Resilience as a Mediator of the Relationship between Perceived Social Support and Public Health Emergency-related Post-traumatic Growth among Medical staff

doi:10.21203/rs.3.rs-4963394/v1

Background

As central participants in Public Health Emergency (PHE), medical staffs may face positive changes, such as post-traumatic growth, while being traumatised. However, previous research remains deficient in factors influencing Post-Traumatic Growth (PTG). The aim of this paper is to examine how resilience mediates the relationship between perceived social support and PTG among medical staff.

Method

Using statistical descriptive and one-way analyses, we investigated the mediating effects of a cross-sectional study with 730 medical staff from a general hospital in Hubei Province, the epicenter of PHE in China, through Structural Equation Modelling(SEM).

Results

The mean PTG score among medical staff was 60.48 (SD = 24.49). The direct impact of perceived social support on PTG was significant (0.218, 95% CI [0.083, 0.361], P < 0.001), constituting 49.98% of the total effect. Moreover, the indirect impact of perceived social support on PTG via resilience was also significant (0.218, 95% CI [0.119, 0.320], P < 0.001), accounting for 50.02% of the total effect.

Conclusion

Our study demonstrated the positive impact of perceived social support on PTG among medical staff, with psychological resilience playing a mediating role. It suggests that interventions should focus on increasing perceived social support and resilience to foster positive psychological changes and improve the quality of healthcare services.

public health emergency

medical staff

post-traumatic growth

perceived social support

Public Health Emergency (PHE) is a formal proclamation made by the World Health Organization (WHO) in response to an exceptional event. It refers to an exceptional incident recognized as posing a public health threat to other nations due to the global transmission of disease and possibly necessitating a coordinated international reaction [1]. Despite WHO has declared end to COVID-19’s emergency phase [2], The psychological problems of medical staff who treated patients during the pandemic persist and are still overlooked [3].

PHE has presented unparalleled challenges and risks to the physical and mental well-being of medical staff [4], who combated the virus and cared for the infected patients during PHE. Medical staff are exposed to high levels of stress, fear, anxiety, depression, and trauma [5], which may have negative consequences for their well-being and functioning [6]. Nevertheless, certain medical staff might encounter favorable psychological transformations while navigating the pandemic, exemplified by Post-Traumatic Growth(PTG) [7]. PTG embodies the psychological advantage stemming from an adjusted response to trauma [8], encompassing improved interpersonal bonds, emerging prospects, heightened inner fortitude, spiritual advancement, and an amplified zest for life [9]. This growth can enhance their professional identity [10] and mental health. Exploring these positive changes in PTG could encourage reflection on and making sense of their experiences, which can reduce the detrimental effects of trauma and increase their levels of life satisfaction [11].

The factors that influence the development of PTG are complex and multifaceted, one of the most studied factors is perceived social support. People have been discovered to benefit from perceived social support, which helps them manage, feel secure, and derive meaning from their experiences [12, 13]. Perceived social support can provide substantial social interactions that could directly lead to positive changes, such as expressing emotions and giving feedback. Previous research had found significant positive correlation between perceived social support and PTG [14–17], and a favorable indirect influence on PTG was found in one study [18], however the type of trauma, culture, age, and sample size may affect this association [19]. Perceived social support not only directly promotes post-traumatic growth [20], but also exerts an indirect effect [21] through other factors. Therefore, it is of great significance to analyze the relationship between perceived social support and post-traumatic growth in depth.

Another factor that may play a role in PTG is resilience, it is an adaptation in the face of adversity [22], it can be defined as the preservation of mental health or rapid recovery following periods of exposure to stressors [23], which may be brought on by potentially traumatic events, difficult circumstances, a crucial life stage, or physical disease [24]. Resilience was found to be a protective factor that engaged in the PTG of severe illness [25], and have closely related to PTG [26]. Resilience can enable healthcare workers to cope effectively with trauma-related stressors, which enables people to thrive and gain experience in the face of hardship [27].

