key: cord-0945070-vy9dcrst authors: Tang, Jiao; Zhang, You; Xiong, Fangfang; Li, Fuying; Zheng, Zehong; Gao, Xi; Luo, Zhongchen title: A survey of coping strategies among clinical nurses in China during the early stage of coronavirus disease 2019 pandemic: A cross‐sectional study date: 2021-05-03 journal: Nurs Open DOI: 10.1002/nop2.908 sha: fe27d3c53f4baac2a444bbc4c40ba58dfe55eb55 doc_id: 945070 cord_uid: vy9dcrst AIMS: To investigate coping strategies and identify their associated factors among Chinese clinical nurses during the early stage of coronavirus disease 2019 pandemic. DESIGN: A cross‐sectional study. METHODS: This study was conducted in seven designated hospitals involved in the diagnosis and treatment of the coronavirus disease 2019 in the southwest of China between 1 February and 31 March, 2020. Multiple linear regression was conducted to explore the association of different factors with the coping strategies of nurses. RESULTS: Nurses’ positive coping was associated with higher psychological capital (B = 0.185, 95% CI 0.158–0.213), social support (B = 0.292, 95% CI 0.244–0.340) and lower frustration (B = −0.065, 95% CI −0.123 to −0.007). In contrast, higher frustration (B = 0.091, 95% CI 0.044–0.139), lower performance (B = −0.054, 95% CI −0.101 to −0.007) and psychological capital (B = −0.035, 95% CI −0.055 to −0.014) were associated with negative coping. work against the COVID-19 pandemic may lead to burnout, psychological distress and poor performance at work, and may be detrimental to nurses' health and patient outcomes (Ding et al., 2015; Li et al., 2017; Zhou et al., 2017) . In the face of an EID, evidence shows that medical workers, especially nurses situated in the forefront of the healthcare system, have extensive responsibilities including identifying suspected and confirmed patients with EID infections (Lam et al., 2019) , controlling the spread of EID using high-quality infection control measures (Lam et al., 2016) , and offering appropriate quarantine arrangements for suspected and confirmed patients (Lam & Hung, 2013) . The COVID-19 pandemic is no exception. These commitments have imposed a high physical and mental workload on nurses (Carayon & Gürses, 2005; Mohammadi et al., 2016) . Excessive workload has been verified as a significant stressor for nurses, decreasing their productivity (Greenglass et al., 2003) , comfort and health (Mohammadi et al., 2016; Rubio et al., 2004) . Studies have also indicated that high workload risks medical errors, patient safety and even patient death (Abbey et al., 2012; Tarnow-Mordi et al., 2000) . Coping, as an integral element, is vital to the reduction of an individual's stress levels (Lazarus & Folkman, 1984; Parker et al., 1993) . According to the psychological stress and coping theory, when the internal and external demands of the person-environment transaction exceed individual resources, coping refers to the cognitive and behavioural efforts of the individual to deal with the problem and regulate emotion (Folkman & Lazarus, 1980; Lazarus & Folkman, 1984) . Coping consists of diametrically opposed positive and negative categories (Xie, 1998) . When faced with stress, individuals with positive coping have positive thoughts and solutions (e.g., taking constructive actions) (Ding et al., 2015; Garrosa & Moreno-Jiménez, 2013) . In contrast, negative coping consists of palliative coping strategies and negative appraisals under stressful conditions (e.g., avoidance) (Ding et al., 2015) . Nurses may adopt negative attitudes or actions once EID-related deaths begin to be reported, especially when they are directly involved in the affected patients' care (Oh et al., 2017) . Research based in Saudi Arabia found that nearly half of a sample of nurses had a negative attitude towards treating patients with suspected or confirmed Middle East respiratory syndrome (Alkot et al., 2015) . Moreover, evidence suggests that nurses adopting a positive coping had significantly better job performance and satisfaction, which can promote patient safety (Ding et al., 2015; Li et al., 2017; Zhou et al., 2017) . Additionally, according to the psychological stress and coping theory, the individual's attempts to utilize the personal (e.g., psychological capital) and social (e.g., social support) resources are important in the process of coping (Folkman & Lazarus, 1980; Lazarus & Folkman, 1984) . Psychological capital, proposed by Luthans and his colleagues (Luthans et al., 2004) , refers to a "positive appraisal of circumstances and probability for success during the growth and development of an individual based on motivated effort and perseverance" (Luthans et al., 2007) , and is corroborated as a useful personal resource affecting nurses' coping styles in stressful situations (Ding et al., 2015; Zhou et al., 2017) . Nurses with higher levels of psychological capital were more likely to develop positive coping styles, but lower psychological capital was significantly correlated with negative coping (Ding et al., 2015; Zhou et al., 2017) . Evidence also indicates that social support, as an important social resource, improves nurses' coping skills (Ben-Zur & Michael, 2007; Gifkins et al., 2017; Pisanti, 2012) and shields them from stress (Lin et al., 2010) . Moreover, previous studies found that age, gender and marital status were associated with nurses' coping strategies (Pisanti, 2012; Zhou et al., 2017) . In summary, psychological capital, social support and other characteristics (e.g., age, gender and marital status) of nurses played important roles in their coping strategies. Therefore, the present study aimed to investigate coping strategies and identify their associated factors among Chinese clinical nurses during the early stage of the COVID-19 pandemic. This cross-sectional study was conducted in Chongqing, a municipal- The participants were recruited from seven designated hospitals involved in the diagnosis and treatment of COVID-19 in Chongqing. Participants were invited to take part in this study if they were: (a) registered nurses in China; (b) fighting against the COVID-19 pandemic at designated hospitals. The sample size was determined using a power analysis and calculated using the G*Power program (Erdfelder et al., 1996; Faul et al., 2007) . Linear multiple regression in G*Power program was conducted using a random model. When using two-tailed test and considering an effect size of 0.05, 16 related factors were based on the psychological stress and coping theory (Folkman & Lazarus, 1980; Lazarus & Folkman, 1984) and relevant published work (Brudek et al., 2019; Ding et al., 2015; Gifkins et al., 2017; Li et al., 2017; Zhou et al., 2017) , significance level (p) of 0.05, and 95% power, yielding a minimum sample size of 627 (Graph 1). The data were collected by convenience sampling between 1 February and 31 March, 2020. An electronic questionnaire was created using Questionnaire Star, a professional online survey platform with 33.75 million users in China. The questionnaire link was sent by nursing managers at the seven designated hospitals to registered nurses using the social media platforms WeChat or QQ inviting them to anonymously join the study by clicking the link and following the prompts to complete the questionnaire. The questionnaire stated the purpose, methods and any risk of participating in the study on the first page to acquire informed consent. Furthermore, two items were included ("Are you a registered nurse working in one of designated hospitals for the diagnosis and treatment of COVID-19 in Chongqing?" and "Are you currently engaged in the fight against COVID-19 pandemic now?") to ensure the participant met the inclusion criteria for the study. If the participants' responses to the two items were both "Yes," he or she would then be allowed to access the questionnaire content, otherwise the questionnaire would be terminated and submitted. The electronic questionnaires included a demographic data sheet, Simplified Coping Style Questionnaire (SCSQ), National Aeronautics and Space Administration Task Load Index (NASA-TLX), Psychological Capital Questionnaire (PCQ) and Social Support Rating Scale (SSRS). Coping strategies were measured using the SCSQ (Xie, 1998) . Based on the Ways of Coping Questionnaire (Folkman & Lazarus, 1988) , the SCSQ is a 20-item instrument consisting of two subscales: positive coping (12 items) and negative coping (eight items). Each item of the SCSQ is ranked on a four-point Likert scale ranging from zero G R A P H 1 Sample size calculation using G*Power to three points. The SCSQ has adequate content validity, internal consistency and test-retest reliability in Chinese (Li et al., 2017) . In the present study, the Cronbach's alpha of the positive coping and negative coping was 0.904 and 0.877, respectively. The NASA-TLX was used to measure the workload. The NASA-TLX is a self-report instrument, developed by Hart and Staveland (1988) . It includes six items on mental demand, physical demand, temporal demand, performance, effort and frustration. Participants rate the level of their workload for each item on a 10-cm visual-analog scale which was then converted to a 0-20 scale, higher scores indicating higher workload. The NASA-TLX has been validated in Chinese nurses as having good reliability and validity (Liang et al., 2019) . In the present study, the Cronbach's alpha of the scale was 0.638. Psychological capital was measured using PCQ (Luthans et al., 2004) , a 24-item questionnaire including four subscales: self-efficacy, hope, optimism and