Resilience and sense of agency among healthcare professionals during crisis

TL;DR

This study shows that psychological traits like resilience and psychological capital are important for healthcare workers' sense of control during crises, more than just their experience.

Contribution

The study demonstrates that psychological resources predict perceived agency in healthcare professionals during crises, beyond traditional factors like experience.

Findings

Psychological capital and resilience were strongly linked to perceived agency in healthcare professionals during crises.

Paramedics and EMTs reported higher perceived agency than nurses and physicians.

Spirituality was found to predict perceived agency among healthcare professionals.

Abstract

Healthcare professionals (HCPs) are central to emergency response, and their effectiveness depends not only on clinical expertise but also on psychological resources. Strengthening these resources may sustain workforce capacity and safeguard care under crisis conditions. This study examined the contribution of psychological capital—particularly resilience—to perceived agency among Israeli HCPs during mass casualty incidents and violent conflict after 7th of October 2023. The objective was to assess whether psychological resources predict perceived effectiveness beyond traditional factors, with implications for preparedness, organisational support, and policy. Findings may inform interventions relevant to resource-restricted environments and adaptable to developing countries.

The study was designed as an observational-cross-sectional study, conducted using encrypted online questionnaires distributed via QR codes in trauma centres, dispatch stations, and professional forums. Participants were qualified physicians, surgeons, nurses, paramedics, and EMTs providing patient care during the conflict. Instruments measured psychological capital (PCQ-24), resilience (CD-RISC 10), and perceived agency (RSES).

204 HCPs participated (mean age 37.4, SD = 11.6; 61.8% male). Psychological capital (r = 0.387, p < 0.001) and resilience (r = 0.485, p < 0.001) were strongly associated with agency, surpassing prior experience. Paramedics/EMTs reported higher agency than nurses/physicians (p < 0.001). Spirituality also predicted agency (β = 0.142, p = 0.022).

Psychological capital and resilience are key determinants of HCPs’ perceived agency in crises. Embedding resilience-building into public health systems, alongside organisational and policy measures, may enhance workforce readiness across conflict, disaster, and health threats. These findings are especially relevant to resource-limited settings, where psychological preparedness may be a cost-effective means to support frontline staff and sustain delivery.

Figures

Study population - participant flow diagram. Eligibility criteria required participants to be ≥ 18 years of age, official medical qualification (EMT, paramedic, nurse, physician, or surgeon), and to have actively provided patient care during the conflict period from October 7th, 2023, through June 11th, 2024. The survey was distributed via QR codes in trauma centres, emergency dispatch stations, and electronically through professional forums and social media using snowball sampling (this limits the ability to present the amount of people approached). Completion rate among eligible participants - 61.3%.

Tables

Table 1. Demographic and professional characteristics and associated perceived agency scores (response to Stressful Experiences Scale).

Variable	Total (n = 204)	Perceived agency score (M ± SD) *	p value
Demographic characteristics
Age (y), M ± SD (min-max)	37.4 ± 11.6 (18–68)	r = −0.015	0.836a
Gender
Male	126 (61.8%)	64.6 ± 11.0	0.248b
Female	77 (37.7%)	66.4 ± 10.2
Other	1 (0.5%)
Family status
Single	57 (27.9%)	63.7 ± 9.4	0.091b
In a relationship	147 (72.1%)	66.4 ± 10.8
Parents of children	130 (63.7%)	66.0 ± 11.0	0.591b
Educationd
Non-Academic	57 (27.9%)	69.5 ± 10.4	< 0.001b
Academic	147 (72.1%)	64.1 ± 10.1
Religiosity
Secular	70 (34.3%)	63.0 ± 9.7**	0.012c
Traditional	34 (16.7%)	67.1 ± 9.5
Devout	60 (29.4%)	65.3 ± 11.4
Very devout	40 (19.6%)	69.6 ± 10.2**
Professional characteristics
Profession
Physician/Surgeon	58 (28.4%)	62.6 ± 9.8**	< 0.001c
Nurse	38 (18.6%)	62.3 ± 9.8**
Paramedic/EMT	108 (53.0%)	68.5 ± 10.3**
Years of experience (y),M ± SD (min-max)	10 ± 8.5 (0–41)	r = −0.036	0.613a
Treatment environment
Pre-hospital	77 (37.7%)	69.2 ± 10.5**	< 0.001c
Military	53 (26.0%)	65.2 ± 10.1
Acute Caree	49 (24.0%)	62.6 ± 9.7**
Other	19 (9.3%)	61.1 ± 10.5**
Provided care in their pre-conflict treatment environment
Yes	126 (61.8%)	65.0 ± 10.7	0.326
No (Different treatment settingf)	75 (36.7%)	66.5 ± 10.1
Unknown	3 (1.5%)

Table 2. Descriptive statistics for resilience and psychological capital scores.

