Impact statement
Chinese nurses played a vital role in combating the virus under great pressure and during the COVID-19 regular pandemic prevention and control. It’s of great importance to investigate effects of insomnia and anxiety between social support and PTSD among Chinese nurses in the context of regular COVID-19 pandemic prevention and control. It could aid the hospital with interventions to ameliorate PTSD among Chinese nursing staff during COVID-19 regular pandemic prevention and control. However, studies focusing on the relationship among these variables are insufficient. The present study aimed to focus on how social support would influence PTSD in Chinese nursing staff during the period of COVID-19 regular pandemic prevention and control.
Introduction
The coronavirus disease 2019 (COVID-19) has brought about mental problems to the healthcare staff (Chew et al., Reference Chew, Lee, Tan, Jing, Goh, Ngiam, Yeo, Ahmad, Ahmed Khan, Napolean Shanmugam, Sharma, Komalkumar, Meenakshi, Shah, Patel, Chan, Sunny, Chandra, Ong, Paliwal, Wong, Sagayanathan, Chen, Ying Ng, Teoh, Tsivgoulis, Ho, Ho and Sharma2020a; Chew et al., Reference Chew, Ngiam, Tan, Tham, Tan, Jing, Sagayanathan, Chen, Wong, Ahmad, Khan, Marmin, Hassan, Sharon, Lim, Mohaini, Danuaji, Nguyen, Tsivgoulis, Tsiodras, Fragkou, Dimopoulou, Sharma, Shah, Patel, Sharma, Komalkumar, Meenakshi, Talati, Teoh, Ho, Ho and Sharma2020b; Le et al., Reference Le, Nguyen, Onyango, Nguyen, Pham, Ta, Nguyen, Le, Vu, Hoang, Vu, Latkins, Ho and Ho2021; Pham et al., Reference Pham, Le, Phan, Nguyen, Ta, Nguyen, Nguyen, Nguyen, Le, Luong, Koh, Haoang, Pham, Vu, Nguyen, Tran, Latkin, Ho and Ho2021; Tan et al., Reference Tan, Wang, Yap, Chan, Ho, Hamid, Landaluce-Olavarria, Pellino, Gauhar, Chand, Wroclawski, Hameed, Ling, Sengupta, Gallo, Chiu, Tanidir, Tallada, Garcia, Colleoni, Abiddin, Campi, Esperto, Carrion, Elterman, Chung, Ng, Moschini, Rivas, Mayol, Teoh and Chiong2023), especially nurses (Dong et al., Reference Dong, Yeo, Tham, Danuaji, Nguyen, Sharma, Rn, Pv, Tai, Ahmad, Tan, Ho, Chua and Sharma2022). Studies suggested that the nursing staff suffered more problems from trauma-related stress during the outbreak of COVID-19 (Benfante et al., Reference Benfante, Di Tella, Romeo and Castelli2020; Chatzittofis et al., Reference Chatzittofis, Karanikola, Michailidou and Constantinidou2021; Chen et al., Reference Chen, Sun, Chen, Jen, Kang, Kao and Chou2021a; Yunitri et al., Reference Yunitri, Chu, Kang, Jen, Pien, Tsai, Kamil and Chou2022). According to recent literature in China, the incidence rate of PTSD in Chinese nurses following the outbreak of COVID-19 was 36.2% (Lai et al., Reference Lai, Ma, Wang, Cai, Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, Wang, Wang, Liu and Hu2020).
China stepped into the stage of the COVID-19 regular pandemic prevention and control on May 7, 2020 (The State Council, 2020). Therefore, the policy of national COVID-19 pandemic prevention and control was changed into regular pandemic prevention and control (Xinhua Press, 2020), resulting in an increased workload of nurses.
With the COVID-19 epidemic prevention work changing from emergency to normalization, hospitals were checkpoints for epidemic prevention and control, confronting potential risk factors and the nosocomial infection prevention and control measures will exist for a long period of time (Wu et al., Reference Wu, Li, Yan and Li2022). The contents of nurses’ jobs have changed. Excluding routine nursing work, they need to take on more responsibilities, including the strict procedure of admission of patients to hospitals and nursing services for patients from high- and medium-risk areas (Jiang et al., Reference Jiang, Wang, Shen, Zhao, Wang, Chen, Qiao, Wei, Dong, Ding and Yang2022). Moreover, constantly working under stressful environments has also resulted in pandemic fatigue among nurses (Zhang et al., Reference Zhang, Liu, Lu and Cheng2021). Thus, though the grim situation faced by Chinese nurses has changed, they still work under great pressure under the stage of COVID-19 regular pandemic prevention and control.
