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. 2023 Apr 13:1–10. Online ahead of print. doi: 10.1007/s12144-023-04546-9

Mediating role of psychological flexibility in the effect of obsessive-compulsive symptoms on sleep quality among nurses during the COVID-19 pandemic

Difan Wang 1,2,3,4,#, Bingyan Lin 5,#, Heting Liang 1,2,3, Yu Deng 5, Lin Zhang 1,2,3,6,✉
PMCID: PMC10097520  PMID: 37359595

Abstract

Front-line nurses suffered unprecedented mental distress and severe insomnia during the COVID-19 pandemic. Present study aimed to explore the relationship between obsessive-compulsive symptoms and sleep quality and examine the potential mediating role of psychological flexibility between obsessive-compulsive symptoms and sleep quality. A total of 496 nurses from a Chinese large-scale Class 3 A Comprehensive Hospital were included in an online cross-sectional survey and completed the revised obsessive-compulsive inventory (OCI-R), Multidimensional Psychological Flexibility Inventory (MPFI) and Pittsburgh Sleep Quality Index (PSQI). As predicted, obsessive-compulsive symptoms were negatively associated with psychological flexibility and sleep quality, and psychological flexibility was positively associated with sleep quality. In addition, the relationship between obsessive-compulsive symptoms and sleep quality was partially mediated by psychological flexibility, which can provide some reference for the treatment of the obsessive-compulsive disorder (OCD) and insomnia, and lead to improvements in clinical and psychotherapy planning.

Keywords: Obsessive-compulsive symptoms, Psychological flexibility, Sleep quality, Nurse, Mediating role

Introduction

Since the outbreak of COVID-19, heavy workloads, depletion of personal protection equipment, widespread media coverage, lack of specific drugs, and feelings of insufficient support may all contribute to healthcare workers’ mental distress (Lai et al., 2020). Front-line clinical nurses were reported to have poor sleep, with a high incidence of insomnia at 64.15% (Zhan et al., 2020), this proportion is 48% in Poland (Zdanowicz et al., 2020). Facing huge physical and mental struggles, nursing staff were reported to have physical hardship, tight schedules, and frequent exposure to disease (Tracogna et al., 2002). Carrying the unique mission of their profession, nurses are more likely to suffer from insomnia due to their great responsibility, workload, stress, and the work in shifts (Huang et al., 2018). Improving sleep quality and reducing the incidence of insomnia among nurses during the pandemic is significant in accelerating personal development, alleviating physical and psychological disorders, ensuring the quality of nursing, and stabilizing the nursing group.

Sleep quality is defined by a couple of standards, including the total sleep duration (4–10 h per day), the amount of time it takes to fall asleep, the frequency of waking, and the satisfaction when one wakes up (Burgard & Ailshire, 2009). Previous studies have found that nurses’ insomnia was associated with occupational stress, emotional exhaustion, and depersonalization positively, and associated with personal achievements negatively (Huang et al., 2019; Kousloglou et al., 2014). It can induce not only physiological diseases such as hypertension, diabetes, and cardiovascular disease, but also cause psychological diseases such as anxiety, depression, two-way emotional disorder, and suicide tendency (Khan & Aouad, 2017). Sufficient sleep is essential for nurses to maintain physical and mental health, good quality of life, and professional performance (Karagozoglu & Bingöl, 2008; Kunzweiler et al., 2016).

Meanwhile, another aspect of mental health that may be particularly impacted by the pandemic is obsessive-compulsive disorder (OCD). Obsessive-compulsive symptoms (OCS) are characterized by intrusive, distressing thoughts (i.e., obsessions) and repetitive, uncontrollable behaviors intended to reduce the distress of the obsessions (i.e., compulsions) (Cox & Olatunji, 2021; McKay et al., 2004; Zhang et al., 2021). Against the backdrop of the COVID-19 outbreak, there has been an obvious rise in the washing symptoms of OCS (Cox & Olatunji, 2021). Recent studies showed that healthcare workers had a higher prevalence of obsessive-compulsive symptoms than the public during the COVID-19 outbreak (Zhang et al., 2020). Forced prevention methods such as mandatory repeated disinfection, frequent nucleic acid testing and equipment replacement for the general public, strict hand washing and extensive cleaning of operating theatres have increased nurses’ awareness of compulsion. As nurses’ mental health may be more susceptible to negative effects in the context of a pandemic, this study wanted to examine the relationship between OCS and sleep quality in a population of nurses during the COVID-19 pandemic.

