Introduction
One of the most sensitive departments of the hospital where nurses play an important role is the intensive care unit (ICU). Nurses working in these departments show more depression, anxiety and irritability than nurses in other departments. the American Society of Safety Professionals has introduced nursing as one of the top 40 stressful professions, and it is probably the most stressful profession among health professions. The health of nurses in departments related to COVID-19 is more important due to the risk of infection. Considering the key role of nurses in caring for and meeting the needs of patients and given the destructive effects of stress on the performance and various aspects of nurses’ lives, intervention to reduce nurses’ stress and its consequences seems necessary.
One of the coping strategies that help a person to deal effectively with stressful situations is resilience skills. Resilience is a factor that helps people to face and adapt to difficult and stressful life conditions and protects them from mental disorders. Self-care is an important part of treatment process in chronic diseases and involves all physical, mental and emotional aspects of the patient. Patients’ understanding of the role of spiritual self-care can lead to the management of chronic diseases. Considering the importance of the role of resilience in the mental health of nurses and the fact that in the studies conducted in the field of spiritual self-care, the group of nurses has received less attention, this study aims to assess the effect of spiritual self-care education on the resilience of nurses working in the ICUs dedicated to COVID-19 patients.
Methods
This is an experimental study with a pretest/posttest design. Participants were 64 nurses working in the ICUs dedicated to COVID-19 patients in Ziaeian Hospital in Tehran, Iran who were selected with a census method. They were randomly (by coin toss) assigned to intervention (n=32) and control (n=32) groups. To collect data, a demographic form (surveying age, sex, marital status, employment status, and type of shift), and the Connor-Davidson resilience scale (CDRS) with 25 items rated on a Likert scale from 0 to 4 were used. The higher score in CDRS indicates high resilience. The cut-off point for CDRS is 50 points; a score higher than 50 indicates that nurses have resilience. The spiritual self-care education for the intervention group was carried out in the meeting hall of the hospital at 6 sessions of 45 minutes every other day. The educational packages were designed based on the spiritual strategy of Richards and Bergin based on the Islamic approach. To comply with the ethical issues, after collecting the data, educational materials were also provided to the control group. Data analysis was done in SPSS software, version 25 using descriptive (mean and standard deviation) and inferential (independent t-tests, chi-square) statistics.
Results
The mean age of the intervention and control groups were 36.00±6.62 and 34.13±7.29 years, respectively. Other demographic characteristics are presented in Table 1.


The results in Table 2 showed that the highest score of resilience was related to the intervention group in the post-test phase, and the lowest score was related to the control group in the pretest phase, and there was a statistically significant difference (P<0.001).


Discussion
The results of this study showed that the resilience of nurses in the ICUs dedicated to COVID-19 patients increased after spiritual self-care education. Due to the fact that nurses deal with stressful factors in their work environment, which can negatively affect their general health, nursing managers can play an effective role in managing the well-being of nurses by providing education to nurses in this field and periodic consultations for nurses and making arrangements such as changing their departments. It is recommended to include the spiritual self-care education in the training program of nurses, and educational planners and educational officials should pay attention to this matter. To increase knowledge and awareness in this field by holding retraining courses, a positive step can be taken in the direction of spiritual self-care. This program can be used as an effective, inexpensive and complication-free program for all nurses. One of the challenges of this study was the unwillingness of some nurses to participate in the research. This can has a negative effect on the generalizability of the findings. It is recommended to provide the necessary grounds for providing spiritual self-care training and participating in spiritual activities for nurses, which can be effective in improving their psychological condition and resilience and thus they can provide better care to patients.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Tehran University of Medical Sciences (Code: IR.TUMS.MEDICINE.REC.1400.544). All ethical principles such as obtaining informed consent, confidentiality of information, voluntary participation, and being free to leave the study were considered.

Funding
This study was extracted from a master thesis and funded by Tehran University of Medical Sciences.

Authors' contributions
Design, conceptualization, data collection, data analysis and interpretation, draft preparation, final approval of the draft: Sajjad Mirzaee.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank the personnel of Ziaeian Hospital for their cooperation.