resilience, each with six items. All items were rated using a six-point Likert scale, ranging from strongly disagree (one point) to strongly agree (six points), with higher scores indicating better psychological capital. The original PCQ has been translated into Chinese and found to have adequate validity and reliability (Zhang et al., 2010) . In the present study, the Cronbach's alpha of the four subscales ranged from 0.769-0.880. Social support was measured using the SSRS, which was developed by Xiao (1994) and found to have acceptable validity and reliability. This 10-item instrument consists of three subscales: objective social support (three items), subjective social support (four items) and support utilization (three items). Items six and seven are rated on a ninepoint Likert scale ranging from zero to eight points, while the other items are recorded on a four-point Likert scale ranging from one to four points. Higher scores indicate higher levels of social support. In the present study, the Cronbach's alpha of the three subscales ranged from 0.678-0.756. Demographic characteristics, such as age, gender, educational attainment and working seniority, were collected using a demographic data sheet. Data were analysed using SPSS version 25.0 (IBM Corporation). Descriptive statistics were used to present the sample characteristics and study variables. Categorical variables were described using frequencies and percentages. Continuous variables were expressed as mean [standard deviation (SD)] or median [inter-quartile range (IQR)]. Mean (SD) was used to express normally distributed data; otherwise, median (IQR) was used. The following assumptions were testing prior to multiple linear regression analysis: (a) Linearity of the model, The total scores for positive and negative coping were 24.46 (SD = 6.22) and 8.96 (SD = 4.10), respectively. Table 2 shows the item score of coping strategies. The result of a paired-samples t-test showed that the mean score of positive coping was significantly higher than that of negative coping (t = 42.36, p <.01). The score of the NASA-TLX was 84.76 (SD = 13.92). The item with the highest score was physical demand (mean = 17.70, SD = 3.56), and the item with the lowest score was frustration (mean =8.92, SD = 5.60) ( Table 3) . As shown in Table 3 , the total score on the PCQ was 108.55 (SD = 13.31). The highest score was on the self-efficacy subscale (mean = 4.58, SD = 0.63), and the lowest was on the resilience subscale (mean = 4.43, SD = 0.59). According to the results of the multiple linear regression models predicting coping strategies in the present study, positive coping (Table 4) . Prolonged and constant stress and ineffective coping strategies compromise nurses' health and patient outcomes (Brudek et al., 2019; Li et al., 2017; Zhou et al., 2017 of stress for nurses, other sources including a lack of resources, financial responsibilities and facing patients' death (Abraham et al.,2018; Mohammadi et al., 2016) . Findings of the present study indicated that the Chinese clinical nurses fighting against COVID-19 pandemic in general had adopted more positive coping strategies (such as taking an optimistic view, making and following a plan of action, and attempting to control disappointment, regret, sadness and anger) than negative ones (such as acceptance of fate, or a sense of bad luck) to cope with the challenges of their work. This finding provides indicators to improve nurses' mental health, thus providing better quality care and improving patient outcome in difficult situations. In this study, we found that psychological capital was one of the main factors associated with nurses' positive coping. Nurses with higher psychological capital tended to adopt positive coping strategies, and lower psychological capital was significantly correlated with negative coping. The findings are in agreement with those of previous studies (Ding et al., 2015; Zhou et al., 2017) . Psychological capital has been corroborated as a useful personal resource affecting nurses' coping strategies in stressful situations (Ding et al., 2015; Zhou et al., 2017) . Previous research has identified that psychological capital can indeed be developed and enhanced by establishing hope, cultivating an optimistic attitude, self-efficacy and enhancement of self-resilience based on psychological capital intervention (Liang et al., 2018) . Accordingly, a psychological intervention based on the psychological capital theory could be designed to evaluate the effect of the intervention programme on the psychological capital of nurses, and provide feedback with the aim of prompting them to use a more positive way to respond to challenges in those critical circumstances. The present study also showed that nurses with better social