Psychological Well-Being of Nurses and Influencing Factors During Normalization of Epidemic Prevention and Control in China

Introduction

The importance of mental health has increased in tandem with growing awareness, changing living conditions, or escalating work-related stress, impacting individuals across different domains, notably nurses who depend on robust mental well-being for peak professional efficacy [1]. As the COVID-19 pandemic response shifts from immediate measures to enduring tactics, healthcare facilities have implemented rigorous patient care protocols, improved pre-diagnostic processes, standardized fever clinics, and restricted entry to fever wards. These modifications have notably increased the occupational strain on nurses, resulting in prolonged stress and a spectrum of mental health issues [2].

When the National Health Commission’s “COVID-19 Pneumonia Prevention and Control Plan (ninth edition)” specified normal prevention and control measures, epidemic prevention in China has become an enduring commitment. Nurses play crucial and longitude roles in this commitment. By the end of 2022, China’s national epidemic prevention policy was optimized and adjusted, all cities no longer had strict lockdown measures, and all populations had already experienced a peak in infections. The management of COVID-19 in China has transitioned to a normalization phase since this stage. The “normalization” of epidemic prevention and control refers to a long-term management state in which social operation and epidemic prevention and control form a dynamic balance in the context of the long-term risk of virus transmission and the difficulty of completely eliminating it. The core goal is to minimize the impact of the epidemic on society and economy through scientific, precise, and sustainable prevention and control measures. However, the ongoing sporadic domestic outbreaks, the decline COVID-19 cases, and recurrent infection still pose challenges in preventing a resurgence [3]. The highly transmissible, severe, and fatal nature of COVID-19 underscores the critical importance for healthcare professionals to adhere to preventive measures to mitigate further outbreaks. Healthcare institutions face the strain, with nursing staff bearing increased clinical responsibilities and epidemic control measures, impacting their mental well-being and job performance [4].

The COVID-19 outbreak in Dalian city has repeatedly been associated with the products of the imported cold chain logistics. In December 2022, with the optimization and adjustment of the national epidemic prevention policy, Dalian also experienced a peak of infection. However, during the normalization control period, nurses in tertiary hospitals undertake daily COVID-19 prevention work and nucleic acid collection support work inside and outside the hospitals. Comprehensive tertiary hospitals are characterized by their extensive scale and diverse departments. Nurses in these tertiary hospitals already have complex work demands and familial pressures [5], and they were now experiencing heightened psychological stress due to additional non-nursing responsibilities during the pandemic controls. These additional responsibilities add to the workload of nurses, resulting in a high risk of infection and increasing nurses’ stress, leading to their physical and mental exhaustions, with increased anxiety, fear, and nervousness [6]. Failure to address these negative emotions can result in job burnout, reduced service quality, and higher turnover rates [7].

The nurses caring for COVID-19 patients reported significant chronic fatigue, diminished care quality, low job satisfaction, and a strong inclination to leave their positions [8,9]. Healthcare professionals are confronted with heightened risks of anxiety, depression, burnout, substance abuse, and post-traumatic stress disorder during the pandemic, with potential long-term psychological repercussions [10,11]. Hospital administrators are encouraged to enhance psychological monitoring, provide timely professional counseling, and implement tailored interventions, mainly focusing on younger nursing professionals [12,13].

During the normalization control period, nurses not only undertake daily nursing work, but also have non-nursing responsibilities, which can lead to physical and mental exhaustion, job burnout, reduced service quality, and higher turnover rates among nurses. The aim of this study was to examine the psychological status and its related factors among nurses in 4 tertiary hospitals in Dalian during the normalization phase of COVID-19 epidemic prevention and control. This study was designed to provide a reference for hospital managers to better understand the current nursing situation and improve the management of nurses.

Material and Methods

RESEARCH PARTICIPANTS:

From September 1 to September 30, 2023, all in-service nurses from 4 tertiary hospitals in Dalian city were involved in this study and completed the questionnaire. These nurses were from different departments, such as pediatrics, emergency, outpatient, internal medicine, surgery, and intensive care units. All clinical nurses from the 4 hospitals who met the inclusion criteria were invited to complete an electronic web-based questionnaire. The survey was conducted across the 4 tertiary hospitals within 1 month, resulting in 778 valid responses out of the 790 questionnaires distributed. Each participant signed a written informed consent before taking the survey. We included nurses holding a nurse practice qualification certificate and currently employed. Exclusion criteria included 1) Nurses with less than 6 months of experience due to internships, advanced training, or limited working hours; 2) Nurses who were not on duty during the survey period; 3) All nurses must demonstrate the ability to comprehend and independently complete the questionnaire.