About 16.10% of Chinese nurses from low-risk areas still experienced moderate to severe psychological pressure during the stage of COVID-19 regular pandemic prevention and control (Chen et al., Reference Chen, Arber, Gao, Zhang, Ji, Wang, Wu and Du2021b). Moreover, Li and colleagues found that 50.54% of the frontline nurses in Wuhan, China, reported moderate (42.21%) to severe (8.33%) levels of stress in the context of COVID-19 regular pandemic prevention and control (Wen et al., Reference Wen, Shen, Zhang, Liu, Liu and XianYu2022). Nurses’ mental health was directly related to their performance quality in caring for patients and work efficiency (Mirzaei et al., Reference Mirzaei, Molaei and Habibi-Soola2022). PTSD was an important aspect of psychological health in Chinese nursing staff exposed to COVID-19 (Lai et al., Reference Lai, Ma, Wang, Cai, Hu, Wei, Wu, Du, Chen, Li, Tan, Kang, Yao, Huang, Wang, Wang, Liu and Hu2020). Therefore, it’s of great importance to investigate the influential factors of PTSD in Chinese nursing staff in the context of regular COVID-19 pandemic prevention and control.
Social support is defined as “the feeling that one is cared for and has assistance available from other people” and “that one is part of a supportive social network” (Somville et al., Reference Somville, De Gucht and Maes2016). The stress-buffering hypothesis supposes that social support plays a role in buffering stress by increasing the levels of self-efficacy and self-esteem (Cohen et al., Reference Cohen and Wills1985). Perceived social support was positively correlated with mental well-being and could help cultivate the ability to overcome stressful events (Xu et al., Reference Xu, Li and Yang2019; Huang et al., Reference Huang, Wu, Wu, Yang, Zheng and Wu2020). According to existing literature focusing on PTSD, social support was thought to be a strong predictive factor of PTSD among adults. A meta-analysis focusing on risk factors of PTSD has shown that low level of social support was the strongest predictor of PTSD (Brewin et al., Reference Brewin, Andrews and Valentine2000). Similarly, another meta-analysis conducted by Ozer and colleagues suggested a similar result (Ozer et al., Reference Ozer, Best, Lipsey and Weiss2003). Moreover, Guay et al. reviewed numerous studies and summarized that social support played a significant role in PTSD (Guay et al., Reference Guay, Billette and Marchand2006).
Recently, PTSD among medical staff has drawn plenty of attention from researchers. For example, it was supposed that lacking social support was a significant risk factor for PTSD among traumatized nurses from South Korea (Kim and Yeo, Reference Kim and Yeo2020). Besides, lacking social support was found to be a vital predictive factor of PTSD in healthcare staff fighting against the COVID-19 pandemic (d’Ettorre et al., Reference d’Ettorre, Ceccarelli, Santinelli, Vassalini, Innocenti, Alessandri, Koukopoulos, Russo, d’Ettorre and Tarsitani2021).
Therefore, we could infer that those lacking social support might be more prone to PTSD among nurses under the stage of COVID-19 regular pandemic prevention and control in China.
Insomnia has been proven to be associated with PTSD of healthcare staff during the outbreak of COVID-19. Blekas and colleagues found that 73.3% of Greek healthcare professionals with PTSD reported problems of insomnia. However, only 28% of the Greek healthcare professionals without PTSD suffered from bad sleep quality (Blekas et al., Reference Blekas, Voitsidis, Athanasiadou, Parlapani, Chatzigeorgiou, Skoupra, Syngelakis, Holeva and Diakogiannis2020). Yin et al. conducted a structural equation model and found that the sleep quality of Chinese medical staff could significantly predict PTSD symptoms (Yin et al., Reference Yin, Chen, Song, Deng and Dong2021). Li et al. discovered that insomnia played a significant partial mediating role between being a nurse and post-traumatic stress symptoms during the outbreak of COVID-19 (Li et al., Reference Li, Wang, Tan, Li and Yuan2022).
