td><td>89</td><td>Hospitals</td><td>Quantitative (observational)</td><td>N/A</td><td>Depression, Burnout</td><td>No</td></tr><tr><td>Maffoni et al. (2022)</td><td>Italy</td><td>HCPs (mixed)</td><td>315</td><td>Hospitals (N = 6)<sup>6</sup></td><td>Quantitative (observational)</td><td>Conservation of Resources (COR) Theory</td><td>Resilience, well-being</td><td>No</td></tr><tr><td>Magnavita et al. (2022)</td><td>Italy</td><td>HCPs (mixed)</td><td>218</td><td>Hospital (N = 1)</td><td>Quantitative (observational)</td><td>Organisational Justice Theory</td><td>Mental health</td><td>No</td></tr><tr><td>Manchanda et al. (2021)</td><td>US</td><td>Nurses and doctors</td><td>154<sup>7</sup></td><td>Hospitals (N = 2)</td><td>Mixed methods</td><td>Gender Socialization Theory</td><td>Burnout</td><td>No</td></tr><tr><td>McLinton et al. (2018)</td><td>Australia</td><td>HCPs (mixed)</td><td>27</td><td>Hospitals (N = 3)</td><td>Mixed methods</td><td>Job Demands-Resource (JDR) Model</td><td>Psychological safety</td><td>No</td></tr><tr><td>Nelson et al. (2014)</td><td>Brazil</td><td>Nurses</td><td>868</td><td>Hospitals (N = 4)</td><td>Quantitative (observational)</td><td>Social Exchange Theory (SET)</td><td>Psychological Well-being</td><td>No</td></tr><tr><td>Newnham et al. (2023)</td><td>Australia</td><td>Nurses</td><td>431</td><td>Hospitals (N = 4) and mental health clinic (N = 1)</td><td>Quantitative (observational)</td><td>N/A</td><td>Depression and anxiety</td><td>No</td></tr><tr><td>Pavithra et al. (2023)</td><td>Australia</td><td>Nurses and doctors</td><td>512</td><td>Hospitals (N = 7)</td><td>Quantitative (observational)</td><td>N/A</td><td>Subjective well-being</td><td>No</td></tr><tr><td>Ralph et al. (2021)</td><td>Canada & US</td><td>Nurses</td><td>36</td><td>Hospitals<sup>8</sup></td><td>Qualitative</td><td>N/A</td><td>Psychological well-being</td><td>Yes</td></tr><tr><td>Rees et al. (2019)</td><td>Australia</td><td>Nurses</td><td>1884</td><td>Hospitals and community nursing<sup>9</sup></td><td>Quantitative (observational)</td><td>Job Demands-Control (JDCS) Theory; Job Demands-Resources (JDR) Model; Conservation of Resources (COR) Theory</td><td>Burnout and Resilience</td><td>No</td></tr><tr><td>Reknes et al. (2014)</td><td>Norway</td><td>Nurses</td><td>2059 at t1, 1582 at t2</td><td>Hospitals</td><td>Quantitative (observational)</td><td>Cognitive Activation Theory of Stress (CATS)</td><td>Depression and anxiety</td><td>No</td></tr><tr><td>Riley et al. (2021, A)</td><td>UK</td><td>Junior doctors</td><td>21</td><td>Hospitals</td><td>Qualitative</td><td>N/A</td><td>Work-related stress/ distress</td><td>No</td></tr><tr><td>Riley et al. (2021, B)</td><td>UK</td><td>Junior doctors</td><td>21</td><td>NHS</td><td>Qualitative</td><td>N/A</td><td>Stress</td><td>No</td></tr><tr><td>Salas-Vallina et al. (2022)</td><td>Spain</td><td>Doctors</td><td>518</td><td>Hospitals</td><td>Quantitative (observational)</td><td>Self-Determination Theory (SDT)</td><td>Individual resilience</td><td>Yes</td></tr><tr><td>Salehi et al. (2023)</td><td>Australia</td><td>Nurses and doctors</td><td>163</td><td>Hospitals</td><td>Quantitative (observational)</td><td>Conservation of Resources (COR) Theory</td><td>Employee well-being</td><td>Yes</td></tr><tr><td>Sampaio et al. (2022)</td><td>Portugal</td><td>Nurses</td><td>247</td><td>Hospitals, community health centres, private clinic</td><td>Quantitative (observational)</td><td>Neuman System Model</td><td>Well-being and quality of Life</td><td>Yes</td></tr><tr><td>Schneider et al. (2019)</td><td>Germany</td><td>Nurses and doctors</td><td>350<sup>10</sup></td><td>Tertiary hospital (N = 1)</td><td>Mixed methods</td><td>Systems Engineering Initiative for Patient Safety (SEIPS) framework</td><td>Well-being</td><td>No</td></tr><tr><td>Sillero & Zabalegui (2018)</td><td>Spain</td><td>Nurses</td><td>130</td><td>University hospital (N = 1)</td><td>Quantitative (observational)</td><td>N/A</td><td>Burnout</td><td>No</td></tr><tr><td>Skinner et al. (2018)</td><td>Australia</td><td>Nurses</td><td>24</td><td>Hospitals</td><td>Qualitative</td><td>Organisational Justice Theory</td><td>Subjective well-being</td><td>No</td></tr><tr><td>Tawfik et al. (2023)</td><td>US</td><td>Nurses</td><td>16,797</td><td>Community hospitals and regional referral hospitals</td><td>Quantitative (observational)</td><td>N/A</td><td>Emotional exhaustion, Intentions to Leave</td><td>No</td></tr></tbody></table>

