Abstract
Objective
To qualitatively explore the factors that enhance resilience among emergency nurses (ENs).
Design
This study is an exploratory qualitative investigation. Semistructured in-depth interviews were used for data collection, while qualitative content analysis was applied for data analysis.
Setting
A grade A tertiary hospital in Shanghai, China.
Participants
The study subjects comprised 17 ENs, who were selected using a purposive sampling method.
Results
Three main themes and the nine subthemes emerged from the study, that is, individual resources, including competency, personality traits and occupational benefits; family resources, including close parent–child attachment and supportive family dynamics; social resources, including peer support, organisational support, resilient leadership and popular support.
Conclusion
This qualitative study explored the factors promoting resilience among ENs and provided a reference for managers to formulate future management strategies. From the perspective of positive psychology, nurses should receive comprehensive support, focusing on improving their professional accomplishment and role ability while prioritising the development of resilient leadership. These efforts are expected to drive progress and growth across the emergency care team.
Keywords: Burnout, Nurses, MENTAL HEALTH, ACCIDENT & EMERGENCY MEDICINE, QUALITATIVE RESEARCH
STRENGTHS AND LIMITATIONS OF THIS STUDY.
In-depth interviews were conducted with 17 emergency nurses (ENs) to explore the factors contributing to their resilience.
From the unique perspective of positive psychology, this study delves into the facilitating factors contributing to ENs’ resilience, thereby offering valuable insights for future targeted intervention research.
This study can serve as a valuable resource for managers seeking to enhance their understanding of the psychological needs of ENs and facilitate the promotion of their mental well-being.
However, it should be noted that our findings may not be applicable to broader populations.
Introduction
The emergency department is a pivotal component within the medical care system, characterised by its high concentration of critically ill patients, diverse range of diseases and the challenging task of conducting rescue operations and managing patient care.1 Since the beginning of the 21st century, China has been witnessing a pervasive phenomenon of population ageing2; concurrently, there have been notable transformations in the disease spectrum among Chinese residents, with a substantial rise in the prevalence of acute cardiovascular and cerebrovascular diseases3; the frequent incidence of traffic accidents, natural calamities, epidemics and public health crises has also elicited significant apprehension,4 the provision of emergency treatment and care for patients afflicted with these injuries and conditions is one of the pivotal responsibilities within the emergency department.5 Furthermore, the rapid societal development and advancements in human health concepts have propelled the demand for emergency medicine. For example, emergency treatments in China experienced significant growth, with a 16.73% rise recorded in 2018 compared with 2017.6 As an important force in the emergency medical service system, emergency nurses (ENs) are vital in prehospital first aid, intrahospital patient transportation, rescue and resuscitation efforts, and treatment and monitoring procedures. However, the global shortage of nurses has emerged as a ubiquitous concern across nations,7 this issue is particularly pronounced within China. At the end of 2022, the nurse-to-population ratio in China was only 3.7 per 1000 individuals, which is below the threshold of 4.45 recommended by the WHO.8 In light of the conditions mentioned above and the inherent characteristics of the emergency department, such as limited control and high variability, ENs endure prolonged physical tension and significant psychological pressure. Compared with their counterparts in other departments, ENs are more susceptible to job burn-out and even resignation,6 thereby perpetuating a detrimental cycle.
The high cost of ENs turnover hinders the regular operation of hospitals9; meanwhile, training exceptional ENs with outstanding skills is time and energy-consuming. Therefore, reducing ENs burn-out and curbing turnover rates have become crucial in contemporary healthcare settings. Resilience is the ability to thrive in adversity, effectively manage workplace stress, and harmoniously balance demands and responsibilities.10 Individuals with high resilience are better equipped to navigate setbacks, take positive ownership, and effectively integrate their professional and personal lives.11 Qualitative research is an investigative approach where the researcher acts as a research instrument, working in natural settings, using various data collection methods and interacting with the subjects of study to gain a comprehensive understanding of their behaviour and meaning construction.12 In comparison to quantitative research, the content of qualitative research is more extensive, allowing for a profound exploration of the experiences and perspectives of the subjects.13 The outcomes from qualitative research can complement those obtained through quantitative studies. According to the literature search results, previous studies primarily focused on quantitatively analysing factors influencing nurses’ resilience, with limited attention to qualitative investigations, especially the qualitative research on the factors promoting the resilience of ENs. Therefore, the objective of this study is to qualitatively investigate the factors in daily life and work experiences that can enhance the resilience of ENs. This research aims to provide valuable insights for enhancing the mental health status of ENs and assist managers in developing strategies to improve their resilience.