 

References

1. Pashaee S, Lakdizaji S, Rahmani A, Zamanzadeh V. [Priorities of caring behaviors from critical care nurses viewpoints (Persian)]. Preventive Care in Nursing and Midwifery Journal. 2014; 4(1):65-73. [Link]
2. Khanmohammadi S, Hajibeglo A, Rashidan M, Bekmaz K. Relationship of resilience with occupational stress among nurses in coronavirus ward of Khatam Al-Anbia Hospital, Gonbad Kavous, 2020. Neuropsychiatria I Neuropsychologia. 2020; 15(1-2):1-6. [DOI:10.5114/nan.2020.97397]
3. Pouraboli B, Esfandiari S, Ramezani T, Miri S, Jahani Y, Sohraby N. [The efficacy of psychological empowerment skills to job stress in nursing staff in intensive care wards in center of Shahid Rajaee hospital in Shiraz in 2013 (Persian)]. Journal of Clinical Nursing and Midwifery. 2016; 5(1):23-35. [Link]
4. Mu J, Ostrowski RP, Soejima Y, Rolland WB, Krafft PR, Tang J, et al. Delayed hyperbaric oxygen therapy induces cell proliferation through stabilization of cAMP responsive element binding protein in the rat model of MCAo-induced ischemic brain injury. Neurobiology of Disease. 2013; 51:133-43. [DOI:10.1016/j.nbd.2012.11.003] [PMID] [PMCID]
5. Liu CY, Yang YZ, Zhang XM, Xu X, Dou QL, Zhang WW, et al. The prevalence and influencing factors in anxiety in medical workers fighting covid-19 in China: A cross-sectional survey. Epidemiology and Infection. 2020; 148:e98. [DOI:10.1017/s0950268820001107] [PMID] [PMCID]
6. Gralinski LE, Menachery VD. Return of the coronavirus: 2019-nCoV. Viruses. 2020; 12(2):135. [DOI:10.3390/v12020135] [PMID] [PMCID]
7. Xu K, Lai XQ, Liu Z. [Suggestions for prevention of 2019 novel coronavirus infection in medical staff of otolaryngology head and neck surgery (Chinease)]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2020; 55(4):313-5. [DOI:10.3760/cma.j.cn115330-20200201-00240]
8. Mirzaei Rad SZ, Arsalani N, Dalvandi A, Rezasoltani P, Hoseini SD. [The effect of resilience skills training on nursing stress of nursing staff in hospitals of Golestan province (Persian)]. Journal of Health Promotion Management. 2019; 8(2):41-8. [Link]
9. Rasti L, Arsalani N, Maghsoudipour M, Hosseinzadeh S. [Assessment and comparison of the impact of ergonomic patient transfer method training on the operating room staff performance using two instruments of “patient transfer assessment” and “rapid entire body assessment” (Persian)]. Journal of Health Promotion Management. 2016; 5(6):1-8. [DOI:10.21859/jhpm-06021]
10. Sotoudeh A, Rahmani Anarki H, Sabzi Z. [Evaluation of resilience and its relationship with some individual professional factors of nurses working in the intensive care unit (ICU) of hospitals affiliated to Golestan University of Medical Sciences 2020 (Persian)]. Nursing Development in Health. 2021; 11(2):36-43. [Link]
11. Wilson CA, Saklofske DH. The relationship between trait emotional intelligence, resiliency, and mental health in older adults: The mediating role of savouring. Aging & Mental Health. 2018; 22(5):646-54. [DOI:10.1080/13607863.2017.1292207] [PMID]
12. Mealer M, Conrad D, Evans J, Jooste K, Solyntjes J, Rothbaum B, et al. Feasibility and acceptability of a resilience training program for intensive care unit nurses. American Journal of Critical Care. 2014; 23:e97-105. [DOI:10.4037/ajcc2014747] [PMID]
13. Bakhshizadeh S, Afrooz GA, Beh-pajooh A, Ghobari Bonab B, shokoohi Yekta M. [The effectiveness of resiliency based on Islamic spirituality training on mental health and spiritual resiliency among mothers of slow pace (mentally retarded) Children (Persian)]. Armaghan-e-Danesh. 2016; 21(5):492-512. [Link]