Variable	(M ± SD)	Min-Max	Median	IQR
Resilience Levels (CD-RISC 10 score)	32.0 ± 4.9	19.0–40.0	32.0	28.3–36.0
PCQ 24 – General score	4.7 ± 0.6	3.1–6.0	4.7	4.3–5.1
PCQ 24 – Hope component	4.7 ± 0.7	2.3–6.0	4.7	4.3–5.2
PCQ 24 – Efficacy component	4.6 ± 0.9	2.0–6.0	4.7	4.0–5.3
PCQ 24 – Resilience component	4.9 ± 0.6	3.0–6.0	5.0	4.4–5.4
PCQ 24 – Optimism component	4.6 ± 0.8	1.75–6.0	4.5	4.3–5.0

Table 3. Exposure characteristics and associated perceived agency score (response to Stressful Experiences Scale).

Variable	Total (n = 204)	Perceived agency score (M ± SD) *	p value
Previously provided care under stressful conditions
No	81 (39.7%)	66.1 ± 10.2	0.648b
Yes, Mass casualty event (MCE)	52 (25.5%)	65.4 ± 10.7
Yes, Natural disaster	4 (2.0%)
Yes, Military operation	17 (8.3%)
Yes, War	20 (9.8%)
Yes, other	30 (14.7%)
Personal residence near fighting zone
Yes	23 (11.3%)	67.7 ± 9.7	0.300c
Treatment in facility or field under threat
Yes	115 (56.4%)	65.8 ± 11.5	0.930b
Were you or a colleague of yours wounded while treating a patient?
Yes	24 (11.8%)	66.4 ± 11.0	0.664b
A personal loss of a close relative during the current conflict
Yes	111 (54.4%)	65.4 ± 11.1	0.575b
Frequency of stressful events and perceived imminent threat
Frequency of professional stressful events since Oct. 7th,M ± SD **	4.0 ± 1.8	r = 0.016	0.822a
Frequency of personal stressful events since Oct. 7th,M ± SD **	3.8 ± 1.8	r = − 0.083	0.236a
Level of personal imminent threat felt during events,M ± SD **	3.2 ± 1.9	r = 0.077	0.272a

Table 4. Key statements indicative of high ‘perceived agency’ total score (response to Stressful Experiences Scale).

Key statements of each questionnaire	Correlation with total score of perceived agency*	p value
Perceived agency questionnaire
“During/after medical treatment under significant stress, I find an opportunity for growth.”	r = 0.679	< 0.001
“During/after medical treatment under significant stress, I see it as a challenge that will make me better.”	r = 0.654	< 0.001
“During/after medical treatment under significant stress, I calm and comfort myself.”	r = 0.601	< 0.001
Resilience questionnaire (CD-RISC 10)
“Coping with stress can make me stronger.”	r = 0.432	< 0.001
“I believe that I can achieve my goals, even if there are obstacles.”	r = 0.395	< 0.001
“I think I am a strong person who can cope with life’s challenges and difficulties.”	r = 0.366	< 0.001
Psychological capital questionnaire (PCQ24)
“Currently, I see myself as being quite successful at work.”	r = 0.364	< 0.001
“I approach this job as if “every cloud has a silver lining.”	r = 0.363	< 0.001
“I can think of many ways to reach my current work goals.”	r = 0.353	< 0.001

Table 5. Multivariant analysis - linear regression for predictors of self-efficacy (response to Stressful Experiences Scale).