support would adopt positive coping strategies. Previous studies showed that social support could improve nurses' coping skills and shield them from stress (Ben-Zur & Michael, 2007; Gifkins et al., 2017; Lin et al., 2010; Pisanti, 2012 ). An Australian study reported that social support at work from nursing manager, family and friends was key to both experienced and graduate nurses' coping (Gifkins et al., 2017) . In addition, Tesfaye (2018) found that social support and carefully planned problem-solving were the most preferred strategies for nurses to cope with job stress. Therefore, social support was also a key factor to nurses' coping strategies. In our study, sufficient and effective social support was found in Chinese clinical nurses fighting against COVID-19 pandemic. This result should be partly ascribed to the Chinese government and health management system for its provision of sufficient objective support to increase nurses' confidence and motivation to complete the task, such as improved working and rest conditions, strengthened humanistic care, improvements for a safer practice environment, implementation of industrial injury recognition and satisfaction from promotion and progression at work (Health Commission of Henan Province, 2020; National Health Commission of the People's Republic of China, 2020c). Conversely, the frustration item of NASA-TLX, used to measure workload, was negatively associated with the nurses' positive coping strategies, but other items, especially physical, temporal and mental demand of workload had no significant influence on coping strategies. When tackling this large-scale infectious public health event, nurses are susceptible to various psychological and mental problems due to the death risk of virus infection (Wu et al., 2009; Xu & Zhang, 2020) . Nurses working with critically infected patients reportedly experience a sense of frustration frequently, since neither effective antiviral treatment nor vaccine is available and some deaths are inevitable (Sohrabi et al., 2020) . Research has also indicated that participating in systematic psychological training to increase their psychological knowledge and skills was the primary demand of medical staff in disaster relief situations (Brooks et al., 2019; Yan et al., 2015) . This is consistent with our finding that frustration and not physical or time-related items had a significant influence on nurses' coping strategies, measured using the NASA-TLX. During the COVID-19 pandemic, many Chinese medical institutions and universities have taken measures such as opening online platforms to provide psychological counselling for medical personnel, or building a psychological intervention medical team providing online courses to guide medical staff to deal with common psychological problems (Chen et al., 2020; Xiang et al., 2020; Xiao, 2020) . These measures may have had a positive effect on reducing nurses' frustration and helped them adopt positive coping in this stressful situation. However, the psychological interventions were not without problems, such as insufficient attention being paid to their practical implementation, or overall inadequate planning (Duan & Zhu, 2020) . Chinese clinical nurses tended to adopt positive coping in fighting against the COVID-19 pandemic. Positive coping was associated with high levels of psychological capital, adequate social support and low sense of frustration. This group, which tended to respond in a positive coping way, might benefit from a series of interventions in Chinese health system as follows: (a) paying attention to and monitoring the psychological problems of nurses, and helping them address frustration by corresponding systematic and powerful psychological intervention; (b) providing enough objective support to increase nurses' confidence and motivation to complete the task and cope with the challenges; (c) encouraging and stimulating the positive emotions in nurses so that they can gain respect, pride and satisfaction in their job. The research team would like to express our sincere thanks to all of the participants, the Guizhou Medical University and Chongqing Municipal Education Commission for its financial support. The authors declare that there were no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request. https://orcid.org/0000-0002-8863-5654 Understanding the work of intensive care nurses: A time and motion study Morale, stress and coping strategies of staff working in the emergency department: A comparison of two different-sized departments Knowledge, attitude and practices of healthcare providers towards MERS-CoV infection at Makkah hospitals Burnout, social support, and coping at work among social workers, psychologists, and nurses: The role of challenge/control appraisals. Social