QUALITY CONTROL: In this study, an electronic questionnaire survey was administered through a researcher-generated QR code. Researchers provided detailed explanations of the standard instructions of all evaluating scales that were given to participants. Eligible nurses received and completed the questionnaire. The questionnaire included information such as the purpose of the questionnaire, response time, privacy policy, and support line for the nurses’ convenience to ask any questions. The questionnaire (see Questionnaire in English version) was developed and contained a psychological well-being assessment section (about the nurses’ personal information), a Chinese SCL-90 section [14], and the Chinese Nurse Work Stressors Scale [15]. Each mobile number was limited to 1 survey submission, and participants were given standardized instructions for completing the questionnaire. The gathered data was then reviewed using the survey platform. To guarantee the authenticity, reliability, and completeness of responses, a double-check procedure was employed to remove any invalid submissions. Two of our authors entered the data from the paper questionnaire, and then used the check function of the software to verify the consistency of the data. If the 2 sets of data were different, they asked the person who filled out the questionnaire what the specific answer was to ensure the consistency of the data. When analyzing data, for questions that exceed the set numerical range or have logical relationships but are answered illogically, we repeated data cleaning to ensure that the data were correct. We excluded questionnaires that were 20% or more uncompleted or with the same answers to all questions.

STATISTICAL ANALYSIS:

SPSS 26.0 software was utilized for statistical analysis, presenting demographic data proportions through frequency and composition ratios. The Shapiro-Wilk test was used to assess for data normality, and skewed indicators like gender, smoking, and alcohol consumption were evaluated with rank-sum tests between groups. Variables such as age, working years, and working hours were analyzed by the non-parametric Kruskal-Wallis test. Variables that were found to be significant in rank-sum and Kruskal-Wallis testing were integrated into a logistic regression model to identify independent factors influencing nurses’ psychological status, with statistical significance set at P<0.05.

Results

BASIC DEMOGRAPHIC INFORMATION ABOUT THE RESEARCH PARTICIPANTS:

In this survey, 790 questionnaires were distributed, and all successfully recovered, resulting in 778 valid responses. Among the participants, 29 were men, and 749 were women, aged 20 to 55. Table 1 summarizes the basic information of the research subjects.

UNIVARIATE ANALYSIS OF STRESSORS ON THE WORK OF CLINICAL NURSES:

A higher stress was noted in the scores related to “workload and time allocation” and “working environment and resources” in the married nurses than the unmarried nurses. Additionally, significantly higher scores were found in the nurses who consumed alcohol and those who did not across 4 aspects: “nursing profession and work”, “workload and time allocation”, “patient care”, and “total stress” (P<0.05). Furthermore, lower scores were noted in the nurses working ≤40 hours per week compared to those working > 40 hours in all stressors and the total scores (P<0.05). Notably, significantly lower scores were also identified in the nurses with frontline work experience compared to those without, particularly in stressors other than “nursing profession and work” (P<0.05), as detailed in Table 2.

The nurses aged 30–39 experienced more stress in various stressors such as the “nursing profession and work”, “workload and time allocation”, “working environment and resources”, “patient care”, “management and interpersonal relationships”, and overall stress levels compared to those aged 20–29 (P<0.05, Table 3). Similarly, significantly more stress was observed in the nurses aged 40–55 than those aged 20–29 in areas such as “workload and time allocation”, “working environment and resources”, “patient care”, “management and interpersonal relationships”, and overall stress levels (P<0.05, Table 3). However, no statistically significant differences were found between the 40–55 age group and the 30–39 age group across all stressor categories, as detailed in Table 3.

Higher total pressures were observed in senior nurses than registered nurses (P<0.05, Table 4). Nurses in charge were found to experienced more stress than registered nurses in workload, time management, working conditions, nursing profession and work, and the total pressure score (P<0.05, Table 4). Chief nurses were found to experience more stress in workload, time management, working conditions, and patient care than registered nurses (P<0.05, Table 4). The total pressure score among senior nurses was significantly higher than that among registered nurses (P<0.05), but no significant differences were noted in the scores of various stressors (P>0.05, Table 4).

In workload and time allocation, more stress was noted between nurses with 5–8 years of experience and those with less than 5 years (P<0.05, Table 5). More stress was also evident in the nurses with over 8 years of experience than their counterparts with less than 5 years of experience across multiple factors, including workload and time allocation, working environment and resources, patient care, and overall pressure (P<0.05, Table 5). In contrast, no statistically significant differences were observed in stressors between nurses with over 8 years of service and those with 5 to 8 years of experience, as outlined in Table 5.

UNIVARIATE ANALYSIS OF VARIOUS PSYCHOLOGICAL SYMPTOMS IMPACTING CLINICAL NURSES:

Married nurses showed more symptoms in the areas of somatization, obsessive-compulsive symptoms, hostility, and overall symptoms than unmarried nurses (P<0.05, Table 6). Additionally, nurses who consumed alcohol had significantly higher scores than those who did not consume alcohol, specifically in somatization, obsessive-compulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, terror, psychosis, sleep and diet issues, and overall symptoms (P<0.05, Table 6). Nurses working 40 hours or less per week had fewer symptoms in somatization, obsessive-compulsive symptoms, and hostility than those who work more than 40 hours. Finally, nurses with frontline work experience had symptoms that differed from those of other nurses, excluding somatization and anxiety (Table 6).