Methods
Study design
A qualitative descriptive research design14 was used to explore the perceptions and experiences of promotion factors of resilience among ENs through face-to-face, in-depth interviews conducted in Shanghai in October 2023. Qualitative content analysis was employed for data analysis, and the participants were selected using the purposive sampling method.
Participants and settings
The participants of study were purposefully sampled from the emergency department of a grade-III class A hospital in Shanghai, which holds the highest level of medical service qualification bestowed by the Ministry of Health. This hospital boasts a nursing staff of nearly 700 and is responsible for clinical nursing care across more than 1000 beds. Inclusion criteria encompass possessing a valid nursing professional qualification and having a minimum of 1-year experience as an EN. Exclusion criteria are applicable to nurses who are on leave, those diagnosed with mental illness and those not affiliated with the unit, such as nurses who are undergoing rotations. All participants provided informed consent and willingly volunteered for participation in this study. A total of 17 respondents were recruited without any withdrawals during the interview process. The detailed information of all respondents is presented in table 1.
Table 1.
Demographic characteristics of the participants
| Characteristics | N (%) or mean (SD) |
| Sex | |
| Male | 5 (29.4) |
| Female | 12 (70.6) |
| Age | 32.1 (5.9) |
| Education level | |
| Diploma | 1 (5.9) |
| Baccalaureate degree | 15 (88.2) |
| Master | 1 (5.9) |
| Marital status | |
| Single | 6 (35.3) |
| Married | 11 (64.7) |
| Ethnicity | |
| Han | 17 (100) |
| Work experience (year） | 10.4 (6.2) |
Data collection
The face-to-face interviews were conducted in a quiet hospital room within the emergency department on October 2023. Each interview lasted for 30–60 min (mean 48 min) and was recorded with consent. The semistructured interview outline is derived from a comprehensive literature review conducted prior to this study, as well as the research interests and expertise of the first author. This interview outline serves solely as a guiding tool for data collection by the researcher.15 The interview was conducted by the first author, who had a deep understanding of qualitative research methodologies and extensive experience in conducting interviews. There was no prior relationship between the interviewer and the research subjects. The interview begins with a demographic question, such as, ‘To start, I’d love to get to know you better. Could you kindly share with me your educational background and work experience?’ Then introduce the resilience to the interview subjects in a popular way, so that the interview can be better conducted, such as: ‘You can understand the resilience as a kind of psychological immunity, that is, when you encounter setbacks and difficulties can calmly cope with and rebound.’ This is followed by a conversation centred on an interview outline to delve into the topic. During the interview, it is advisable to encourage the interviewees to provide detailed explanations for each point. Additionally, careful attention should be paid to the interviewees’ attitude, tone and facial expression. At the conclusion of the interview, each participant was afforded the opportunity to expound on unaddressed aspects or articulate their expectations for the interview. Subsequently, at the termination of every interview, any missing sociodemographic characteristics such as age, length of service and education were duly documented. Observations or spontaneous analytical thoughts from interviews were meticulously transcribed into field notes and memos and subsequently integrated into the data analysis.16 Finally, the researchers summarised the key findings and bestowed each participant with an umbrella as a token of appreciation. After 15 interviews, the first saturation occurred during the analysis. Subsequently, two additional interviews were conducted to validate and confirm this saturation. Two researchers participated in the interview process; one conducted the interview, and the other recorded the content. The formal interview outline is detailed in table 2.
Table 2.
Outline of the formal interview
| No. | Question |
| 1 | How do you effectively manage stress and overcome challenges in your professional role? |
| 2 | What positive experiences have you had dealing with stress and difficulties? |
| 3 | Which factors contribute to your resilience？ |
| 4 | What people and things have touched you? |
| 5 | What other experiences and feelings do you have? |
| 6 | Please provide three examples of emergency work that has brought you the highest level of satisfaction. |
Data analysis
The data collection and analysis were conducted simultaneously, while all interview recordings were transcribed verbatim by the first author within 24 hours of each interview to avoid potential bias in researchers’ recollection of the interview process. If any doubts arose during transcription, the researcher contacted the respondents for clarification (participants consented to future contact). The data extraction and analysis were conducted by two proficient researchers using the computer-assisted qualitative analysis software NVivo V.14.0, in conjunction with the qualitative content analysis approach proposed by Graneheim and Lundman.17 The data analysis steps are as follows18:
Step 1: Acquaint with the textual data: the researchers thoroughly reviewed the transcribed transcripts of the interviews iteratively to develop a comprehensive understanding and grasp the participants’ comprehension and articulation of resilience-promoting factors.