A study of Japanese daytime workers revealed that social support was an independent risk factor for insomnia (Nakata et al., Reference Nakata, Haratani, Takahashi, Kawakami, Arito, Kobayashi and Araki2004). Besides, social support was significantly related to the increased risk of sleeping difficulties during the COVID-19 pandemic. Specifically, people with good social support reported lower risk of sleeping difficulties (Grey et al., Reference Grey, Arora, Thomas, Saneh, Tohme and Abi-Habib2020). Moreover, it could be inferred from the existing literature that the protective effect of support from organizations on sleep quality among Chinese healthcare workers (Zou et al., Reference Zou, Liu, Li, Chen, Ye, Yang, Zhou and Ling2021) and nurses (Du et al., Reference Du, Liu, Zhang, Shao, Hua, Li, Lang and Ni2022) during the outbreak of COVID-19.
Based on the studies above, insomnia may play a mediating role between social support and PTSD in Chinese nursing staff during COVID-19 regular pandemic prevention and control.
Similarly, anxiety was also found to be a predictive factor of PTSD among medical professionals during the COVID-19 pandemic (Lu et al., Reference Lu, Ahorsu, Kukreti, Strong, Lin, Kuo, Chen, Lin, Chen, Ko and Ko2021; Yin et al., Reference Yin, Chen, Song, Deng and Dong2021; Yao et al., Reference Yao, Xie, Bai, Li, Zhang, Li, Ma, Hui and Chen2022). For example, Lu et al. found anxiety symptoms of COVID-19 frontline medical staff from Taiwan, China, significantly predicted PTSD using a method of hierarchical linear regression model (Lu et al., Reference Lu, Ahorsu, Kukreti, Strong, Lin, Kuo, Chen, Lin, Chen, Ko and Ko2021). Moreover, social support had a positive effect on anxiety among 4,658 adults (Roohafza et al., Reference Roohafza, Afshar, Keshteli, Mohammadi, Feizi, Taslimi and Adibi2014). Another research during the COVID-19 pandemic found that sufficient social support might reduce anxiety in medical staff (Zhu et al., Reference Zhu, Wei, Meng and Li2020).
Hence, it is reasonable to infer that anxiety may mediate the relationship between social support and PTSD in Chinese nursing staff during COVID-19 regular pandemic prevention and control.
Insomnia and anxiety always co-occurred and were significantly associated (Jansson-Fröjmark and Lindblom, Reference Jansson-Fröjmark and Lindblom2008; Marcks and Weisberg, Reference Marcks and Weisberg2009; Chinese Society of Neurology, 2020). Plenty of research investigated the relationship between insomnia and anxiety. Taylor et al. discovered that insomnia played a negative role in the elevated risk for anxiety in their review (Taylor et al., Reference Taylor, Lichstein and Durrence2003). Besides, subjects suffering from sleeping difficulties reported more symptoms of anxiety than those with good sleep quality (Taylor et al., Reference Taylor, Lichstein, Durrence, Reidel and Bush2005). Moreover, participants diagnosed with insomnia suffered from higher levels of anxiety, indicating the vital role of insomnia in anxiety (Mason and Harvey, Reference Mason and Harvey2014; Chen et al., Reference Chen, Huang, Weng, Wu, Ho, Wang, Tsai and Hsu2017). These studies above indicated that insomnia might lead to anxiety.
Consequently, it could be inferred that insufficient social support might lead to PTSD. Besides, insomnia and anxiety were significant mediators between social support and PTSD. Chain mediating model refers to a condition that there are two or more mediators in a mediating model, which is used to study how an independent variable influences dependent variable through a series of variables. In the chain mediation model, the mediators are not independent of each other (Liu and Ling, Reference Liu and Ling2009). Given existing evidence about the effect of insomnia on anxiety, we supposed that insomnia and anxiety might act as chain mediators in the association between social support and PTSD among nurses during COVID-19 regular pandemic prevention and control.