(continued on next page)
<table><caption>**Table 2 (continued)**</caption><thead><tr><th>Reference</th><th>Country</th><th>Population</th><th>Observations</th><th>Setting</th><th>Research design</th><th>Theories</th><th>Outcome(s)</th><th>Covid-19 related</th></tr></thead><tbody><tr><td>Teoh et al. (2020)</td><td>UK</td><td>Doctors</td><td>157</td><td>Hospitals (all in the country)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Stress and presenteeism</td><td>No</td></tr><tr><td>Walker et al. (2022)</td><td>US</td><td>Doctors</td><td>33</td><td>University hospital (N = 1)</td><td>Qualitative</td><td>N/A</td><td>Well-being at work</td><td>Yes</td></tr><tr><td>Ward et al. (2022)</td><td>Australia</td><td>Doctors in training</td><td>55</td><td>Hospitals (N = 4)</td><td>Mixed methods</td><td>N/A</td><td>Well-being and Burnout</td><td>Yes</td></tr><tr><td>Weigl et al. (2016)</td><td>Germany</td><td>Nurses</td><td>111 at 1st survey, 202 at 2nd survey</td><td>Hospital (N = 1)</td><td>Quantitative (observational)</td><td>Job Demands-Resource (JDR) Model</td><td>Depression and emotional exhaustion</td><td>No</td></tr><tr><td>Wing et al. (2015)</td><td>Canada</td><td>Junior nurses</td><td>394</td><td>Hospitals 4</td><td>Quantitative (observational)</td><td>Theory of Structural Empowerment</td><td>Depression and anxiety</td><td>No</td></tr><tr><td>Yragui et al. (2017)</td><td>US</td><td>HCPs (mixed)</td><td>417</td><td>Psychiatric hospitals (N = 2)</td><td>Quantitative (observational)</td><td>Conservation of Resources (COR) Theory</td><td>Burnout</td><td>No</td></tr><tr><td>Zutautiene et al. (2023)</td><td>Lithuania</td><td>Doctors</td><td>647</td><td>Hospitals (N = 6)</td><td>Quantitative (observational)</td><td>N/A</td><td>Stress</td><td>No</td></tr></tbody></table>

<table><caption>**Table 3**
Emerging categories and antecedents.</caption><thead><tr><th>Category</th><th>Antecedents of resilience</th><th>Resources</th><th>Demands and/or stressors</th></tr></thead><tbody><tr><td rowspan="2">Relational factors</td><td>Co-worker interaction</td><td>Teamwork and spirit, trust, respect, cohesiveness, altruism, social support</td><td>Conflict, disrespect, favouritism, incivility, blame, lack of empathy and support</td></tr><tr><td>Leader-worker interaction</td><td>Supervisor support, availability, authenticity, inspiration, recognition, communication and feedback</td><td>Lack of organisational justice</td></tr><tr><td rowspan="2">Job-related factors</td><td>Job characteristics</td><td>Role clarity, decision-making authority and latitude</td><td rowspan="2">Excessive workload, task distribution, shift organisation</td></tr><tr><td>Job empowerment</td><td>Participation in intervention co-design, professional development</td></tr><tr><td>Environment-related factors</td><td>Workplace climate</td><td>Positive psycho-social climate</td><td>Workplace bullying and harassment</td></tr></tbody></table>

studies documented different perceptions of negative relations across roles, experience, and professions. Nurses reported increased stress after mistreatment from physicians, such as not addressing them by name, being yelled at by colleagues, or facing mockery by other nurses or younger peers [46]. While allied health professionals and physicians reported difficult communication, lack of respect and recognition of their expertise, as sources of stress or anxiety [47]. Conflicts, arising from differences in authority and experience, between residents and allied health professionals for example, emerged as a major source of stress [48]. Residents felt ill-equipped when pressured by colleagues to act against their clinical judgment, leading to intense feelings of degradation that could persist over time [40].

For junior physicians, high psychological distress levels were

associated with a blame culture and a lack of empathy and support from team members, consultants, and supervisors after critical incidents such as the death of a patient [49]. Higher levels of stress for female participants were related to episodes of sexism, such as subtle undermining comments or inappropriate sexist comments masked as jokes. Participants also reported distressful experience of racism (Ibidem). Lack of team support remains a key predictor of stress, burnout and anxiety [50–52], while positive team dynamics are strongly associated with job satisfaction due to social support [53].

### Leader-worker interactions

Supervisors play a pivotal role in shaping their subordinates and teams' ability to manage workplace demands. On a continuum from low- to high-quality leader-member exchanges, high-quality relationships are characterised by a better exchange of resources (e.g., respect, trust, knowledge, information) that is rewarded by supervisors with increased support, clear expectations, and relaxation of rules. In contrast, low-quality relationships engender close supervision due to scarce trust and poor information exchange. Most studies focus on the positive attitudinal and performance outcomes of high-quality supervisor-subordinate relationships (e.g. reducing work demands, easing role stressors). However, other studies highlight that in certain circumstances high-quality exchanges can lead to higher strains, especially for senior positions or middle-managers where role boundaries are more ambiguous.

Team leaders who are available, debrief after critical incidents, explain the processes behind decisions, and provide support and recognition, contribute to a positive unit environment or a low-risk psychosocial climate. In these contexts, HCW feel able to speak openly with their supervisors without fears of reprisal. Conversely, in a high-risk psychosocial climate, HCW believed they had to 'push on' through unsafe environments or risk being unfavourably viewed by supervisors [54].

Supportive leadership is particularly critical during crises. During the COVID-19 pandemic waves, frontline healthcare workers who received better supervisor support exhibited less psychological distress [55,56] and lower burnout rates [43]. Leaders' physical presence and availability during shifts were shown to enhance nurses' feelings of

<footnote n="1">¹ 370 observations, 74 participants.</footnote>

<footnote n="2">² medical, surgical, spinal, and ITU wards.</footnote>

<footnote n="3">³ nursing homes, hospitals, and outpatient care.</footnote>

<footnote n="4">⁴ survey sent to the database of registered nurses.</footnote>

<footnote n="5">⁵ Andorra, Germany, Iran, Ireland, Italy, Spain, Romania.</footnote>

<footnote n="6">⁶ participants working in the palliative care sector or in the neuro-rehabilitation medicine specialty.</footnote>

<footnote n="7">⁷ 20 participants in the qualitative phase and 134 participants in the survey phase.</footnote>

<footnote n="8">⁸ either in Canada or the US.</footnote>

<footnote n="9">⁹ survey administered to nurses in a union.</footnote>

<footnote n="10">¹⁰ 149 survey responses and 201 participants in observation sessions.</footnote>
safety, while their absence caused fear and increased distress [57]. Leaders who communicated clearly and planned transparently, going above and beyond their usual practice, helped instil a sense of trust and stability, contributing to HCWs' resilience [32].