Certain investigations have revealed that perceived social support could intertwine with additional elements, like resilience, to impact PTG. Resilience could potentially function as a mediating element in the interplay between perceived social support and PTG. Wu's research [28] highlighted that resilience acted as a mediator in the connection between perceived social support and PTG among primary caregivers of individuals with schizophrenia. This implies that the constructive impact of perceived social support on PTG was more pronounced for individuals with lower resilience levels compared to those with higher resilience levels. Hou's study [29] found that resilience mediates the impact of perceived social support on healthcare workers' mental health to some extent, and is moderated by age. Given that PTG is one of the positive changes in mental health [30], we wanted to verify whether psychological resilience also mediates the effect of perceived social support on PTG.

Previous studies have mainly focused on the impact and factors of the pandemic's enduring effects, such as PTG [31]. However, little is known about the PTG of medical staff facing PHE, and its determinants and mechanisms. This paper examines the relationship between perceived social support and PTG in healthcare workers, and the mediating role of resilience. Our hypotheses are: H1: Perceived social support has a positive direct effect on PTG among medical staff. H2: Perceived social support has a positive indirect effect on PTG through resilience among medical staff. We used regression models and bootstrapping techniques to measure the direct and indirect effects of perceived social support on PTG via resilience.

2.1 Design and Participants

The study recruited 730 medical staff from two general hospitals in Hubei Province in 2023. The inclusion criteria were: (1) age over 18 years old; (2) obtained a physician or nurse qualification certificate; (3) voluntarily participated in this study. The exclusion criteria were (1) psychological problems; (2) uncooperative. We conducted an online survey using a web-based platform (“SurveyStar”, provided by Changsha Ranxing Science and Technology, China) that ensured the anonymity and confidentiality of the respondents. Before taking the survey, the participants provided their electronic informed consent by selecting “yes” from two options on the consent page. The survey system also implemented logic checks to verify the quality and validity of the responses. The data from the completed questionnaires were automatically entered into a data file and double-checked by two independent researchers. We prevented multiple responses from the same IP address by restricting one response per question per device.

2.2 Measurements

2.2.1 General demographic information

We designed an online questionnaire based on the research objectives and collected the demographic data of the respondents, including age, gender, marital status, length of employment, education level, and occupation type.

2.2.2 Chinese post-traumatic growth inventory (C-PTGI)

.The study employed the Posttraumatic Growth Inventory (PTGI) developed by Tedeschi and Calhoun [32], a scale designed to gauge the extent of PTG in individuals who have undergone significant crises. The Chinese iteration of PTGI was introduced by Wang, demonstrating a total Cronbach's alpha coefficient of 0.874 [33]. The Chinese version, C-PTGI, operates on a 6-point Likert scale ranging from 0 (no change) to 5 (significant change). C-PTGI evaluates five dimensions of positive psychological changes or growth following trauma: life perception, personal power, new possibilities, relationships with others, and self-transformation. Elevated scores correspond to heightened levels of post-traumatic growth. In this study, the Cronbach's alpha coefficient was an impressive 0.98, signifying internal consistency.

2.2.3 Multidimensional Scale of Perceived Perceived social support (MSPSS)

The study used the Chinese version of the 12-item Multidimensional Scale of Perceived Perceived social support (MSPSS) [34], consisting of three dimensions from family, friends, and others, to measure perceived level of perceived social support of participants. The MSPSS is a Likert 7-point scale, ranging from 0 (Strongly Disagree) to 6 (Strong Agree), with higher mean scores on the dimensions indicating a higher level of support [35]. The Cronbach’s alpha coefficient in this study was 0.98.

2.2.4 The 10-item Connor-Davidson Resilience Scale (CD-RISC-10)

The study used the Chinese version of the CD-RISC-10, translated by Wang [36] in 2010, to measure psychological resilience during stress. Chinese version shows good psychometric properties [37], Employing a five-point Likert scale ranging from 0 (never) to 4 (always), it encompasses three dimensions: tenacity, strength, and optimism, wherein higher scores signify heightened psychological resilience [36]. In this study, the Cronbach's alpha coefficient was even higher, at 0.98.