Step 2: Break the entire text into smaller parts, each of which is called a semantic unit.
Step 3: The semantic unit is compressed to form a compressed semantic unit, which is then extracted and encoded.
Step 4: Compare the extracted ‘codes’ from all text data, identifying common characteristics to classify them into corresponding ‘items’, and subsequently construct an interconnected yet independent ‘item spectrum’.
Step 5: Engage in iterative discussions and reflections within the research team to establish consensus on the identified ‘codes’ and ‘items’, subsequently interconnecting all ‘items’ to form a cohesive thematic framework.
Study rigour
Standards for Reporting Qualitative Research19 was used in this study. The rigour in qualitative research can be conceptualised as ‘credibility’.20 High credibility in research indicates its fairness, ethicality and the accurate reflection of the experiences of the subjects.21 To enhance credibility, this study ensured verification of the final transcribed text and extracted topics by the respondents. Furthermore, detailed descriptions of research methods were provided, and two qualitative research experts independently evaluated the findings.
Patient and public involvement
No patients were involved in this study.
Results
After analysing the interview data, three main themes emerged, namely (1) individual resources, including competency, personality traits and career benefits; (2) family resources, such as supportive familial dynamics and close parent–child attachment relationships and (3) social resources, encompassing peer support, organisational support, resilient leadership and popular support. Details are shown in figure 1.
Figure 1.
Themes and subthemes extracted from the data.
Theme 1: individual resources
Subtheme 1: competency
The majority of interviewees (n=13) reported that their resilience improved in tandem with their enhanced competency. Given the unique working environment and high-pressure nature of emergency departments, numerous nurses gradually accumulated experience and bolstered their courage and professional skills through day-to-day training. As personal abilities improved, individuals experienced a positive shift in confidence levels and adopted more effective strategies for overcoming challenges. For instance, one interviewer visually expressed this transformation: ‘I've worked in the emergency room for over ten years, experiencing countless emergencies. From a panicked beginner to someone who handles difficulties calmly, I now have more self-confidence. I believe that no obstacle is insurmountable.’ (N13) Additionally, owing to the unique nature of emergency department work, it experiences a heightened level of activity during holiday periods. Seven respondents emphasised their proactive engagement in self-psychological fortification as a coping mechanism for navigating the challenging days within the emergency department during these times. In addition to the challenges encountered in daily work, ENs play a crucial role as ‘gatekeepers’ of public health during certain public health emergencies. Taking the COVID-19 pandemic as an illustrative example, ENs bravely stepped onto the front lines, tirelessly combating against time constraints and overwhelming medical demands while persistently fighting against the virus. Their unwavering dedication ultimately led to profound personal growth and development. One interviewee highlighted this aspect: ‘The epidemic has brought us much suffering (frowning), but we have joined our forces and overcome all difficulties. I have survived this challenging time and will face no future hardships (waving).’ (N7)
Subtheme 2: personality traits
Optimism and cheerful personality traits were identified by many respondents (n=15) as important factors promoting their resilience. The respondents emphasised the efficacy of adopting positive coping strategies to manage stress, reevaluating problems from a novel perspective and employing affirmative psychological cues. These coping mechanisms play a pivotal role in facilitating individuals’ resilience towards frustration: ‘Every industry has its pressures; the key is how you deal with them.’ (N15) and ‘Perhaps I am naturally more optimistic (laughing). Bitterness and difficulty belong to the past. As the People’s Daily says, ‘Although the night may be cold, there is always light at the end of it.’ (N3）
Subtheme 3: career benefits
The perception of occupational benefits pertains to nurses’ recognition of the gains and advantages derived from their profession. Several nurses have highlighted the impact of this factor on their resilience (n=14). In addition to their primary duties, ENs also experience the convenience brought about by their work, such as using their professional knowledge to provide health guidance for family and friends or leveraging interpersonal relationships to offer improved medical consultation for family members. The nursing industry, in addition to its high employment rate and stability compared with other industries, offers ENs the advantages of their profession. One interviewee highlighted this by stating: ‘Because of the pandemic, many people are losing their jobs and experiencing reduced income. Despite the immense pressure and heavy work, I am grateful to have a stable job, which allows me to support my family.’ (N11)
Theme 2: family resources
Subtheme 1: supportive family dynamics
The respondents consistently emphasised the crucial role of parental, spousal and filial support in fostering their resilience (n=17). Within the context of the family as a social system, through effective interpersonal interactions, individuals receive psychological support and encouragement from family members such as parents, spouses and children. These supportive influences gradually permeate into individuals’ innermost being, fostering their resilience to overcome challenges and enhancing their psychological well-being and behavioural capabilities. ENs often receive life support, comfort and understanding from parents and spouses to facilitate mood adjustment, as well as care from children to alleviate daily fatigue. As one interviewee stated: ‘After saving a critically ill patient with ECMO, I returned home exhausted. As I stepped into the house, my clever kids immediately brought me slippers and took the bag from my hand, saying, ‘Mom, you've worked hard! Let’s have dinner quickly, and then we'll give you a massage.’ It warmed my heart! (laughing).’