Variable	Unstandardized Coefficients		Standardized Coefficients		p value
	B	Std. error	β	t
Constant	20.574	7.229		2.846	0.005
Gender	−0.695	1.400	−0.032	−0.497	0.620
Age	0.113	0.064	0.122	1.773	0.078
Education	−3.641	1.719	−0.156	−2.119	0.035
Religiosity	3.159	1.371	0.142	2.303	0.022
Resilience Levels(CD-RISC 10 score)	0.742	0.168	0.342	4.423	< 0.001
PCQ 24 – Hope component	3.681	1.245	0.238	2.956	0.004
PCQ 24 – Efficacy component	0.206	0.891	0.017	0.231	0.817
PCQ 24 – Resilience component	−2.153	1.343	−0.128	−1.603	0.111
PCQ 24 – Optimism component	1.587	0.918	0.125	1.728	0.086
Profession	2.303	1.652	0.109	1.394	0.165
Treatment environment	0.030	0.704	0.003	0.042	0.967

Full text

Introduction

1

Emergencies, whether natural or man-made, are unforeseen and characterized by elements of uncertainty, and significant harm to individuals, communities, and the environment (1). In such crises, healthcare professionals (HCPs) encounter multifaceted challenges, including self-imposed and societal expectations to sustain optimal performance under substantial mental and cognitive strain (2, 3). Psychological capital has been recognized as a key factor in mitigating the mental effects of crisis (4).

Psychological capital (PsyCap) is a construct comprising self-efficacy, hope, optimism, and resilience, which plays a crucial role in disaster scenarios. Studies have shown that PsyCap is positively correlated with disaster preparedness and coping styles (5). For HCPs involved in disaster response, higher PsyCap levels are associated with lower secondary traumatic stress (6). PsyCap is significant in enhancing individual and organizational resilience, reducing psychological distress, and improving disaster preparedness across various sectors affected by catastrophic events (7, 8).

Resilience is a pivotal part of PsyCap and is conceptualized as the capacity to avoid succumbing to distress, function at or near pre-crisis levels and later “bounce back” or even “bounce forward,” achieving post-traumatic growth (9). For individuals assuming key roles in emergency scenarios, resilience is an essential resource to cope and perform under adversity (2, 10). Agency refers to the ability of an individual to act effectively in a given environment. Subjectively, it reflects an individual’s perception of self-efficacy, mainly being able to purposely initiate and successfully execute actions and a sense of ownership over their consequences. A positive sense of agency has been linked to successful functioning. A lack agency has been linked to adverse outcomes and post-traumatic stress disorder (PTSD) (11).

On October 7th, 2023, Israel experienced the country’s largest ever mass casualty event (MCE), one of the largest civilian MCEs in modern history. The day ended with 1,200 fatalities, 1,455 surviving casualties, and 239 hostages taken (12, 13). Medical teams were mobilized to address these overwhelming challenges, operating under extreme and prolonged stress. Many medical teams were impacted directly with numerous providers injured or killed. Providers were required to perform while managing the uncertainty for the fate of loved ones, and at times receiving devastating news. The healthcare system was challenged with an unprecedented surge of patients and at times scarcity of resources on the national, organizational and provider levels. October 7th, and the tragic events that ensued presented extreme societal, organizational and personal challenges.

While existing literature has examined psychological capital and resilience in healthcare settings separately (14, 15), and several studies have explored the mental health consequences of the October 7th attacks on the general population (16, 17), significant gaps remain. First, most studies focus on either organizational or individual psychological factors in isolation, rather than examining their interplay during sustained crisis conditions. Second, research on HCPs’ perceived agency, a critical determinant of performance and psychological outcomes, during prolonged mass casualty events, remains limited. Third, cross-professional comparisons (physicians, nurses, paramedics, emergency medical technicians (EMTs)) across different treatment environments (pre-hospital vs. hospital) during extended conflict are scarce. This study addresses these gaps by examining the contribution of psychological capital and resilience to perceived agency among diverse HCPs who provided care during an unprecedented and sustained crisis. The novelty of our research lies in its comprehensive approach as a cross-disciplinary medical sample, spanning multiple professional roles and settings. In addition, the research examines an ongoing, prolonged conflict rather than a discrete event, and focuses on perceived agency as an outcome, which has implications for both immediate performance and long-term psychological wellbeing.

Methods

2

Study design

2.1

This study was designed as an observational, cross-sectional investigation conducted among Israeli healthcare professionals (physicians, surgeons, nurses, paramedics, and EMTs) who actively provided medical care in both pre-hospital and hospital settings during the ongoing conflict in Israel. The estimand of interest was the population-level association between resilience and perceived agency among healthcare professionals during the defined conflict period. The study setting encompassed pre-hospital emergency medical services and hospital-based care across Israel. For the purposes of this study, the “current conflict” was operationalized as the period from October 7th, 2023, marking the mass casualty event that initiated the regional conflict in Israel, through June 11th, 2024 (the end of data collection). This period was characterized by sustained operational demands on the healthcare system, including ongoing casualty care, heightened security threats, and prolonged organizational strain.