2.3 Ethical Statement

The research adhered to the Declaration of Helsinki guidelines [38]. Prior to completing the questionnaire, participants provided informed consent by acknowledging and electronically signing the consent form. The study maintained data integrity and confidentiality, allotting each participant a numerical identifier for absolute anonymity. The study received approval from the Research Ethics Committee of Tongji Medical College, Wuhan, China.

2.4 Data analysis

We used SPSS 26.0 and AMOS 26.0 for data analysis. Out of 877 distributed questionnaires, we excluded the incomplete and illogical ones and retained 730 valid questionnaires, with an effective rate of 83.2%. We performed descriptive statistics and correlation analysis to describe the sample and examine the relationships among the variables. We employed structural equation models to examine the mediating influence of psychological resilience on the relationship between perceived social support and PTG. We utilized a two-way bootstrapping approach, generating 5,000 bootstrapped samples at a 95% confidence interval (95% CI) to assess the significance of the standardized coefficient (β). Significance of mediation or direct effect was considered when the 95% CI for β did not encompass zero (P < 0.05). The predictor was perceived social support, the mediator was resilience, and PTG served as the outcome variable.

3.1 Descriptive analysis

TABLE 1 presented demographic characteristics of participants along with corresponding PTG scores. Additionally, it provided outcomes from the univariate analysis exploring the association between these characteristics and medical staff' PTG. Most participants were women (79.7%, n=730), and 80.3% were aged 25-44 years (n=586). Medical staff who were younger (5.2%, n=38), had fewer years of employment (6.3%, n=46), and were paid less (6.3%, n=46) tend to have higher PTG scores. Married medical staff had lower PTG scores (60.13±25.30) than those in other statuses(62.05±20.35) (unmarried, divorced).

TABLE 1 Demographic characteristics of the participants and analysis for the factors associated with PTG (n=730)

Variable	N (%)	Post-traumatic Growth (PTG)
		Mean (SD)	t/F	p
Gender			1.055	0.305
Male	148(20.3)	59.76(23.16)
Female	582(79.7)	60.66(24.83)
Age			0.618	0.603
18-24	38(5.2)	65.39(23.01)
25-34	291(39.9)	60.68(23.67)
35-44	295(40.4)	59.69(25.96)
>44	106(14.5)	60.36(23.04)
Marital Status			9.806	0.020
Unmarried	131(17.9)	62.05(20.35)
Married	599(82.1)	60.13(25.30)
Education Level			0.338	0.713
College	68(9.3)	59.99(23.69)
University	521(71.4)	60.93(24.90)
Over graduate	141(19.4)	59.06(23.40)
Type of occupation			0.882	0.414
Doctor	151(20.7)	58.58(24.16)
Nurse	570(78.1)	60.87(24.58)
Others	9(1.3)	67.33(24.54)
Average monthly income (Yuan)			1.662	0.174
<5000	46(6.3)	67.78(18.89)
5000-9999	403(55.2)	60.54(25.31)
10000-14999	226(31.0)	58.96(23.46)
≥15000	55(7.6)	60.15(26.16)
Years of working			0.687	0.560
≤2	46(6.3)	65.35(21.33)
3-10	244(33.4)	60.54(23.89)
11-20	298(40.8)	59.80(25.53)
>20	142(19.5)	60.23(24.31)
Night Shift			0.521	0.471
Yes	522(71.5)	60.26(24.26)
No	208(28.5)	61.01(25.11)
Occupational exposure			1.165	0.281
Yes	109(14.9)	61.35(25.31)
No	621(85.1)	60.33(24.36)

3.2 Correlation Analysis of Psychological Resilience, Perceived social support, and PTG

In TABLE 2, the participants reported a mean perceived social support score of 71.07 (SD = 13.02), a mean PTG score of 60.48 (SD = 24.49), and a mean resilience score of 22.48 (SD = 11.79). We found significant positive correlations between perceived social support and PTG (r = 0.231, P < 0.01), between perceived social support and resilience (r = 0.577, P < 0.01), and between resilience and PTG (r = 0.268, P < 0.01).