Even outside crisis settings, the role of leadership remains influential when facing higher workloads due to budgetary cuts or constant staff shortages. Sillero et al. [58] found that Spain, along other countries with similar levels of staff shortages, register higher rates of burnout among HCW. In these contexts, low leadership support for nurses was related to emotional exhaustion and depersonalisation, especially for those working in high-complex settings such as operating and recovery rooms. On the contrary, subordinates who experienced supervisor support and high-quality relationships reported lower levels of strains and higher levels of well-being [59–61]. Nevertheless, high-quality relationships can be both a resource and a demand itself, tracing a non-linear relationship between supervisor support, role stressors and strain [61]. Hesselgreaves & Scholarios [61] show that supervisors are not always able to buffer the negative effects of some high demands for senior roles as result of job enlargement (e.g. evolving into management from clinical backgrounds).

Leadership styles, traits, and skills also play a role [62]. Trans-
formational leaders—those who inspire and motivate—significantly
reduced burnout among psychiatric nurses [63]. Similarly, Kohnen et al.
[64] used the concept of ‘engaging leaders’ to describe leaders who
create working conditions characterised by empowerment (i.e. giving
voice and recognising ownership), strength (stimulate talent and skills
by assigning challenging tasks), and inspiration (i.e. contribution and
commitment to a vision). In such settings, engaging leaders can prevent
the negative effect of job demands on nurse well-being, while fostering
their intrinsic motivation. Nurses who felt empowered, inspired,
strengthened, and connected as result of leaders’ engaging behaviour
were more likely to perceive a strong team connection and contribute
meaningfully to their workplace (Ibidem).

Being a role model, making staff feeling valued and providing
recognition were important predictors of HCWs' psychological safety
[54]. The impact was even greater for residents, who indicated an
enhanced sense of confidence and a learning environment that fostered
their developing clinician identity [40]. Furthermore, leaders showing
family-supportive behaviours reduced the negative effects of patients'
aggression on HCWs' mental health and well-being [65]. Finally,
authentic leadership, underpinned by ethical decision-making, trans-
parency and fairness reduces staff perceptions of organisational injus-
tice. When staff feel poorly engaged or their input is ignored, for
instance in decision-making and scheduling, it leads to higher stress and
mental health problems [46,66,67]. In contrast, authentic leaders
positively influenced staff well-being by reducing work harassment and
enhancing their psychological capital (hope, self-efficacy and resilience)
[68,69].

Effective communication is a core leadership competency. Leaders who provide constructive feedback and are predictably available support nurses during stressful times [57] and reduce burnout while learning from errors [70]. During the COVID-19 pandemic, employing new methods and tools of communication (e.g. Zoom, Facebook) and hospital-wide communication platforms bolstered effective communication [32,33]. Atkins et al. [71] recommend streamlining communication channels and establishing norms for clear, concise communication to include all personnel in the decision-making process and alleviate distress in times of crisis. Communication structures, like debriefs and safety huddles, are opportunities for staff to openly disclose their vulnerability with supervisor which foster psychological safety [46,54,72]. Motivating language by managers has also been linked to greater work engagement of nurses, even if not directly to reduced psychological distress [36].

3.3.2. Job-related factors

With few exceptions, the variables analysed under this category were

underpinned by postulates of the Job-Demands-Resources Theory [73],
and were prevalently explored in relation to burnout and stress.

Job characteristics

Job characteristics such as autonomy in task-related decisions (job control), role clarity and decision-making authority, are valuable resources that professionals can leverage to buffer the effects of workload, bureaucracy and other job demands [31,64].

Role clarity—having well-defined tasks, clear expectations and no conflicting job requirements—was shown to moderate the effect of third-party aggression (patients or their relatives) on depersonalisation. Furthermore, when paired with supervisor support, role clarity acts as defence against burnout when experiencing the harmful effects of emotional work triggered by patient aggressive behaviour [74]. Sharing experiences with supervisors about abusive patients and receiving emotional support or behavioural guidelines can help nurses recover from tensions associated with high emotional demands throughout the day (Ibidem).

Similarly, decision-making authority and latitude, the degree to which individuals are autonomous in deciding on their tasks, were identified as protective factors against stress and burnout [63]. In a sample of Lithuanian physicians, Zutautiene et al. [75] found that a quarter of respondents reported low levels of decision-making authority, while one-third of them had low decision autonomy. The results showed that decision-making authority significantly reduced HCW chances of stress, while greater decision latitude was linked to better subjective physical and mental evaluation (Ibidem). Conversely, high rate of depression was recorded when decision-making latitude was low across different disciplines [76].

Work-related aspects, such as workload and worktime (quantitative demands), require sustained physical and/or mental efforts and are highly related to (psychological) health outcomes. Over-time work and extended shifts without breaks or flexibility in schedules negatively affect HCW' (dis)stress [49–51], lead to increased risks of depression [76,77], higher of levels of burnout, and emotional exhaustion [78,79]. An early outcome of heavy workloads is HCW's perception of distress. Constant distress, in turn, makes work less pleasant and thwarts individual resources to cope with increased demands [78].

Excessive workload often stems from understaffed units and high turnover rates. Professionals experiencing unfair task distribution and workload imbalance, such as unfair nursing assignment, high patient-to-nurse ratio, and cancelled vacations, reported negative perceptions of distress [46], and emotional exhaustion [71]. During COVID-19 emergency, these stressors intensified especially where ward managers maintained high expectations with limited support despite changes in work conditions and extremely demanding routine [80]. De Wijn et al. [79] found that worktime demands together with aggressive-conflict situations are particularly detrimental on emotional exhaustion reported by emergency nurses. The perception of high quantitative demands, however, might vary across specialties, with physicians in surgery and internal medicine reporting higher rates compared to other medical fields [77]. Nevertheless, the interaction of quantitative demands with supportive teams and supervisor recognition has a moderating impact on burnout [81].

