being able to always go outside and still be able to be quarantined or socially distanced ” was a perceived benefit of rural living with lower population density , more personal space , and outdoor access .
Demonstrating resourcefulness , the rural communities developed practical approaches to address limited resources and scarcity during the pandemic . Given the regional history of limited resources , creatively solving problems was a noted characteristic of the local residents . Specific examples of overcoming challenges were recounted by participants . “ In rural Appalachia , there ’ s limited internet access , so , parking lots at the university turned into K-12 internet hotspots .” Regarding limited available food , there was a sense of resourcefulness : “ I know how to hunt . We can go fishing and hunt if we have to . We wouldn ’ t have gone hungry , and I think that ’ s a lot of Appalachian , rural upbringings . You see a lot of people hunting and fishing .”
Specific to rural Appalachia , “ culture is all about family and connectivity ,” one respondent said . Familial , community , and friendship connections characterize the people of the region . Repeatedly , participants emphasized that family and community are “ treasured ” in rural Appalachia . Many extended families live in close proximity , further strengthening the connectedness . The sense that “ there ’ s a ton of family support ” among the people in the region was supported by the description of a pharmacist : “ They live in houses with brothers and sisters and cousins and friends where they have an entire group of people surrounding them .” Participants described positive aspects of the experience of living through the COVID-19 outbreak in their rural communities as an opportunity for people to “ come together as a community ” and “ look out for each other .”
DISCUSSION
Four themes were identified from the qualitative narratives regarding resilience among healthcare providers working in clinical care during the COVID-19 pandemic in rural Appalachia . Participants provided their personal understanding of resilience in relation to living in rural Appalachia , including innate characteristics and external factors that contributed to resilience . Being connected to family and community was considered essential and facilitated the receipt and provision of social support during the pandemic . Family support has consistently been associated with resilience and reduced risk of burnout . 14 Other contributing factors to individual resilience included incorporating self-care activities , staying in touch with family and friends by phone or technology-based communication , and drawing on inner strength , beliefs , optimism , and adaptability . Adaptability is a particular characteristic of resilience among healthcare providers working in rural areas . 6
As healthcare providers in rural Appalachia , participants felt professional responsibility , dedication , and a mission to serve the people in the region . Their roles in caring for their community members motivated them . Limited resources , uncertainty , morbidity , mortality , and fatigue during the pandemic may have exacerbated the strain on healthcare providers . In an online survey , perceived lack of skills , insufficient expertise , misalignment between core values , and triage decisions during the pandemic increased the risk for severe distress among physicians . 15 Nurses interviewed early in the pandemic expressed frustration and anger at the lack of consistent guidelines . 9 Despite the evolving guidelines , the healthcare providers in the current study expressed positivity as they used the scientific process in providing care and shared updates and information with colleagues .
The healthcare providers described how they cherished collegial camaraderie , administrative support , and community appreciation although they also felt their resilience wavered when faced with barriers , crises , and negative messages . Facilitating resilience building among healthcare providers in rural Appalachia is critical to effective and sustained function of the healthcare team . 14 Adaptive resilience can strengthen the sense of teamwork and camaraderie among healthcare providers during crisis . Researchers found that resilience among healthcare providers was bolstered through support from management , teamwork , worklife balance , and boundaries , and personal , social and recreational factors . 6 Similarly , participants emphasized that ongoing communication with family and friends , along
with self-care and engagement in wellness activities fostered resilience during the pandemic .
A possible limitation of our qualitative study is that participants were from only two states in rural Appalachia , potentially limiting the transferability of the findings to other regions , although the findings corresponded to contributing factors to resilience identified among Appalachian adults . 12-13 While resilience levels may wane with time as the pandemic continues , the interviews were conducted during multiple peaks of the outbreak , prior to and after vaccines were available for the public , representing different time periods in the pandemic .
CONCLUSION
Healthcare providers in rural Appalachia noted internal and external sources supporting their resilience . Adaptive resilience facilitated the healthcare providers ’ ability to persevere in their professional roles during the pandemic . The study findings highlight the importance of promoting resilience among healthcare providers who experience personal , professional , and community levels of stress . The identified themes can inform the development of culturally appropriate recommendations for further resilience among healthcare providers in rural Appalachia to provide support and nurture resilience among members of the healthcare team .
REFERENCES
1 . Greenberg N , Docherty M , Gnanapragasam S , Wessely S . Managing mental health challenges faced by healthcare workers during covid-19 pandemic . BMJ . 2020 ; 368 : m1211 . [ PMID : 32217624 ].
2 . Huey CWT , Palaganas JC . What are the factors affecting resilience in health professionals ? A synthesis of systematic review . Med Teach . 2020 ; 42 ( 5 ): 550-560 . [ PMID : 31984844 ].
3 . Schroeder J , Bouldin ED . Inclusive public health preparedness to promote resilience
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