TABLE 2 Correlation analysis of social support, PTG, and resilience

	Scores(M±SD)	1	2	3	4	5	6
1.Social support-Family	23.88(4.43)	1.000
2.Social support-Friends	23.52(4.48)	.896**	1.000
3.Social support-Others	23.68(4.44)	.945**	.937**	1.000
4.Social support-Total scores	71.07(13.02)	.971**	.969**	.985**	1.000
5.PTG	60.48(24.49)	.221**	.234**	.222**	.231**	1.000
6.Resilience	22.48(11.79)	.566**	.560**	.561**	.577**	.268**	1.000

Notes: **. P <0.01. PTG, Post-traumatic Growth.

3.3 Analysis of mediating effects based on a structural equation model

We employed a structural equation model to examine the mediating effects. Model fit indices are meaningless for saturated models, so we did not report them. The standardized path coefficient for the structural equation model is depicted in FIGURE 1, and the path analysis outcomes are presented in TABLE 3. The bootstrap method was utilized to scrutinize the mediation effect of psychological resilience. Findings revealed that perceived social support had a direct impact on PTG (β = 0.231, 95% CI: [0.083, 0.361]) and an indirect impact on PTG mediated by psychological resilience (β = 0.116, 95% CI: [0.119, 0.320]). Notably, psychological resilience acted as a mediator in the relationship between perceived social support and PTG, accounting for 49.98% of the total effect. Detailed results concerning direct and indirect effects, along with 95% CIs, are elaborated in TABLE 4 within the structural equation models.

TABLE 3 Mediation model test of psychological resilience

Regression Equation		Fit Index		Systematic Significance
Outcome Variable	Predictor Variable	R²	F	β	t
PTG		0.238	6.196
	Gender			0.787
	Age			0.529	-0.630
	Marital Status			0.891	-0.137
	Social Support			0.231	6.360***
Resilience		0.578	51.760
	Gender			0.981	0.024
	Age			0.428	0.793
	Marital Status			0.817	0.231
	Social Support			0.575	18.786***
PTG		0.289	8.230
	Gender			0.781	-0.278
	Age			0.439	-0.774
	Marital Status			0.859	-0.178
	Social Support			0.116	2.644**
	Resilience			0.201	4.610***

Notes: **. P <0.01. ***. P <0.001.

TABLE 4 Decomposition table for total, direct and mediating effects

	Effect	BootSE	BootLLCI	BootULCI	Efficiency Ratio
Indirect	0.218	0.052	0.119	0.320	49.98%
Direct	0.218	0.070	0.083	0.361	50.02%
Total	0.436	0.066	0.316	0.574

We selected medical staff from Hubei Province, China’s PHE epicenter, to obtain more representative results. Our findings revealed the unique challenges and psychological well-being of medical staff during a critical time. We examined how perceived social support influenced PTG among medical staff, mediated by psychological resilience. Our study advanced the literature on the interplay of perceived social support, resilience, and PTG, especially in healthcare.

In our study, the PTG score of medical staff was 60.48±24.49, lower than the score of frontline nurses in a previous study (M=70.53) [31]. As the pandemic continues to be out of control, the positive emotions of frontline medical staff are increasingly weakening, leading to a significant decline in their PTG levels during the normalization stage of pandemic prevention and control [39]. We found that younger (M=65.39) and less experienced medical staff (M=65.35) tended to have higher PTG scores, which was inconsistent with previous studies [31, 40]. A possible reason is that younger medical staff were more willing to accept life changes and could get help and support from more sources (such as different types of online platforms). Moreover, less experienced and non-clinical medical staff might have lower risk exposure during PHE, resulting in less psychological stress than clinical workers, and thus could recover and grow faster from the trauma.