Therefore, the current study aimed to reveal the associations between social support, insomnia, anxiety, and PTSD among nurses. We hypothesized that insomnia and anxiety played chain mediating roles between social support and PTSD in nursing staff during the stage of COVID-19 regular pandemic prevention and control in China. Our research is of realistic significance and could aid the hospital with interventions to ameliorate PTSD among Chinese nursing staff during COVID-19 regular pandemic prevention and control. A chain mediation model was constructed to test our hypotheses (Figure 1). The variables in Figure 1 were listed as follows: X = Social support, Y = PTSD, M1 = Insomnia, M2 = Anxiety. Specifically, social support was the independent variable, and PTSD was the dependent variable. Insomnia and anxiety were calculated as chain mediators in the relationship between social support and PTSD among nursing staff.
Figure 1. Hypothesized model about social support, insomnia, anxiety, and PTSD.
Methods
Participants and procedures
The current research was conducted in January 2022. Inclusion criteria: I) normal ability of speech, comprehension, and expression; II) ≥18 years old; III) working as a nurse during COVID-19 regular pandemic prevention and control. Exclusive criteria: diagnosed with psychiatric illness before. A total of 784 nurses were recruited from five tertiary hospitals using a convenience sampling method in China.
The mean age of the participants was 26.37 years with a standard deviation of 6.59. 94.4% of the nurses were female. About two in three of the respondents were married. The average working seniority was 8.81 ± 6.87 years. A detailed flowchart is shown in Figure 2.
Figure 2. Flowchart of subjects’ enrollment in January 2022.
Measures
Demographics
Demographic information (e.g., age, gender, marital status, and working seniority) of nurses was collected in this study.
Perceived social support scale (PSSS)
PSSS includes 12 items and is a classic evaluation tool for measuring the perceived social support (Zimet et al., Reference Zimet, Dahlem, Zimet and Farley1988). Each item is rated from 0 (strongly disagree) to 7 (strongly agree). The highest score of the scale is 84. The scale has shown good validity and reliability and has been widely used among the Chinese population (Mao et al., Reference Mao, Dong, Zhang, Zhang, Deng, Li and Hou2023a; Mao et al., Reference Mao, Hou, Wang, Tang, Ni, Zhang, Zhang, Deng, Chen, Wang, Li, Jia, Dong and Qian2024). In this study, the coefficient of Cronbach’s alpha was 0.968.
Insomnia severity index (ISI)
ISI is a 7-item questionnaire and a classic evaluation tool for perceived insomnia severity (Bastien et al., Reference Bastien, Vallieres and Morin2001). Each item was rated from 0 (not at all) to 4 (nearly every day). The highest score of the scale is 28. The scale has presented sufficient validity and reliability and has been widely used among the Chinese population (Mao et al., Reference Mao, Lin, Liu, Zhang, Deng, Li, Hou and Dong2023b; Mao et al., Reference Mao, Hou, Wang, Tang, Ni, Zhang, Zhang, Deng, Chen, Wang, Li, Jia, Dong and Qian2024). In this study, the coefficient of Cronbach’s alpha was 0.927.
Generalized anxiety disorder-7 (GAD-7)
GAD-7 is a 7-item questionnaire and a classic evaluation tool for anxiety and its severity (Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006). Participants were asked to report the frequency of each item during the last 2 weeks. “Not at all,” “several days,” “more than half the days” and “nearly every day” were scored as 0, 1, 2, and 3, respectively. The highest score of the scale is 21. The scale has been widely used with excellent validity and reliability among the Chinese population (Mao et al., Reference Mao, Zhang, Wei, Li, Huang, Sun, Zhang, Deng, Hou and Dong2023c; Mao et al., Reference Mao, Hou, Wang, Tang, Ni, Zhang, Zhang, Deng, Chen, Wang, Li, Jia, Dong and Qian2024). In this study, the coefficient of Cronbach’s alpha was 0.960.
Impact of event scale-revised (IES-R)
IES-R is a 22-item and a classic evaluation tool for assessing posttraumatic stress symptoms. There are three subscales (intrusiveness, avoidance, and hyperarousal) in this scale. The highest score of the scale is 88. The cut-off of IES-R is 33 (Asif et al., Reference Asif, Price, Ewing, Rao, Harmon and Drezner2016). The scale has shown good validity and reliability in the Chinese population (Mao et al., Reference Mao, Luo, Li, Zhang, Zhang, Deng, Li, Hou and Dong2023d; Mao et al., Reference Mao, Hou, Wang, Tang, Ni, Zhang, Zhang, Deng, Chen, Wang, Li, Jia, Dong and Qian2024). In this study, the coefficient of Cronbach’s alpha was 0.976.”
