Reinforcement and Maintenance of Human Resources for Health Systems during Long-Term Crises: A Systematic Review of Systematic Reviews

Background Human resources are one of the most critical organizational resources, the reinforcement and maintenance of whom require much energy in health organizations, particularly in long-term crises. Many methods have been suggested in this regard; however, there is a need for their integration and clarification. Methods We systematically searched the international databases, including PubMed, Scopus, and Web of Science, from 2003 to April 2021by using some relevant keywords. The quality of the included studies was assessed using the AMSTAR checklist. Results The search resulted in 1613 papers, among which there were 16 systematic reviews. The studies addressed a wide range of problems and solutions. Twelve items and four items were classified with moderate quality (AMSTER score 5–8) and high quality (AMSTER score 9–11), respectively. Half of the studies (n = 8) dealt with mental and psychological problems resulting from crises as the most important factor in the decline of health system staff's durability in organizations. They also provided different solutions such as mental health counselling during and after the crisis, flexible work schedule, promoted trust in the organization, support of staff's family, and enhanced awareness to support employees. And the other articles addressed managerial problems as the most critical factor in the decline of health system staff's durability in organizations and proposed solutions such as suitable planning before, during, and after the crisis and the use of material and spiritual incentives to increase the employees' motivation and organizational resilience to maintain the staff. Conclusion In the present review study, three dimensions (namely, resilience, motivation-hygiene measures, and development of manager's soft skills) are considered as the main factors reinforcing and maintaining human resources in the health systems in long-term crises and disasters.


Introduction
e rate of crises and the number of their adverse consequences are increasing worldwide, which usually occur fast and suddenly [1]. According to Kristine Qureshi's report in eir reluctance could negatively influence the healthcare system's potentials to meet the needs of a sudden increase in the number of patients under such a condition [5,6]. On the other hand, healthcare staff, in particular nurses, who make up the largest number of healthcare providers and play the pivotal role in crises response and care, are required to have sufficient knowledge, skills, competencies, and adequate preparation to respond to crisis [1,7]. In this regard, the findings reported by Said and Chiang indicate that nurses should focus on psychological preparedness to develop and create better educational plans to reinforce knowledge and care abilities required in crises [1].
Modern challenges have been diverse and include a complicated range of issues such as climate changes, severe economic downturns, and political instabilities. In this interconnected world, these main issues could be a sudden threat to organizations' life and survival. at is why these kinds of challenges encourage organizations to stay adaptable and responsive while organizing and managing their staff [8]. Under such conditions, resilience makes systems adapt to emerging challenges and let organizations continue their activities in the new condition [9]. However, organizations have faced a huge challenge with the COVID-19 outbreak, which makes them manage their employees using different technical, physical, and social-psychological techniques never experienced before [8].
In a crisis, one of the critical duties of human resources (HR) management is maintaining employees' health while preserving their morals and loyalty and encouraging them to continue their activities in line with the organization's goals [10]. COVID-19 has created a challenging condition, particularly for the HR management since the HR department is one of the most pivotal parts of modern organizations, the role of which becomes even more highlighted during crises and in the crisis management [5,8]. In this situation, many employees have been encouraged to work in their homes, and their managers monitor tasks remotely; however, health organizations, especially those with emergency personnel and healthcare specialists, need their staff in their workplace [2]. Under this condition, human resource managers should help the staff deal with changes occurring in the workplace and social environment and adapt themselves to these changes [8] since it affects how personnel are supposed to make decisions. Moreover, plans, policies, and organizational decisions should be made based on the best available evidence [3]. Accordingly, this systematic review was to detect and integrate techniques of reinforcing and maintaining human resources in long-term crises in healthcare organizations.

Materials and Methods
e paper is presented in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) reporting checklist (Supplementary 1).

Search Strategy.
A comprehensive search was first conducted on PubMed, Scopus, Web of Science, and Cochrane databases from 2003 due to the occurrence of the first long-term crisis (SARS) to April 2021 to detect the best techniques to maintain human resources of the health system during crises and under stressful conditions. To this end, the following keywords, either alone or by conjunctions of "and" or "or," were used to find relevant papers with the concerned keywords in the title, abstract, and keywords sections: "Management," "Strategy," "Method," "Support," "Maintenance," "Sustaining," "Compliance," "Human Resources," "Healthcare worker," "Physicians," "Doctors," "Nurses," "Medical staff," "Crisis," "Disaster," "Catastrophic," "Systematic review," Long term," and "Longterm." We manually searched the reference lists to identify studies missed. In addition, we contacted with authors included articles for identifying more studies.

Study Selection.
Inclusion criteria were systematic reviews in English, full-text papers, and healthcare workers as the statistical population. Exclusion criteria were nonsystematic reviews, irrelevant studies, qualitative studies, studies presented in conferences and/or seminars, and letters to the editors.
To select the articles and extract the data, initial screening was based on titles and abstracts. e articles were evaluated independently. e abstracts lacking data were revised for full-text assessment. en two researchers individually evaluated the full text of the articles and determined their fitness ( Figure 1).