Some interventions demonstrated promising results. For instance, Schneider and colleagues [82] describe a co-developed initiative with emergency departments (ED) that improved job control, reduced overtime hours and enhanced patient perception of ED organisation—evet if the overall effects on work conditions, provider well-being and quality of care were mixed.

Job empowerment

Beyond job characteristics, job empowerment emerged as a distinct and influential antecedent associated with HCWs resilience. Unlike individual-level capabilities, empowerment refers to contextual opportunities within the work environment that enables professionals to perform effectively. Two key components were frequently highlighted: participation in decision-making (e.g. involvement in shaping
workplace interventions), and access to professional growth and development opportunities.

Ward et al. [83] describe a co-designed programme by physicians in training that used a multiformat toolkit to support staff well-being and prevent burnout. Participants reported a 31.9 % improvement on the Well-being Index, along with a sustained shift towards a more sup- portive and connected workplace culture. Similarly, opportunities for professional development were linked to lower stress and burnout across both physicians [77,78] and nurses [84]. Kohnen and fellows [84] found that work motivation mediates the relationship between job empower- ment and burnout. Specifically, nurses who experienced autonomy and access to development resources reported stronger motivation, more effective time and effort allocation, greater job satisfaction and lower susceptibility to burnout and job-related strain.

### 3.3.3. Environment-related factors

Closely linked to co-worker and leader-worker dynamics, this cate- gory focuses on the collective impact of the organisational work envi- ronment—both in terms of psycho-social safety climates and toxic cultures, including patient aggression and workplace violence.

#### Workplace climate

McLinton et al. [54] highlight several factors shaping psycho-social climate, including supervisory support and internal communication, group norms and how organisations manage conflicting pressures. Group expectations can either exacerbate risk by encouraging perse- verance under unsafe conditions or mitigate it by fostering a culture of safety. In low-risk psycho-social climates, HCWs can better balance their own safety and optimal patient care by applying realistic, well-supported procedures [54].

Conversely, several studies emphasised the effects of workplace bullying, harassment, and abuse, which are consistently linked to burnout, poor mental health and post-traumatic-stress symptoms. Exposure to workplace bullying, such as constant criticism and humili- ation at work, excessive monitoring and burst of rage from both co- workers and supervisors, negatively influenced clinical nurses' mental health [85], and predicted symptoms of post-traumatic stress disorder [86]. Experience of bullying behaviour at Time 1 was shown to increase anxiety and fatigue at Time 2, often through mechanisms of chronic stress activation [87].

In a Greek sample of 398 neonatal intensive care unit staff, 53 % reported workplace bullying [88]. Comparably, in a sample of 166 Korean nurses, 37 % reported direct experience with bullying, and nearly half witnessed it [89]. These experiences were associated with higher burnout. Internal factors related to positive psychological capital mitigate the damaging effects of workplace bullying [86], while external factors as social support did not significantly predict burnout [89].

Interestingly, age and experience had a detrimental effect on bullying events. Younger nurses (under 29) and those with fewer years of role experience (1–3y) reported more frequent workplace bullying [88,90], particularly those in high-intensity settings like operating rooms and intensive care units. Although nurse resilience was not significantly affected by bullying, such experiences lead to anxious and uncomfortable work environments [90].

Studies also revealed high rates of bullying and abuse among junior physicians, often from senior physicians, consultants, or nursing staff. These behaviours—ranging from verbal humiliation to intimi- dation—were linked to work-related stress, anxiety, depression, and even suicidal ideation [49,88,91]. Finally, harassment, including sexual harassment and discrimination by patients disproportionately affected female professionals. Participants described a cultural tolerance and acceptance of bullying, often avoiding complaints due to fear of reper- cussion or futility of reporting.

## 4. Discussion

The establishment of healthcare workforce policy research as a

recognised academic field is critical for informing evidence-based so- lutions that improve HCWs' work experience and health systems governance [2]. Although research has traditionally focused on man- aging professional work and individual resilience [92], policy-level attention is growing [16]. This review has identified three primary categories of factors influencing HCWs' resilience. Relational factors encompass interpersonal dynamics, including co-worker and leader-worker interactions. Job-related factors pertain to job design and empowerment, pointing out the positive effect of role clarity and decision-making latitude on individual resilience while high workload demands and shift structures as stressors. Environment-related factors refer to the broader workplace climate. A positive psychosocial atmo- sphere supports resilience, whereas experiences of bullying and harassment constitute an environmental strain.

Our findings contribute to the evolving field through three main lines of argument, elaborated below, which emphasise the need for holistic and context-sensitive interventions and propose a conceptual frame- work of HCWs' resilience centred on intermediate-level factors.

First, interventions often target isolated issues, overlooking the interconnectedness of workplace dynamics (individual, professional, and environmental factors). Our review emphasises the need for inte- grated approaches. For example, team-building and conflict resolution training are more effective when accompanied by systemic measures like adequate staffing and flexible scheduling. Similarly, fostering job autonomy and role clarity enhances HCWs' ability to manage stress and aggression, particularly in high-pressure settings. Policymakers could consider embedding meso-level indicators (e.g. team cohesion, super- visor support) into health workforce planning and monitoring frameworks.

Second, a prevalent approach to HCW resilience-supportive in- terventions has been instrumentally driven, prioritising the type of intervention - such as training or counselling - without assessing contextual fit. This review shows that the success of interventions like supervisor training depends heavily on local factors, including organ- isational culture and available resources. Moreover, the implementation process itself is critical: it must be participatory and adaptive, not top- down. The hybrid positions of middle managers, bridging clinical and managerial logics, underscore the need for tailored leadership devel- opment—particularly in ethical decision-making and communication. Policy-driven investments could mandate leadership training, especially for middle management.