Theoretical and empirical studies have demonstrated that obsessive-compulsive symptoms have important effects on poor sleep quality (Sun et al., 2022; Timpano et al., 2014). According to the cognitive model of insomnia maintenance, insomnia will get worse when people accelerate the negative cognition to make the corresponding compulsive protective response, such as controlling thoughts, controlling imagination and suppressing emotions, etc. (Harvey, 2002; McCracken & Gutierrez-Martinez, 2011). Existing empirical studies have also reported the association between OCS and sleep quality. For example, previous studies found that the severity of obsessive-compulsive symptoms was associated with the amount of self-reported sleep concerns positively, and associated with total sleep time, sleep quality, and sleep efficiency negatively (Miniksar & Özdemir, 2021; Segalàs et al., 2021; Storch et al., 2008). Patients with obsessive-compulsive symptoms reported poor sleep quality, characterized by difficulty falling asleep, inadequate sleep duration, nightmares, and early morning awakenings (Papadimitriou & Linkowski, 2005). Compulsion was associated with both short sleep duration and poor sleep quality (Seow et al., 2020).

However, the psychological mechanism for the association between OCS and sleep quality has not been comprehensively investigated. To the best of our knowledge, only one previous study investigated the psychological mechanism for the association between OCS and sleep quality, which found cognitive concerns of anxiety sensitivity partially mediated the association (Raines et al., 2015). The potential mediating role of psychological flexibility has been ignored by the existing research.

Psychological flexibility is an ability to pursue value and live a meaningful life in the presence of discomfort and other unwanted inner experiences (Hayes et al., 2006). Previous studies have reported that obsessive-compulsive symptoms are associated with a lack of psychological flexibility (Bluett et al., 2014; Twohig et al., 2015). Faced with aversive internal experiences, people with obsessive-compulsive symptoms tend to use unhelpful behaviors (e.g. resistance or avoidance), which may compromise meaningful living (i.e. psychological flexibility) (Hayes et al., 2006; Ong et al., 2020). In addition, people with obsessive-compulsive symptoms are accustomed to performing repetitive behaviors through stereotypical rituals. This reduces the ability of patients to change their behavior in response to environmental cues, so their flexibility is reduced (Okasha et al., 2000).

Psychological flexibility is also associated with sleep quality. Liu et al. (2020) found that psychological flexibility was a protective factor for sleep quality in healthcare workers. Both psychological flexibility and its components were positively associated with sleep quality (McCracken & Gutierrez-Martinez, 2011). Psychological flexibility was significantly negatively correlated with insomnia symptoms (Booker et al., 2018). Psychological flexibility is a personal characteristic that can be improved. Improving psychological flexibility can improve mental health and work performance (Masuda et al., 2011). For example, individuals with high psychological flexibility were better able to regulate negative emotions to improve their sleep quality (Peng, 2020; Yanjiao, 2020). In addition, they can adapt to stress and adversity better, and sleep better (Seelig et al., 2016). It is reasonable to consider psychological flexibility as the psychological mechanism for the association between OCS and sleep quality.

Therefore, the aim of this study was to examine the relationship between obsessive-compulsive symptoms and sleep quality among nurses and to explore the role of psychological flexibility in their association. Specifically, we proposed the following hypotheses:

Hypothesis 1

Obsessive-compulsive symptoms are negatively associated with psychological flexibility and sleep quality, while psychological flexibility is positively associated with sleep quality.

Hypothesis 2

psychological flexibility mediates the relationship between obsessive-compulsive symptoms and sleep quality.

Materials and Methods

Participants and procedures

This study was an online questionnaire survey conducted in August 2022 using a self-developed online platform (Fig. 1). A total of 510 nurses with single-seat numbers were recruited among 1020 nurses in a training auditorium from a Class 3 A Comprehensive Hospital in Beijing, the inclusion criteria is: (1) age from 18 years to 65 years, (2) no using of psychotropic drugs or treatment of psychotherapy (counseling) during the past 3 months, (3) no major physical/mental illness, (4) no history of substance abuse, (5) no risk of suicide and self-injury, (6) access to a computer or cell phone with an Internet connection. 14 nurses were excluded from the study because 8 of them failed to meet the criteria and 6 of them didn’t complete the questionnaire. Hence, the final number of participants was 496.

