Background
There is desperate need for stable, well trained and fully engaged nursing staff to provide effective patient care in China. However, the turnover rate of the contract nurses at the hospital in the first two years of employment is approximately 70 %, which is a major issue impacting on the performance and profitability of hospital [
1,
2]. While the factors that cause nursing turnover can be fairly complex, more attention has been paid to the two major elements including mental health and interpersonal relationships. Rogers [
3] explained in his analysis that behavior changes, such as nurses’ determination of changing jobs, concomitantly or resultantly with the change of self perception and individual’s perception of reality. Thus, if we would probe the reason of nurses’ turnover, the concept of self should be measured. Self as it is emphasized in Rogers’ theory, is the consistency of the inner self, and the identification of oneself and experience. Self could also be understood as the cognition and comprehension of oneself. Wang [
4] defines the self-harmony as lower
self-stereotype (the feeling of inconsistency) and
self-conflict (conflicts and assessment of confidence), and higher
self-flexibility (the ability of coping with common events and situational demands).
Psychosocial job characteristics, social support, and sense of coherence are the key determinants of occupational mental health among nurses. Psychosocial job characteristics require nursing staff with high self-consistency and good mental health [
5,
6]. Symptom Checklist-90 (SCL-90) has been used to measure the nurses’ mental health, which focuses on description of psychosomatic symptoms [
7]. However, SCL-90 was unable to further consider the situation and examine the relations between self-congruence and mental health. Mental well-being integrates pleasant physiological and emotional state, and good social adaptation. Therefore, it may not be accurate to evaluate the inner harmony using SCL-90 questionnaire [
8]. In the present study, the Self-Consistency and Congruence Scale (SCCS) was employed in evaluation of mental health. Based on the current meta-analysis of nurses’ mental health measured by SCL-90, which indicates that, in general, Chinese nurses show higher scales (or worse mental health status) than normal samples [
7], we assumed that the measurement of self-consistency and congruence are same.
Social support has a favorable impact on the maintenance of health and on coping with illness. Thus, social support as a valuable psychosocial factor could be used to predict the mental health status. Social support refers to one’s social bonds, social integration, and primary group relations. Strong social support to mental health has beneficial effects, such as feelings of love, care, respect and gratification [
9]. The study of social support and its relationship to mental health has become one of the fastest growing areas of research and application in psychology [
10,
11]. In early studies, social support was annotated with the society structural factors [
12,
13]. Recently, researchers are focusing on the analysis of different social support resources and characteristics to probe their association with mental health [
14]. Social support has been classified into objective support and subjective support [
15]. Social support and mental health of special groups of nurses have received concerns in other cultures and positive correlation between social support and nurses’ turnover has been demonstrated [
16,
17]. The researchers have explored the impact of social support on mental health of bedside nurses [
17,
18]. However, the attention and effort of such study remained very limited in China. We propose a reconceptualization of social support by hypothesizing that the inner harmony with confident and tranquil emotional state may be influenced by the social relationships. We report empirical findings in order to provide the impact of social factors on social support.
Methods
Study design
A cross-sectional study was designed to test the correlation between the levels of social support and mental health in the Fourth Hospital of Hebei Medical University, China. Social Support Rating Scale (SSRS) (see Additional file
1) was used to measured social support, and Self Consistency and Congruence Scale (SCCS) (see Additional file
2) were used to measure the levels of mental health [
4,
19].
Study subjects
Participants signed a consent form allowing investigators to analyze their information. The recruited participants from different departments in the hospital have been working at least 36 h per week in 6 months. Three groups of bedside nurses were excluded from this study: nursing managers, supporting staff that worked on quality control, infection control and indirectly care for patients, and those who had been off work for more than one month in 6 consecutive months. The norm-referenced group, which were employed to compare with the sample group in SCCS scores, included 502 college students (260 males and 242 females, with an average of 18.5 (17–22) years old) [
4].
Data collection
The anonymous self-administered questionnaire was distributed by a trained investigator during a meeting with the participants. The questionnaire included different items and scale to measure psychosocial risk, working and socio-demographic characteristics, the SCCS and the SSRS. The questionnaire also included an open-ended question to gather subjective opinions of participants on their working conditions and major problems. A total of 218 bedside nurses were administered the survey and required to complete the questionnaires in 30 min. Data from the group of college students were obtained from the published article [
4], which were employed as standards in most published studies.
Questionnaire
There are two parts in the questionnaire survey.
Part-1 is the multiple choice format of assessment, including questions on the bedside nurse’s working department, marital status, years of work, cooperation with other health workers, health status, income, career decision, and education. Only one best possible answer was marked during the survey.
Part-2 is composed of the SCCS and SSRS. In SCCS, 35 questions are divided into three subscales. Subscale-1 included 16 questions on self-conflict; Subscale-2 had 12 questions on self-flexibility; Subscale-3 included 7 questions on self-stereotyping. The total SCCS score is the sum of results from the three subscales. Participants who have the higher scores of the subscale-1 (self-conflict) and subscale-3 (self-stereotype) showed the lower levels of self-consistency and mental health. In contrast, those who have the higher scores of the subscale-2 (self-flexibility) exhibited the higher levels of the interpersonal flexibility [
4]. SSRS comprises three subscales: Subjective Support (question # 1 and 3–5), Objective Support (question # 2 and question 6–7), and Utilization of Social Support (question 8–10). The total SSRS score is the sum of the score from the three subscales. A higher score indicates more social support [
19].
Statistical analysis
Each questionnaire was numbered and entered into a spreadsheet (Excel). Input errors were corrected by a third party. The statistical program SPSS version 10.0 was used for statistical analysis. A descriptive analysis was conducted on the demographic variables, SCCS and SSRS subscales. Questions such as only child, marital status, working department, position, years of work and career decision were coded as categorical variables; questions such as cooperation with other health worker, health status, income, and education were coded as ranked data; SCCS and SSRS were coded as continuous variables. Comparison tests were made between the participants and the college students. Correlation analysis was performed between subscales of the SCCS and SSRS. ANVOA was performed to test SSRS and subscale scores among different demographic groups. The level of statistical significance in each analysis was 5 %.
Conclusion
Bedside nurses in this study show better self-congruence compared to the college students. Their mental health closely correlates with the levels of social support. Individual characteristics such as marriage, years of work, education, self-assessed health, career decision, cooperation with other health worker, only-child family and income have influence on social support the person receives and perceives. Therefore, it is substantial to improve inner perception of support and external workplace support, and offer beneficial social environment to decrease the high turnover rate of bedside nurses.
Abbreviations
ANVOA, analysis of variance; SCCS, Self-Consistency and Congruence Scale; SCL-90, Symptom Checklist-90; SRRS, Social Support Rating Scale
Acknowledgements
The authors would like to thank Dr. Hong Wang from MD Anderson Cancer Center for his help in the final manuscript. Also, we would like to thank Fang Xie and Li Yang for their help in the clinical investigation.
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