Lastly, while much research focuses on macro-level policies or in- dividual experiences, this review highlights the critical role of inter- mediate factors—team dynamics, supervisors, job and workplace conditions—in shaping HCWs' resilience. We define these intermediate factors as a *close workplace environment* encompassing all direct inter- action individuals have within their workplace. These include, for instance, the relationship with the supervisor, team dynamics, job characteristics, roles and team climate. For example, supportive super- visors demonstrably reduce burnout through transparent communica- tion and equitable workload, especially during crises like COVID-19. Likewise, cohesive teams, built on trust and respect, bolster resilience, while negative interactions, such as bullying or conflict, undermine it. These findings point to the unit or intermediate level as the key site for intervention, especially in multidisciplinary healthcare environments. A representation of this is reported in Fig. 2.

This review also reveals disparities in the scholarly representation of different professional groups. Nurses are overrepresented in the litera- ture, while the unique challenges faced by physicians are comparatively neglected. This may reflect the siloed nature of human resources man- agement in professional bureaucracies [93]. In healthcare, the nursing personnel is typically governed through centralised structures, while physician staffing is often decentralised or informal, as the medical di- rector is often more a *primus inter pares* than an actual manager. This is even more relevant in systems where physicians are contracted rather than salaried. In this regard, integrated human resource policies
<figure><img src="image_4.png" /><figcaption>Fig. 2. Comprehensive model of meso-level factors and their interplay on individual resilience.</figcaption></figure>

informed by strong scientific evidence, run at the hospital level, can
prove beneficial.

Leadership style and supervisor relationships are also less frequently
cited as stressors for physicians compared to nurses: this observation
may reflect the relatively less hierarchical nature of the medical pro-
fession to confer recognition and social prestige, and where greater
autonomy is afforded to physicians. However, it also raises questions
about the subtler forms of organisational stress experienced by physi-
cians, which may not be captured by traditional measures focusing on
direct supervision (for instance, the amount of autonomy in clinical
decision-making). Furthermore, while workplace aggression, particu-
larly patient-related aggression, is a prominent concern for nurses due to
their direct and prolonged patient interaction, it is less frequently re-
ported as a stressor for physicians. On a motivational side, the emotional
burden of resource scarcity resonates differently for physicians and
nurses, impacting their core motivations [46]. For physicians, driven by
a deep-seated desire for clinical mastery, the inability to provide optimal
patient outcomes triggers intense distress, striking at the core of their
professional identity. Nurses, however, find their emotional well-being
more closely tied to the quality of patient relationships and the provi-
sion of direct care. Staffing shortages that curtail bedside time and a lack
of collegial recognition profoundly impact their sense of purpose, rooted
in compassion and hands-on support. These differences suggest the need
for more nuanced and comparative, across professions, analyses of
meso-level influences on the resilience of diverse HCWs.

## 4.1. Limitations of the review

This scoping review is not exempt from limitations. It synthesises a
wide body of evidence without assessing the quality of individual
studies, in line with its exploratory purpose [94]. A considerable portion
of the articles was limited in describing the presence of relationships
between studied factors, while others went further by establishing the
effect of those factors. Methodological heterogeneity across studies
precluded direct comparison of outcomes. Furthermore, the sample of
reviewed studies encompasses high-income countries, limiting applica-
bility to low- and middle-income countries. Even within this pool of
studies, the variability in significance of factors may be influenced by
context-specific factors beyond the scope of this review. For example,
the relationship between supervisor-supervisee dynamics and leader-
ship styles seems highly variable across organisations and individuals,
shaped by local interpretations of roles. As all included studies were
published in English, this review may have missed important
context-specific insights from non-English-speaking regions. Finally,

due to the rapidly evolving nature of the field, some relevant articles
published after our literature search may not have been included in the
analysis.

## 5. Conclusion

The findings of this scoping review highlight the complex, multi-
dimensional and complex nature of individual resilience among
healthcare professionals and underscores the need for more rigorous,
evidence-based discussions around intermediate-level interventions.
While individual resilience is frequently framed as an individual trait,
this review emphasises the substantial influence of team dynamics and
its development and sustainability. A knowledge gap remains in trans-
lating resilience research into actionable strategies that foster ‘saluto-
genic’ work environments. Clear, transparent communication of
intervention outcomes will be critical in enabling organisational leaders
and policymakers to design healthcare systems that proactively support
staff resilience – ultimately promoting more sustainable and high-
quality patient care. Interventions that go beyond isolated individual
or systemic efforts are persistently needed, with greater focus on how
organisational design mediates health policy and impacts daily profes-
sional experience. In this study, we set out to offer a valuable interpre-
tive framework to both scholars and practitioners to better understand,
in between the individual and systemic level, what drives resilience in
healthcare workers: to support evidence-informed decision-making, a
comprehensive framework is indeed essential for evaluating mecha-
nisms through which intermediate-level interventions operate. While
necessarily simplified compared to real-world complexity, we hope this
contribution will prove helpful in framing physicians and nurses’ resil-
ience dynamics. We also believe that the model naturally connects with
established theoretical frameworks that have long shaped discussions in
this area. These traditional frameworks, in our view, are still highly
relevant, with the Job Demands-Resources (JD-R) theory [73] being
particularly prominent.

## List of abbreviations

ASReview: Active Researcher-in-the-Loop Machine Learning Algorithm

COVID-19: Coronavirus Disease 2019

HCW: Health care workers

OECD: Organisation for Economic Co-operation and Development

PICO: Population, Intervention, Comparator, Outcome

PRISMA-ScR: Preferred Reporting Items for Systematic Reviews and
# Meta-Analyses extension for Scoping Reviews
ScR: Scoping Review

## Funding

This work was supported by the EU Horizon Europe Programme
Agreement n° 101137144 (APOLLO2028 Project).

## Availability of data and materials

The datasets used and/or analysed during the current study are
available from the corresponding author on reasonable request.

## CRediT authorship contribution statement

**Natalia Oprea:** Writing – review & editing, Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization.
**Giorgio Giacomelli:** Writing – review & editing, Visualization, Formal analysis, Data curation, Conceptualization.
**Marco Sartirana:** Writing – review & editing, Formal analysis, Conceptualization.
**Elisabetta Trincherero:** Writing – review & editing, Validation, Supervision, Funding acquisition, Formal analysis, Conceptualization.
**Irène Georgescu:** Writing – review & editing, Validation, Supervision, Funding acquisition.