Statistical analysis
IBM SPSS (version 21.0) was adopted to analyze the data. The significance level is set as α = 0.05, and all tests are double-tailed tests (Mao et al., Reference Mao, Hou, Wang, Tang, Ni, Zhang, Zhang, Deng, Chen, Wang, Li, Jia, Dong and Qian2024). Common method bias was detected by the Harman single-factor test (Mao et al., Reference Mao, Lin, Liu, Zhang, Deng, Li, Hou and Dong2023b). Hence, the Harman single-factor test was chosen to detect the presence of common method bias in this study. Pearson correlation analyses is a common statistical method to detect the correlations between variables (Hou et al., Reference Hou, Yin, Xu, Gao, Bin, Li, Cai, Liu, Dong, Deng and Ni2021). Therefore, we calculated the correlations among anxiety, insomnia, social support, and PTSD with Pearson correlation analyses. The Hayes SPSS macro program process (version 3.4.1, Model 6) is a good tool to detect the chain mediating model (Hayes, Reference Hayes2013). We adopted the Hayes SPSS macro program process (version 3.4.1, Model 6) to conduct the bootstrapped method (5000 resamples) to estimate 95% confidence interval (CI) for significance testing for mediating model (Preacher and Hayes, Reference Preacher and Hayes2008). According to the method, the chain mediation model would be established if zero was included in 95% CI.
Results
Common method Bias test
Common method bias may appear in self-report inventory (Campbell and Fiske, Reference Campbell and Fiske1959). Harman single-factor test was selected to detect if common method bias existed in this study (Podsakoff et al., Reference Podsakoff, Mackenzie, Lee and Podsakoff2003; Zhou and You, Reference Zhou and You2004). Six values with an eigenvalue more than 1 were found. The first factor accounted for a variance of 36.81% (<40%). Therefore, common method bias did not exist in the current study.
Pearson’s correlation
Results of Pearson’s correlation among social support, insomnia, anxiety, and PTSD (Table 1) indicated that four variables were related to each other significantly (all P < 0.01).
Table 1. Results of bivariate analysis among variables
Note: **P < 0.01.
Mediating roles of insomnia and anxiety
PROCESS 3.4.1 (Model 6) was applied to test the chain mediating model (Figure 3). Studies revealed age, gender, marital status (Zhou et al., Reference Zhou, Shang, Zhang, Wu, Sun, Jia, Yu and Liu2021) and working seniority (Goh et al., Reference Goh, Jou, Lu, Yeh, Kao, Liu and Kan2021) were closely related to PTSD. Therefore, demographic information (age, gender, marital status, and working seniority) was controlled as confounders.
Figure 3. Chain mediating model about social support, insomnia, anxiety, and PTSD (**P < 0.01, ***P < 0.001).
As shown in Table 2, the direct effect was significant since the 95% CI (−0.245 ~ −0.102) did not contain 0. The total mediating effect was significant since 0 wasn’t included in the 95% CI (−0.382 ~ −0.260). The indirect effect of social support on PTSD via insomnia was significant as 0 wasn’t contained in the 95% CI (−0.064 ~ −0.012). Similar results were detected among the mediating effects of anxiety and the chain mediating effects of insomnia and anxiety.
Table 2. Chain mediating roles of insomnia and anxiety
Figure 3 shows the chain mediating effects of insomnia and anxiety in the association between social support and PTSD. As showed in Figure 3, all paths in chain mediating model were significant (**P < 0.01, ***P < 0.001). The results revealed that the negative relationship between social support and PTSD was significant, with insomnia and anxiety partially mediating the relationship between social support and PTSD, respectively. Besides, a significant chain mediating effect of insomnia and anxiety was also detected in the current research. The total mediating effects was 64.77%.
To sum up, insomnia and anxiety played chain mediating roles between social support and PTSD among nurses during COVID-19 regular pandemic prevention and control.