Subtheme 2: close parent–child attachment relationships
Some respondents indicated that strong emotional bonds within the family significantly contribute to enhancing resilience (n=12). The close parent–child attachment relationship fosters familial connections, while emotional commitment instils a sense of belonging in individuals, thereby reducing anxiety and depression levels and promoting happiness. Consequently, this facilitates positive and stable development of resilience. During the interviews, a majority of respondents expressed that whether they assumed the role of parents or children, this emotional bond among family members enhanced their self-assurance in overcoming adversities. As highlighted by interviewees: ‘The best role models for children are often said to be parents, and I personally believe in using actions to educate them.’ (N12) and ‘As the sole child in my family, I bear all my parents' hopes and must remain resilient despite any setbacks.’ (N9)
Theme 3: social resources
Subtheme 1: peer support
The majority of interviewees (n=15) underscored the pivotal role of peer support in bolstering individual resilience, with several participants (n=12) highlighting the significance of colleague support within their department and the conducive atmosphere therein for fostering psychological resilience: ‘I've noticed that many of my colleagues have faced similar challenges, so if they can handle it, I can too (laughing).’ (N12) and ‘Our department has a great atmosphere where colleagues support and encourage each other, making us highly effective!’ (N15) . Four respondents mentioned the support and encouragement from their friends in daily life. For example, one respondent said, ‘I accompanied my good friends to take the postgraduate entrance exam, encouraging each other and striving to improve myself (fist pump).’ (N5)
Subtheme 2: organisational support
Organisational support, as a positive work resource, can mitigate nurses’ experience of burn-out in clinical practice. The stronger the perceived organisational support, the greater the motivation and initiative demonstrated by ENs in their professional responsibilities, ultimately resulting in heightened levels of resilience. During the interview, five nurses mentioned that the hospital subsidises department staff to travel to other cities for rest and recuperation. Additionally, six nurses highlighted the sleep blanket provided by the hospital’s social work department, which effectively addresses sleep problems among ENs. Furthermore, organisational support in terms of bonuses was emphasised as a significant factor that greatly enhances ENs’ determination to remain committed to their roles and fosters their resilience. For example, one interviewee mentioned the experience of the hospital financing their recuperation: ‘Almost three years since the epidemic, the hospital arranged for us to go to Xiamen and Chongqing in groups for recovery this year. Our cost is only 200 yuan, while the hospital will cover the remaining 4000 yuan. I'm feeling super thrilled (clapping), really happy (laughing).’ (N9)
Subtheme 3: resilient leadership
Most respondents (n=13) highlighted the importance of resilient leadership from department heads in supporting their resilience. By combining resilience and leadership, resilient leadership is highly contagious and can enhance employees’ ability to face challenges and improve their resilience. For example, the interviewees mentioned that during the COVID-19 pandemic, their head nurse has been playing a leading role in the forefront of the team, setting an example, while the director of the department will personally lead the team to rescue critically ill patients. In addition, they are thoughtful, calm and considerate of others: ‘Our leaders have a knack for thinking clearly, staying cool under pressure, guiding us through emergencies with finesse, and always putting themselves in our shoes.’ (N8) and ‘Our Nurse manager has always been at the forefront, especially during last year’s epidemic peak, and her resilience deeply inspired us.’ (N2). Resilient leadership specifically refers to how leaders exhibit resilience at the helm, effectively influencing their respective organisations and teams. This concept is distinct from the broader notion of resilience that can be applied to individuals, organisations and systems.