## Declaration of interest statement

The authors declare that they have no competing interests.

## Supplementary materials

Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.healthpol.2025.105412.

## References

[1] Azzopardi-Muscat N, Zapata T, Kluge H. Moving from health workforce crisis to health workforce success: the time to act is now. Lancet Reg Healt - Eur 2023;35: 100765.

[2] Kuhlmann E, Lotta G, Dussault G, Falkenbach M, Correia T. The workforce crisis in healthcare: moving the debate to bridge evidence and policy. Int J Health Plann Manag 2024;39(3):607-13.

[3] Dussault G, Dubois C-A. Human resources for health policies: a critical component in health policies. Hum Resour Health 2003;1(1):1.

[4] World Health Organization, "Human Resources for Health." 2022.

[5] Kuhlmann E, Dussault G, Wismar M. Health labour markets and the 'human face' of the health workforce: resilience beyond the COVID-19 pandemic. Eur J Public Health 2020;30. no. Supplement_4, pp. iv1-iv2.

[6] Byrne J-P, Humphries N, McMurray R, Scotter C. COVID-19 and healthcare worker mental well-being: comparative case studies on interventions in six countries. Health Policy (New York) 2023;135:104863.

[7] World Health Organization, "Health and care workforce in Europe: time to act," 2022.

[8] Kuhlmann E, Falkenbach M, Brínzac M, Correia T, Panagioti M, Ungureanu M. The mental health needs of healthcare workers: when evidence does not guide policy. A comparative assessment of selected European countries. Int J Health Plann Manag 2024;39(3):614-36.

[9] Aburn G, Gott M, Hoare K. What is resilience? An Integrative Review of the empirical literature. J Adv Nurs 2016;72(5):980-1000.

[10] Iasiello M, et al. What's the difference between measures of wellbeing, quality of life, resilience, and coping? An umbrella review and concept map of 155 measures of positive mental health. Int J Wellbeing 2024;14(2):1-25.

[11] Delgado C, Upton D, Ranse K, Furness T, Foster K. Nurses' resilience and the emotional labour of nursing work: an integrative review of empirical literature. Int J Nurs Stud 2017;70:71-88.

[12] Waddimba AC, Scribani M, Hasbrouck MA, Krupa N, Jenkins P, May JJ. Resilience among employed physicians and Mid-level practitioners in Upstate New York. Health v Res 2016;51(5):1706-34.

[13] Hall LH, Johnson J, Watt I, Tsipa A, O'Connor DB. Healthcare staff wellbeing, burnout, and patient safety: a systematic review. PLoS One 2016;11(7):e0159015.

[14] Paterson E, Paterson NAB, Ferris LJ. Mental health and well-being of anaesthetists during the <scp>COVID</scp>-19 pandemic: a scoping review. Anaesthesia 2023;78(2):197-206.

[15] Brand SL, Thompson Coon J, Fleming LE, Carroll L, Bethel A, Wyatt K. Whole-system approaches to improving the health and wellbeing of healthcare workers: a systematic review. PLoS One 2017;12(12):e0188418.

[16] Burau V, et al. Post-COVID health policy responses to healthcare workforce capacities: a comparative analysis of health system resilience in six European countries. Health Policy (New York), 139; 2024, 104962.

[17] Anderson JE, et al. Multilevel influences on resilient healthcare in six countries: an international comparative study protocol. BMJ Open 2020;10(12):e039158.

[18] Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005;8(1):19-32.

[19] Tricco AC, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018;169(7):467-73.

[20] Peters MDJ, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evid Synth 2020;18(10):2119-26.

[21] van de Schoot R, et al. An open source machine learning framework for efficient and transparent systematic reviews. Nat Mach Intell 2021;3(2):125-33.

[22] van Dijk SHB, Brusse-Keizer MGJ, Bucsán CC, van der Palen J, Doggen CJM, Lenferink A. Artificial intelligence in systematic reviews: promising when appropriately used. BMJ Open 2023;13(7):e072254.

[23] Oude Wolcherink MJ, Pouwels XGLV, van Dijk SHB, Doggen CJM, Koffijberg H. Can artificial intelligence separate the wheat from the chaff in systematic reviews of health economic articles? Expert Rev Pharmacoecon Outcomes Res 2023;23(9): 1049-56.

[24] Cavallaro L, Arditto V, Drummond M, Ciani O. Machine Learning-assisted Health Economics and Policy reviews: a comparative assessment. Appl Health Econ Health Policy 2025.

[25] Martin GP, et al. Toward a framework for the design, implementation, and reporting of methodology scoping reviews. J Clin Epidemiol 2020;127:191-7.

[26] Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z. JBI Manual for Evidence Synthesis. JBI 2024.

[27] Maynard BR. Research synthesis methods: a guide for conducting rigorous and relevant reviews. Res Soc Work Pr. 2025.

[28] Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3 (2):77-101.

[29] Badu E, et al. Workplace stress and resilience in the Australian nursing workforce: a comprehensive integrative review. Int J Ment Health Nurs 2020;29(1):5-34.

[30] Lee KJ, et al. Promoting staff resilience in the pediatric Intensive Care unit. Am J Crit Care 2015;24(5):422-30.

[31] Kranenburg LW, et al. Need for support among healthcare professionals during the COVID-19 pandemic: a qualitative study at an academic hospital in the Netherlands. BMJ Open 2022;12(2):e059124.

[32] Brown L, et al. Sources of resilience in frontline health professionals during COVID-19. Healthcare 2021;9(12):1699.

[33] Walker HR, et al. 'I need to have a fulfilling job': a qualitative study of surgeon well-being and professional fulfillment. Am J Surg 2022;223(1):6-11.

[34] Sampaio F, et al. Workplace wellbeing and quality of life perceived by Portuguese nurses during the COVID-19 pandemic: the role of protective factors and stressors. Int J Env Res Public Health 2022;19(21):14231.