Data Extraction and Quality
Assessment. Two researchers (A. S. and M. M.) extracted data regarding standard criteria, and the results were reviewed by two senior researchers (M. K. and S. K.). e extracted data included the first author, year of publication, period, objectives, number of studies, and findings. e studies were evaluated using a checklist entitled "Measurement Tool to Assess Systematic Reviews (AMSTAR)" [11] to assess methodological quality (Supplementary 2). e tool consists of 11 items and has good face and content validity for measuring the methodological quality of systematic reviews.

Results
Based on Table 1, findings are classified in three areas of "organizational resilience," "motivation-hygiene measures," and "managers' soft skills." ese factors can help healthcare workers to resist and keep on in long-term crises.

Organizational Resilience.
We categorized the organizational factors such as material resources, scarce resource allocation management strategies, preparation, planning, diverse programming for critical episodes, crisis treatment standards, critical incident stress management, risk management, social media, government's measures, leadership methods, organizational culture, special training program, education systems, information management, cooperation, and peer support in a set and according to the literature labeled it as "organizational resilience." According to the standards, organizational resilience is the organization's ability to predict, plan, react, and adapt to crisis in order to survive and succeed [27,28]. e organizational resilience has a significantly positive relation to the organizational members' intentions for contributing to organizational effectiveness after a crisis situation [29].

Motivators and Hygiene Factors.
e human resource features factors are thought to be relevant to the maintenance and motivation factors to respond to the crisis. ese are organized into motivators and hygiene factors category. Hygiene or maintenance factors do not motivate employees; however, they merely prevent dissatisfaction and maintain the status [30]. In our study, hygiene factors covered aspects such as providing safety and protective equipment, availability of resources, shift flexibility, rest, workload, financial awards, and job promotion. Motivation factors were inherently job-related and, in this study, motivators reflect the pursuing professional education, role transparency, footprint of the organization's risk, and adaptive capacity. Managers should be aware that satisfaction is associated with motivational factors and that dissatisfaction is associated with hygiene factors.

Managers' Soft Skills
. "Soft skills" refer to all the competencies that are not directly related to a specific task. e soft skills enable managers to succeed in an increasingly complex, interconnected, and rapidly changing situation such as crisis. e social abilities, language and communication capability, and friendliness and team working ability, as well as other personality traits that characterize relationship between people are soft skills [31]. So, listening skills, emotional skills, empathy, complex problem-solving, creative strategies to support and manage personnel, critical thinking, learning to learn, collaboration, creating opportunities for development for the employees working under crisis conditions, and generally sparing efforts to build trust were classified in the managers' soft skills category.