Study population

2.2

The study population consisted of Israeli medical professionals who actively provided care between October 7th, 2023, and June 11th, 2024 (from crisis beginning to study data collection commencement). Eligible participants included emergency medical technicians (EMTs), paramedics, nurses, physicians, and surgeons. Inclusion criteria required participants to possess an official medical qualification and actively engage in patient care. Individuals <18 years old, those lacking certification, and HCPs who did not actively provide patient care were excluded.

The questionnaire link was accessed by 468 individuals. Of these, 59 did not proceed beyond the consent page. Among the remaining 409 individuals who provided consent, 333 (81.4%) met the eligibility criteria and initiated the questionnaire. Of the eligible participants, 237 (71.2%) completed at least 80% of the survey items, and 204 (61.3%) completed the questionnaire in full. The final analytic sample therefore comprised 204 healthcare professionals who provided complete responses to all study instruments. The overall completion rate was 61.3% among eligible participants who initiated the questionnaire. The detailed participant flow is presented in Figure 1.

Study population - participant flow diagram. Eligibility criteria required participants to be ≥ 18 years of age, official medical qualification (EMT, paramedic, nurse, physician, or surgeon), and to have actively provided patient care during the conflict period from October 7th, 2023, through June 11th, 2024. The survey was distributed via QR codes in trauma centres, emergency dispatch stations, and electronically through professional forums and social media using snowball sampling (this limits the ability to present the amount of people approached). Completion rate among eligible participants - 61.3%.

Variables and tools

2.3

Demographic data and professional characteristics

2.3.1

Participants provided data on socio-demographic characteristics, professional background, and personal exposure to threats.

Past exposure and stress characteristics

2.3.2

Past exposure and stress characteristics were assessed using items adapted from the conceptual framework established by Fergusson et al.’s (14) study of the Canterbury (New Zealand) earthquake sequence. That study demonstrated that disaster exposure could be reliably measured (α = 0.92) by assessing two domains - immediate impacts of the earthquakes and consequential ongoing disruptions following the disaster. This approach significantly predicted mental health outcomes 20–24 months post-disaster, establishing that measuring past exposure to high-stress conditions is both methodologically feasible and clinically meaningful (14).

Following this principle of measuring both exposure and its consequences, we developed items appropriate specifically to healthcare providers during conflict. We assessed - prior professional experience in high-stress scenarios (mass casualty events, natural disasters, military operations, war), direct exposure to threat and harm (proximity of residence to conflict zones, provision of care under threat, personal or colleague injuries, personal losses), and ongoing frequency and intensity of professional and personal stressful events since October 7th. Like the original research, we used binary responses (yes/no) for categorical exposure variables and multi-point scales (7-point Likert: 1 = infrequent, 7 = very frequent) for frequency and intensity measures.

Measures of psychological capital and resilience

2.3.3

Psychological capital was measured using the Psychological Capital Questionnaire (PCQ-24), developed by Luthans, Avolio, and Avey in 2007 (15). The PCQ-24 provides both overall and subscale scores for four dimensions- hope, efficacy, resilience, and optimism. Scores range from 1 to 6, representing the average response to items within each category on a 6-point Likert scale (1–6), with higher scores reflecting greater psychological resources. The PCQ-24 has demonstrated strong reliability in prior studies with an internal consistency of α = 0.92 (16).

Resilience, a key component of psychological capital, was further assessed using the 10-item Connor-Davidson Resilience Scale (CD-RISC 10), derived from the original CD-RISC 25 questionnaire developed by Connor and Davidson in 2003 (17, 18). This scale generates scores ranging from 0 to 40, calculated as the sum of responses to all items on a 5-point Likert scale (0–4), with higher scores indicating greater resilience. The reliability of the CD-RISC 10 has been validated in previous research with an internal consistency of α = 0.91 (19).

While resilience is conceptually nested within PsyCap as one of its four dimensions, we measured it separately for two main reasons. First, resilience has been identified as particularly crucial in crisis contexts and warranted deeper examination beyond its representation in the PCQ-24. Second, the use of two validated resilience measures allows for convergent validation and provides a more comprehensive assessment of this critical construct, both as part of the broader PsyCap framework and as a standalone construct.