[35] Lanzara R, et al. Changes in hospital staff' mental health during the Covid-19 pandemic: longitudinal results from the international COPE-CORONA study. PLoS One 2023;18.

[36] Kunie K, Kawakami N, Shimazu A, Yonekura Y, Miyamoto Y. The relationship between work engagement and psychological distress of hospital nurses and the perceived communication behaviors of their nurse managers: a cross-sectional survey. Int J Nurs Stud 2017;71:115-24.

[37] López Gómez MA, et al. Organizational and psychosocial working conditions and their relationship with mental health outcomes in patient-care workers. J Occup Env Med 2019;61(12):e480-5.

[38] Kilroy S, Chenevert D, Hill K. Reducing burnout among nurses: the role of high-involvement work practices and colleague support. Health Care Manage Rev 2022; 47(2):115-24.

[39] Blanco-Donoso ML, Garrosa Hernández E, Demerouti E, Moreno Jiménez B. Job resources and recovery experiences to face difficulties in emotion regulation at work: a diary study among nurses. Int J Stress Manag 2017;24(2):107-34.

[40] Corgan S, Winkel AF, Sugarman R, Young JQ. From burnout to wholehearted engagement: a qualitative exploration of psychiatry residents' Experience of stress. Acad Med 2021;96(5):709-17.

[41] Carmona-Cobo I, Lopez-Zafra E. Hospital nurses experiencing day-to-day workplace incivility: a diary study on the benefits of daily social support. J Nurs Manag 2022;30(6):1577-89.

[42] Kelly EL, Fenwick KM, Brekke JS, Novaco RW. Sources of social support after patient assault as related to staff well-being. J Interpers Violence 2021;36(1-2). NP1003-NP1028.

[43] Finuf KD, Lopez S, Carney MT. Coping through COVID-19: a mixed method approach to understand how palliative care teams managed the COVID-19 pandemic. Am J Hosp Palliat Med 2022;39(7):874-80.

[44] Pavithra A, Mannion R, Li L, Westbrook J. The impact of vulnerability and exposure to pervasive interprofessional incivility among medical staff on wellbeing. Front Public Health 2023;11.

[45] Wing T, Regan S, Spence Laschinger HK. The influence of empowerment and incivility on the mental health of new graduate nurses. J Nurs Manag 2015;23(5): 632-43.

[46] Jelen A, Goldfarb R, Rosart J, Graham L, Rubin BB. A qualitative co-design-based approach to identify sources of workplace-related distress and develop well-being strategies for cardiovascular nurses, allied health professionals, and physicians. BMC Health v Res 2024;24(1).
[47] Barros C, Baylina P, Fernandes R, Ramalho S, Arezes P. Healthcare workers' Mental health in pandemic times: the Predict role of psychosocial risks. Saf Health Work 2022;13(4):415-20.

[48] Manchanda ECC, et al. The role of gender in nurse-resident interactions: a mixed-methods study. West J Emerg Med 2021;22(4):919-30.

[49] Riley R, et al. Sources of work-related psychological distress experienced by UK-wide foundation and junior doctors: a qualitative study. BMJ Open 2021;11(6):e043521.

[50] Daouda OS, et al. Multilevel approach to individual and organisational predictors of stress and fatigue among healthcare workers of a university hospital: a longitudinal study. Occup Env Med 2022;79(12):839-47.

[51] Kowalczuk K, Krajewska-Kulak E, Sobolewski M. The effect of subjective perception of work in relation to occupational and demographic factors on the mental health of Polish nurses. Front Psychiatry 2020;11.

[52] Teoh K, Hassard, Cox J. Individual and organizational psychosocial predictors of hospital doctors' work-related well-being: a multilevel and moderation perspective. Health Care Manage Rev 2020;45(2):162-72.

[53] Chana N, Kennedy P, Chessell ZJ. Nursing staffs' emotional well-being and caring behaviours. J Clin Nurs 2015;24(19-20):2835-48.

[54] McLinton SS, Dollard MF, Tuckey MR. New perspectives on psychosocial safety climate in healthcare: a mixed methods approach. Saf Sci 2018;109:236-45.

[55] Lee BEC, Ling M, Boyd L, Olsson CA, Sheen J. Key predictors of psychological distress and wellbeing in Australian frontline healthcare workers during COVID-19 (Omicron wave). Front Psychol 2023;14.

[56] Newnham EA, et al. Mental health status, risk and protective factors for healthcare staff prior to the first major COVID-19 outbreak in Western Australia. Int J Public Health 2023;68.

[57] Ralph J, Freeman LA, Ménard AD, Soucie K. Practical strategies and the need for psychological support: recommendations from nurses working in hospitals during the COVID-19 pandemic. J Health Organ Manag 2022;36(2):240-55.

[58] Sillero A, Zabalegui A. Organizational factors and burnout of perioperative nurses. Clin Pr Epidemiol Ment Hea 2018;14(1):132-42.

[59] Nelson SA, et al. The influence of bullying on the wellbeing of Brazilian nursing professionals. Public Money Manag 2014;34(6):397-404.

[60] Weigl M, Stab N, Herms I, Angerer P, Hacker W, Glaser J. The associations of supervisor support and work overload with burnout and depression: a cross-sectional study in two nursing settings. J Adv Nurs 2016;72(8):1774-88.

[61] Hesselgreaves H, Scholarios D. Leader-member exchange and strain: a study of job demands and role status. Hum Resour Manag J 2014;24(4):459-78.

[62] Rees CS, et al. Individual and environmental determinants of burnout among nurses. J Hea l v Res Policy 2019;24(3):191-200.

[63] Madathil R, Heck NC, Schuldberg D. Burnout in psychiatric nursing: examining the interplay of autonomy, leadership style, and depressive symptoms. Arch Psychiatr Nurs 2014;28(3):160-6.

[64] Kohnen D, De Witte H, Schaufeli WB, Dello S, Bruyneel L, Sermeus W. Engaging leadership and nurse well-being: the role of the work environment and work motivation—A cross-sectional study. Hum Resour Health 2024;22(1).

