key: cord-0791308-g0rsedn3 authors: Shaohua, Hu; Dai, Qing; Wang, Ting; Zhang, Qianqian; Li, Chaoqun; He, Hongye title: Relationship between work stressors and mental health in frontline nurses exposed to COVID-19: A structural equation model analysis date: 2021-02-16 journal: Ann Med Psychol (Paris) DOI: 10.1016/j.amp.2021.02.015 sha: f0b8c61640000ea1800fb70dbd7c82e8460f73c1 doc_id: 791308 cord_uid: g0rsedn3 The current cross-sectional study aimed to explore the relationship between work stressors and mental health in frontline nurses exposed to COVID-19. Participants were recruited from 16 general hospitals in Anhui province from February 2020 to March 2020. The general sociodemographic questionnaire, Nurse Job Stressors Scale, Simplified Coping Style Questionnaire, NEO Five-Factor Inventory, Perceived Social Support Scale, and Kessler Psychological Distress Scale were used in this study. Based on 723 valid questionnaires retrieved (100%), the total mean scores of work stressors and mental health of frontline nurses were (94.38±23.42) and (22.81±7.16), respectively. The results of the structural equation model showed that work stressors had an indirect positive effect (β=0.484, P<0.01), social support had a direct negative effect (β=-0.934, P<0.01), personality traits had a direct positive effect (β=0.209, P<0.01), and positive coping style had both direct positive (β=0.246, P<0.01) and indirect negative effects (β=-0.873, P<0.01) on frontline nurses’ mental health. In conclusion, nursing staff can reinforce positive influences by accepting social support, adopting positive coping methods, and weakening negative influences factors to reduce or buffer their negative mental states and further reduce work stress. Since the end of December 2019, pneumonia caused by a new coronavirus (COVID- 19) infection has been discovered in Wuhan, Hubei, China and throughout the whole country. To date, the origin of COVID-19 is still unknown. On January 31, 2020, WHO officially recognized the epidemic as an infectious public health emergency of international concern on the basis of on-the-spot investigation in China. The frontline nurses were those who directly participated in clinical activities of treating or providing care to patients with positive COVID-19. As we all know, with increasing number of confirmed and suspected cases of COVID-19, overwhelming workload, lacking personal protection equipment, and feelings of being inadequately supported may contribute to the mental burden of these frontline nurses [14] and cause a series of psychological stress reactions in frontline nurses, including anxiety, depression, insomnia, and fear [11] . Psychological stress is a state of psychological tension resulting from an imbalance between subjects' objective demands and coping abilities under certain environmental stimuli. A study showed that 85.37% of clinical frontline supporting nurses had adverse emotional reactions, including somatization (21.9%), compulsive symptoms (14.6%), interpersonal sensitivity (26.8%), depression (4.8%), anxiety (39.0%), and fear (51.2%) [27] . Mei's study showed a poor sleeping quality in frontline nurses exposed to new coronavirus pneumonia, and anxiety and high-stress load were risk factors for nurses' sleeping quality [18] . Frontline medical personnel had not only sleeping disorders but also psychological and stress disorders [21] . A study showed that frontline nurses in Sichuan province had anxiety in response to the epidemic, but the level of anxiety is lower than the national norm [8] . Most nurses had a milder stress response to the crisis stress of the epidemic, with mild impairment in cognition, emotion, and behavior. The epidemic may vary from region to region, leading to slightly different findings. The psychological stress response of frontline nurses in infectious public health emergencies is affected by various factors, including cognitive evaluation, coping styles, and Page 4 of 16 J o u r n a l P r e -p r o o f 4 social support [17] . Nurses who used coping styles to solve problems and actively ask for help usually have a higher score of overall mental health, whereas those who used avoidance coping styles were accompanied by coercion, depression, anxiety, and other symptoms [31] . In terms of the overall level of social support, as well as the endogenous and exogenous support from the family, the higher the level of social support of frontline medical personnel, the better their mental health status [25] . In a word, with the help of social support, nurses' stress responses can be significantly reduced. Kakemam's study showed that psychological stress was more prominent on frontline nurses dealing with infectious public health incidents [12] . Stressors pass through intermediary factors such as individual cognitive evaluation, coping activities, and social support to further influence an individual's physical and mental health. According to Kakemam's study [12] , overworking and caring and treating critically ill patients are the main stressors of frontline nurses. Wheeler et al. et al. [24] found that nursing workload and working environment are the main stressors of frontline nurses. Coyne et al. [4] showed that higher social support is always accompanied by better mental and physical conditions and that maintaining a positive coping style can lead to less susceptibility to the effects of stressful events. However, whether the above factors are effective in predicting the psychological stress response of frontline nurses is unclear. In addition, whether these factors are correlated and how these factors act on the psychological stress response need to be explored. Therefore, this study aimed to use the stress system model as a theoretical framework to systematically understand the stress states of frontline anti-epidemic personnel from three aspects, namely, stressors, cognitive evaluation, and stress