14. Gholamnia-Shirvani Z, Ghaemi Amiri M, Khosravi-Larijani AA, Rohollah-Pour E, Hosseini-Motlagh Z. [The study of spiritual health from the Islamic perspective in medical and dental students of Babol University of Medical Sciences (Persian)]. Medical Education. 2020; 8(1):53-8. [Link]
15. Salimi T, Tavangar H, Shokripour S, Ashrafi H. [The effect of spiritual self-care group therapy on life expectancy in patients with coronary artery disease: An educational trial (Persian)]. Journal of Rafsanjan University of Medical Sciences. 2017; 15(10):917-28. [Link]
16. Iri Z, Hojjati H, Akhoondzadah G. [The impact of spiritual self- care education on self- efficacy in adolescents with thalassemia in children’s hospital Taleghani Gonbad Kavoos Golestan 2017-18 (Persian)]. Iranian Journal of Nursing Research. 2019; 14(1):8-13. [Link]
17. White ML. Spirituality self-care practices as a mediator between quality of life and depression. Religions. 2016; 7(5):54. [DOI:10.3390/rel7050054]
18. Hojjati H, Hekmati Pour N, Khandousti S, Mirzaali J, Akhondzadeh G, Kolangi F, et al. [An investigation into the dimensions of prayer in cancer patients (Persian)]. Religion and Health. 2015; 3(1):65-72. [Link]
19. Gijsberts MHE, Liefbroer AI, Otten R, Olsman E. Spiritual care in palliative care: A systematic review of the recent European literature. Medical Sciences (Basel). 2019; 7(2):25. [DOI:10.3390/medsci7020025] [PMID] [PMCID]
20. Ramazani B, Bakhtiari F. [Effectiveness of spiritual therapy on cognitive avoidance, psychological distress and loneliness feeling in the seniors present at nursing homes (Persian)]. Journal of Gerontology. 2019; 3(4):32-41. [DOI:10.29252/joge.3.3.32]
21. Rahnama M, Rahdar M, Taheri B, Saberi N, Afshari M. The effect of group spiritual care on hope in patients with multiple sclerosis referred to the MS society of Zahedan, Iran. Neuropsychiatria i Neuropsychologia/Neuropsychiatry and Neuropsychology. 2021; 16(3):161-7. [DOI:10.5114/nan.2021.113317]
22. Petersen CL, Callahan MF, McCarthy DO, Hughes RG, White-Traut R, Bansal NK. An online educational program improves pediatric oncology nurses’ knowledge, attitudes, and spiritual care competence. Journal of Pediatric Oncology Nursing. 2017; 34(2):130-9. [DOI:10.1177/1043454216646542] [PMID]
23. Ye ZJ, Qiu HZ, Li PF, Liang MZ, Wang SN, Quan XM. Resilience model for parents of children with cancer in mainland China-an exploratory study. European Journal of Oncology Nursing. 2017; 27:9-16. [DOI:0.1016/j.ejon.2017.01.002] [PMID]
24. Darabinia M, Gholami S, Heidari Gorji AM. [Evaluation of Islamic spiritual self-care (musharatah) in the students of Mazandaran University of Medical Sciences (Persian)]. Religion and Health. 2016; 4(1):12-20. [Link]
25. Keyhani M, Taghvaei D, Rajabi A, Amirpour B. [Internal consistency and confirmatory factor analysis of the Connor-Davidson resilience scale (CD-RISC) among nursing female (Persian)]. Iranian Journal of Medical Education. 2015; 14(10):857-65. [Link]
26. Richards PS, Bergin AE. A spiritual strategy for counseling and psychotherapy. Washington: American Psychological Association; 2005. [DOI:10.1037/11214-000]
27. Thuné-Boyle IC, Stygall JA, Keshtgar MR, Newman SP. Do religious/spiritual coping strategies affect illness adjustment in patients with cancer? A systematic review of the literature. Social Science and Medicine. 2006; 63(1):151-64. [DOI:10.1016/j.socscimed.2005.11.055] [PMID]
28. Revheim N, Greenberg WM. Spirituality matters: Creating a time and place for hope. Psychiatric Rehabilitation Journal. 2007; 30(4):307-10. [DOI:10.2975/30.4.007.307.310] [PMID]