Discussion
The present investigated how social support would influence PTSD among nurses during the period of COVID-19 regular pandemic prevention and control in China. The results revealed that insomnia and anxiety played chain mediating roles between social support and PTSD. As far as we know, our study is the first to focus on the effect of social support on PTSD among Chinese nursing staff via chain mediating effect of insomnia and anxiety.
We discovered social support could negatively and significantly predict PTSD, which was in line with previous research. Schnurr and colleagues investigated influencing factors of PTSD among Vietnam veterans. They found that social support played an important role in the development and maintenance of PTSD (Schnurr et al., Reference Schnurr, Lunney and Sengupta2004). Besides, leadership social support was supposed to be related to PTSD in pediatric oncology nursing staff (Schuster et al., Reference Schuster, Berbert, Meyer and Dwyer2022). Song et al. conducted a cross-sectional study on 14,825 Chinese medical staff during the outbreak of COVID-19. They found that those with insufficient social support were more likely to develop PTSD (Song et al., Reference Song, Fu, Liu, Luo, Wang, Zhou, Yan and Lv2020).
Social support is a protective factor against psychological difficulties. Kerasiotis et al. suggested that social support might act as a protective factor in helping nursing staff to deal with work pressure (Kerasiotis and Motta, Reference Kerasiotis and Motta2004). The coping theory supposed that social support was considered as a vital coping strategy when facing stress. Specifically, social support might have a significant effect in relieving negative influence from kinds of pressure events by solving problems and relieving negative emotions via assistance from social ties (Mo et al., Reference Mo, Chen, Lam, Li, Kahler and Lau2020). Besides, the stress-buffering hypothesis supposes that social support plays a role in buffering stress by increasing the levels of self-efficacy and self-esteem (Cohen et al., Reference Cohen and Wills1985). Insufficient social support played a predictive role in PTSD among medical staff during the COVID-19 pandemic (d’Ettorre et al., Reference d’Ettorre, Ceccarelli, Santinelli, Vassalini, Innocenti, Alessandri, Koukopoulos, Russo, d’Ettorre and Tarsitani2021). A Korean study indicated that nurses might experience more PTSD if they got lower levels of support from their managers during the COVID-19 pandemic (Bae et al., Reference Bae, Yoon, Kim and Kim2022). Moreover, social support was thought to be a protective factor of psychological resilience that maintained mental health and eliminated psychological barriers (Sripada et al., Reference Sripada, Lamp, Defever, Venners and Rauch2016). This may be the possible explanation for the positive effect of social support on PTSD.
As hypothesized, we demonstrated the chain mediating roles of insomnia and anxiety. Social support could influence PTSD through three paths (Figure 3). First, paths 1 and 2 indicated that insomnia and anxiety played significant mediating roles between social support and PTSD, respectively. The results indicated close relationships among insomnia, anxiety, and PTSD. Specifically, insomnia and anxiety were positively predictive factors of PTSD among nurses during COVID-19 regular pandemic prevention and control, which were in line with previous studies. For example, Yao et al. found sleep disorder and anxiety were significant mediators of PTSD in medical staff during the COVID-19 pandemic (Yao et al., Reference Yao, Xie, Bai, Li, Zhang, Li, Ma, Hui and Chen2022). Similarly, Yin et al. found sleep quality and anxiety were mediators of PTSD in medical staff combating against COVID-19 (Yin et al., Reference Yin, Chen, Song, Deng and Dong2021). Besides, Li and colleagues discovered that insomnia was a significant partial mediator, which explained 32.53% of the association between being a nurse and post-traumatic stress symptoms among frontline medical staff during the COVID-19 pandemic in China (Li et al., Reference Li, Wang, Tan, Li and Yuan2022). Meanwhile, anxiety symptoms of COVID-19 frontline healthcare workers from Taiwan, China were proved to be a significant predictor of PTSD (Lu et al., Reference Lu, Ahorsu, Kukreti, Strong, Lin, Kuo, Chen, Lin, Chen, Ko and Ko2021). Moreover, social support was proven to be a predictive factor of insomnia and anxiety among Turkish medical professionals (Yılmaz et al., Reference Yılmaz, Kıraç and Sahin2021). The same results were also observed in Chinese medical staff. Social support was negatively related to sleep quality and anxiety significantly (Xiao et al., Reference Xiao, Zhang, Kong, Li and Yang2020). Secondly, path 3 suggested that insomnia and anxiety acted as chain mediators in our model. Namely, insufficient social support would lead to sleep problems, which may increase the level of anxiety and then result in PTSD among nurses. However, previous studies did not classify the relationship among social support, insomnia, anxiety, and PTSD.