Participants were informed about all relevant aspects of the study (e.g., methods and objectives of the research) before they started to fill in the questionnaire. On the premise of obtaining informed consent, participants logged in to the online platform to fill in the demographic information and questionnaires. The present study was approved by the Institutional Review Board of the Medical Ethics Committee of Chinese PLA General Hospital.

Fig. 1.

Fig. 1

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Interface of the platform

Measures

Obsessive-compulsive symptoms

The 18-item revised obsessive-compulsive inventory (OCI-R) (Foa et al., 2002) was used to assess the frequency and pain of individual obsessive-compulsive symptoms (e.g., “I always check the doors, windows and drawers again and again”). It consists of six dimensions: washing, checking, obsessing, neutralizing, ordering, and hoarding. Participants were asked to rate the frequency of obsessive-compulsive symptoms that had occurred in the past month (0 being “never,“ 4 being “almost always”) and how painful they had been (0 being “not painful at all,“ 4 being “extremely painful”). The total score ranged from 0 to 72, with higher scores indicating more pain (Cronbach’s α = 0.818). The Confirmatory factor analysis (CFA) indicated that the obsessive-compulsive inventory had good construct validity, χ2 / df = 1.44, p < 0.001, RMSEA = 0.03, CFI = 0.98, TLI = 0.97, NFI = 0.93, IFI = 0.98.

Psychological flexibility

The Multidimensional Psychological Flexibility Inventory (MPFI) (Rolffs et al., 2018) contains two subscales (psychological flexibility subscale and psychological inflexibility subscale). Each subscale contains six dimensions, corresponding to six facets of psychological flexibility (e.g., “I try to reconcile my negative thoughts and feelings instead of fighting them”) and six facets of psychological inflexibility respectively (e.g., “When I have negative thoughts or emotions, it’s hard to get out of them”), with a total of 60 items in the whole scale. All questions were graded 1–6. The content validity, structure validity, and scale validity of the total scale and each subscale all meet the statistical requirements (Rolffs et al., 2018). The psychological flexibility subscale was adopted in this study. The higher the score was, the higher the degree of psychological flexibility was (Cronbach’s α = 0.823). CFA indicated that the psychological flexibility subscale had good construct validity, χ2 / df = 2.76, p < 0.001, RMSEA = 0.06, CFI = 0.77, TLI = 0.75, NFI = 0.69, IFI = 0.78.

Sleep quality

The 18-item Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989)was used to examine participants’ sleep quality (e.g., “What time did you usually go to bed in the past month”). It consists of seven dimensions to evaluate a wide variety of issues relating to sleep quality of individuals within 30 days: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, used sleep medication, and daytime dysfunction. All questions were graded 0–3, and the total score range is 0–21. For better understanding, we reverse scored all items. The higher the SQ score is, the better the individual’s sleep quality is (Cronbach’s α = 0.860). CFA indicated that the Pittsburgh Sleep Quality Index had good construct validity, χ2 / df = 4.47, p < 0.001, RMSEA = 0.08, CFI = 0.95, TLI = 0.90, NFI = 0.94, IFI = 0.95.

Data Analysis

Data analyses were performed with SPSS version 25. The independent samples t-test, one-way ANOVA and non-parametric test were used to test the differences in obsessive-compulsive symptoms, psychological flexibility, and sleep quality in different socio-demographic characteristics. Pearson correlation analysis was performed next to investigate the interrelation between all main variables.

Finally, annual income was included as a covariate in the mediation model. We tested the indirect effect of psychological flexibility using obsessive-compulsive symptoms as the predictor and sleep quality as the outcome. The mediation model was tested with Process3.5 (Hayes & Preacher, 2014) using a bias-corrected nonparametric percentile bootstrap test. This method has good statistical power by resampling in the original data and extracting a certain number of sample data to test the moderated mediation effect. The bootstrapping procedures in the Model 4 of PROCESS macro was used, with 5,000 bootstrap resampling and 95% confidence intervals (CI) with full adjustment for the covariates. The indirect effect was significant when 0 was not between the lower and upper confidence limit.

Results

Demographics analysis

As shown in Table 1, there is no significant difference in obsessive-compulsive symptoms, psychological flexibility, and sleep quality between different variables, including sex, employment status, single-child identity, having or not having children, marital status, educational level, professional title, age, years of service (all p > 0.05).

Table 1.

