**1. Introduction**

The COVID-19 pandemic appeared in China in the fall of 2019 and has since spread worldwide [1]. In February 2021, when the third wave occurred, the virus had infected hundreds of millions of people and millions had died [2,3]. Moreover, numerous severe cases led to hospitalizations, putting the healthcare system and professionals under heavy pressure over a prolonged period of time [4].

Nurses have been among the most sought-after healthcare workers during the pandemic. During the different waves of COVID-19, they faced death, uncertainty, and work overload every day [4]. Such circumstances are likely to elicit stress, depressive symptoms, insomnia, and anxiety [5,6]. In turn, stress can lead to cognitive overload that can result in errors at work [7,8] and feelings of a lower quality of life (QoL), which is a strong correlate of nurses' engagemen<sup>t</sup> in dire contexts [9–11]. QoL is defined by the World Health Organization as 'an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns [12]. This definition highlights the multi-dimensionality of the QoL concept that articulates four broad domains: physical health, psychological wellbeing,

**Citation:** Jubin, J.; Delmas, P.; Gilles, I.; Oulevey Bachmann, A.; Ortoleva Bucher, C. Protective Factors and Coping Styles Associated with Quality of Life during the COVID-19 Pandemic: A Comparison of Hospital or Care Institution and Private Practice Nurses. *IJERPH* **2022**, *19*, 7112. https://doi.org/10.3390/ ijerph19127112

Academic Editors: V. K. Kumar, Jasmin Tahmaseb-McConatha andPaulB.Tchounwou

Received: 13 April 2022 Accepted: 8 June 2022 Published: 10 June 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

social relationships, and environment. During the COVID-19 crisis, QoL was found to be associated with the use of adaptive strategies, particularly, resilience and coping [13,14]. QoL is thus a key indicator of an individual's well-being or life experiences during crises and it allows us to understand how nurses adapt to crises [15].

Nurses' QoL has been extensively explored during the COVID-19 pandemic [16]. However, most researchers have adopted a 'pathogenic' perspective [17], focusing on risk factors that impair health [18,19]. Such a pathogenic approach is limited because it tends to categorize individuals as sick or healthy and considers that disease prevention consists solely in avoiding or minimizing risk factors [20]. Hence, this approach does not necessarily provide nurses with tools to anticipate or cope with crises such as a pandemic. Thus, identifying protective factors seems to be a more efficient strategy to allow crisis anticipation and provide nurses with actionable resources, particularly when the sources of stress cannot be avoided. Thus, in the present study, we adopted a salutogenic approach, which aims at identifying factors that protect one's QoL and health [17]. In the context of the COVID-19 pandemic and its duration, investigating which protective factors might reinforce nurses' ability to deal with stress is of paramount importance. Salutogenicoriented studies could help us understand how to maintain or improve nurses' QoL and health. Protective factors are relevant to guiding the development of interventions aimed at educating nurses to help them cope with prolonged a crisis [17,21,22].

Nevertheless, investigators have taken little interest in identifying protective factors. We identified three key resources to help nurses cope with stress during the pandemic. First is resilience, which reflects the ability of an individual to face the difficulties of life and bounce back after a traumatic event [23,24]. Resilience has been found to mediate the association between sources of stress and psychological distress during COVID-19, and several studies recommend training nurses to become resilient to prepare them for crises [5,25,26]. The second is social support, which measures the psychological and material support provided by an individual's entourage [27,28]. Lastly, the third, is coping strategies that individuals use to react and adapt to stressful situations [29]. Maladaptive coping during the pandemic has been shown to be associated with poor outcomes [6]. On the other hand, several studies point to the conjoint effect of resilience, social support, and coping strategies [26]. For example, resilience combined with other adaptive coping strategies has been shown to help manage stress and sustain personal growth [30]. To our knowledge, no study has explored the role of these factors in maintaining nurses' QoL. Therefore, the main objective of this study was to identify which protective factors were most helpful in maintaining the nurses' QoL during the pandemic in France.

Studying the protective role of resilience, social support, and coping strategies is important in France because nurses can work as employees at hospitals or care institutions (NHCIs) (e.g., retirement homes, care homes) or have a private independent practice (NPPs) where they provide care prescribed by a physician at patients' homes [31]. Both categories of nurses had to adapt to multiple sources of stress during the pandemic. A survey of French NPPs in 2020 found that around a third of the respondents did not have sufficient medical supplies to do their work, and half of them reported having to reorganize their work schedules and feeling stressed by their work during the pandemic [32]. However, to our knowledge, no study has investigated the similarities and differences in how these two groups reacted to the pandemic. Such knowledge would allow us to provide nurses with the necessary support to help them adapt to the specific sources of stress in their practice during crisis times. Thus, the second objective of the current study was to investigate the role of different protective factors in determining QoL specific to the two types of practice (NHCI and NPP) and across both groups.

#### **2. Materials and Methods**

#### *2.1. Design and Population*

This cross-sectional survey was conducted in France between February and March 2021 during the third COVID-19 wave. An invitation to participate in the study accompanied by a link to the online self-administered questionnaire was sent to all registered nurses through the Ordre National des Infirmiers (French National Order of Nurses), followed by three weekly reminders. About 400,000 nurses are registered at the Ordre National des Infirmiers. Participation was anonymous and voluntary. The questionnaire was developed with Sphinx iQ2 v7.4.5.1. The data used in this study were part of a larger study focused on nurses' QoL and health-protecting factors in European countries [33].