The current research is the first study to investigate possible mechanisms underlying the relationship between social support and PTSD of nurses during COVID-19 regular pandemic prevention and control.
Implications
The current study has several implications for the amelioration of PTSD in nursing staff after public health emergencies. Our study gave empirical evidence for the possible mechanism underlying the relationship between social support and PTSD among Chinese nursing staff. Social support could not only directly influence PTSD, but also indirectly impact PTSD through three pathways: (1) social support-insomnia-PTSD; (2) social support-anxiety-PTSD; (3) social support-insomnia-anxiety-PTSD. The results of our research suggested to the Chinese hospital authorities the possible methods to reduce or even prevent PTSD. The nursing staff should take action concentrating on promoting sleep problems and anxiety. Prior studies revealed that cognitive behavioral therapy (CBT) and internet cognitive behavioral therapy (I-CBT) were effective in treating psychiatric symptoms (Zhang and Ho, Reference Zhang and Ho2017) or psychological outcomes during the COVID-19 pandemic (Ho et al., Reference Ho, Chee and Ho2020; Soh et al., Reference Soh, Ho, Ho and Tam2020). Therefore, CBT and I-CBT focusing on promoting sleep quality and anxiety could be taken to reduce PTSD among nurses.
Limitations
There are some limitations in our study. Firstly, the cross-sectional design adopted in the current study could not determine causal associations among variables. Longitudinal or experimental approaches are needed in the future to infer the possible causal relationships among variables. Second, our subjects were recruited using the convenience sampling method. The small sample size might limit the sample representativeness, which may limit the generalizability of the findings. Further research had better-recruited subjects with random cluster sampling and expanded the sample size to enhance the external validity. Thirdly, burnout during the COVID-19 pandemic is an important public health issue and is worthy of further study (Mao et al., Reference Mao, Hou, Wang, Tang, Ni, Zhang, Zhang, Deng, Chen, Wang, Li, Jia, Dong and Qian2024; Lau et al., Reference Lau, Ho, Pang, Su, Kwok, Fung and Ho2022). However, burnout was not considered in the present study. Future research should consider this issue to explore the association of burnout with PTSD among nurses.
Conclusion
To conclude, the study demonstrated the chain mediating roles of insomnia and anxiety in the relationship between social support and PTSD among nursing staff during COVID-19 regular pandemic prevention and control. The Chinese hospital authorities need to pay extra attention to nursing staff with insufficient social support to prevent and reduce PTSD. Moreover, actions targeting the reduction of insomnia and anxiety also need to be taken to reduce or even prevent PTSD in nursing staff.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2024.91.
Data availability statement
The data that support the findings of this study are available on request from the corresponding authors. The data are not publicly available due to the de-identified data possibly containing information that could compromise the privacy and safety of the research participants.
Acknowledgements
The authors would like to acknowledge the volunteers who participated in the study.
Author contribution
Xiaofei Mao, Tianya Hou, and Weizhi Liu designed the study. Yulin Zhang, Jianguo Zhang, and Fan Zhang collected the data. Xiaofei Mao and Tianya Hou analyzed the data and drafted the manuscript. Weizhi Liu led the whole study. All the authors have read and approved the final manuscript.
Financial support
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Youth Initiation Fund of Naval Medical University (2023QN028); Social Science Cultivation Fund of Naval Medical University (2023SK015); Youth Talent Initiation Fund of Faulty of Psychology of Naval Medical University (2023RC003). Youth Social Science Cultivation Fund of Faulty of Psychology of Naval Medical University (2023SK001).
Competing interest
The authors declare no competing interests.
Ethics statement
All participants signed a written informed consent form in ethics approval and consent to participate. The study was approved by the ethics committee of Naval Medical University in accordance with the ethical standards established in the 1964 Declaration of Helsinki and its later amendments.
Open access