responses, and then established a psychological stress model for analysis. This was a cross-sectional study conducted in Anhui province, China from February 2020 to March 2020. The hypothesized model of this study was derived from stressors-mediation mechanism-stress response. The model assumed that frontline nurses' work stressors can predict their mental health through the mediation effects of social support, coping styles, and personality traits. Meanwhile, coping styles, social support, and personality traits can be direct predictors of mental health. With the help of this model, we can gain insights into the psychological states of frontline nurses and then take effective measures against poor psychological states. The hypothesized model was presented in Figure 1. A total of 723 frontline registered nurses were recruited from 16 general hospitals, Anhui province, China. All demographic data were collected using electronic questionnaires. The purpose of this study was explained to participants, and detailed instructions were listed to guide them in filling out the questionnaires. Two researchers collected the data and checked the electronic questionnaire system for IDs; relevant information; and feedback records, such as submission time, fill time, equipment, and IP address to ensure the accuracy of the exported data. Individuals who hold a certificate of nurse qualification granted by the Ministry of Health PR China and have been working as a registered nurse in a hospital for at least one year were included. 10 The model fits the data well (χ 2 /df=4.656<5, RMSEA=0.071<0.08, GFI=0.969>0.9, AGFI=0.925>0.9, IFI=0.978>0.9, and CFI=0.978>0.9). A fully adjusted model was also tested, and the effects among variables were consistent with the hypothesized model. Based on the theoretical framework of stress (stressors-mediation mechanism-stress response), a structural equation model of the relationship between work stressors and mental health in frontline nurses was developed using e1-e13 as indicators of measurement errors. Work stressors were used as an exogenous variable, whereas personality traits, positive coping, social support, and mental health were used as endogenous variables. The final model is presented in Figure 2 . The effect decomposition among work stressors, social support, positive coping, and personality traits on mental health is shown in Table 3 Infectious public health events usually have the characteristics of high complexity, low predictability, and large-scale impacts. The COVID-19 epidemic, an unknown, unexpected, and devastating disease, is the most extensive to afflict humanity in a century and poses a grave threat to human life and health. There is no doubt that medical workers play an important role and make great sacrifices in fighting this new virus. In addition, medical workers bear psychological stress in the face of this epidemic. Therefore, we need to understand the mental health state of frontline nurses fighting COVID-19, analyze its influencing factors, and further provide a basis for intervening mental health of frontline nurses. In general, the mental health of frontline nurses in this study was at a poor level. The prevalence of psychological problems in frontline nurses was 57.8%, which was much higher than in the general population (22%) [29] . Tam et al. [22] showed that the prevalence of depression was 45% in clinical nurses during the period of SARS in 2003, indicating that the epidemic had caused severe mental health problems in nurses. We found that the overall average work pressure in frontline nurses was at a medium level, which is consistent with the findings of Nickell et al. [20] .The difference is that the dimension with the highest pressure source score in this study is caring for patients. COVID-19, which is caused by a new coronavirus infection, mainly transmitted through the respiratory tract and close contact. This disease causes pulmonary inflammation. Frontline nurses worked directly with suspected or confirmed patients and suffered from enormous psychological pressure even if taking precautions in advance. At the same time, wearing a protective suit with other protective equipment at work increases the physical exertion of frontline nurses, which could lead to decreased physical fitness, affect physical and mental health, and tend to cause anxiety and stress [28] . In addition, frontline nurses care for patients for a long time and the working environment is closed, which also increases the risk of transmission of the virus. Most frontline nurses are also worried about transmitting the virus to their family members. Under this pressure, most nurses may suffer from physical and mental health problems without effective adjustment [24] . All these findings suggest that we should pay great attention to the work pressure and mental states of frontline nurses while fighting COVID-19 and timely identify the crux of psychological problems. If necessary, we should also provide psychological crisis intervention to promote nurses' mental health. As an uncontrollable objective factor, work stressors can have an impact on nurses' mental health. The structural equation model of this study showed that work stressors played a role in mental health through the intermediary role of path relationships such as positive coping, personality traits, and social support. This study also found that the above intermediary variables played an important role in the process between work stressors and mental health, verifying the theoretical model of the process of psychological stress: the source-mediating mechanism-theoretical framework of stress response [9] . It suggested that frontline nurses could adjust intermediary variables, such as self-efficacy and coping style to reduce the adverse effects of work stressors on anxiety and depression by taking effective interventions. Social support can buffer