By investigating correlations and mediation effects, we have substantiated the substantial impact of perceived social support on PTG and the mediating function of resilience within this connection. We found a positive direct effect of perceived social support on PTG in the context of PHE. This is consistent with previous research [18, 41] highlighting the importance of perceived social support in promoting positive psychological outcomes in individuals who have experienced traumatic events. Perceived social support from colleagues, family, and friends in healthcare settings can offer emotional validation [42] and a beneficial role in coping with stressors, which may facilitate the process of PTG [43]. These results emphasize the significance of fostering a supportive work environment for medical staff. Our results indicated a favorable correlation between perceived social support and PTG within the medical staff population. This can contribute to the betterment of medical personnel's well-being and the enhancement of medical service quality.

Moreover, our study established resilience as a substantial mediator in the association between perceived social support and PTG. This signifies that the beneficial impacts of perceived social support on PTG are, in part, elucidated by the resilience exhibited by medical staff. [28]. Resilience is critical for the rapid recovery mental health of medical staff from PHE [44]. Previous studies have found that resilience is a protective factor for them [45]. Based on our findings, we suggest that interventions aiming to enhance resilience among medical staff may be beneficial for their positive psychological well-being and growth. Enhancing resilience among medical staff can potentially enable more effective coping with the challenges and stressors inherent in frontline work, fostering personal transformation and development [46].

We acknowledge several limitations in our study that merit consideration. Firstly, the utilization of a cross-sectional design restricts our ability to establish causal relationships, and future studies should employ longitudinal or experimental designs to establish the temporal and causal relationships among the variables. Secondly, the generalis ability of the conclusions may be limited by the fact that only areas with a high prevalence of outbreaks were selected by this study. Random or stratified sampling are needed to enhance the external validity and diversity of the sample. Thirdly, this study did not consider rumination, self-disclosure, and coping styles, which may affect the experimental results.

This study has both theoretical and practical implications. First, it enriches the literature on the psychosocial well-being of medical staff in traumatic events by examining the positive psychological changes they can experience when facing public health challenges. Second, it proposes a mediated model to explain how perceived social support and resilience can facilitate PTG among medical staff, and provides empirical evidence using a sample of medical staff from Hubei Province, the epicenter of the pandemic in China. Third, it suggests that enhancing perceived social support and resilience can improve the well-being of medical staff and the quality of healthcare services they provide. Fourth, it highlights the importance of perceived social support and resilience for PTG, and calls for policymakers to create supportive environments and resources for medical staff.

To sum up, our study offers empirical evidence affirming the favorable influence of perceived social support on PTG within medical staff, where resilience acts as a mediating factor. These outcomes imply that medical staff might encounter favorable psychological transformations or growth while navigating the challenges of PHE. Additionally, perceived social support and resilience emerge as crucial factors in facilitating this process. Given these insights, psychosocial interventions become imperative for medical staff, promoting constructive coping mechanisms and fostering personal growth in the face of demanding circumstances. Our study underscore the importance of fostering a supportive environment and enhancing resilience among medical staff. Future endeavors in both research and practical applications should delve deeper into and bolster the factors that contribute to fostering PTG among medical staff in PHE.

Acknowledgements

We extend our gratitude to the survey participants and the entire study personnel for their dedicated endeavors in carrying out the data collection process.

Author contributions

Corresponding author presented the idea and supervised the findings of this work. All authors discussed the results, contributed and approved the final manuscript.

Funding

This work was supported by grants from the Natural Science Foundation of Hubei Province (No. 2022CFB721).

Data availability

In this study, the original data can be further consulted to the corresponding author.

Ethics approval and consent to participate

All methods were performed in accordance with the relevant guidelines and regulations. Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors declare that they have no conflicts of interest.

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No competing interests reported.

Resilience as a Mediator of the Relationship between Perceived Social Support and Public Health Emergency-related Post-traumatic Growth among Medical staff

Status:

Version 1

Abstract

Background

Method

Results

Conclusion

Figures

INTRODUCTION

METHODS

2.1 Design and Participants

2.2 Measurements

2.2.1 General demographic information

2.2.2 Chinese post-traumatic growth inventory (C-PTGI)

2.2.3 Multidimensional Scale of Perceived Perceived social support (MSPSS)

2.2.4 The 10-item Connor-Davidson Resilience Scale (CD-RISC-10)

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1