Subtheme 4: popular support
Popular support plays a pivotal role in influencing factors such as mental well-being, cognitive abilities and enhanced resilience. The respondents (n=11) emphasised the significant support they receive from their social networks, which can be categorised into two aspects: recognition and commendation through media platforms, and understanding and appreciation from patients and their families. The respondents noted that the media’s promotion of nursing’s importance during the COVID-19 pandemic has heightened public awareness and respect towards the nursing profession. The goodwill and comprehension expressed by patients and their families not only bolstered nurses’ professional identity but also fortified their resilience: ‘Thanks to the epidemic, many management departments recognized the importance of ENs. Nurses received extensive media coverage and praise on Nurses' Day this year, which made me realize the bittersweet nature of this career (Laughing).’ (N10) and ‘A patient who came to the hospital alone made a strong impression on me when he suddenly collapsed in the pre-examination office before we could even ask for his name. We immediately rushed him to the emergency room, started an IV, performed CPR, and took other necessary measures. When his family arrived, they were incredibly grateful and kept thanking us. It was a sacred moment for me as an ER nurse.’ (N6)
Discussion
Through the interview of 17 nurses in the emergency department, we have identified that enhancing nurses’ resilience primarily encompasses three key factors: individual, family and social resources. Among these factors, personality traits and family resources are inherent and relatively resistant to change. However, by focusing on further augmenting social resources, nursing managers can foster the development of resilience among ENs through intervention strategies such as enhancing their competency, increasing perceived professional benefits and well-being, bolstering social support networks and cultivating resilient leadership qualities.
Our research findings demonstrate that ENs encounter a diverse range of emergencies in their workplace, operating within a complex and high-pressure occupational environment. The unique nature of this setting necessitates the possession of extensive professional knowledge and skills. Enhancing competency is essential for enabling nurses to effectively manage various challenges at work with composure, thereby playing a pivotal role in fostering resilience development, which aligns with previous research outcomes.22 Given the intricate nature of competency promotion training, meticulous design of training methods becomes imperative to achieve desired training outcomes. Through literature search, we found that ADDIE model can be applied to the training of ENs’ resilience, which includes five stages: analysis, design, development, implementation and evaluation,23 serves as a universal framework for instructional system design. Its inherent advantage lies in its closed-loop structure that facilitates teaching design updates and iterations through implementation, feedback and revision processes while emphasising dynamic and creative teaching approaches. This study proposes using both the ADDIE model and the well-known competency iceberg model as foundations for ENs’ competency training. After identifying the teaching object, the teaching objective can be categorised into different levels based on educational background, ability, length of service and other criteria. The training objectives and programmes are developed using a competency level progression model. Specific training programmes are tailored for each level, considering the characteristics and components of competency. High-quality online and offline resources are carefully selected to enhance the richness of training content. A comprehensive approach is adopted by integrating preclass, in-class and postclass training methods. Scenario simulation and clinical practice activities reinforce the integration of theoretical knowledge with practical application. Nurse engagement is closely monitored throughout the entire training process while support systems are provided to encourage interaction and experience sharing among participants. The effectiveness of nurses’ learning is evaluated through questionnaires as well as theoretical and practical assessments which guide updates and improvements to future training programmes. The competency training diagram of ENs based on the ADDIE model is illustrated in figure 2. Furthermore, it is crucial to integrate managers’ humanistic care for nurses, as this can effectively enhance nurses’ motivation and proactiveness towards learning.24
Figure 2.
Competency training diagram of ENs. ENs, emergency nurses.