Measures of perceived agency

2.3.4

Perceived agency, the primary outcome, was evaluated using the Response to Stressful Experiences Scale (RSES), developed by Johnson and colleagues in 2011 (20), The 22-item scale measures individual differences in cognitive, emotional, and behavioral responses to stressful life events, utilizeing a 5-point Likert format, producing scores ranging from 0 to 88, where higher scores indicate greater perceived agency. The RSES was originally developed and the reliability of the RSES has been validated in U. S. military populations, with an internal consistency of α = 0.92 (20).

Factor analysis identified five protective factors: meaning-making and restoration, active coping, cognitive flexibility, spirituality, and self-efficacy—all contributing to agency during stressful events. In military and first responder populations, RSES scores have predicted successful psychological adaptation to combat and operational stress, making it particularly appropriate for assessing HCPs facing crisis conditions (20). The scale’s focus on growth-oriented responses to stress, aligns with our conceptualization of perceived agency as encompassing both sense of control and capacity for purposeful action under adversity.

Tool validation

2.4

A pilot study with 30 participants was conducted to test the internal validity of the translated instruments, which underwent a standard forward–backward translation and linguistic validation. Each measure was required to achieve Cronbach’s α > 0.7 and to demonstrate clarity and alignment with the study aims. All instruments exceeded thresholds (CD-RISC 10: α = 0.84; PCQ-24: α = 0.82; perceived agency: α = 0.88). Participant feedback was used to refine the final questionnaire.

Study procedure

2.5

Data were collected via an encrypted web-based platform (Qualtrics) between May 30th and June 11th, 2024, using convenience and snowball sampling. To enhance accessibility across diverse healthcare professionals (HCPs), the questionnaire was distributed in both physical and online settings. QR codes were placed in four Level I trauma centres in central Israel and Jerusalem, urgent care clinics, and three regional emergency medical dispatch centres. The questionnaire link was also shared through professional forums and social media platforms. Snowball sampling was used to encourage participants to invite colleagues.

Participation was voluntary and anonymous, and no incentives were provided. Due to the anonymous design and snowball sampling methodology, specific institutional affiliations were not systematically recorded. This approach enabled broader geographic and institutional representation while preserving participant confidentiality. Respondents represented a diverse range of healthcare settings across Israel, including Level I trauma centres, community hospitals, and pre-hospital emergency services operating in both civilian and military contexts.

Statistical analysis

2.6

Based on prior studies (21) and accepted standards, a minimum of 163 participants was calculated to ensure 80% power to detect an effect size of 0.8 with 95% CIs. Analyses were performed using IBM SPSS® v29.0. Continuous variables were summarized as means ± SD and categorical variables as frequencies/percentages. Normality was tested with Kolmogorov–Smirnov; parametric tests were applied given sample size. Univariate analyses included t-tests, Pearson correlations, and ANOVA with Bonferroni corrections. Multicollinearity and homoscedasticity were checked (VIF < 1.91). Multivariate linear regression identified predictors of perceived agency, with significance at p < 0.05 (unless adjusted).

Results

3

Characteristics of participants

3.1

A total of 204 HCPs participated in the study. The mean age was 37.4 (SD = 11.6, range 18–68) years, with 61.8% males. The sample included both civilian (74%) and military (26%) HCPs, across diverse professional backgrounds and experience levels. Detailed demographic and professional characteristics are presented in Table 1.

Psychological capital and resilience of participants

3.2

The mean psychological capital score, assessed using the PCQ-24, was 4.7 (SD = 0.6, range 3.1–6.0). Detailed subscale scores are presented in Table 2. The mean resilience score, measured by the CD-RISC-10, was 32.0 (SD = 4.9, range 19–40). Overall, these findings reflect moderate to high levels of psychological capital and resilience within the sample, indicating that healthcare professionals who continued providing care during the ongoing conflict exhibited relatively strong psychological resources. Table 2 further summarizes descriptive statistics for psychological measures.

Perceived agency and associated factors

3.3

We applied three tools to assess participants’ psychological capital, resilience and perceived agency: The PCQ-24 for psychological capital, the CD-RISC 10 for resilience and the Response to Stressful Experiences Scale (RSES) for perceived agency.