Demographics of the participants (n = 496)

OCS PF SQ
N/Percentage t/F/H (p) t/F/H (p) t/F/H (p)
Sex -0.95 (0.34) 1.21 (0.23) 0.11 (0.91)
Male 31/6.3%
Female 465/93.8%
Employment status 1.3 (0.2) -0.21 (0.83) -0.21 (0.84)
Employed 430/86.7%
Further education or internship 66/13.3%
Single-child identity 1.71 (0.09) 0.35 (0.73) -1.08 (0.28)
Yes 100/20.2%
No 396/79.8%
Having children 0.51 (0.61) -0.83 (0.41) -0.7 (0.49)
Yes 191/38.5%
No 305/61.5%
Educational level 1.12 (0.34) 0.50 (0.68) -1.87 (0.13)
High school and below 5/1%
Vocational 202/40.7%
Undergraduate 286/57.7%
Master 3/0.6%
professional title 0.46 (0.71) 0.46 (0.71) -2.35 (0.07)
Nurse 237/47.8%
Senior nurse 145/29.2%
Supervisor nurse 112/22.6%
Co-chief superintendent nurse 2/0.4%
Marital status 0.47 (0.64) -0.4 (0.69) 0.11 (0.91)
Married 219/44.2%
Unmarried 277/55.8%
Age 0.14 (0.94) 0.16 (0.93) -0.4 (0.76)
19–30 315/63.5%
31–40 168/33.9%
41–50 10/2%
over 50 3/0.6%
Years of working 0.03 (0.97) 0.41 (0.66) -1.48 (0.23)
1–10 years 322/64.9%
11–15 years 113/22.8%
over 15 years 61/12.3%
Annual income 0.75 (0.56) 0.41 (0.80) -4.58(< 0.01)
50,000 or less 155/31.3%
6-100000 yuan 212/42.7%
11-200000 yuan 103/20.8%
21-300000 yuan 24/4.8%
more than 300,000 2/0.4%
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Note. OCS : obsessive-compulsive symptoms; PF : psychological flexibility; SQ : sleep quality

However, the quality of sleep varied significantly among nurses with different annual incomes (p < 0.01), which were included as covariate into the mediation model. Ad-hoc test results showed that there are significant differences in sleep quality between nurses’ earnings. Compared with those earning 110,000 yuan − 200,000 yuan, nurses with less than 50,000 yuan per year (p < 0.05), and nurses earning 60,000 yuan − 10,0000 yuan per year (p < 0.001), and nurses earning 210,000 yuan − 30,0000 yuan per year (p < 0.01) have better sleep quality.

Correlation analysis

Table 2 provided the correlations among the variables studied. The obsessive-compulsive symptoms was negatively associated with the sleep quality (r = -0.21, p < 0.01) and negatively associated with the psychological flexibility (r = -0.19, p < 0.01). The psychological flexibility was positively associated with the sleep quality (r = 0.16, p < 0.01). Thus, H1 were supported.

Table 2.

Correlation analysis between primary variables (n = 496)

M SD obsessive-compulsive symptoms psychological flexibility Sleep quality
obsessive-compulsive symptoms 47.20 7.66 1
Psychological flexibility 73.38 13.23 -0.19** 1
Sleep quality 11.45 3.33 -0.21** 0.16** 1
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Note. * = p < 0.05, ** = p < 0.01, *** = p < 0.001

Mediation model

As shown in Fig. 2; Table 3, to test our exploratory hypotheses, we tested the mediation model (PROCESS model number 4) with obsessive-compulsive symptoms as the independent variable, sleep quality as the dependent variable, and psychological flexibility as the mediator. The results showed the obsessive-compulsive symptoms predicted psychological flexibility negatively (β = -0.193, p < 0.001), and predicted sleep quality negatively (β = -0.186, p < 0.001). Psychological flexibility predicted sleep quality positively (β = 0.122, p < 0.01).

Fig. 2.

Fig. 2

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The mediating model of psychological flexibility

Table 3.