Significantly more symptoms were observed in nurses aged 30–39 than in those aged 20–29 in somatization, obsessive-compulsive symptoms, sensitive interpersonal relationships, depression, anxiety, hostile, fear, sleep, and diet (P<0.05, Table 7). Nurses aged 40–55 had significantly more symptoms than those aged 20–29, except for fear (P<0.05, Table 7). Conversely, no statistically significant differences in symptoms were found between nurses aged 40–55 and those aged 30–39 (P>0.05), as detailed in Table 7.

Senior nurses and nurses in charge had significantly more symptoms than among registered nurses in symptoms such as “somatization”, “obsessive-compulsive symptoms”, and “interpersonal sensitivity” (P<0.05, Table 8). Chief nurses had more symptoms in 7 aspects compared to registered nurses, encompassing “somatization”, “obsessive-compulsive symptoms”, “depression”, :hostility”, “paranoia”, “sleep and diet”, and “total symptoms” (P<0.05) (Table 8). No significant differences were found in other psychological symptoms.

Nurses with >8 years of work experience had higher SCL-90 scores in every aspect than nurses with <5 years of work experience (P<0.05), and nurses with 5–8 years of work experience had higher scores than nurses with <5 years of work experience (P<0.05) (Table 9). There was no statistically significant difference in symptoms between nurses who had worked for >8 years and nurses who had worked for 5–8 years, as shown in Table 9.

CORRELATION ANALYSIS OF NURSES’ STRESSORS AND PSYCHOLOGICAL SYMPTOMS:

The study revealed a direct positive correlation between the stress levels encountered by nurses and the intensity of their mental health symptoms, signifying a proportional increase in psychological distress with greater stressors (P<0.01, Table 10).

LOGISTIC REGRESSION ANALYSIS OF INDEPENDENT FACTORS IMPACTING NURSES’ PSYCHOLOGICAL SYMPTOMS:

After conducting a rank-sum test, various factors, including marital status, alcohol consumption, frontline work experience, weekly working hours, age, professional title, and years of work, were found to impact the psychological well-being of nurses (P<0.05, Table 11). The logistic regression model was constructed using marital status, alcohol consumption, frontline work experience, weekly working hours, age, professional title, and years of work as independent variables, and psychological symptom scores are dependent variables (Table 11). The score of the total symptom index was between 0 and 0.5, indicating that the subjects did not feel the symptoms listed in the scale. Between 0.5 and 1.5 indicated that the subject felt some symptoms, but the occurrence was not frequent. A range of 1.5–2.5 indicated that subjects felt symptoms, and their severity was mild to moderate. Between 2.5 and 3.5 indicated that subjects felt symptoms and the degree was moderate to severe. Between 3.5 and 4 indicated that the subject felt symptoms and the frequency and intensity of symptoms were very serious (Table 11).

The analysis indicated that nursing job title and alcohol consumption were significant independent risk factors for nurses’ psychological symptoms. Conversely, age 20–29 years and working ≤40 hours per week were identified as independent protective factors for nurses’ psychological well-being during the epidemic (P<0.05), as detailed in Table 12.

Discussion

LIMITATIONS:

This study has some limitations that should be considered. First, the study is limited to nurses working in 4 tertiary hospitals in Dalian, China. This restricts the generalizability of the findings to other regions or healthcare settings. Second, the reliance on self-reported data and the potential for social desirability bias should be acknowledged, as these may affect the reliability of the results. Third, the study’s design makes it difficult to establish causal relationships. For example, it is unclear whether alcohol consumption is a cause or a consequence of poor psychological outcomes. Fourth, the study focused on a limited set of variables (eg, professional title, alcohol consumption, age, working hours) but does not account for other potential factors, such as familial, economic, or workplace social support, which could influence psychological well-being. Five, cultural factors (eg, reluctance to report psychological issues in a collectivist culture like China) are not discussed, which may have influenced the results. Further research with larger samples that address these limitations are needed to validate our results.

Conclusions

This study investigated the psychological well-being of nurses at 4 tertiary hospitals in Dalian city during the normalization phase of epidemic prevention and control. It identified factors influencing their mental health, such as professional title, alcohol consumption, age, and weekly working hours. The research found that senior nurses and those who consumed alcohol were more likely to have poor psychological outcomes, whereas younger nurses (aged 20–29) and those working ≤40 hours per week displayed better mental health. The results highlight the significant impact of increased workload and stress on nurses during epidemics and stress the importance of targeted interventions to support their mental health. These interventions may involve ensuring adequate staffing, implementing flexible scheduling, providing psychological support services, and offering stress management programs. Addressing these factors is essential for improving nurses’ well-being, increasing job satisfaction, and maintaining high standards of patient care.