29. khodabakhshi Koolaee A, Mohammad Beigi M, Bahari F. [The relationship between attachment to God with resilience and mental health among parents of children with special needs (Persian)]. Journal of Pizhūhish dar dīn va Salāmat (i.e., Research on Religion & Health). 2016; 2(4):5-14. [DOI:0.22037/jrrh.v2i4.13695]
30. Sadri Damirchi E, Mohammadi N, Ramezani S, Amanzad Z. [The effectiveness of spirituality group therapy on happiness and hardiness in elderly women (Persian)]. Journal of Research on Religion and Health. 2018; 4(2). [Link]
31. Ravandi N, Maryam, Arfai S, Fariborz. [The role of religion and spirituality in promoting resilience and mental health (Persian)]. Paper presented at: The first National Conference on Islam and Mental Health. 2-3 April 2015; Bandar abbas, Iran. [Link]
32. Rashidzadeh A, Badri Gargari R, Vahedi S. [The effects of positive thinking skills training based on Islamic teachings and beliefs on resilience and psychological well-being of mothers with autistic children (Persian)]. Applied Issues in Islamic Education. 2018; 3(2):59-86. [DOI:10.29252/qaiie.3.2.59]
33. Haghi H, Nazemi A, Karimollahi M. [Role of personality factors and religious beliefs in resiliency of patients with esophageal cancer (Persian)]. Journal of Health and Care. 2016; 18(2):150-60. [Link]
34. Jangi Aghdam Kh, Sardari B. [The effect of religious attitudes (religiosity) on resilience of cancer patients (Persian)]. Iranian Journal of Cancer Care. 2020; 1(2):1-8. [DOI:10.29252/ijca.1.2.1]
35. Hashemi L, Jokar B. [Examining the relationship between spiritual excellence and resilience in university students. Journal of Educational Psychology Studies (Persian)]. 2011; 8(13):123-42. [DOI:10.22111/jeps.2011.712]
36. Mehrinejad SA, Tarsafi M, Rajabimoghadam S. Predictability of students’ resiliency by their spirituality. Procedia - Social and Behavioral Sciences. 2015; 205:396-400. [DOI:10.1016/j.sbspro.2015.09.024]
37. Taghizade ME, Miralaie M. [The study of spiritual group therapy on resiliency in female multiple sclerosis patients in Isfahan (Persian)]. Journal of Health Psychology. 2013; 2(7):82-102. [Link]
38. Reutter KK, Bigatti SM. Religiosity and spirituality as resiliency resources: Moderation, mediation, or moderated mediation? Journal for the Scientific Study of Religion. 2014; 53(1):56-72. [DOI:10.1111/jssr.12081]
39. Rajabiyan Dehzireh M, Dortaj F, Dortaj F, Allahi Z. [Role of spiritual health in the resiliency of Kashan university students (Persian)]. Rooyesh-e-Ravanshenasi Journal (RRJ). 2019; 8(1):97-108. [Link]
40. Yousefian Z, Ahadi H, Keraskian Mojmanari A. [Effectiveness of spirituality therapy on the quality of life and mindfulness of the patients with thalassemia (Persian)]. Medical Journal of Mashhad university of Medical Sciences. 2020; 62(5.1):750-60. [DOI:10.22038/mjms.2020.15576]
41. Lucchetti G, Koenig HG, Lucchetti ALG. Spirituality, religiousness, and mental health: A review of the current scientific evidence. World Journal of Clinical Cases. 2021; 9(26):7620-31. [DOI:10.12998/wjcc.v9.i26.7620] [PMID] [PMCID]
42. Izadi Tame A, Mahmoudi Daraei K. [The effectiveness of spiritual training on the resilience and quality of life of divorced women (Persian)]. The Women and Family Cultural Education. 2018; 13(43):53-73. [Link]
43. Bolhari J, Naziri G, Zamanian S. [Effectiveness of spiritual group therapy in reducing depression, anxiety, and stress of women with breast cancer (Persian)]. Quarterly Journal of Women and Society. 2012; 3(9):87-117. [Link]
44. Heydari A, Fayyazi Bordbar M, Ebrahimi M, Meshkinyazd A. The impact of spiritual care skills on quality of life in spouses of veterans with post-traumatic stress disorder: A randomized controlled trial. Home | Journal of Caring Sciences. 2020; 9(4):220-4. [DOI:10.34172/jcs.2020.033] [PMID] [PMCID]