Standardized Model Coefficients for the Mediation Model (n = 496)

Outcome
Predictor psychological flexibility sleep quality
CI (LL, UL) SE t CI (LL, UL) SE t
obsessive-compulsive symptoms -0.193 (-0.484, -0.184) 0.076 -4.374*** -0.186 (-0.119, -0.043) 0.019 -4.176***
psychological flexibility 0.122 (0.009, 0.053) 0.011 2.739**
annual income 0.002 (-1.293, 1.358) 0.675 0.048 -0.058 (-0.552, 0.108) 0.168 -1.320
R 0.193 0.247
R² 0.037 0.061
F 9.582 10.632
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Note. * = p < 0.05, ** = p < 0.01, *** = p < 0.001

As shown in Table 4, the bootstrap analysis with 5000 bootstrap samples showed the total effect is -0.091 (SE = 0.019; 95% CI: -0.129, -0.054). The direct effect of obsessive-compulsive symptoms on sleep quality is -0.081 (SE = 0.019; 95% CI: -0.119, -0.043), accounting for 88% of the total effect. For the indirect effect, 95% bootstrap confidence intervals (CIs) without “zero” indicates the significant mediation effect. The mediating effect was − 0.010 (SE = 0.004; 95% CI: -0.020, -0.003), accounting for 11% of the total effect. In other words, psychological flexibility partially mediated the relationship between obsessive-compulsive symptoms and sleep quality. Taken together, H2 were supported.

Table 4.

Total effect, direct effect and mediation effect

Effect value Boot SE Boot LLCI Boot ULCI %
Total effect -0.091 0.019 -0.129 -0.054
Direct effect -0.081 0.019 -0.119 -0.043 89%
Mediation effect -0.010 0.004 -0.020 -0.003 11%
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Note. Bootstrap sample size = 5000. LL = low limit, CI = confidence interval, UL = upper limit

Discussion

To the best of our knowledge, this study is the first to explore the mediating role of psychological flexibility between obsessive-compulsive symptoms and sleep quality. The results provide support to the proposed hypothesized model, suggesting psychological flexibility partially mediated the relationship between obsessive-compulsive symptoms and sleep quality. Higher obsessive-compulsive symptoms were associated with lower psychological flexibility and sleep quality and higher psychological flexibility were associated with better sleep quality. Although previous studies have found the main symptom of OCD include sleep complaints and insomnia (Paterson et al., 2013; Reynolds et al., 2015), the more severe the obsessive-compulsive symptoms, the lower the psychological flexibility (Thompson et al., 2021; Twohig et al., 2018). Psychological flexibility is negatively associated with sleep quality (Kato, 2020; McCracken & Gutierrez-Martinez, 2011; McCracken et al., 2011), but the internal mechanism among the three variables have not been directly explored. Our findings not only supported the previous conclusion but also provide further evidence to the internal mechanism among obsessive-compulsive symptoms, psychological flexibility, and sleep quality, which can help to identify new advancements in the clinical assessment, prevention, and treatment of both insomnia and OCD amongst this high-risk population.

The results of the study showed no correlation between sleep quality and sex, education level and age, which is consistent with the findings of previous studies (Han et al., 2016; Huth et al., 2013). Furthermore, employment status, single-child identity, having or not having children, marriage status, professional title and working years were not associated with sleep quality. However, there were differences in sleep quality among nurses earning different annual incomes, which would add new evidence for the relevance of nurses’ income and provide some indication for hospital administration to focus more on Chinese nurses earning between RMB 110,000 and 200,000 per year. In addition, future study will also be required to examine why those with annual incomes of RMB 110,000–200,000 have inferior sleep quality than nurses with annual incomes of under RMB 100,000 and RMB 210,000–30,0000.

Recently, there has been a growing crop of research on insomnia among nurses, but the existing studies have a small sample size and limited representativeness. For example, 200 nurses were organized from two hospitals in a study to investigate the current state of insomnia among Polish nurses (Zdanowicz et al., 2020). Another study of 255 frontline clinical nurses in the Philippines were recruited to evaluate the impact of pandemic fatigue on clinical nurses’ mental health, sleep quality and job satisfaction (Labrague, 2021). Our study included 496 nurses in China and the results demonstrated that the mean score of obsessive-compulsive symptoms was 47.21 and 94% of participants scored above the median of 36 (the total score of OCI-R is 72), indicating an even higher prevalence of OCS. The mean score of psychological flexibility was 73.38 and 90% of participants scored below the median of 90 (total score of PF subscale of MPFI is 180), indicating an even lower level of PF. The mean score for sleep quality was 11.45 in our study. A PSQI total score below 16 represents a poor sleep quality and a clinically relevant sleep disturbances (Buysse et al., 1989; Patel et al., 2018; Wallace et al., 2020), and it has been shown that the PSQI is a valuable measurement of subjective sleep quality (Buysse et al., 1989). 90% of participants in our study scored lower than 16 on sleep quality, which indicates a greater prevalence of poor sleep quality.