patients' psychological stress and pressure, help patients improve their emotional experience, and then promote their physical and mental health [7, 23] . Cohen et al. [2] put forward a buffering effect model of social support regulating stress and found that social support can reduce individual perception and evaluation of stress events, as well as their emotional and physiological responses to stress, by providing individuals with positive emotional experiences. As mentioned before, positive social support could provide individuals with more available resources and help them improve positive emotional state. Social support is an important protective factor in regulating stress from the external environment. In this study, frontline nurses' social support was negatively correlated with their mental health. The structural equation model validated that social support is an important influencing factor of nurses' mental health. It not only had a direct positive effect on mental health but also acted as an intermediary variable and indirectly affected work stressors. The relationship between positive coping style and mental health proved that social support played an intermediary role in buffering protection while responding to stress [19] . Therefore, caregivers should guide and help patients to establish good interpersonal relationships; encourage them to strengthen communication with others; and reduce the experiences of anxiety and depression by increasing the support of family, friends, medical staff, and others. Coping styles refer to the coping strategies or methods that individuals can adopt when confronted with different stressors. Different coping styles have different coping outcomes, with reduced or aggravated psychological stress response [15] . In this study, positive coping style was negatively correlated with mental health, whereas negative coping style was positively correlated with mental health. The level of mental health is related to the choice of stress coping styles. Positive coping style could promote the mental health of frontline nurses, whereas negative coping style can be detrimental to their mental health. In this structural equation model, the positive coping style had a direct positive impact on nurses' mental health, and it could also exert an indirect effect on mental health through the intermediary role of social support. Dunkley et al. [5] stated that the positive coping style referred to adopting a positive attitude and actively seeking help from family and society to reduce nurses' negative emotional experience. Therefore, hospital managers should focus on In conclusion, our findings suggested that frontline nurses could take targeted measures of positive coping style and social support, such as strengthening the guidance of nursing knowledge and nursing skills to improve their positive coping ability. Moreover, family members and other social support systems should be mobilized to give nurses' psychological and emotional support. Through these methods, frontline nurses' mental health could be improved. Social Support, Type A Behavior, and Coronary Artery Disease Stress,social support,and the buffering hypothesis Revised NEO personality inventory (NEO PI-R) and NEO five-factor inventory Social factors and psychopathology:stress, social support and coping process Advancing complex explanatory conceptualization of daily negative and positive affect: Trigger and maintenance coping action patterns Stress among hospital staff :Its causes and midwives Determining the Correlation Between Social Support and Hopelessness of Syrian Refugees Living in Turkey Investigation of psychological status of medical staff and analysis of related factors during the outbreak of "A stream Comprehension Social Support Scale Medical Psychology-Theory, Methods and Clinical. Beijing: People's Medical Publishing House Sleep quality investigation and influencing factors of clinical front-line nurses in the fight against the new coronavirus pneumonia epidemic 2020 Occupational stress and cognitive failure of nurses and associations with self-reported adverse events: A national cross-sectional survey Final version of our non-specific psychological distress scale Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease Effect of Illness Representations and Catastrophizing on Quality of Life in Adults With Irritable Bowel Syndrome A survey of nurses'work stressors and job fatigue Research on the mental health status and coping style of nurses nursing SARS patients Psychological and sleep status analysis of medical staff in the infection of new coronavirus pneumonia Stressors,social support,and tests of the buffering hypothesis: Effects on psychological responses of injured athletes Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution Investigation and analysis of the psychological status of clinical nurses Impact of SARS on Avian Influenza Pre-paredness in Healthcare Workers Social support moderates the association between traumatic life events and depression a-mong migrant and nonmigrant men in almaty,Kazakhstan Occupational stress in general nurses and mid-wives Preliminary exploration of psychological crisis intervention strategies at the scene of public emergencies A preliminary study on the reliability and validity of the Simple Coping Style Scale Mental status survey of the first batch of clinical frontline support nurses to fight against new coronavirus infection pneumonia 2020 A qualitative study on the psychological experience of the first batch of nurses to fight against the new coronavirus pneumonia Investigation of psychological status of SARS clinical nurses Hanbook of coping: John Wiley& Songs Investigation on the coping style and social support of nurses in SARS We would like to thank all volunteers who participated in this study for their effort and time and those who made huge sacrifices in fighting the epidemic.