Discussion
In this study, some review studies on the techniques causing the reinforcement and maintenance of human healthcare resources under the long-term crisis conditions were examined, according to which three main dimensions were detected. e first dimension was organizational resilience. Resilience is defined as an organization's capability to continue its activities in line with its goals in the presence of challenges. Resilience not only increases the system's capacity to resist strikes but also adapts and changes in accordance with the challenges. In this regard, managers need to consider crises in advance and adopt some management techniques such as the accelerated successive overrelaxation and ASOR method, identify the organization's weaknesses and strengths, and make necessary plans [9]. is planning is also necessary for the provision of human resources. In crises, workers could be classified into three groups. e first group includes workers who work in the organization and continue their activities during the crises period. is group of workers might either be satisfied with their jobs or not be satisfied and stay in the organization due to their lack of willingness to search for a new job and family commitments, while they are dissatisfied with their jobs. is is not good for the organization since such workers fail to be creative and dynamic and finally quit the organization when they find an appropriate job. Organization managers must take management measures to promote the satisfaction of dissatisfied and unmotivated workers because the lack of motivation could decrease the quality of service [11,32]. e second group includes workers lost because of job dissatisfaction, retirement, death, or other causes [32]. e third group encompasses workers coming to the organization during the crisis. ese workers might be just graduated or senior students, who join the organization with the incentive of employment upon the call of the health system [32]. According to Collado-Boira, despite the threats of COVID-19, senior students were more willing to accept the government's request due to their social commitment and professional ethics [11].
In the three groups, job satisfaction is considered a critical factor in maintaining staff under crisis conditions. e other finding of this study was the necessity of motivation-hygiene measures, which are the activities performed by health managers and policymakers for their staff to help them maintain their morals. ese measurements positively affect the organization's output, thus providing high-quality care since these outputs are the results of the staff's efforts.
Moreover, the motivation-hygiene measures decrease the likelihood of staff leaving service and changing job, thereby decreasing the organization's costs [33]. Factors such as job security, flexible attendance time, and        participation in decision-making increase the staff's willingness to work and, consequently, their maintenance in the organization [34]. Furthermore, Pavani Rangachari's investigations in 2017 indicated that excluding nurses from the decision-making process was the leading cause of job burnout [33]. According to Chia-Ching Wu's research findings on nurses' willingness to care for patients with SARS in 2012, the workers' willingness to work during crisis periods does not change significantly, and the majority of workers are willing or unwilling under normal conditions. In this investigation, considering their financial needs, family support, safeguarding individual health, and human resource policies, nurses found it a better decision to stay in their jobs during the outbreak of SARS [24]. erefore, motivation-hygiene measures need to be adopted under both crisis and normal condition [13][14][15] since workers' reluctance to work in both conditions reduces the quality of work and service even if it does not make workers quit their jobs. is will be more alarming under the crisis condition.
Nevertheless, Mary Chaffee's findings are in contrast with those reported by Chia-Ching Wu. Considering 30 studies, she stated that biological events might significantly decrease individuals' willingness to work; however, the provision of protective and training equipment is likely to improve their willingness [35]. According to the critical role of motivation-hygiene measures in establishing trust, they are of great importance in promoting job satisfaction and willingness to work, and precise economic planning should be proposed to provide their financial resources [36,37]. To manage crisis and achieve the best results under the crisis, the measures can be categorized according to their priority. According to Herzberg's motivation-hygiene theory, hygienic factors such as security, work, and salary decrease dissatisfaction; however, they cannot enhance satisfaction.
is is while motivational factors promote job satisfaction. According to workers' needs, an increase in motivationhygiene measures can play a pivotal role in maintaining workers in the long-term crises. ese measures in healthcare systems include the provision of protective equipment required by workers, shift change programs to let the worker rest [12], information dissemination [24], training programs, and increased awareness in dealing with illness, all of which would decrease their feelings of fear [13]. High work pressure should also be considered since it has negative effects on the nurses' performance. In this regard, if a nurse's mistake aroused by high work pressure under a crisis condition makes a patient die or get worse, the consequences have destructive effects on the nurse's morals and her/his willingness to continue working [38]. Accordingly, employee new graduates and entrusting simple tasks to these individuals would make more experienced health workers have more time and concentrate on handling high-level care services [3]. Moreover, if it is possible not to reduce salaries with a decrease in work hours, a motivation-hygiene Managers' soft skills measure should be adopted, which would have a positive effect during the crisis period [39]. e provision of personal protective equipment can significantly influence individuals' mental and physical health. It makes workers be less concerned with their health status and their families' health, as such the likelihood of disease transmission is decreased [33,38]. Moreover, training, public health, families' awareness of mental and social supports, and the appreciation of workers are considered motivation-hygiene measurements that positively influence workers' mental and physical health and prevent job burnout and the loss of healthcare workers under such conditions [15]. One of the main study findings was the necessity of developing managers' soft skills. e skills are as significant as establishing an intimate relationship with workers to promote organizational resilience in crisis. Organizations with more competent managers respond to crises better [14,40]. Establishing effective relationship under critical conditions promotes trust among workers [33]. Trust as the driving force of ethics and the incentive for employees is of great importance for organizations, especially in crisis since psychological trust and safety are the prerequisites of organizational resilience in health organizations [33,41]. Such measures require not many financial resources; however, managers' attention and managerial skills are of paramount importance. e measures include tasks such as listening to workers, learning from their personal problemsolving experiences, making clear strategies to support and manage workers, and generally sparing efforts to build trust.
Moreover, given that these measures can create a sense of trust in employees, providing opportunities to promote employees in crises had positive effects on the maintenance of workers in the organization in crisis [42]. e sense of trust and mental safety among healthcare workers is necessary to let them convey their concerns to managers under such conditions since managers can eliminate the leading causes of mistakes and hinder their recurrence [33]. According to the Social Exchange eory (SET), when employees find the organization a supportive environment, where their social-emotional needs are met and favorable working conditions are provided, a psychological attachment is created, making them committed to the organization [43].
In general, flexibility in strategic planning and human resource planning and the provision of motivation-hygiene measures for employees can improve the likelihood of survival for health workers under critical conditions. is comes true, especially if these measures are accompanied with promoting managers' soft skills to establish an effective relationship having significant positive effects on the maintenance of individuals and improving their performance in the organization [42]. e strengths of our study include the use of appropriate databases in identifying potentially eligible review studies, providing search strategy in detail, selecting the studies based on AMSTAR, and reporting based on a PRISMA 2020 checklist. e limitations of our study may be due to the use of systematic reviews with no registration predetermined protocol. Although we searched the Cochrane database for unplanned duplication, the study protocol was only registered at the Student Research Committee after the Research Ethics Committee confirming to enable the representative of the Research Vice-Chancellor at Hamadan University of Medical Sciences in comparing the reported review with what was planned in the protocol.

Conclusion
In the present review study, three dimensions (namely, resilience, motivation-hygiene measures, and development of managers' soft skills) are identified as the main factors maintaining employees in healthcare centers in long-term crises. Incentives and motivational measures promote job satisfaction among employees and consequently increase their willingness to work and stay in a concerned organization. Under crisis, only motivational measures are not enough to maintain employees in the organization, and managers need to be equipped with strong soft skills as communication skills to meet the employees' physical and psychological needs and build trust among them. Some further plans and programs should be put forth to be performed in the best way to maintain workers in organizations.
Data Availability e data are available by contact with the corresponding author.

Conflicts of Interest
No potential conflicts of interest were reported by the authors.