In the context of public health recommendations against infection during the pandemic, coercive prevention methods have increased nurses’ awareness of compulsion. Besides, being affected by the social isolation requirements and the constant concern of infectivity, insomnia also became a noticeable problem during the pandemic(Jahrami et al., 2021; C. Zhang et al., 2020). Nurses who are not getting enough sleep tend to engage in more mistakes regarding patient care (Johnson et al., 2014) and deliver a poorer quality of nursing care (Gómez-García et al., 2016). Therefore, it is imperative to seek and use all available resources and therapies to tackle the psychological and physical problems caused by the pandemic.

The mediating role of psychological flexibility underscores the importance of introducing interventions that focus on boosting psychological flexibility in nurses through empirically driven strategies, including educational and interventions, which will further contribute to the better quality of sleep and the decline of OCS. Empirical studies have confirmed that various forms of Acceptance and Commitment Therapy (ACT) can effectively improve psychological flexibility (McCracken et al., 2011), it combines the concept of Mindfulness, advocates paying attention to and accepting current feelings, breaks through the obstruction of invalid cognitive contents to positive behaviors, and reconstructs self-concept and personal value system to activate positive behaviors (Zhang et al., 2012). Furthermore, the forced strict social distancing measures such as city lockdown, school and public facilities closure, and stay-at-home instructions, researchers suggest remote delivery of medical treatment may be the ideal solution for intervention treatment (Racine et al., 2020; Whaibeh et al., 2020; Yildirim et al., 2020) combined virtual reality technology (VR) with mindfulness intervention found that VR-based interventions could lead to a higher level of Mindfulness. Therefore, we suggest internet-based ACT (iACT) and VR-based Mindfulness interventions for the future intervention study, which aims to provide references and insight into strategies for OCD and insomnia treatment, presently and in the future.

The present study had several limitations worth noting. Firstly, the use of self-report scales may potentially cause response bias. Participants may also lose the patience to fill in carefully. Further, using adaptive algorithms to customize differentiated scales for different participants, i.e., real-time jump to the most relevant items can be realized through the interaction of participants’ answers. Secondly, the nurses included in this study were located in one city of China. Therefore, future studies that involve nurses from other areas of the country may provide more generalizable results. Finally, the partially mediating effect of psychological flexibility on the relationship between obsessive-compulsive symptoms and sleep quality indicates that other factors may not have been accounted for in this study. Hence, future research should therefore explore other individual factors (e.g. emotional intelligence, coping styles, self-efficacy) and organizational factors (e.g. hospital resources, work shifts and the number of patients admitted) that may have an impact on the quality of nurses’ sleep.

Conclusion

This study provides additional knowledge regarding the state of psychological flexibility, obsessive-compulsive symptoms and sleep quality among front-line nurses during the coronavirus pandemic. Overall, front-line nurses reported moderate-high levels of obsessive-compulsive symptoms and lower levels of psychological flexibility and sleep quality. Further, Acceptance and Commitment Therapy (ACT) was seen to improve sleep quality and reduce obsessive-compulsive symptoms by improving psychological flexibility, it may be vital to effectively support frontline nurses’ mental and physical health and foster job satisfaction.

Author Contribution

Difan Wang and Bingyan Lin: conceptualization, data analysis, and original draft writing. Lin Zhang: review, proofreading and editing. Heting Liang: review and data analysis. YD: data collection. All authors contributed to the article and approved the submitted version.

Funding

Our work was supported by the Research Project of Shanghai Science and Technology Commission (20dz2260300) and The Fundamental Research Funds for the Central Universities, self-determined research funds of CCNU from the colleges’ basic research and operation of MOE (No.CCNU20TD001), and the Fundamental Research Funds for the Central Universities, and by the Faculty Development Funds of Central China Normal University: 0900-31101210201.

Data Availability

The raw data of the present study are available from the corresponding author on reasonable request.

Declarations

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Ethics approval

The research involving human participants was reviewed and approved by the Ethical Committee for Scientific Research of Chinese PLA General Hospital with the registration number of S2021-568-01. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent to participate

The participants gave informed consent through an online process.

Consent for publication

The participants gave consent for publication through an online process.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The raw data of the present study are available from the corresponding author on reasonable request.

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