Work in Health Care Protecting the psychological wellbeing of staff exposed to disaster or emergency at work: A qualitative study The mediating role of types of coping styles in the relations between temperamental traits and staff burnout among psychiatric nurses A human factors engineering conceptual framework of nursing workload and patient safety in intensive care units. Intensive and Critical Care Nursing Mental health care for medical staff in China during the COVID-19 outbreak The perpetual challenge of infectious diseases Status of risk perception on needlestick injuries caused by insulin injections among nurses in 14 hospitals in Chongqing. Occupation and Health The mediating role of coping style in the relationship between psychological capital and burnout among Chinese nurses Psychological interventions for people affected by the COVID-19 epidemic GPOWER: A general power analysis program G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences An analysis of coping in a middleaged community sample Ways of Coping Questionnaire: Research edition Burnout and active coping with emotional resilience Work experience of frontline nurses from Guangdong province fight war against COVID-19 in Wuhan: A qualitative study Coping strategies and social support needs of experienced and inexperienced nurses performing shiftwork Reactions to increased workload: Effects on professional efficacy of nurses Development of NASA-TLX (Task Load Index): Results of empirical and theoretical research Specific rules of Henan Province on the protection of the rights and interests of medical personnel fighting the coronavirus in the frontline Perceptions of emergency nurses during the human swine influenza outbreak: A qualitative study Bridging the gap between guidelines and practice in the management of emerging infectious diseases: A qualitative study of emergency nurses Emergency nurses' perceptions of their roles and practices during epidemics: A qualitative study Moderating effects of coping on work stress and job performance for nurses in tertiary hospitals: A cross-sectional survey in China The psychological capital of leftbehind university students: A description and intervention study from China Chinesization, reliability and validity test of national aeronautics and space administration task load index Depression among female psychiatric nurses in southern Taiwan: Main and moderating effects of job stress, coping behaviour and social support Positive psychological capital: Beyond human and social capital Psychological capital Evaluation of Mental Workload among ICU Ward's Nurses National Health Commission of the People's Republic of China (2020c). Notification of the leading group of the CPC Central Committee for Novel Coronavirus Prevention and Control on the full implementation of a number of measures to further care for and protect medical personnel Exploring nursing intention, stress, and professionalism in response to infectious disease emergencies: The experience of local public hospital nurses during the 2015 MERS outbreak in South Korea If it changes, it might be unstable: Examining the factor structure of the Ways of Coping Questionnaire Job demands-control-social support model and coping strategies: Predicting burnout and wellbeing in a group of Italian nurses Evaluation of subjective mental workload: A comparison of SWAT, NASA-TLX, and workload profile methods World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19) Hospital mortality in relation to staff workload: A 4-year study in an adult intensive-care unit Coping strategies among nurses in South-west Ethiopia: Descriptive, institution-based cross-sectional study Coronavirus disease (COVID-2019) situation reports The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed A novel approach of consultation on 2019 Novel Coronavirus (COVID-19)-related psychological and mental problems: Structured Letter Therapy The theoretical basis and research application of social support rating scale The reliability and validity test of the Simplified Coping Style Questionnaire Psychological status survey of first clinical first-line support nurses fighting against pneumonia caused by a 2019 novel coronavirus infection Investigation of nursing human resources in Chinese hospitals Disaster nursing skills, knowledge and attitudes required in earthquake relief: Implications for nursing education Positive psychological capital: Measurement and relationship with mental health Mediating effect of coping styles on the association between psychological capital and psychological distress among Chinese nurses: A cross-sectional study A survey of coping strategies among clinical nurses in China during the early stage of coronavirus disease 2019 pandemic: A cross-sectional study