Additionally, our study also revealed that managers should prioritise the consideration of ENs’ perception of occupational benefit and well-being as a crucial factor in fostering resilience.25 26 This finding aligns with previous research, emphasising the significance of positive psychology in mitigating burn-out among ENs while concurrently addressing their negative emotions and enhancing their capacity to effectively cope with setbacks. Previous researches have identified several key factors that influence nurses’ perception of professional benefits and well-being, including job-related stress, professional competence, social support and career satisfaction.25 27 To enhance ENs’ ability to cope with work-related stress and enhance their job satisfaction, managers can adopt the following strategies. First, it is imperative for managers to establish and sustain a conducive and salubrious work environment. Managers should foster a positive ambience within the department, fostering unity among the staff members. Additionally, there is a need to bolster public opinion by highlighting the exemplary accomplishments of nurses, thereby enhancing their standing in society and garnering public understanding and support for nursing endeavours. Furthermore, managers ought to prioritise the development of nurses’ communication skills and emotional intelligence, guiding them in building patient trust and cultivating constructive nurse–patient relationships. Second, when ENs are experiencing pressure, it is crucial for managers to provide them with timely and effective resource support. Managers should engage in more communication with nurses to gain a better understanding of their work-related difficulties and needs, assist them in managing negative emotions, and offer prompt assistance and support. Additionally, implementing appropriate salary improvements for nurses as well as mindfulness-based stress reduction techniques, concentrated short-term treatment options and other psychological intervention measures can also prove effective in combating occupational stress.28 Third, managers should proactively encourage nurses to engage in skills training during peacetime, thereby preparing them for future emergencies and fostering a heightened awareness of their professional value. Managers can facilitate the organisation of professional lectures within the hospital, thereby offering abundant learning and training opportunities for ENs. Simultaneously, personalised teaching should be emphasised to guide nurses in selecting learning paths that align with their individual interests. For instance, male nurses often exhibit a keen interest in using advanced medical equipment; thus, it is imperative for managers to provide these male nurses with relevant learning opportunities.29
Resilient leadership plays a pivotal role in fostering the development of individual resilience among ENs, as evidenced by our study findings. This aligns with previous research conclusions that resilient leaders can enhance the individual resilience of their team members through a trickle-down effect and bolster team resilience through their compelling charisma and aptitude for learning.30 As a critical asset for fostering continuous organisational development, this form of leadership warrants heightened attention, particularly in the context of public health emergencies. Resilient leadership encompasses two fundamental components: resilience and leadership itself. It pertains to the leader’s proactive capacity to effectively respond to adversities faced by the organisation, rebound from setbacks, and facilitate employees’ recovery and personal growth.31 Numerous studies have proposed the characteristics of resilient leadership, such as dialectical thinking, a high level of resilience and strong learning ability.32 33 Consequently, the key to developing resilient leadership lies in reshaping leaders’ mentality and enhancing their learning ability. However, cultivating resilient leadership is challenging due to its requirement for long-term and systematic multidimensional training. Hospitals can enhance leaders’ self-efficacy, resilience, emotional stability and learning ability through regular intervention training that includes interventions like positive emotion enhancement techniques, stress management training programmes, role-playing exercises, cognitive restructuring techniques and cognitive skill development programmes. Furthermore, when recruiting or selecting leaders, prospective personality tests and professional ability assessments should be carried out, giving priority to individuals with strong initiative and excellent professional ability, while also emphasising flexible leadership.34 35
Strengthens and limitations
This study used qualitative research to explore the factors that promote resilience among ENs, as the qualitative study can more deeply explore the real needs of nurses, thus further broadening the content of this research field. Our results can help managers formulate more detailed resilience improvement plans. In addition, we also proposed various ideas for managers to promote the development of ENs’ resilience. However, the limitations of this study should be acknowledged: this qualitative study was conducted in a specific city, therefore, when considering the application of strategies to promote resilience among ENs, it is crucial to consider their suitability within different cultural contexts and healthcare systems across various countries. Future research is needed to expand the sampling scope and reinforce researchers’ comprehension of the factors that enhance resilience among ENs.
Conclusion
The phenomenon of shortage and job burn-out among ENs necessitates attention. This qualitative study provides further insights into the factors fostering resilience among ENs. In the future, managers should adopt a positive psychology perspective to offer comprehensive support to nurses, focusing on enhancing their sense of career fulfilment and role competence while prioritising the development of resilient leadership among leaders. These efforts will contribute to advancing the progress and growth of the entire emergency care team.
Supplementary Material
Acknowledgments
We would like to thank the nurses who participated in this study.
Footnotes
JJ and SL contributed equally.
Contributors: JJ and SL: conception, design and revising the article critically for intellectual content. JJ, SL, CC, YL and PH,: acquisition of data. SL, CC, JJ, LS and YZ: analysis, interpretation of data and drafting the article. All authors contributed to the article and approved the submitted version. JJ: guarantor.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review: Not commissioned; externally peer reviewed.
Data availability statement
Data are available on reasonable request. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
Ethics statements
Patient consent for publication
Not applicable.
Ethics approval
The study was approved by the Ethics Committee of Shanghai Tenth People’s Hospital (approval number: 23KN25), and all participants signed informed consent. They were also informed that they could withdraw from the study anytime. Audio recordings were immediately destroyed after transcription, while transcripts will be securely stored for 5 years before being destroyed. Throughout the research process, participant privacy was protected by using numerical identifiers instead of names.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available on reasonable request. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.