[65] Yragui NL, Demsky CA, Hammer LB, Van Dyck S, Neradilek MB. Linking workplace aggression to employee well-being and work: the moderating role of Family-supportive supervisor behaviors (FSSB). J Bus Psychol 2017;32(2):179-96.

[66] Magnavita N, et al. Organizational justice and health: a survey in Hospital workers. Int J Env Res Public Health 2022;19(15).

[67] Skinner N, Van Dijk P, Stothard C, Fein EC. It breaks your soul': an in-depth exploration of workplace injustice in nursing. J Nurs Manag 2018;26(2):200-8.

[68] Salehi N, Brunetto Y, Dick T. The role of authentic leadership on healthcare street-level bureaucrats' well-being during the pandemic. Aust J Public Adm 2023;82(2):271-89.

[69] Brewer K, Ziegler H, Kurdian S, Nguyen J. Relationships of individual and workplace characteristics with nurses' moral resilience. Nurs Ethics 2023.

[70] Tawfik DS, et al. Leadership behavior associations with domains of safety culture, engagement, and health care worker well-being. Jt Comm J Qual Patient Saf 2023; 49(3):156-65.

[71] Atkins K, et al. Day to Day and environmental risk factors for psychological distress among healthcare workers: a mixed methods analysis. J Occup Env Med 2023;65 (9):E593-603.

[72] Riley R, et al. Protective factors and sources of support in the workplace as experienced by UK foundation and junior doctors: a qualitative study. BMJ Open 2021;11(6).

[73] Demerouti E, Nachreine F, Bakker AB, Schaufeli WB. The job demands-resources model of burnout. Jounrla Appl Psychol 2001;86(3):499-512.

[74] Gilardi S, Guglielmetti C, Converso D, Fida R, Viotti S. Third-party aggression and emotion work among nurses: testing a moderated mediation model. Int J Stress Manag 2020;27(2):146-59.

[75] Zutautiene R, Kaliniene G, Ustinaviciene R, Radisauskas R. Prevalence of psychosocial work factors and stress and their associations with the physical and mental health of hospital physicians: a cross-sectional study in Lithuania. Front Public Health 2023;11.

[76] Fond G, Fernandes S, Lucas G, Greenberg N, Boyer L. Depression in healthcare workers: results from the nationwide AMADEUS survey. Int J Nurs Stud 2022;135.

[77] Bernburg M, Vitzthum K, Groneberg DA, Mache S. Physicians' occupational stress, depressive symptoms and work ability in relation to their working environment: a cross-sectional study of differences among medical residents with various specialties working in German hospitals. BMJ Open 2016;6(6).

[78] Debets M, Scheepers R, Silkens M, Lombarts K. Structural equation modelling analysis on relationships of job demands and resources with work engagement, burnout and work ability: an observational study among physicians in Dutch hospitals. BMJ Open 2022;12(12).

[79] de Wijn AN, Fokkema M, van der Doef MP. The prevalence of stress-related outcomes and occupational well-being among emergency nurses in the Netherlands and the role of job factors: a regression tree analysis. J Nurs Manag 2022;30(1):187-97.

[80] Kedmi-Shahar E, Morag I, Hallevi H, Arad D. Caring for COVID-19 patients: nurses' perceptions of the most critical issues and their impact on their well-being and performance. Int Nurs Rev 2023;70(4):578-88.

[81] Diehl E, et al. The relationship between workload and burnout among nurses: the buffering role of personal, social and organisational resources. PLoS One 2021;16 (1):e0245798.

[82] Schneider A, Wehler M, Weigl M. Effects of work conditions on provider mental well-being and quality of care: a mixed-methods intervention study in the emergency department. BMC Emerg Med 2019;19(1):p. 1.

[83] Ward MC, et al. The kindness COVID-19 toolkit: a mixed-methods evaluation of a programme designed by doctors in training for doctors in training. BMJ Open 2022;12(11):e060575.

[84] Kohnen D, De Witte H, Schaufeli WB, Dello S, Bruyneel L, Sermeus W. What makes nurses flourish at work? How the perceived clinical work environment relates to nurse motivation and well-being: a cross-sectional study. Int J Nurs Stud 2023;148: 104567.

[85] Hong S, Kim H, Nam S, Wong JYH, Lee K. Nurses' post-traumatic stress symptoms and growth by perceived workplace bullying: an online cross-sectional study. J Nurs Manag 2021;29(5):1338-47.

[86] Spence Laschinger HK, Nosko A. Exposure to workplace bullying and post-traumatic stress disorder symptomology: the role of protective psychological resources. J Nurs Manag 2015;23(2):252-62.

[87] Reknes I, Pallesen S, Magerøy N, Moen BE, Bjorvatn B, Einarsen S. Exposure to bullying behaviors as a predictor of mental health problems among Norwegian nurses: results from the prospective SUSSH-survey. Int J Nurs Stud 2014;51(3): 479-87.

[88] Chatzioannidis I, Bascialla FG, Chatzivalsama P, Vouzas F, Mitsiakos G. Prevalence, causes and mental health impact of workplace bullying in the Neonatal Intensive Care Unit environment. BMJ Open 2018;8(2):e018766.

[89] Bae S-R, Hong H-J, Chang J-J, Shin S-H. The Association between Korean Clinical Nurses' Workplace Bullying, positive psychological capital, and social support on burnout. Int J Env Res Public Health 2021;18(21):11583.

[90] Kang H, Han K. Moderating effects of structural empowerment and resilience in the relationship between nurses' Workplace bullying and work outcomes: a cross-sectional correlational study. Public Health 2021;18:1431.

[91] Forbes MP, Iyengar S, Kay M. Barriers to the psychological well-being of Australian junior doctors: a qualitative analysis. BMJ Open 2019;9(6):e027558.

[92] Huey CWT, Palaganas JC. What are the factors affecting resilience in health professionals? A synthesis of systematic reviews. Med Teach 2020;42(5):550-60.

[93] Currie G, Procter SJ. The antecedents of middle managers' Strategic contribution: the case of a professional bureaucracy. J Manag Stud 2005;42(7):1325-56.

[94] Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018;18(1):143.