Demographic characteristics

3.3.1

Professional role exhibited the largest effect size, with paramedics and EMTs reporting higher perceived agency scores compared to doctors and nurses (F(3,200) = 6.128, p < 0.001). This was followed by the treatment environment, where individuals working in pre-hospital settings reported greater perceived agency than those in hospital-based settings, independent of their roles (e.g., paramedic, nurse, etc.) (F(3,194) = 5.847, p < 0.001). Regarding education, individuals holding non-academic qualifications reported higher perceived agency scores than academically trained providers (t_(202)_ = 3.368, p < 0.001). Religiosity was significantly associated with perceived agency, as participants identifying as highly devout consistently demonstrated higher perceived agency scores (F(3,200) = 3.759^1^, p = 0.012), suggesting a potential link between spiritual beliefs and resilience under stress. We did not find a significant association between perceived efficacy and the number of years of experience in the role (r = −0.036, p = 0.613).

Past exposure

3.3.2

We examined the relationship between various exposure factors and perceived agency. Despite diverse previous exposure to significant stressors, most variables did not show a clear association with perceived agency scores (Table 3). Prior experience in stressful conditions (Table 3) did not yield significant differences in perceived agency (t_(202)_ = 0.457, p = 0.649). Direct exposure to danger, such as treating patients under threat (t_(196)_ = −0.088, p = 0.930) or experiencing personal/colleague injuries (t_(194)_ = −0.435, p = 0.664), showed no significant impact on perceived agency. The frequency of stressful professional events (r = 0.016, p = 0.822) and personal events (r = −0.083, p = 0.236) showed no significant correlations with perceived agency.

Personal characteristics and perceived agency

3.3.3

Resilience demonstrated a positive correlation with perceived agency (r = 0.485, p < 0.001) as did the overall psychological capital (PCQ-24) score (r = 0.387, p < 0.001). Additionally, significant positive correlations were observed across all four components of the PCQ-24, with correlation coefficients ranging from r = 0.408 for optimism (p < 0.001) to r = 0.183 for efficacy (p < 0.009). These findings highlight the association between existing psychological resources and perceived agency. Furthermore, we found key statements that are highly indicative of perceived agency, with growth-oriented perspectives showing the highest correlations (Table 4).

Multivariant analysis and predictors of perceived agency

3.4

A linear regression model was employed to evaluate the predictive power of variables associated with perceived agency identified in the univariate analysis (Table 5). The model was statistically significant (F = 10.04, degrees of freedom = [11,185], p < 0.001), accounting for 37.4% of the variance in perceived agency. Significant predictors as presented in Table 5, include resilience (β = 0.342, p < 0.001), the hope component of PCQ-24 (β = 0.238, p = 0.004), education (β = −0.156, p = 0.035) and religiosity (β = 0.142, p = 0.022).

Discussion

4

This study examined the psychological capital (PsyCap) of HCPs, emphasizing resilience and its effect on perceived agency during MCEs and violent conflict. Findings indicate that hope, personal growth, professional perseverance, spirituality, and emotional regulation are key predictors of coping, exerting stronger influence on resilience and agency than traditional professional factors such as experience and prior exposure. The psychological and societal impacts of the October 7th, 2023, attack on Israel are still unfolding and may parallel outcomes of large-scale natural disasters such as Events like Hurricane Katrina (2005) (22), the 2011 Tōhoku earthquake and tsunami (23), and the Australian bushfires (2019–2020) (24) which caused displacement, destruction, and long-term psychological distress including PTSD. The unprecedented casualties, displacement, and trauma of October 7th will likely pose similar recovery challenges. While early studies have examined mental health consequences among survivors (25–27), our focus was HCPs perceived agency and effectiveness while treating. Positive agency has been shown to protect against PTSD, whereas negative agency may be harmful (28–30).

The diverse sample of HCPs across roles, treatment settings (Table 1) and exposure levels (Table 3) supports generalizability to other professionals working under crisis conditions. Prior research links resilience to reduced stress, burnout, and depression (31), and studies during COVID-19 underscored its role in lowering anxiety and improving capacity to function (32). Higher resilience has also been associated with empathy and attentiveness in HCPs (33), and with superior decision-making and adaptability in military contexts (21). Resilience, a core PsyCap component, enables composure, adaptability, and sound decision-making under stress (34, 35).

Although personality traits and psychological resources influence resilience and agency (2), interventions to enhance resilience have shown mixed results (36). Professional role and treatment setting also shape performance (37): hospitals provide structured workflows and collaboration but may constrain decision-making (38), while pre-hospital settings demand rapid, autonomous action under resource limitations—fostering adaptability yet increasing stress (39). Our findings mirror these distinctions: paramedics and EMTs reported higher agency than physicians and nurses, and pre-hospital environments were associated with higher efficacy than hospital settings.

Evidence on experience is conflicting—some studies link it to better coping (40), while others suggest greater PTSD vulnerability (41). Although intuitively experience should enhance resilience, our study found no association between prior exposure and perceived agency, indicating exposure alone is insufficient. Instead, coping mechanisms, resilience, and psychological resources play a larger role in determining efficacy. Resilience is increasingly seen as a dynamic process (42) shaped by emotional regulation (43), optimism (44), growth-oriented mindset (45), rather than solely by exposure. The Response to Stressful Experiences Scale, developed in military populations and used in the current research, identified meaning-making, active coping, flexibility, spirituality, and self-efficacy as resilience factors (20), which align with our HCP findings.

These results suggest resilience-building interventions across healthcare should extend beyond accumulating experience. Programs may strengthen PsyCap (46), promote adaptive coping (47), and encourage post-traumatic growth (48). Developing internal psychological resources may provide more reliable protection than exposure-based adaptation.

Resilience was strongly associated with perceived agency under pressure. Defined as the ability to “bounce back” or “bounce forward,” it supports crisis response and fosters post-traumatic growth (9). Religiosity, conceptualized as a spiritual dimension of life, correlates positively with mental health and well-being (49, 50),suggesting possible value in integrating spiritual dimensions into HCP training. A 2012 study by Falb and Pargament highlighted mindfulness practices as a potential pathway for developing spiritual qualities (51).

Future research can further examine how environments, exposures, and training affect resilience, and test interventions designed to strengthen it. Additionally, linking perceived efficacy with objective performance measures could yield important insights.

Implication for health policy

4.1

Findings of the research carry significant implications for health policy, particularly regarding the preparedness, support, and retention of healthcare personnel during and after large-scale emergencies. Current health policies often emphasize clinical training and operational readiness, yet our results suggest the need to institutionalize psychological preparedness as a core component of professional development. Incorporating resilience-building interventions—such as stress regulation techniques, cognitive reframing, and mindfulness-based practices into training frameworks, could enhance functional capacity under stress. Tailoring these initiatives to specific clinical roles and treatment environments may be important, given significant differences among professional groups and settings (38, 39). Training and support strategies reflect the unique psychological demands faced by hospital-based versus pre-hospital providers. Additionally, the demonstrated association between hope, spirituality, and psychological well-being suggests that spiritual support in various methods, may be a valuable addition to workforce resilience strategies (49, 50, 52). Importantly, the absence of a consistent link between prior exposure and perceived efficacy, challenges assumptions embedded in many emergency preparedness models (40), and points toward the need for proactive psychological resource development. Integrating psychological capital assessments and development opportunities into routine professional evaluations may help standardize and sustain these efforts. By expanding the definition of readiness to include psychological resilience, health systems may better protect and empower their workforce, ensuring more effective, sustainable care delivery in the face of future crises. As global challenges increasingly expose providers to high-intensity stressors, policies that prioritize psychological resources will be essential in safeguarding both workforce stability and population health outcomes, especially in resource-restricted settings.

Limitations

4.2

This study has several limitations. Outcomes relied on HCPs’ self-reports, which may not reflect objective functioning. Voluntary participation and non-probabilistic sampling introduce potential selection bias. Data were collected after the initial peak of exposure, but participants may not have fully consolidated their perspectives, raising the possibility of recall bias. A potential limitation of this study is that resilience constitutes a core component of psychological capital (PsyCap), while also being examined as a distinct variable in the analyses. This conceptual overlap may introduce concerns regarding circularity or shared variance, potentially biasing statistical estimates. However, diagnostic testing indicated that multicollinearity was not a significant concern within the analytical models. Finally, the cross-sectional design limits causal inference between resilience and perceived agency.

Conclusion

5

Resilience and psychological capital, specifically hope, personal growth, professional perseverance and spirituality were found to be key determinants of HCPs’ perceived agency in crises. Embedding resilience-building into public health systems, alongside organisational and policy measures, may enhance workforce readiness across conflict, disaster, and health threats. These findings are especially relevant to resource-limited settings, where psychological preparedness may be a cost-effective means to support frontline staff and sustain delivery.